Improving the appropriateness of diagnostic tests

The number of diagnostic imaging tests performed on Canadian patients has been increasing rapidly in recent years.

Although the cost of each test is small, the aggregate costs add up quickly. The costs have become sufficiently large that both doctors and the government have raised questions about whether all the tests that are being performed are beneficial to patients.

At the same time, there has been growing awareness that diagnostic tests can also cause harm. Some tests cause harm directly –  for example by increasing the risk of cancer by a small amount. Other tests can cause harm indirectly, by leading to additional tests and procedures with their own costs and risks. A closer examination of the benefits and harms of testing has begun at all levels of the health system, with the goal of more appropriate use of tests.

In this article, we focus on tests that are done in response to a patient’s symptoms such as pain, tiredness or shortness of breath, and not on testing done to screen for cancer. Healthydebate has previously published several articles and blogs on the controversy about mammographic screening for breast cancer, which you can view here.

Benefits of testing

CT, MRI, and echocardiography are among the “miracles” of modern medicine. They have helped physicians make diagnoses more quickly and more accurately. They have almost completely eliminated the need for diagnostic surgery – surgery that was done simply to find out what was wrong with a patient rather than to fix a problem. Many young physicians today have never seen a patient whose abdomen was cut open solely to make a diagnosis. In contrast, 50 years ago this was common practice.

The ability to rapidly determine the cause of a patient’s symptoms is at the heart of what medicine is about. Patients can now quickly learn what they do or do not have, and subsequently receive an appropriate treatment plan for their illnesses.

In many instances, an early, accurate diagnosis leads to swifter treatment and better outcomes, such as the rapid treatment of internal bleeding after trauma detected through CT scanning or ultrasound.

Diagnostic tests can also be useful to help determine if a patient is responding to treatment, or to look for recurrence of disease. One example is echocardiography, which can be used to monitor heart failure and other forms of heart disease.

There is also important value in the reassurance that a normal CT scan can bring to patients such as those who are concerned they might have a brain tumour because they are suffering from severe headaches.

Harms of testing

It is also important to consider the potential harms that accompany testing.

No test is perfect. Some test results are “false positives”: results that suggest an abnormality even when no abnormality is actually present. False positive tests can lead to unnecessary stress and anxiety for patients.

Modern tests are not always definitive. For example, about one-quarter of CT scans of the abdomen and chest in Ontario find an abnormality which can’t be definitively diagnosed, and results in the radiologist recommending another test in an attempt to come to a diagnosis.  For example, if a CT scan shows an abnormality, an ultrasound may be recommended to characterize it better, and if a question remains an MRI might be ordered. Sometimes a more invasive test such as endoscopy, biopsy or rarely even surgery is recommended. Endoscopy, biopsies and surgery all carry small risks, which can include bleeding, pain, and infection. If all of these test lead to the definitive diagnosis of an abnormality , then all these tests were worth it. If it turns out that the original abnormality really was a false positive and was nothing to worry about, then the patient underwent a series of tests, and was exposed to their inconvenience and small risks, for no real benefit.

Recently, doctors have become more concerned about the long-term effects of radiation from CT scanning, which expose patients to low dose radiation. In younger people who undergo numerous CT scans, the amount of radiation is enough to cause a small increase in the risk of cancer decades after the scans are complete.

Costs of testing

In recent years there has been a marked increase in the use (and related costs) of several types of diagnostic tests, which cannot be accounted for by the aging of the population or new indications for testing.

One test that has seen dramatic increases is echocardiography, which is an ultrasound test of the heart.  According to data Healthydebate has acquired from the Institute for Clinical Evaluative Sciences, 652,714 echocardiograms were done by cardiologists in Ontario in 2010/11, which is about one echocardiogram for every 20 Ontarians in one year. That compares with only 361,440 echocardiograms 5 years earlier – an 81 percent increase.

The Ministry of Health and Long-Term Care spent $68 million on physicians’ fees alone for echocardiograms in 2010/11. (The Ministry pays “technical fees” as well, which are not included in this figure).

