The topic of unnecessary medical testing comes up all the time in the health care reform debate and is a recurrent theme in news headlines.
Study finds that unnecessary tests ordered in 43 percent of checkups – CBS News
$700 billion each year is spent on unnecessary medical tests – Healthcare Economist
Why doctors order unnecessary tests – KevinMD (with some excellent insights)
Millions squandered in unnecessary tests ordered in routine doctor visits – Medical News Today
The Cost Conundrum – New Yorker article by Atul Gawande
Even this month’s Night Shift column in EP Monthly details a family discussion about unnecessary medical testing and health care reform.
The term “unnecessary testing” is on its way to becoming the new “death panel” of the health care reform debate. But just as the term “death panel” was disingenuous, the term “unnecessary testing” is ambiguous.
What exactly is an “unnecessary test”?
Perhaps an unnecessary test is a stress test that has little predictive value in determining death from heart disease. A study of 25,000 men who underwent stress testing showed that in ten years only 158 men died from heart disease. Stress testing was normal in 40% of the men who died. Is stress testing “unnecessary”?
Perhaps an unnecessary test is one that has a low likelihood of showing a positive result. Spontaneous carotid artery dissections occur less than 1 in 34,000 individuals. Maybe we shouldn’t be performing all those expensive magnetic resonance angiograms on patients who have headaches or neck pain. After all, a vast majority of the tests will be normal.
Personally, I think that the term “unnecessary testing” is a misnomer. To me, the term “unnecessary” means that there is absolutely no likelihood that a test will find or exclude a disease process and that there is absolutely no likelihood the test results will change the patient’s proposed treatment — like performing saliva screening for food particles. A majority of tests aren’t really “unnecessary,” they just don’t show abnormalities very often.
Everyone is quick to criticize the necessity of a negative test after it has been performed. What about a prospective look at the testing?
A more appropriate term for testing considered by some to be “wasteful” should be “low-yield testing.” Sure a vast majority of “low yield” tests will be normal, but if you perform enough low yield tests, you will eventually find something wrong. The outside chance that patients may have an uncommon disease picked up by an “unnecessary test” is one of the biggest reasons why low yield testing is performed.
Failure to perform low yield testing serves as the basis for many medical malpractice lawsuits. Regardless of how rare the disease is, a common question raised by malpractice plaintiff attorneys is “What would it have hurt to just do the test?” That question is followed by some iteration of the statement that “if only that horribly negligent doctor had just ordered the simple test on this patient, Little Johnny wouldn’t be an orphan.” During closing arguments, some attorneys can even channel voices from beyond to prove their point.
If we all agree that “unnecessary testing” is such a bad thing, what tests are we all going to agree that doctors should stop ordering? Give me a list of unnecessary tests that I should no longer perform and I’ll follow it. No more wasteful MRIs for back pain? Sign me up. No more CT scans for the patient with chronic abdominal pain? I’m all for it. PET scans? Outta here.
Maybe we could use percentages instead. If a test has less than a “Y” percent chance of showing an abnormality, then it will be considered “unnecessary” and will not be performed. Now go ahead and define “Y”.
We’ll save millions … no … BILLIONS of dollars.
But here’s the catch … if we stop performing all of the “unnecessary testing”, then there will be an increase in the number of patients whose medical problems will go undiagnosed. So don’t blame me if things go wrong.
If I stop ordering things on your list of “unnecessary tests,” then you can’t hold me responsible if you have a bad outcome because you didn’t get the “unnecessary” test. You can’t complain to the hospital administrators that the mean doctor didn’t order the seventeenth CT scan for you chronic abdominal pain. You give up your right to sue because the doctor missed a heart attack for failing to perform the “unnecessary test” that had less than a 1% chance of catching your heart disease. Sucks that you happened to be in that “less than 1%” category, but “unnecessary” is “unnecessary.”
Many people want extensive testing done to diagnose their problems, but few want to dole out the cash for others to have that same testing. Adding to the problem is that doctors have no incentive to stop performing low yield testing, yet can incur extensive liability if a rare disease is missed.
So Mr. Obama, Congressional Counselors at Law, esteemed colleagues, and distinguished guests, here’s how to solve the problem of “unnecessary medical testing”:
- Stop throwing around the phrase “unnecessary testing” until you define the term. If you continue to use this term ambiguously, you’re being intentionally disingenuous and your arguments about how such testing is ruining our health care system are suspect.
- Don’t retrospectively wag your finger at me and tell me I shouldn’t have ordered that normal test. Grow some gonads and give us prospective examples of “unnecessary tests” that doctors should never be ordering. I’m waiting to be enlightened.
- Make it very clear to the public that a reduction in “unnecessary testing” will invariably reduce the number of tests performed, but it will also invariably increase the number of deaths and bad outcomes from failure to diagnose uncommon diseases or uncommon presentations of common diseases. Are we going to swallow the “red pill or the blue pill“?
- Fix the medical malpractice system so that doctors aren’t threatened with professional sanctions or financial ruin if they don’t perform “unnecessary testing” or you will never achieve your goal. When doctors are faced with a decision between protecting oneself from being sued for millions of dollars and advancing a government goal to reduce health care spending, lawsuit protection will win every single time.
Now … when we’re done debating this, do we get to talk about other “unnecessary” government expenditures?