Is Less Really More?

The smart folks at the American Board of Internal Medicine Foundation have published an additional 90 procedures (to the 45 that they listed last year) that they feel are overused and often times unnecessary. This is part of the Choosing Wisely initiative to encourage patients to ask more questions about the tests that they are having and the reasoning behind it.

Unfortunately, we have become a test-happy medical society in the US and the reasons for this are myriad. Firstly, old habits die hard. Doctors in a given specialty see similar diagnoses and have been doing the same testing routines for years. It is difficult to get physicians to change their diagnostic/therapeutic habits when they have been doing it with success for eons.

Secondly, medicine is a business. And for doctors, it has not been a very good one of late. Reimbursement rates for everything from office visits to echocardiograms have plummeted and physicians are not immune to the squeeze of earning less money for the same amount of effort. Already, we are beginning to hear murmurs of doctors objecting to answering phone calls in the middle of the night when they're not getting paid for it. This used to be part and parcel of being a "patient of the practice" but this old style of long, personal relationships with your physician is waning. Five years ago less than 10% of all cardiologists were employed by a hospital and as of 2012, more than 60% of US heart doctors have some formal business relationship with a hospital system. Healthcare providers are having to see more patients in less time and modalities like telemedicine, pharmacy consultations, outpatient phone calls and remote monitoring will become more and more important in the years to come.

Finally, many tests and procedures are done for fear that the doctor may miss something and pay a much steeper penalty than wasting a few health care dollars on a test. Most patients that come in to the ER with chest pain can very readily be diagnosed with a good history and physical. Heart attack symptoms can be tricky but there are some universal features that put patients at higher or lower risk. However, the fear of missing any diagnosis, no matter how unlikely prompts serial blood draws, CT scans, stress tests and increased length of stay. Attempts to lessen the threat of lawsuits and financial demise from medical management have been met with a great deal resistance and so doctors will consider doing CT angiograms of every young woman who presents to the ER with shortness of breath and happens to be taking oral contraceptives - even if they have a very low likelihood pulmonary embolus.

Initiatives like ChoosingWisely.org are a great start in changing the consensus opinion of how patients should be managed and allowing the doctors who choose not to over-test to fall back on educated and validated medical opinions confirming that sometimes a good history and physical in addition to carefully selected testing (or perhaps no testing at all) is the best thing that can be done.

If nothing else, a perusal of this list of overused and over-ordered tests can give you good reason to ask your physician more questions about exactly why they are ordering the test and what will change as a result of the outcome? Is the test safe, what are the risks? The ChoosingWisely website also has answers to specific questions like 'Do I need a Chest XRay before surgery?' and 'When do I need a stress test?' It is a very worthwhile stop on your Internet travels so give it a read and take more control of your medical care.