The use of many other tests, such as CT and MRI scans, has increased dramatically in Ontario as well. The increase in CT and MRI scans has been partly driven by a government focus on decreasing wait times for CT and MRI. Despite a marked increase in MRI availability in Ontario, many patients continue to wait an inordinately long time for an MRI .

No studies have calculated the costs of all diagnostic tests in Ontario, or the magnitude of the rise in costs, but the costs are large enough that the cash strapped Ministry of Health and Long-Term Care has taken notice. Earlier this year, the Ministry appointed an Expert Panel to provide “advice regarding the appropriate utilization of diagnostic and imaging studies.”

Decreasing “unnecessary” testing is not easy

The panel’s interim report states that “….echocardiographic studies carried out for inappropriate indications [should not be] paid by the Ministry.”, and suggests that a recent report from the Cardiac Care Network should be used to determine the appropriateness of echocardiography.

The CCN report lists 107 appropriate indications for echocardiography, many of which are imprecise, and lists no inappropriate indications. In many ways, this is not surprising since it is almost impossible to list every possible patient symptom for which a test like an echocardiogram is either appropriate or inappropriate.However, it is not clear how this approach will increase appropriateness.

Many tests fall into the “grey zone” of medical care, meaning that they are often done “just in case” something has been missed even though the likelihood of the patient actually having an ailment is quite low.  For example, less than 2% of CT scans done for headaches in Ontario find an abnormality that may actually explain the reason for the headaches.

At the same time, some tests are not used as frequently as they should be, or at least not in patients who need them. For example, Andrea Gershon, a respirologist at Sunnybrook Health Sciences Centre, has shown that fewer than half of adults in Ontario treated for asthma by their doctors received the appropriate test to confirm the diagnosis. The extent to which physicians make other diagnoses without ordering the confirmatory diagnostic test is largely unknown.

Can the public become more informed consumers of diagnostic tests?

According to Wendy Levinson, chair of the Department of Medicine at the University of Toronto, improving the appropriateness of testing will require changing the culture of “more is better” that is deeply embedded in health care.

Patients generally believe that more tests will benefit them, and are often not aware of the potential harms that can be associated with testing. Physicians may also be concerned that they could be held legally liable if they do not “leave no stone unturned” by ordering every test to rule out a potential problem. One approach to addressing the “more is better” culture is the Choosing Wisely initiative, which is a partnership between nine physician groups in the United States and Consumer Reports.

“The goal of Choosing Wisely is to get both patients and doctors thinking about values and risks,” says Levinson, who has been involved in launching the programme in the United States.  The hope is to improve understanding among both groups of when procedures and tests are necessary and when they are not.

Levinson believes the key to the initiative is that it targets both doctors and patients. “For patients, this is about becoming informed consumers,” she says.

To help patients, Consumer Reports has created summaries of research that are easy to understand, like this one: “Many people who experience severe headaches want a CT scan or MRI to see if they’re caused by a brain tumor or other serious problem. But most of the time neither test is necessary.”

These reports also detail the times when the tests are appropriate. In the case of CT scans for headaches, if the headaches are: sudden or explosive, different from other headaches you’ve had in the past (especially if you’re 50 or older), brought on by exertion, of if accompanied by fever, seizure, vomiting, a loss of coordination, or a change in vision, speech, or alertness.

With this kind of information, Levinson hopes patients will be able to better judge whether they should be asking their doctor for a particular test (or whether to decline a test that may be offered).

For doctors, the nine medical specialties involved have created evidence-based lists of the top five areas where unnecessary tests and procedures are likely to occur, along with a transparent methodology of how these lists were generated.

There is a combination of reasons that low yield tests are done, and decreasing their frequency is certainly no small task. While Levinson is hopeful that Choosing Wisely can help improve the appropriateness of diagnostic tests, this has not yet been demonstrated. She cautions that the culture of “more is better” did not start overnight – it has been built over decades – and so change will take time.

Diagnostic tests are both more expensive and used more frequently in the United States than in Canada.  It is also generally agreed that the frequency of inappropriate testing is greater south of the border. So, it is not at all clear what impact a Choosing Wisely approach would have in Canada, especially considering the evidence that in Canada we may be testing too infrequently in some instances.

