Sklar, David P. MD
About a year ago, I changed gyms. Every gym has its own culture; some are dominated by young professionals focused on their muscle tone and fashion statements; some promote the athleticism of the members; some focus on health, diet, and personal trainers. My new gym had a higher proportion of the “older crowd” than my previous gyms did. I got a locker in a large open area where there was a lot of traffic and conversation. Gradually I became acquainted with “the regulars,” mostly older men like me trying to maintain a consistent exercise regimen and stay healthy, but also many struggling with some chronic ailment—hip pain, back pain, tendonitis, fatigue. Among the regulars were “Jake,” a partially retired loquacious man with values and ideals still influenced by the 1960s counterculture, “Teach,” a former school teacher who remembered all the names of his former students (many of whom would seek him out for conversation and advice in the locker room), and “Glenn,” who raised organic vegetables, herbs, and chickens and made candles that he would sell out of his locker.
One day a few weeks after my arrival, they gathered around me to find out who I was. I told them my name and what I did; thereafter, I was called “Doc.” When someone had a medical problem—back pain, rash, hernia, cough—after Glenn had recommended some herbs and a diet, and Jake had shared what he knew from the Internet, they would test me out to see if my opinion confirmed what they already had decided was the answer to the problem.
One day, Jake and Teach cornered me in front of my locker as I was getting dressed. “Doc, what do think about an MRI?” asked Jake.
“Well, what would you be using it for?” I asked.
“Remember when I told you I was dizzy after my workout and you said to go to my primary care doctor?” said Jake.
Once I confirmed that, he continued: “Well, I went to my primary care doctor and he couldn’t find anything wrong. So he sent me to the ENT. And now the ENT doctor wants me to get an MRI. So what do you think about an MRI?” Now I noticed that there were several gym members, including Glenn, gathering around me, all eyeing me suspiciously, as if I had personally ordered this MRI.
Teach said: “And I am going to have to get up at 6 AM to take him there because he won’t be able to drive back home. They are giving him some kind of pill that makes him sleepy.”
“I get claustrophobic,” explained Jake. “I might have a panic attack. That’s why they are giving me the pill. But what do you think, Doc? Do I really need the MRI? They said it would rule out cancer.”
Now there were more people around me. Everyone in the locker room knew someone who had been diagnosed with cancer. Some proposed alternative diagnoses for Jake’s dizziness. One person mentioned vitamin deficiency. Another mentioned gluten sensitivity. Someone else mentioned low T.
Finally, Teach asked: “What do you think, Doc? Does he need that MRI?”
“Well, I don’t know,” I responded. “Sometimes doctors order tests to be safe even though they don’t really think you have a problem like cancer. I’ve seen you, Jake, on that treadmill. You seem to be working pretty hard, and maybe you get dehydrated and feel dizzy from that.”
“That’s what I told him,” said Glenn. “He needs more electrolytes. But he won’t drink enough water.”
“An MRI is a pretty expensive test. If you are worried, maybe you should discuss it with the doctor,” I said.
“I’m not worried about the cost. I have Medicare. But I am worried about freaking out when they put me in some little box. It’s like a casket. So what do you think, Doc?”
“Well, it sounds like you have a lot of concerns. I think you should talk to the doctor to see if an MRI is really needed. And maybe you should go over there where they are going to do the test and see the machine and try it out, if they will let you, and see how you feel.”
Everyone nodded, and Jake said: “Thanks, Doc. I think I will do that.”
As I got onto my elliptical exercise machine and started my routine, I began to reflect on that conversation. The questions that Jake, Teach, and Glenn had asked reminded me of the Choosing Wisely campaign,1,2 sponsored by the American Board of Internal Medicine Foundation. That campaign attempts to encourage conversations between patients and doctors in various specialties about potentially unnecessary tests, particularly expensive radiological studies. I suspected that an MRI for a patient like Jake with occasional dizziness after working out at the gym would probably be just such a test. Why hadn’t Jake and his doctor had a careful conversation about the need for the test, particularly since Jake had serious concerns about being able to tolerate it?
