There are often diagnostic approaches and treatment options that result in the same clinical outcome but are less invasive. Examples include the use of ultrasound instead of computed tomography (CT) scanning to diagnose acute appendicitis in children, or the use of an oral antibiotic that has similar oral bioavailability as its intravenous counterpart. Taking time to consider the diagnostic sensitivity and specificity of less invasive tests or the therapeutic effectiveness of less invasive treatments can minimize unnecessary patient exposure to harmful side effects of more invasive tests or treatments.
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When ordering tests, it is important to always consider the diagnostic characteristics such as sensitivity, specificity and predictive value in light of the patient’s pre-test probability. Patients who are at very low baseline risk often do not require an additional test to rule out the diagnosis. Furthermore, evidence suggests that in such low-risk patients, diagnostic tests do not reassure patients, decrease their anxiety, or resolve their symptoms. Examples include the use of computed tomography (CT) scanning in low-risk patients to rule out pulmonary embolism, or pre-operative cardiac testing for patients prior to low risk surgery. Evaluation of baseline risk and the use of decision tools wherever possible, along with a ‘how will this change my management’ approach, can help to avoid unnecessary ‘rule out’ testing in patients.
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Rolfe A, et al. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med. 2013;173(6):407-16. PMID: 23440131.
Stein EG, et al. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the emergency department. AJR Am J Roentgenol. 2010 Feb;194(2):392-7. PMID: 20093601.
Patient requests sometimes drive overuse. For example, a parent might request antibiotics for his or her child who likely has viral sinusitis, or a patient might request magnetic resonance imaging (MRI) for low-back pain. Often patients are unaware of the benefits, side-effects and risks of tests and treatments. Taking time to explore a patient’s concerns, and counseling them about the relative benefits and risks of tests or treatments represents a patient-centered approach to ensuring the appropriate use of resources.
Brett AS, et al. Addressing requests by patients for nonbeneficial interventions. JAMA. 2012;307(2):149-150. PMID: 22235082.
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Schumann SA, et al. Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”. J Fam Pract. 2008 Jul;57(7):464-8. PMID: 18625169.
Smith SR, et al. Treatment of mild to moderate sinusitis. Arch Intern Med. 2012 Mar 26;172(6):510-3. PMID: 22450938.
Williams CM, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010 Feb 8;170(3):271-7. PMID: 20142573.
Unfortunately, in some learning environments, a hierarchy exists between supervisors and students that makes it difficult for students to feel comfortable speaking up. As a result, students might observe unnecessary care, but avoid saying anything for fear of potential consequences. Supervisors need to encourage students to feel free to question whether tests or treatments are truly necessary without fear of repercussion. The clinical training environment should be one where students feel safe to ask questions.
Moser EM, et al. SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve. J Hosp Med. 2015 Sep 28. PMID: 26416013.
The clinical training years in medical school represent an important opportunity for students to translate what was learned in the classroom to the bedside. This can be a challenging time of great uncertainty for students. Students may order tests excessively due to a lack of clinical experience, or recommend investigations in order to build upon their personal experience.
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A “hidden curriculum” pervasive in the academic environment encourages medical students to search for zebras through extensive (and often unnecessary) diagnostic workups. Because restraint is often discouraged, students adopt the belief that faculty expect an exhaustive diagnostic approach, and feel that they need to demonstrate their knowledge, thoroughness and curiosity through test ordering. Students can overcome this practice by articulating why they chose not to order a specific test. This, combined with a shift towards ‘celebrating restraint’ by faculty can help to combat this pervasive practice in medical training.
Detsky AS, et al. A new model for medical education: celebrating restraint. JAMA. 2012 Oct 3;308(13):1329-30. PMID: 23032547.