Increasing the appropriateness of testing will require many approaches, including establishing clear criteria about when tests are likely to be appropriate and when they are not, changes to the way physicians are paid so that unnecessary testing is discouraged, better oversight of diagnostic test quality to ensure that tests are of high quality and correctly interpreted (thus decreasing repeat tests), mechanisms to electronically transfer imaging studies and results from one centre to another (also decreasing the need for repeat testing), a greater emphasis in medical training that “more is not always better” and that the costs and harms of low-yield tests are considerable, as well as a greater understanding by the public about the value, risks and costs of diagnostic tests.

Although it is clear that we have a lot of work to do to optimize appropriateness, small changes – for example a decrease in unnecessary MRIs for back pain – could start to free up capacity and possibly even decrease wait times.

Read the Toronto Star’s coverage of unnecessary testing.

The comments section is closed.

  • P.C. says:

    My radiologist is refusing to perform an abdominal MRI with contrast, here in Alberta, post vasculitis (NYD) and still suffering from stomach pain from large palpable nodules in my abdomen and all along my flanks and under my ribs with persistent and gross hematuria with sterile pyuria, even post treatment with antibiotics. This MRI was ordered by my treating physician and it was cancelled without notification to either of us. I suspect there is some conflict of interest, as the E.R. doctor who originally diagnosed my petechial rash (covering my entire abdomen and into my breasts and thighs, along with my ankles) failed to perform a punch biopsy and instead ruled my rash as a leukocytoclastic vasculitis, in spite of my palpable purpura and lack of medicines, besides Naproxen, which I ceased then but continued just prior to my dermatologist appointment months later, when the petechia had subsided. I am not allergic to Naproxen per my dermatologist and this vasculitis has forever changed my health for the worse.

    Is this permitted in Alberta?

  • P.C. says:

    My radiologist is refusing to perform an abdominal MRI with contrast, here in Alberta, post vasculitis (NYD) and still suffering from stomach pain from large palpable nodules in my abdomen and all along my flanks and under my ribs with persistent and gross hematuria with sterile pyuria, even post treatment with antibiotics. This MRI was ordered by my treating physician and it was cancelled without notification to either of us. I suspect there is some conflict of interest, as the E.R. doctor who originally diagnosed my petechial rash (covering my entire abdomen and into my breasts and thighs, along with my ankles) failed to perform a punch biopsy and instead ruled my rash as a leukocytoclastic vasculitis, in spite of my palpable purpura and lack of medicines, besides Naproxen, which I ceased then but continued just prior to my dermatologist appointment months later, when the petechia had subsided. I am not allergic to Naproxen per my dermatologist and this vasculitis has forever changed my health for the worse.

    Is this permitted in Alberta?

  • J Miles says:

    Frequently when I have been referred to a specialist, the new doctor wants tests redone by her own people. When I question this, the response has never been that the first test was somehow flawed or inconclusive. When pressed, the stated reason usually boils down to one doctor’s lack of confidence in the calibration of another doctor’s machine.

    I find this explanation vaguely unsatisfactory. Is it really true that Ontario is experiencing an epidemic of clinically significant calibration errors?

  • Malvinder Parmar says:

    The major problem is with the providers and to an extent with the receivers. Often, the providers order unnecessary tests to justify their lack of clinical skills and the reading radiologists perpetuates this by highlighting clinical insignificant incidental findings that later the physicians follow, what I call is “Chasing MIRANCaS [Multiple Incidental Radiological Abnormalities of No Clinical Significance”.

  • Shirie Leng, MD says:

    %featured%I am a physician in the US, but the same over-imaging problem exists here.%featured% There are a couple of main problems. The first is that there are either no large-scale clinical trials evaluating the benefit of imaging in various circumstances, or such research will never be done become of the scale and cost. And when such studies do exist, they are largely ignored by the practicing physician community. The second problem is litigation. A doctor who does his best to order he appropriate testing for what he/she thinks is the problem and is wrong is likely to end up in a lengthy legal battle, expensive and painful for everyone involved.

