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Curbside Consult with Dr. Jayne 4/9/12

April 9, 2012 Dr. Jayne 12 Comments

The hot news around the non-virtual water cooler this week has been the call by many physician professional organizations to reduce unnecessary medical tests and procedures. The move is aimed at lowering health care costs and improving decision making. The campaign, called “Choosing Wisely,” hopes to engage doctors and patients in a dialog around the procedures and tests.

In my experience, even the most educated patients are reluctant to go along with guidelines and evidence-based medicine, frequently demanding tests “just to make absolutely sure” that a problem doesn’t exist, or even worse, “because insurance will pay for it.”

I have had countless arguments with patients over all manner of tests and treatments. It’s difficult to help patients understand that medical testing isn’t entirely harmless. There is always the risk of a false-positive test that can result in further unneeded testing, stress, and potential harm. Radiation exposure is cumulative. Tests aren’t necessarily indicated just because a cardiology practice that owns a CT scanner is running radio ads that offer discounted cardiac risk scoring.

Many of the tests on the list are obviously questionable, yet patients consistently demand x-rays for low back pain. I have many colleagues who order colonoscopies every seven years for low-risk patients.

I’m sure many think this list will be helpful to stimulate discussion with patients, but I’ve tried the literature and data route before. Patients have accused me of trying to ration care when I’m simply following evidence-based guidelines.

Every patient has a story about something that “the doctors missed” and is afraid it will happen to them. There is also the subset of providers who don’t want to get caught on the wrong side of a lawsuit should something be missed.

A glance at my local newspaper today revealed four of five reader comments along the lines of, “The doctor didn’t want to do the test, but I demanded it and it saved me from a life-threatening situation.” I appreciate these individuals’ stories, but ordering every test on every patient every time is not only poor patient care, but a recipe for economic collapse.

The participating physician groups are partnering with Consumer Reports and AARP to get the word out, but I’m not sure it’s going to make a difference. As long as payers continue to cover some of these items (such as annual EKGs for low-risk patients without symptoms) it’s going to be an uphill battle.

Additionally, hospitals still often require some of these tests – such as a preoperative chest x-ray for all patients regardless of risk – making it difficult for physicians to just say no. The entire list of 45 procedures (each of the nine participating specialty groups identified five procedures that are overused) can be found online at Choosing Wisely.

From an EHR perspective, figuring out how to work clinical guidelines into real-world workflows and ensure truly usable clinical decision support is tricky enough when the guidelines are clear cut. When they’re not so clear (especially when you have multiple bodies recommending strategies which are contradictory, such as the mammography guidelines) it’s nearly impossible.

I’ve been asked by individual physicians to re-code clinical decision support during EHR go-lives because they don’t agree with the national standards. Indeed, we are in America, but as long as providers continue to have cowboy attitudes this will be a struggle. Similarly, the transition from “patients as patients” to “patients as consumers / customers” has also created difficulties. When physicians are graded on patient satisfaction scores, the decision to deny unneeded antibiotics or a requested test becomes more difficult.

I’m interested to hear how these recommendations have affected you. If you’re a physician or provider, are your patients hearing any buzz on this topic? And if you’re in IT or software support, are you receiving requests to modify clinical decision support to reflect constantly changing guidelines? Let me know what you think. E-mail me.

E-mail Dr. Jayne.

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Currently there are "12 comments" on this Article:

  1. Right on Dr. Jayne. The downside of patient evaluations has not received enough research. If I have to pick a warm MD smile vs a good diagnostic mind, I’ll go with the latter. Alas, I’m not the typical patient.

  2. Real world and evidence-based world sometimes seem to exist as completely separate dimensional planes! Anecdotes can wage successful battles against even the hardest research. And providers seem no more immune to this phenomenon than the lay public. Emotional responses play a strong trump card. Good piece, Dr. J.

  3. Evidence based medicine is in direct conflict with patients’ perception of individualized care. The vast majority of patients (not to mention physicians!) have a poor understanding of Bayesian statistical analysis or the unintended consequences of the diagnostic cascade. Add to that recall bias, the “my aunt died due to lack of test X” shibboleth, and the new (again) conceit that patient satisfaction is to be measured, rewarded and hence, curried, and “houston we have a problem”. Actually we have a dilemma. A problem can be solved. A dilemma requires a choice. In this case a choice that carries financial and medical legal consequences for one (EBM) and irrational care (patient satisfaction) for the other. Ack…

  4. Excellent piece, Dr. J. And DZA is right n in framing this. It is a dilemma with perception, economics and politics– not to mention narcissism and self-interest! –at its root rather than a mere problem amenable to solution.

  5. I would bet a lot of money that if a patient had to pay the extra cost of those tests that the argument would be solved and the patient would not have the test done.

    If a patient was given a quote on how much they would be charged, including insurance coverage, before having a test done then the problem would work itself out.

