Rational test ordering in family medicine

It is typical in medical teaching to start an article or talk with a case.

What is not typical about about this Canadian Family Physician (CFP) article, written by Australians Drs S Morgan, M van Driel, J Coleman, and P Magin, is that the case is not meant to teach us how to do something. It is meant to challenge us, to teach us how NOT to do something.

When a 'routine annual health check' involves non-evidenced tests, and abnormal results are found, it leads to further testing; anxiety and other harmful effects of the testing cascade or treatments develop. This is the problem of overtesting and overdiagnosis.

It is best to not order irrational, unjustified tests "just to see" because there are harms of "just seeing." If you order enough tests, there will definitely be abnormal findings, many of which are spurious or clinically insignificant.

Many of those reading know this problem, but we are not always sure of the solutions. Morgan et al suggest and expand upon these mitigating steps:

  • Undertake a thorough clinical assessment
  • Consider the probability and implications of a positive test result
  • Practise patient-centred care
  • Follow clinical guidelines or seek other specialist guidance (*my caveat: if the guidelines are reasonable, free of industry bias, and appropriate for the patient in front of you)
  • Do not order tests to reassure the patient
  • Accept a degree of uncertainty
  • Use serial rather than parallel testing
  • Reflect and critically appraise test ordering

I like the list as it challenges some myths, like "ordering the test will make the patient feel better." Many of the drivers of overtesting explained here overlap with the Contributing Factors piece I'm working on, though I'm inspired that perhaps "taking time" (using a longitudinal relationship to slow down, to do serial testing, etc.) may need to be added to the list.

View the article in the CFP to read more.

Source: http://www.cfp.ca/content/61/6/535?etoc