Why There Are No Such Things As Unnecessary Tests

My wife is a family doctor working in a small rural practice owned by a regional hospital. While she has not yet been sued for malpractice she knows many doctors who have, and while the vast majority of these suits never reach court they still inflicted many sleepless nights and higher malpractice premiums on the innocent doctors. She recognizes that everything she does may have to be justified someday so that if she is forced to testify she can explain the rationale of her treatment. This is the essence of defensive medicine.

The American Board of Internal Medicine Foundation in partnership with Consumer Reports has announced Choose Wisely, an educational initiative recommending physicians avoid 45 unnecessary tests and procedures the group believes are performed unnecessarily. These include routine EKGs and Stress Tests as well as prescribing antibiotics for minor ailments such as mild sinusitis. Oncologists are also encouraged not to perform cancer screens on breast cancer and prostate cancer patients diagnosed with non-metastatic forms of these cancers.

But as the New York Times article states, these recommendations are controversial and there is fear among some patients and doctors that they will be applied too broadly. The newspaper quotes Dr. Eric Topol, chief academic officer of Scripps Health who says, “These all sound reasonable, but don’t forget that every person you’re looking after is unique…This kind of one-size-fits-all approach can be a real detriment to good care.”

As a resident of the great state that raised John Edwards to the heights of power on the backs of doctors he sued for malpractice, I’m skeptical over this recommendation for a number of reasons. Dr. Topol makes an excellent point. Those who aren’t health care practitioners may fail to understand that patients often do not present with clear cut symptoms. There is a finite number or reasons your car won’t start in the morning such as the battery is dead, the tank is empty or the ECM needs replacement. But the human body is infinitely more complex. What may present as back pain from too much Pilates can turn out to be bone cancer that had metastasized from the esophagus, as happened to my father-in-law. The chronic tickle in the back of the throat that drove my mother-in-law crazy for months, turned out to be an atypical and rare form of breast cancer. Both were dead within months of their initial complaints both were misdiagnosed by their primary care physicians, though it is unlikely in either case the proper diagnosis would have mattered much. But both cases of cancer could have been treated had they been detected early. Obviously doctors cannot perform these tests on everyone because it would take too much time and cost too much, but this decision should be left to the judgment of the doctor and not interfered with by the government, an insurance company or a non-elected body such as the American Board of Internal Medicine Foundation.

These recommendations will no doubt be cheered by insurance companies and the government (since Medicare, Medicaid and Obamacare make the government a de facto insurance company I’ll lump it together with the likes of Kaiser Permanente and Blue Cross for the rest of the article.) Insurance companies can now refuse to pay for these tests or at the least requiring doctors jump through time-consuming and money-losing hoops such as requiring pre-authorization to do them. The article claims that as much as 1/3 of the $2 trillion spent on health care in the USA is unnecessary, so imagine the savings to their bottom lines these companies will enjoy by cutting nearly $700 million from their payments. The problem with this figure is that it’s like the old saying about half of marketing dollars being wasted, but no one knows which half. Because it is impossible to accurately determine which person needs a test and which doesn’t it will be impossible to reap the savings hinted at in these recommendations.

Doctors are taught the cliche, “When you hear hoofbeats, think horses, not zebras.” The problem is in the real world zebras aren’t limited to the Serengeti, they are mixed in with the horses here. And doctors are blind. The practice of medicine remains an art where such non-quantifiable processes as “intuition” still play an important role. A doctor might be presented with a healthy young man in his prime with no signs of heart problems, but something might trigger his intuition to call for an EKG. While rare, young people do make the headlines when they drop dead of cardiac arrest caused by a previously undiagnosed heart condition. The physician suspecting he might have a patient with an undiagnosed heart problem will have to fight to get the insurance company to pay for the EKG, skip the EKG and console himself that the young man is healthy, or do the test for free.

Imagine the doctor finds himself in the dock, facing an attorney hired by the family of his patient. “Why didn’t you do the test, doctor? It’s a simple test you could have performed in your office that would have saved the life of my client’s son. Yet you didn’t. Why?” The American Board of Internal Medicine Foundation will not be on the stand, the doctor will, and parroting off the American Board of Internal Medicine Foundation’s recommendations will not play very well to the jury.