  • Barb Farlow says:

    Thank you for this very insightful analysis.%featured% From the patient perspective, I consider “economics at the decision point” somewhat akin to “bedside rationing.”%featured% In my view, this reality as you describe it is not fair. The trusting, polite patient who explains their symptoms with the belief and acceptance that their physician will act in their bests interest and order a test if necessary might be the loser. It seems that it is the squeaky wheel that gets the oil. Personally, I would prefer to be transparently given the option of paying out of pocket for a test that is fairly and transparently withheld from everyone in the same circumstance.

    • Andrew Holt says:

      No person is an island. Although we all have personal preferences we cannot escape the impact of our individual decisions on others … therefore we need to grapple with defining an acceptable balance between the millions of individual decisions that are made each day to provide health care in the best way possible. Technology changes, individuals health and social needs and preferences constantly change, new knowledge is generated that recasts old decisions, governments come and go as do the media driven political hot topics…

      Bottom-line, WE ARE IN THIS TOGETHER no matter what system is adopted so how are we going to work together to make this the best possible health system without bankrupting the government we democratically elect and put in place to (in theory) work on our behalf.

      From my vantage point the collective ways we have for evaluating population health needs, evidence based practices, shifting societal values to emphasize a more consumer oriented health care, remuneration and funding schemes along with the associated health policies and regulations all function on a much LONGER TIMESCALES THAN INDIVIDUALS REQUIRING IMMEDIATE HEALTH SERVICES AND SPECIFIC TESTS. Therefore each requires a SPECIFIC BUT INTER-DEPENDENT DECISION MAKING FRAMEWORKS.

      For example, in the absence of CT’s in ALL emergency departments in Ontario – due to the obviously huge costs and small marginal benefits relative to costs – means that medical staff ruling out head trauma must use other means to assess head injuries. Other diagnostic tests may be used to rule out sever head injuries, air/ambulance transport may kick in in remote communities to transport the person … clearly this is not a simple consumer decision available in larger urban setting where the person has time to shop around for an alternate solution.

      This points to the fact that there are WIDELY DIFFERENT TYPES OF CLINICAL TESTS AND DECISIONS … all important to the individual on a very personal level … yet simply equating this to a consumer choice for all tests OVER SIMPLIFIES THE IMPLICATIONS for the broader health system that by necessity must evolve over a longer time scale to balance the millions of individual needs, wants and preferences. Whether we like it or not we all have a large stake in ensuring that health services are available to serve both our individual needs but also those of our neighbors and neighboring communities.

      Individuals already have the choice to access a large number of private options today if they wish – particularly in larger urban centers. Private insurance policies for topping up the public health insurance is a large industry – work benefit plans, private co-payments, executive medical practices, wellness programs etc … and medical tourism to exotic destinations is an massive international market for those with the means to pay for them. The ‘silent majority’ of people too busy working to make ends meet at the end of each month and trying to ensure their kids are well fed, a roof remains over their head and they have a few dollars saved for retirement often only benefit from such benefits plans through their work. Those out of work remain dependent on the public system for all their health care. What choices do these large groups of individuals have in opting out and purchasing tests for their health care needs?

      However, the average person of average means and in need of health care must have access to high quality health care that is shown to be of benefit if we are going to be able to afford it as a society longer term. This requires that we pool our resources, undertake proper evaluations so we are not wasting resources and ensure that the standard for our neighbors is the same we seek for ourselves. The U.S. is currently struggling to move towards this type of system due to the many millions of people uninsured … see the many critiques of the U.S. health system where the number one cause of personal bankruptcy is associated with the overwhelming costs of health care, the high infant mortality rate …

      Is there a middle ground that actually works? … believe it or not the imperfect Canadian health system is seen by much of the world as such a middle of the road health system that provides ‘Universal’ health care for catastrophic events but also have various private benefits plans that fill many needs.

      Where we are seen to lag is in our underdeveloped primary and chronic care mostly provided outside hospitals – although the slower moving regulatory and funding changes are now increasingly moving to address these gaps based on longer term population view and seeing the evidence, political pressure and cost-benefit warrants such a change.

      • Barb Farlow says:

        Andrew Holt- Thank you for your very insightful comments. Indeed, resources expended on care that has “marginal benefit” is something that most would agree should not occur. I think that “benefit” is a term that must be clearly defined however as it can have subjective meaning.

