December 11th, 2013
Making Value-Based Decisions About Ordering Tests
Paul Bergl, M.D.
Every day, piles of money are spent on needless tests and treatments in training hospitals and clinics.
As Dr. David Green reported this week in NEJM Journal Watch, the American Society of Hematology is the latest society to comment on appropriate and cost-conscious care in the ABIM Choosing Wisely campaign. I’ve followed the Choosing Wisely campaign closely and have been using it on the wards and in clinic as academic ammunition. A specialist society’s public advice about showing restraint is an excellent means to challenge the dogma of our so-called routine practices.
I know every conscientious practitioner has struggled with the high price of medical care. Our training environments are currently breeding grounds — and battlegrounds, for that matter — for ideas on how to solve our nation’s cost crisis. I have often wondered how we might change the way we train our residents and teach our students to exhibit financial diligence.
Of course, we are all part of this economic mess, and residents rightly share some of the blame. As naïve practitioners who lack confidence in diagnosis and management, residents tend to overorder and overtreat. I certainly have checked a thyrotropin (TSH) level in the inexplicably tachycardic hospitalized patient, despite my own knowledge that it was probably worthless. And I’ve seen colleagues get echocardiograms “just to make sure” they could safely administer large amounts of IV fluid for hypovolemic patients with hypercalcemia or DKA. When residents don’t have years of experience, they use high-tech diagnostic testing as a crutch.
Then again, the expectations of the learning environment also contribute to the epidemics of excessive echocardiograms and needless TSH levels. First of all, trainees are expected to have their patients presented in neat little bundles, devoid of any diagnostic uncertainty. Additionally, they have been trained through years of positive reinforcement for broad differential diagnoses and suggesting additional testing for unsolved clinical problems.
Although the Choosing Wisely campaign speaks to me and many of my generation, it is only a start. It alone cannot stand up to the decades of decadence and our culture of waste. How can we encourage trainees to truly choose wisely in the training environment? I propose the following:
- Deploy pre-clinical curricula that emphasize value-based medical decision-making. As much as students lament the breadth and depth of their curricula, pre-clinical students have fresh, open minds and are actually receptive to learning about cost-consciousness. We cannot expect that the curricula in residency or CME efforts will have an effect on our cost-ignorant model of care.
- Include cost-conscious ordering and prescribing in our board examinations. I have seen some change from when I took the USMLE Step 1 in 2008, but I notice that clinical board questions still usually ask for a “best next step” that usually doesn’t include “expectant management” as an option. As trainees prepare for these exams, they develop a line of thinking that then permeates clinical practice. When patients with chronic musculoskeletal complaints and unremarkable radiographs are referred for MRIs rather than receiving reassurance, we can put some of the blame on our licensing exams.
- Reward trainee restraint. Residents and students should be commended for not working up insubstantial problems, withholding unnecessary treatments, and showing prudence in choosing diagnostics. Again, our educational constructs are to blame, because we reward expansive thinking and “not missing” things. In morning reports and other case conferences, we often praise residents for adding another diagnostic possibility rather than exhibiting “diagnostic restraint” or cost-conscious care.
- Give trainees some sense of the cost and price of tests and treatments. The literature has not consistently shown that giving physicians cost or price information will prevent wastefulness. But as far as I know, these studies have focused on clinicians in practice who are wedded to their ways. From my experience, trainees thirst for this type of information. Frankly, we are all clueless about how much a chest CT costs. How much was the machine? Are there separate bills for the scan and for the radiologist’s interpretation? How much is the patient expected to pay? What will insurance pay?
- Get leadership buy-in at academic centers. I am neither a healthcare economist nor a chief financial officer. But my experience as a chief resident has taught me that buy-in from the academic leadership is necessary to turn the tide on monumental tasks.
6 Responses to “Making Value-Based Decisions About Ordering Tests”
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Very important article and set of goals. You must though put into your concerns of Malpractice. The attendings who are hearing the presentations from the “cost conscientious practitioner ” may be thinking if we don’t get that test and the patient has a bad outcome, some other practitioner is going to accuse me of being negligent and if I had only ordered that test, the adverse outcome would not have occurred. In order to become “cost conscientious practitioners” there must be tort reform. Without that , your hopes of changing practice will NEVER happen.
THE MOST WISE COMMENT///AXIOM THAT I HAVE HEARD AND FOLLOWED ABOUT “Screening tests”===
“All laboratory data not indicated IS abnormal”
Ain’t it so??? and off we go doing un-needed tests to see why that
“not indicated test” was abnormal. This is why Medicare stopped paying
for the 26 test screen of the 1970-1980s (only cost $100 but the axiom held
true way too often).
I really like these recommendations. Please also include the recommendation (that was taught, although not practiced nearly enough, during my training in the early 2000s) to ask oneself before ordering any test or study, “Is there something I would do differently based on the results?” Even inexpensive tests should be avoided when they aren’t likely to lead to any change in patient care. patient management.
Dr. Paul Bergyl’s five proposals make sense for all clinicians, not just residents in training. He really gets to the essential principles around the Choosing Wisely campaign: Awareness of cost and the need to shepherd valuable health care dollars, diagnostic restraint, considering the value of a test before ordering it, trusting our clinical skills vs over reliance on modern technology. The sustainability of our health care system depends upon this kind of a paradigm shift.
I was an international medical graduate resident (IMGs) at the University of Toronto, Canada. In Canada, IMGs (i.e. those who did their undergraduate medicine outside Canada) are treated differently from Canadian graduates even after finishing a Canadian residency, so an IMG always feels ‘different’. It is not hard to become defensive in such circumstances. During my cardiology rotation, we had started a patient on heparin and his CBC showed a drop in hemoglobin. My main concern was a GI bleed. The patient had fallen on the way to bathroom the night before and had a bruise over his lower back, so the other concern was a retroperitoneal bleed. I checked stool for occult blood to make sure there is no GI bleed and a repeat hemoglobin to see if the drop is continuing. If hemoglobin remained stable, we didn’t need to do anything. The next day at the round, our staff shamed me in front of the whole team for “not caring enough for the patient” and having a “narrow differential diagnosis”. For example, he thought, I should have done a reticulocyte count for hemolytic anemia. He ordered a senior to take over the patient’s care from me. Several unnecessary tests later, a retroperitoneal bleed confirmed by a CT scan of abdomen and pelvis was the only abnormal finding to explain the drop of hemoglobin and because there was no further drop in hemoglobin and no symptoms from the bleed we did nothing further. The even changed my practice, however. It is hard to be shamed in front of your colleagues, particularly if you already have a different label of IMG and different rights. The incident is still affecting my practice and I am sure I sometimes broaden my differential diagnosis just to be safe.
In the ‘International’ non-Canadian University, where I was thought undergraduate medicine, there were four approaches to patient care: Bayesian, Algorithmic, Physiological and Differential Diagnosis. The differential diagnosis approach constitutes considering anything and everything that can cause the symptom, however unlikely, and test for all of them. It is an important approach, but it is economically justified only in certain cases. Routine use of this approach is one of the reasons for high price of medical care.
I read with interest your comments about the Choosing Wisely campaign.
I run a consulting/training company that talks about this very issue of ensuring that physicians are taught to order the appropriate test at the right time. I teach sales reps who promote their labs in the community. I tell them they should be demonstrating how to save healthcare dollars through the use of their lab services (algorithms, interpretive reporting, newer sensitive/specific tests, etc).
I tip my hat to those of you who are on a similar mission within medical school confines. Unfortunately, field reps from labs don’t always have access to residents/fellows; they try to see them on the “outside” after they establish a practice.
Peter Francis