So to avoid that possibility, the doctor will either have to fight the insurance company to pay for the test or will have to perform it gratis. Either way the physician is the one left bearing the responsibility for these recommendations. And 99% of the time the doctor will find that the patient’s heart is fine, in which case outside groups like Consumer Reports will wail about unnecessary tests. But the doctor knows that without tort reform she must do everything to protect herself including ordering tests which may seem considered medically unnecessary but will protect her in court. The tests might be medically unnecessary but until there is tort reform they will be legally necessary and will continue to be performed.

No TweetBacks yet. (Be the first to Tweet this post)

32 Comments

  1. Ken Mueller:

    You do mean “as long as there is no tort reform there will be unnecessary tests,” right?

  2. Scott Kirwin:

    Ken
    Revised the ending for clarity.

  3. NavyOne:

    Ah, my father was a doc and faced this sort of bs. It is a sad state of economic affairs when half your salary goes towards malpractice insurance. We need tort reform, bad. . .

  4. Watcher of Weasels » Watcher’s Council Nominations – Buh Bye Rick Edition:

    [...] of Exclusion The Mellow Jihadi – Female Gun-blogger Gets Angry at Bill Cosby The Razor – Why There Are No Such Things As Unnecessary Tests Rhymes With Right – A Study In Moral Obtuseness Honorable MentionsModern Sojourners – Dads [...]

  5. This Week’s Watcher’s Council Nominations | therightplanet.com:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  6. This Week’s Watcher’s Council Nominations | therightplanet.com:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  7. John:

    What do you call 10,000 lawyers at the bottom of the sea?

  8. Watcher’s Council Nominations…Buh Bye Rick Edition | Sago:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  9. Watcher’s Council Nominations – Buh Bye Rick Edition | Independent Sentinel:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  10. Mary B:

    Tort reform is not enough. Americans need to take more personal control of their health with better food choices, more exercise, and less alcohol, tobacco, etc. And I’ve seen what fee for service reimbursement mentalities (think Medicare) does to the practice of medicine. My nonogenarian parents get more tests/MRIs/CAT scans than they need because the providers can charge for more codes to make up for the shrinking reimbursements. Reducing reimbursements only drives up the number of procedures done.

  11. Trevor Loudon's New Zeal Blog:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  12. Buh Bye! |:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  13. Drama:

    Good post, I think it makes sense for doctors and patients to have a totally formal, strictly business, butt-covering relationship. Let the government take over so we don’t have to hold anyone accountable at all anymore.

  14. Watcher of Weasels Nominations – Buh Bye Rick Edition | Maggie's Notebook:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  15. Scott Kirwin:

    John
    A blessing?

    Mary B
    GPs or Primary Care Physicians make the lowest money yet incur the same “overhead” (student loan debt, practice costs, malpractice insurance, etc). So you make a good point. I would then say that the procedures are necessary to pay the physician’s salary, and honestly, there are much better ways of doing it.

    Drama
    We already have it. It’s called The UK.

  16. Watcher of Weasels » The Council Has Spoken!! This Week’s Watcher’s Council Results:

    [...] serious about controlling the riding costs of healthcare.This week’s winner,The Razor’s Why There Are No Such Things As Unnecessary Tests examines this from a physician’s viewpoint. Here’s a slice:My wife is a family doctor [...]

  17. This Week’s Watcher’s Council Results | therightplanet.com:

    [...] week’s winner,The Razor’s Why There Are No Such Things As Unnecessary Tests examines this from a physician’s viewpoint. Here’s a [...]

  18. Weasel Watcher’s Council Results Are Up! | Independent Sentinel:

    [...] week’s winner,The Razor’s Why There Are No Such Things As Unnecessary Tests examines this from a physician’s viewpoint. Here’s a [...]

  19. Trevor Loudon's New Zeal Blog:

    [...] week’s winner, The Razor’s Why There Are No Such Things As Unnecessary Tests, examines this from a physician’s viewpoint. Here’s a slice: My wife is a family doctor working [...]

  20. Shayne:

    “A doctor might be presented with a healthy young man in his prime with no signs of heart problems, but something might trigger his intuition to call for an EKG.”