  6. Good points, and no doubt the MD is in a real dilemma. Not only because EBM is constantly evolving and changing, but it is now becoming EBPM…that’s Evidenced Based ‘Political’ Medicine.

    The real example was the finding of a year ago by a Presidential appointed group that doing mammos on women under 40 was not only ineffective but dangerous due to false positives. Well what happened? The uproar from the Komen foundation convinced the DHSS Secretary to make a statement that no women would be denied a gov’t paid mammo!

    Then four months later the same Presidential group comes out and says doing Pap smears on women over 50 is ineffective. No uproar, no demand for a free Pap test. Everyone says great study, let’s follow that recommendation.

    Why the big difference? Because breast cancer has a very strong politically connected support group, The Komen Foundation, and secondly, a half-dozen or so large companies make big bucks selling Xray machines. There’s no big influential Ovarian Cancer group, and the equipment to analyze a smear cost a pittance compared to Xray machines.

    It all comes down to an attitude of let’s cut the costs of healthcare, just not my healthcare. And the MD is caught in the middle.

  7. I cannot comment from any direct clinical connection (research/IT only here) – but as a long time patient, and evidently not the “usual” kind, I tend to refute any and every test suggested until I’ve heard very strong, clear, and convincing arguements for it.
    And honestly, they are almost never convincing to me and I almost always skip the tests. I’m 65, and have never yet regretted listening to my own self-knowledge and my own general position against testing of any sort. I have had more than one physician get irritated at me over it, and I’ve even stopped seeing one MD altogether because of his rather demanding insistence. I’ve already saved decades worth of discomfort, immense inconvenience to me and others, untold expense to myself and insurance companies, and very possibly avoided the start of some other unintended health malaise.

    One day I’ll succumb to something, but pay no attention to those who might then say “told you so”, because there is an element of gamble in all of it and impossible to be absolutely conclusive that the tests would have made a difference one way or the other. 🙂 I will still consider my extreme hesitance to undergo tests a big win for me, regardless of future outcomes.

    I’m hoping to not get ‘flamed’ for this comment, because I really don’t have any malice in it – I just don’t go along with suggested testing the way many apparently do, and say what you will, it has served me well and has saved much.

  8. Hey, Strong, not only will I not flame you, I will also suggest that you are strong in ways that most Americans are not. Your posting brings up an interesting, and tremendously challenging, issue in American culture: We’re not at peace with the idea of dying.

    In some ways, it seems very strange to be so uncomfortable with something that is inevitable and universal.

  9. I recently had an interesting experience with my parents’ former GP, who, as he ordered an odd (meaning off-label) set of medications for my dad, kept turning to me to say “I do thus-and-so for my patients, and it works, and THAT is real evidence-based medicine.”

    After the appointment my parents asked me what in the world he was talking about (he repeated this phrase 3 or 4 times).

    Unable to construct a meaningful explanation for them, I told them the doctor was making a political statement for my benefit (he was aware I work in healthcare).

  10. The argument here is really pretty simple – good doctors order tests for which they want to know the answer. Bad doctors order tests when they have no idea what the question is.

  11. I find the debate interesting, because I am firmly of two minds on this issue.

    On the one hand, I “get” EBM and support it wholeheartedly. I am often the one voice in the room asking if there’s any evidence to support something.

    On the other hand, these recommendations have two issues:

    1) They were most likely created for political reasons, intended to show that MDs can police their expenses themselves and don’t need greater regulation or oversight. Not to be cynical, but that’s the only thing that would get so many medical societies moving at the same time, and the timing can’t be coincidental.

    2) Recommendations and guidelines are NOT the same as EBM. Virtually all guidelines have an element of cost factored into them, and the calculation of when to do and not to do a particular test or intervention is normalized through cost. Just quickly glancing through the Choosing Wisely list, virtually every item focuses on reducing the use of a costly test or intervention. In many of those cases (like the EKG, for instance), there is no significant negative clinical cost to performing that procedure, so the only reason it’s on the list is cost. By contrast, looking through that I only found 2 guidelines that were on there for primarily clinical reasons (no NSAIDS in kidney dz, and don’t treat asthmatics w/o spirometry). There may be more, but it was so lopsided I didn’t bother tallying it up.

    The reality is that if we were truly patient-focused, then cost would not be factored into the guidelines and only the evidence would prevail. As it is, too many guidelines let cost prevail over patient-centered care. People who talk about it at a system level, where economics and sustainability are crucial, too often don’t take into account that in the trenches it’s one doctor and one patient, trying to figure out the best thing for that patient, and there’s a significant tension between those two sets of interests that these new guidelines don’t solve any better than the old ones did.

    As an example of this issue, what would the guideline be if there were a treatment that would cure any disease, present or future, in a patient that took it, but it cost $1M/dose, who would the guideline recommend receive it?

  12. Very well written response, DrM.

    Perhaps a hybrid approach between DrM and David above (where patient pays “overages” out-of-pocket) would solve a lot of this.

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