        Trevor Jamieson contributed important insight into what he terms the :”micro-encounter” between physician and patient. Is it fair that abrasive, demanding litigious-type patients might receive more testing or treatment than others?

        Ultimately, I think that everyone would agree that a universal health system must be one that the public can trust. Isn’t it critical to maintain trust for the benefit of those giving and receiving care?

        To me, trust requires system wide transparency and fairness and the ability for the public to be assured that the physician is acting with honesty and integrity and in the best interest of the patient within the transparent confined of the system. .

        If tests (and perhaps other procedures) with “marginal benefit” are not going to be offered to certain populations, (the polite, trusting patient , the elderly or the disabled perhaps) would public trust not eventually be eroded if there is no transparency regarding the decision criteria?

        It might be easy to discount this suggestion when “marginal benefit” relates to very small risks, but isn’t it likely that this will change in the future as the system becomes more financially stressed?

        I think it is important to follow the pathway from policy to bedside and to be certain that all patients receive quality care whether they receive the tests or are among the ones who don’t- especially those who happen to be the 1 in 100 whose tumor was not detected or detected too late from not being tested. .

        My view is that it is not appropriate to keep the public (regardless of their economic status) in the dark because it is unfair to patients and physicians and ultimately will erode trust.

      • John G Abbott says:

        %featured%Well said. The need for transparency in clinical decision-making and the tools that support it cannot be overstated%featured% – and it works both ways as you state. More to follow I hope.

  • Renal Colic says:

    Another dimension is liability and litigation. The professionals ordering these tests are increasingly scrutinized by both patients and their regulatory colleges. In other words, the cost of missing something is huge. Here is the bind; malpractice rates are climbing, patient demands are increasing, litigation is increasing, salaries and OHIP fees are being frozen, and at the same time regulatory colleges are increasing standards and the punishments/discipline for providers who make errors. Now the government wants to restrict the tests and diagnostics that providers can order. I can guarantee you the first person that the “Concerned Patient ” will blame & sue when a tumor is missed because an abdominal CT was not officially indicated, is the provider. I’m not saying providers should be OK to order tests willy nilly but at the end of the day it isn’t the minister or his accountants that face the is personally accountable to the patient (and his lawyer and the College) when a serious medical condition gets missed because of restrictions imposed on diagnostics.

    • Barb Farlow says:

      I think you make an excellent point. If limitations or restrictions exist for ordering tests to the point that the risk of missing a tumor or something significant is greater than the risk of radiation then the patient will logically blame the doctor. That is why I believe that restrictions and limitations must be made public and recognized as a form of rationing. In this way, the physician is not to blame as long as he/she followed explicit indications for ordering tests.

  • MRT X says:

    I would like to add, if you want to get the real story on this issue, poll the people that perform the tests, ask the medical radiation technologists what they think. You will get some interesting responses, perhaps even being able to identify areas of concern for further investigation.

    • Andreas Laupacis says:

      Sorry to be dumb, but what kinds of things would the medical technologists tell us?

      • MRT X says:

        I feel there is a lot to be gained in this discussion by asking the MRT’s. Like anything else if you want to know what is really happening talk to the people at the front lines doing the tests. MRT’s know what is going on and know when and when not a test is appropriate, fustrations over abuses in the system, and frivolous orders; they have seen first hand how the system actually works.

  • MRT X says:

    Working in the field I see (and am told to do) a lot of unnessary tests. Here are some examples: Doing a nuclear medicine scan (bone scan, thyroid scan in particular) to evaluate a nodule/spot <1 cm that showed up on another examine. Nuclear medicine scans don't have the resolution great enough to see something that small so these tests are utterly useless.
    Tests are also being ordered based on how nice they look not whether it is the best test. Look up flouro cystagram vs direct cystagram. The benefit of one over the other compared to the relative radiation exposure to the patient (in most cases a young child).
    Another thing to look at is continually doing staging studies on people with very advanced cancer. We already know the cancer has spread everywhere and treatment isn't working why do we need to keep checking?
    There are also instances of tests being ordered because the physician didn't like the result of the first test. Conclusive test, but the doctor has already made the diagnosis and is looking for a test to confirm it. Sometimes they are just worried about liability which definitely needs to be addressed.
    There are so many examples of misuse of diagnostic tests that a inquiry into the matter would probably make the public surprised. In an era of cost continament something has to be figured out to proved the best most cost effective treatment to patients.