    This happened to be 1o years ago. I wasn’t feeling well, and hadn’t for a few weeks. But since I had a history of stomach ulcers, my doctor refused to rule in anything that didn’t contradict his initial diagnosis. Unfortunately, the very next day, I suffered a massive heart attack (I was only 39 years old). Because the damage done to my heart by the heart attack, I ended up with a heart transplant (following an unsuccessful bypass and subsequent 4 week coma). Thankfully, I am doing very well today. However, how much money, time and effort could have been saved in the doctor worried less about the cost? I tend to believe that had he ordered a stress test and then an angioplasty, I would not have needed a whole new heart.

    My fear with ObamaCare is that since I already cost Medicaid over $1,000,000 – what are the chances they would rush to my side again, if G0d forbid I get sick again?

  21. The Council Has Spoken!! This Week’s Watcher’s Council Results | askmarion:

    [...] week’s winner,The Razor’s Why There Are No Such Things As Unnecessary Tests examines this from a physician’s viewpoint. Here’s a [...]

  22. The Council Has Spoken!! This Week’s Watcher’s Council Results | Sago:

    [...] week’s winner,The Razor’s Why There Are No Such Things As Unnecessary Tests examines this from a physician’s viewpoint. Here’s a [...]

  23. vinny:

    Shayne, it is difficult to say what would have happened. You may have had a heart attack during the stress test and it would have likely been the same. I have even had the experience of sending a patient for a heart catherization, and he had the complication of that catheter causing a clot and wound up being operated on, undergoing emergency bypass grafting, and eventually wound up with a weak heart. The initial catheterization only found mild disease but the procedure itself caused an acute heart attack. As far as ordering unnecessary tests…if a doctor really believes they are not necessary, he/she will likely not order them. I often order tests looking for conditions that are rare, but need to be excluded as possible causes of symptoms. In each case, I firmly believe that my request for the test is justified and necessary. Policy decisions are sometimes based on studies that were never meant to be applied to the groups of people, these policies affect. Tort reform is the only path that makes any sense when it comes to bring down healthcare costs, but Tort reform requires going against American Trial Lawyers…good luck with that.

  24. GayPatriot » Watcher of Weasels Winners (Tax Day Edition):

    [...] Due to my family and alumni responsibilities, was unable  to vote this week in the latest Watcher of Weasels contest, so haven’t had a chance to read many of the posts, so here are the winners.  Among members of the Council, The Razor took the gold for Why There Are No Such Things As Unnecessary Tests. [...]

  25. The Council Has Spoken!! This Week’s Watcher’s Council Results - 4-13-2012 | Virginia Right!:

    [...] week’s winner,The Razor’s Why There Are No Such Things As Unnecessary Tests examines this from a physician’s viewpoint. Here’s a [...]

  26. Bookworm Room » What I’m reading right now — cool Watcher’s Council stuff:

    [...] The Razor – Why There Are No Such Things As Unnecessary Tests [...]

  27. The Quadfather:

    Even if the doctor was running the test to protect himself from a lawsuit, he is acknowledging the fact that the condition being tested could actually exist. After all, if it never happened, there would be no case for a law suit, would there? After all, when you receive a test, and it comes up negative for disease, you feel like the test was unnecessary. But was it? How do you know beforehand what the test will reveal until your doctor runs the test. Then, is that not the whole point of the test? To find out? How do you find out without running the tests? The point is, you can’t. That is why the doctor should be the only one to determine what tests shall be performed. The insurance company should pay for whatever is ordered, tests, medicine, procedures, what ever. That’s what they are being paid for.

  28. lee:

    The single thing that could reduce medical costs the most is tort reform. One of the reasons it gets harder and harder to find an ob/gyn (even if all you will need is the gyn) is because of the costs of malpractice insurance and litigation. (Thank you, John Edwards.)

    Sometimes the diagnosis is zebras, but thanks to ineffective cost cutting measures, the people with zebras will probably die before they get diagnosed.

  29. Late Tax Day |:

    [...] *First place with 2 1/3 votes! The Razor –Why There Are No Such Things As Unnecessary Tests [...]

  30. The Council Has Spoken!:

    [...] *First place with 2 1/3 votes! The Razor –Why There Are No Such Things As Unnecessary Tests [...]

  31. Bookworm Room » Last Week’s Watcher’s Council Winners:

    [...] *First place with 2 1/3 votes! The Razor –Why There Are No Such Things As Unnecessary Tests [...]

  32. The Razor » Blog Archive » The Council Has Spoken: April 13, 2012:

    [...] Council: The Razor –Why There Are No Such Things As Unnecessary Tests [...]

Leave a comment