September 14, 2010 | 3:27 PM |

Top 10 Reasons Doctors Over-Order

FILED UNDER: Medicine/Science, Money, doctors, overtreatment

Just recently out of medical school (and the Kennedy School of Government as well) Dr. Neel Shah has a particularly keen eye for medical culture and its tendency to overlook what things cost. He founded the Boston-based non-profit Costs of Care last year to try to change that culture. We wrote about the group’s essay contest yesterday; for today, we asked Shah, currently a resident in obstetrics and gynecology at Brigham and Women’s Hospital, for his top 10 reasons that doctors might over-order tests or treatments. What do you think? Would you add or subtract anything from this list?

  1. How we’re taught: Doctors are taught to consider whether a procedure is safe and whether it’s likely to work. We’re almost never taught to consider cost — it’s considered taboo.
  2. Trying to do our best for the patient: We’re worried. Often we over-order because of our personal risk aversion.
  3. Pre-emptive ordering: For residents, who do much of the ordering of tests in hospitals, it may be more efficient to order tests now rather than later. Standard practice might be to order a relatively cheap screening test and then if it’s positive, order other expensive tests. Instead we sometimes just order everything at the same time so we don’t have to wait.
  4. Covering all bases: In medical culture, doing more is equated with being thorough. If there are five possible conditions that may explain a patient’s symptoms, and it’s probably going to be one or two of them, we might order tests for all five conditions right away.
  5. General unawareness: We just don’t know what things cost. When you talk to people and say, ‘Do you know a magnesium level is $70?’ it blows their mind.

  6. Broader ignorance: It’s not doctors’ fault for being unaware. Health care costs tend to be very opaque, and many costs are very difficult to determine.
  7. Not realizing how much setting affects costs: An MRI in an emergency room setting can be twice the cost of an MRI for an outpatient.
  8. Defensive medicine: Doctors do fear malpractice claims, but the cost issue is far more complex than malpractice alone.
  9. Patient requests: Ultimately, we believe that good doctors should be at the service of their patients. Many patients, however, are not rational decision-makers. For most people, the current status of our health distorts how we value health care. Those of us who are healthy undervalue care and are less likely to see our primary care doctor. By contrast, those of us who are sick can overvalue care, sometimes even assuming significant debt for very marginal benefit.
  10. Lack of oversight: When administrators or insurance companies impose oversight of any kind that tries to limit doctors’ ordering, everyone tends to push back. Both doctors and patients are uncomfortable with the idea of a third party deciding how health care resources should be used.
  • http://twitter.com/LIESBYOMISSION Therese Francisco

    I think they order the faster test…..time….The risks should weigh more heavily…..choosing a MRI rather than x-ray based tests….They are not worried about lawsuits…..

  • http://twitter.com/davisliumd davisliumd

    Trying to do our best for the patient. Covering all bases. Patient requests. All reasons given for overtesting, but also all within a doctor’s control not to fall for these traps.

    Doing best for patient means knowing when to ask colleagues for an opinion or a specialist (primary care or specialty care) rather than over order testing because of personal risk aversion. If you aren’t sure, ask someone who does.

    Covering all bases means the same as above. If you have five possibilities, it is highly unlikely all five have equal likelihood and weighting. If you over order now, you will undoubtedly get many false positives which require even more unnecessary additional testing and driving costs further. Anyone can order tests. Great doctors can tell what is truly needed and what tests aren’t.

    Patient requests. Patients know what they want; they want to get better or stay healthy. What they don’t know is necessarily how to get there. Do you simply order tests like MRI for knee pain or a treadmill for chest discomfort because they request it or do you evaluate them, talk them down from the request if not appropriate or needed, and focus what they really want? Yes, sometimes you need to order a test because a patient requests it. If that is the case, call out the test result before ordering it. “Yes I know that your chest pain is highly unlikely and a treadmill isn’t necessary. Because you are so worried, I will order it for you. Incidentially, it will be completely normal. Really. Completely normal. So before you leave, would you like me to treat your chest pain which is actually heartburn or would you like to suffer with your symptoms while we wait for you to get the test done?”