  • Jeremy Petch says:

    I agree Wendy – you might find this interesting:

  • Wendy Ungar, Technology Assessment at Sick Kids (TASK) says:

    One contributing factor is lack of price awareness. A simple first step could be to start printing the charges associated with tests, and the technical and proessional fees that are paid, right on the requisition so that physicians and patients alike can see them. Unless tests can lead to improved patient outcomes, their ordering should be reconsidered.

  • Concerned Physician says:

    The idea of decreasing unnecessary testing is a good one. However, the Ministry has recently slashed funding for MRI operating hours across the province as part of its cost containment strategy. The idea that wait-times will improve is wishful thinking if operating time for MRI machines are reduced concurrently with de-listing of certain indications.

    • Andreas Laupacis says:

      I have asked two chiefs of radiology in Toronto hospitals if they are aware that the Ministry has slashed fudning for MRI operating hours, and neither of them had heard of this (either have I). Can you point us to where this has happened?

  • John G Abbott says:

    This article is both timely and informative; as well, it complements a September 2010 report of the Health Council of Canada entitled: Decisions, Decisions: Family Doctors as Gatekeepers to Prescription Drugs and Diagnostic Imaging in Canada. Like your article, we raised the spectre of too much testing with some of the contributing causes and potential solutions. Look forward to more on this topic.

  • Barb Farlow says:

    “The costs have become sufficiently large that both doctors and the government have raised
    questions about whether all the tests that are being performed are beneficial to patients.”

    I am perplexed by the confusion of issues here.

    Is the assessment of benefits and harms of testing dependent on the costs of the tests? Do rising costs actually change the risk of certain tests? Or is it the case that emphasizing the harms of testing helps the public to swallow what is really the bitter pill of rationing?

    • Andreas Laupacis says:

      Thanks for appropriately pointing out the ambiguity of our writing!

      I think there are a few things going on:

      1. Many more diagnostic tests are being carried out than before – because their overall costs are now quite large, that means that the payer (the Ministry of Health, but ultimately the citizens of Ontario) is not unreasonably asking what that increase in cost is buying, in terms of better patient outcomes.
      2. You are right to imply that rising costs do not change the risks of tests. However, if more unnecessary tests are being done, and they are associated with risks (either from the test itself or from subsequent investigations of false positive results), then more people are exposed to the risks. Of course, more people are able to benefit from necessary tests as well.
      3. One thing we didn’t have space to cover in the article is whether the charges for conducting tests in Ontario are reasonable. The amounts charged for tests in Canada are, in general, lower than the charges in the USA. However, I know of no good studies that have compared the charges for tests in Canada with charges in other countries, or studies that have tried to determine whether the “professional fees” that doctors get paid for reading the tests, and the “technical fees” that are paid to actually conduct the tests are a true reflection of the resources consumed to conduct and interpret the tests. If anyone out there knows that information, I’d love to hear about it.
      4. Finally, if some tests are not going to impact care or management in a meaningful way, then I think it is reasonable to say that the costs of those tests are not justified and they should not be conducted. If that is rationing, that’s a rationing I am willing to live with.

      • Barb Farlow says:

        I understand your points Andreas. I believe there are two issues here and that it is important not to confuse them.

        Should the risks and benefits of any test not be discussed between patient and physician as part of the process of informed consent? I would hope that most physicians in Ontario are aware of the risks of radiation and presently have the appropriate discussion with patients. If not, then an awareness campaign should occur related to the risks, but not the cost.

        If the majority of physicians are aware of the risk and are ordering tests appropriately, then it would seem likely that the greatest components of rising costs relate to demographics and/or changes in disease. If policy makers impose limitations or a risk threshold on ordering tests then the justification should transparently be stated as rationing. I believe it is misguided and disingenuous to tout these limitations by over exaggerating risk of radiation or by proclaiming that most of the time the test finds nothing. Isn’t it the nature of testing that (hopefully) most of the time nothing will be found? The two patients in 100 for whom something was found would surely have something to say about whether testing is a waste of money.

