4.05.2012

Questioning Medical Tests (Demanded By Patients)

How many times have you found yourself explaining to patient why a certain tests is NOT being done. 

I do this all the time. So many patients walk in the door demanding one study or another (regardless of the cost) and are offended when they are told it is not necessary. 

Some recent examples:
1) A father who came into the Emergency Department with his daughter who had hurt her ankle when she stepped off a curb. He wanted an MRI when the Xray showed that it was likely only a sprain. 

2) A 22 year old woman who saw her PCP earlier in the day for "chest pain." She was told to take Advil, but she came to Emergency wanting and EKG, CT scan and blood work. 

3) A mother who had two daughters in a car accident. While they refused evaluation and transport on scene, the came into the ED by private vehicle. I had to explain why one patient needed a head CT while the other did not. 

As you can see, some of the these cases are indeed easier than others. 

 I often have to explain the costs, risks and benefits of certain tests to patients and patient families who insisted they were not getting good care unless ALL the possible tests were done and done RIGHT NOW. 

Indeed, we often see patients coming into the ED not because they can't get into their primary care provider for their non-emergent condition, but rather, because they saw their PCP THAT DAY and were unhappy with the result. These days patients demand tests they've heard about on TV or from friends and family and they are often disgruntled if they don't get them.

Oh, and medicaid compensation is going to be tied to patient satisfaction. Just thought I'd mention that.

This week a group nine medical societies released a list of tests that doctors should think twice about automatically ordering. You can check out the lists at Choosewisely.org

Dr. Christine Cassel, president of the American Board of Internal Medicine told MSNBC and that the idea is to reduce medical costs while doing no harm to patients. They looked at the tests that have the least benefit but that are routinely ordered per course.

"We all know there is overuse and waste in the system, so let's have the doctors take responsibility for that and look at the things that are overused," Cassel told MSNBC. "We're doing this because we think we don't need to ration health care if we get rid of waste."

Moreover, the unneeded tests often cause harm -- in radiation damage to the body, or needless suffering. Some tests can prompt doctors to take invasive procedures that cause more damage to the patient than improvement. Routine PSA tests -- as reported earlier this year -- is another example. Even the researcher that helped discover PSA says that the negative impacts of the overuse and misuse of this screening tool has lead to incontinence and impotence in many men with no decrease in cancer deaths.

"I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster." Richard J. Ablin wrote in a New York Times Op-Ed. "The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments."

The problem has a lot to do with patient education. Patient education is hard because you are often telling someone something they don't want to hear. Often you are telling a patient with abdominal pain that we don't know what's causing it. Often you are telling the family member of a cancer patient that any further treatment is likely to cause more suffering without increasing any chance of survival. Sure some tests are ordered to shield doctors from lawsuits, but doctors also have long memories of missed diagnoses. They remember the one time they didn't order that one test and left a disease undetected. 

Will these new lists help? It certainly will lend support to providers who are trying to make the right decisions about what is best for patients based on science rather than social pressures. 

Yet patient education -- something the American healthcare system doesn't do very well right now -- is going to have to get better. 

Being a nurse is all about advocating for your patients. 

Yet, sometimes advocating for a patient means not giving them what they want. 

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