    I agree both doctors and patients are reluctant to have third parties determine what is and isn’t necessary. Until doctors take the charge of ordering appropriate testing (and I realize that the reimbursement structure as it stands makes it impossible to do the right thing and hence the rise of high deductibles / copays so patients now ask you if you are doing the right thing), one can only expect healthcare costs to rise and doctors to over test.

    In the end, are you (not the author of the post specifically) a doctor’s doctor, someone who is gifted and skilled enough to figure out when testing is needed and when it isn’t or are you simply ordering a bunch of tests and trying to rationalize other reasons for the behavior?

    Davis Liu, MD
    Author of Stay Healthy, Live Longer Spend Wisely – Making Intelligent Choices In America’s Healthcare System
    (available in hardcover, Kindle, and iBooks)
    Blog: http://www.davisliumd.blogspot.com
    Twitter: davisliumd

  • StopTheMadness

    Routine-many just put in reflex daily labs/tests for the entire hospital stay-it is just easier than having to do it every day.

    Ignorance of the basic physiology-many tests in a routine hospital stay are checking parameters (eg potassium, heart rate, blood pressure…..) that normally vary widely when you are at home, but when in the hospital virtually everyone seems to think these parameters must be kept within strict normal ranges-despite the fact your normal physiologic responses have coped with these variations unaided for your entire life prior to admission, and in most instances will have to continue to do so from the moment you are discharged.

    Data-free ponzi schemes such as serial cholesterol levels-once you are on the max dose of a statin you can tolerate not clear you ever need it checked again. On the other hand checking it every few months makes the patient and the doctor feel they are doing something and the insurance companies can measure it.

    A common theme is that doctors do lots of things purely because they do not have time to think-largely because they do not get paid anything to think-the one thing you really want them to be doing.

    Another issue is public lack of awareness of the potential downside associated with any (and almost every) medical intervention. As a result everyone “wants everything done” even when it is more likely to harm them than not. This is not only the fault of the profession overstating the benefits of medical intervention, it is also a result of the lack of engagement on the part of most patients in their own healthcare-partly as a result of almost complete uncoupling from market forces.

  • Mab36

    It’s odd that no one is discussing incentives here. Aren’t doctors financially rewarded for over treating or even providing unneeded treatment to patients under the fee-for-service model? I’m sure not all doctors are influenced by the money, but it has to be a factor for some, and I’ve seen studies that suggest this is actually a major cause of rising health care costs.

  • Dac

    I have a few more reasons:
    1. At times physicians order tests for no other reason than to have the information. That is, it won’t change the patient’s treatment, counseling, or behavior, but is ordered just to “have a better look” or for the sake of having more information to give the patient. It would be prudent to ask,”will it (or might it)change management” before ordering the test.
    2. We don’t want to accept that our health and lives come with a price tag. Patients whose expensive (often experimental) treatment options are declined by insurance companies understandably ask” “how can you put a price on someone’s life???” Similarly, they don’t want to hear from their doctors that care could possilby be limited by cost.
    3. As consumers we may belive that More, and More Expensive means Better. Just as a shopper may view a deeply discounted item as “cheap”, patients may view the least expensive health care facilities as having lower quailty.

  • Mfagan90

    Have have 2 more.. You don’t trust the lab results from a different facility and redo it at yours and it is part of a templated set of orders and its just ordered along with the rest of the orders .

  • Allen Bryan

    I have an eleventh reason…

    11: Double-ordering. In the age of collaborative medicine, patients are often transferred from service to service, floor to floor, hospital to hospital. Their records are supposed to follow them… but do not always arrive swiftly, easily, or in a convienent format. Masses of rubber-banded paper; bulky X-ray films; software incompatabilities… the number of ways one doctor’s test result can fail to reach the next in the chain is endless. And sometimes, doctors even know that their colleagues have ordered a test…. and re-order it anyway, because it’s easier to do the test over than find the result in the mountain of records.