        If limitations in testing will be implemented, (and I think it will likely be necessary) I believe it is important to make them clear and transparent to the public. What indications are necessary to order tests? Will certain testing be withheld from certain populations on the basis of a QALY analysis?

        Transparent guidelines would allow patients the liberty of going elsewhere at their own expense if they choose. Moreover, physicians, acting within a transparent standard of care would be absolved from risk taking and the burden of bedside rationing and thus be better able to focus on the best interests of their patient.

      • Trevor Jamieson says:

        If you want to truly reduce the number of unneeded tests, you have to change the economics at the decision point to order or not; economics here is in the broad sense of costs/benefits (not just financial).

        I’m not sure that considerations distant from that individual encounter (like the broader costs to the system) are ever really going to change the micro-interaction.

        What does change the micro-encounter is:
        – the degree of negativity towards the physician for saying no
        – the likelihood that a no will result in an extended visit that causes other patients to be angry and the MD to stay late
        – the likelihood the person just comes back the next day and it’s deja vu all over again
        – the fear (real or perceived) of litigation
        – the fear (more important) that you’re ignorant about something and that you may be missing something catastrophic or that your patient is the “exception to the rules”
        – the likelihood that the person just goes somewhere else to get the test anyway
        – the likelihood that there will actually be a measurable direct downside to the test (i.e. death)
        – financial incentives (whether they are in favor of ordering if someone has a stake or whether they promote not ordering)

        Overall, I think that people are trying….and that many ordered tests are because there is someone who is ill in your office and you’re not entirely sure that they aren’t an exception.

        The pretest probability of porphyria is never high enough to justify testing for it….yet there are people who have it.

        If out of 1000 unnecessary tests, only 1 finds something important….well…how do you know that person in the office isn’t the 1?

        Probabilities are great for populations….but individuals either have something bad or they don’t. Putting everyone with CAD on a statin saves society lots of money, but if you’re the individual patient who ends up with renal failure from rhabdo, that hardly means anything to you.

        I think patient or individual centered care will only make these costs more challenging. I think we love to believe that people are highly rational and are going to hear informed consent and just go “Oh, in that case…no….no test”….but, well, that’s not really true. They might say “do it anyway” and, as the risk of missing something by not testing is not zero, that’s kind of their perogative.

        There are broader educational things as well: there are drug ads that tell people they likely need something…where are the ads that tell them they likely don’t? MDs don’t have time do to 100% of the educational piece….the government has to take up some of that mantle.

        It’s the micro-interaction that must be targeted…both the physican, and perhaps more importantly the patient and broader societal, factors.


  • Dr Charles Wright. Chair, Ontario Health Technology Advisory Committee (OHTAC) says:

    This is an excellent and very timely contribution. In many fields of health care and in many jurisdictions the appropriateness of some services is being questioned. The Ontario Health Technology Advisory Committee has established, with the support of a wide range of stakeholders including the professions, government and managers, an “Appropriateness Working Group” that is now busy working through a long agenda of health care services about which the question of appropriateness has been raised. This committee and the assigned staff at Health Quality Ontario work strictly on the basis of transparent evidence that can lead to recommendations to the ministry, the professions, the health care system in general and indeed to the general public. It is interesting to note that many of the topics that have been suggested for examination are related to tests and diagnostic procedures as discussed above in this HealthyDebate article.

  • Concerned Patient says:

    Have you been to the emergency department lately? The emergency doc has chest xrays and CAT scans ordered by the nurse before the emerg doc sees me. Once the tests are done he spends 10 seconds with me. The heaviest use of these diagnostic tests are in the emergency room where every patient gets a test before even seen by a doctor.

  • Perry Brodkin says:

    I trust that one of the six health care topics to be covered will be Medicare outside Canada.


Jeremy Petch


Jeremy is an Assistant Professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation, and has a PhD in Philosophy (Health Policy Ethics) from York University. He is the former managing editor of Healthy Debate and co-founded Faces of Healthcare

Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

Emily Latourell


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