Newman-Toker et al3 describe an approach to decision modeling for dizziness that takes into account economic and patient-centered perspectives and could lead to more clarity on how to best approach a patient like Jake. It seems to me that by taking into account the patient’s risks, concerns, evidence of efficacy of the test, and costs, the physician and patient could make a decision about testing that might reduce unnecessary tests. This led me to consider how we teach our students to think about diagnostic testing in medical school and residency. Cooke4 questions whether medical education has lived up to its responsibilities to teach students about proper stewardship of medical resources. We tend to reward the students who can create an extensive differential diagnosis and name the various tests to rule them in or out. The differential diagnosis is often a good pedagogical opportunity to help students connect clinical and basic sciences concepts. However, an extensive differential should not lead to a test to explore every possibility. Some diagnoses are so rare that they should not be actively pursued unless there are some specific suggestive findings from the history or physical exam.
We rarely discuss the dangers and costs of overtesting. Berwick and Hackbarth5 suggest that between 21% and 47% of spending in health care is wasted. They identify six areas of waste: failure of care delivery, failure of care coordination, overtreatment, administrative complexity, pricing failures, and fraud and abuse. I believe that if we addressed each of these areas as part of medical education we might be able to engage our students to help reduce costs and improve the quality of care. However, we need to recognize the compelling temptation of additional data from an MRI, CT scan, or laboratory test, particularly for less experienced clinicians. Even if we included an analysis of economic and diagnostic test characteristics of the most common or dangerous conditions, as suggested by Newman-Toker et al,3 we would still have to contend with variations in experience of the clinicians.
Our current health care system has several incentives that encourage overtesting and overtreatment, such as increased reimbursement in fee for service based on the intensity of testing, defensive medicine from fear of litigation for a missed diagnosis, and the need to maximize patient satisfaction as part of payment incentives in the value-based payment programs. Sirovich et al,6 in a survey of primary care physicians, found that 42% of them felt they were delivering too much care; the main reasons were fear of malpractice, need to document clinical performance measures, and inadequate time with patients. To overcome the current incentives and create a new culture, we would likely need new models of care delivery aligned with a different set of incentives. Bitton et al,7 in this issue of Academic Medicine, describe just such a model for primary care practice and education. They recommend
(1) establishing high-functioning interprofessional teams, (2) proactively managing populations, (3) identifying and providing tailored care to medically and psychosocially complex patients, and (4) promoting patient engagement and empowerment.
It seems to me that such a comprehensive approach to education and care delivery may be what is needed to effectively change our thinking about diagnostic testing and patient-centered care.
In the meantime, I offer three recommendations that might help academic health centers to start down the road toward a reduction of overtesting and overtreatment.
First, as part of education on clinical diagnosis, we need to teach about the risks of overtesting and overtreatment as well as undertesting and undertreatment. Our current M&M conferences focus almost exclusively on the diagnosis that was missed for failure to order an additional test. We need to also present cases where patients suffered from false-positive and unnecessary tests, and need to begin to develop a balanced approach along the lines suggested by Newman-Toker et al.3 Most specialties have developed a list of procedures or tests that may not be necessary at their current levels.2 These lists and the data that support them should be a part of all residency education programs.
Second, we need to recognize and honor the communication skills required to lead a patient-centered conversation about decisions on testing and treatment, particularly when the benefits for testing and treatment are low. Such conversations should take into account the patient’s understanding of medical concepts and his or her values regarding medical care. We may also want to consider which medical student applicants appear to have well-developed interpersonal and communication skills and how we can recognize them and encourage their admittance into medical school.
Finally, we need to figure out how to best educate and empower patients about medical decision making and how they can be full participants in all phases of medical care. Patients can become expert in the treatment of their own conditions and become partners in their care as well as advocates for other patients. We are only beginning to skim the surface of this important tool of patient-centered empowerment. Academic health centers can become leaders in how to best develop the education and research in this area.
I was thinking about all of this as I exercised at the gym a few days after the conversation in the locker room, when I was approached by Jake, Teach, and Glenn.
“Well, Doc, I guess you were right,” said Jake.
“What was that?” I asked.
“I went over there to try out that MRI and I couldn’t take it. I felt like I was going to die when I climbed in there. I canceled it. I hope I don’t get cancer.”
“Oh, you’ll probably be fine. I doubt it would have shown anything,” I said.
“Yeah,” said Teach, with a mischievous look on his face, “it wouldn’t have found a brain, at least not a human brain. Maybe a dog or cat brain. I was hoping that we might find out what was in his head and why he acts like a dog. He never crosses the street at the crosswalk. He crosses in the middle just like a dog. I swear to God it’s true. Do you think you could tell if he had a dog brain with the MRI?”
“No, no. That’s the other test they give you now,” said Glenn. “It’s a PET scan. Isn’t that right, Doc? Isn’t that what they give you for that? A PET scan?”
David P. Sklar, MD