Yes, Virginia, we order too many tests. And, we know it – as evidenced by such conferences on overdiagnosis and costs of care. And, even more relevant than such academic exercises, as this study indicates, even the general clinician seems to have a fair bit of self-awareness.
In this survey consisting of 435 respondents, 85% of emergency physicians believed excessive testing occurred in their Emergency Department. Most frequently, such testing was motived by fear of missing even rare diagnoses, but defensive medicine and malpractice came a close second. Patient expectations, local practice patterns, and time saving were also substantially cited as motivators for ordering. Thankfully, administrative and personal motivations to increase reimbursement were rarely reported as reasons.
Despite the protestations of some policy-makers, the clinicians surveyed believed the most helpful change to the system would be malpractice reform. Interestingly, the next ranked helpful interventions included educating patients and increasing shared decision-making. While the first item may be logistically (or politically) unachievable, there are no obstacles to integrating improved communication behaviors into routine practice. It does, however, show a need for increased availability of tools for clinicians to use at the point of care.
There are flaws in these sorts of perception-based surveys with regard to the accuracy of such anecdotal self-assessment. Physician assessment of their own practice and that of others can certainly be questioned. It must be admitted, however, a more intensive just-in-time surveying method would likely impact the variables measured.
There are also some highly entertaining outliers in Figure 2, of course, the perception of self vs. colleague ordering. There is a handful of physicians who believe they, themselves, order over 80% of their CTs and MRIs unnecessarily – but that no one else in their group does. Likewise, there is a handful with just the opposite perception – that their colleagues over-order, while they, themselves rarely do. I wonder if they work in the same department?
Regardless, first step is admitting you have a problem. We have many steps yet to go.
“Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging”
http://onlinelibrary.wiley.com/doi/10.1111/acem.12625/abstract