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

Just One More “Noninvasive” Test…

"Just one more." You never know what a test could lead to if you don't discuss it with whomever is ordering it. Why is it being ordered? What are the risks? Are there any alternatives?

Marilyn Bauriede, a retired attorney in California wrote about her personal experience with this phenomenon. Making decisions as to 'what to do' when offered options is hard. It's harder still when both the disease being tested for and the test itself can be harmful. In this case, there was a question of heart disease, but it would have to be justified in view of the radiation of the test (cardiac perfusion, AKA MUGA) and contribution that might have to an increased risk of cancer.

Hmmmm... what to do? Lately we've been learning that cardiac catheterization is performed on a lot of people who don't need it, and stress tests might not be as accurate or important as once thought. Heart disease is scary, but some of the tests are invasive, risky, and (for US patients or for Canadian Tax Payers) expensive. Plus, they might lead to MORE tests!

. . . That’s when a light bulb turned on in my brain, as I recalled the cardiologist telling me there was a 70% chance the perfusion test would reveal nothing at all wrong, or at least would not show artery blockage. I thought, “There’s way better than a 50% chance the test will find me heart healthy.” Even my PCP had said the ECG and stress test were not very accurate. That would mean they might have been wrong. And if that were the case, then having the perfusion test would needlessly subject me to health risks and no clear benefits. I needed to put the brakes on to more testing and seek a second opinion.

It's interesting to see from the patient perspective how the facts and uncertainties are explored. Ultimately, the situation was resolved because of a good connection with a physician, a thorough review of history and past tests, and probably a bit of wisdom from patient and doctor alike.

Read more in JAMA.

Source: http://archinte.jamanetwork.com/article.as...