The discourse on the problems of the modern healthcare system contains much vitriol and blame. There is a distinct flavor of adversarial combat in the discussion; pitting physicians, those in the trenches, with those politicians and lawmakers on the other side. With estimates of healthcare costs exceeding 15% of the gross domestic product of the United States, it is easy to understand the passion that the topic evokes. The complexity of the problem resists simple solutions. There is no Occam’s razor that can cut through the debate and illuminate the way forward.
So often, when the topic of unnecessary medical testing arises, it is a further demonstration of this antagonistic relationship inherent within the debate. Doctors, the prevailing wisdom goes, are forced to order all of these tests because of the legal climate we practice in. There is little room to walk to your car at the end of a shift with all of the lawyers that are roaming the landscape. This would seem to be a contradiction to everything already stated — that one easy problem in the healthcare quagmire that begs an easy fix. If only there would be regulation and caps on malpractice and torts, unnecessary testing would be largely fixed. With the full realization that the plural of anecdote is not data, let me argue for a different point of view.
The prevalence of electronic medical records, or EMRs as they are commonly known, has lead to an unprecedented ease in procuring a medical test. With a flurry of right clicks, I can order a full battery of tests feeling secure that I will get to the bottom of this patient’s ill humors. But is this a good thing? Is the convenience of having the thyroid-stimulating hormone test right below the complete blood count and the complete metabolic profile a benefit to our patients and our overall system? Regardless of clinical indication, I can cast as wide a net as possible in order to snare that zebra fish. Keeping in mind the danger of specifics to illustrate the general, let me discuss a few recent examples that came up during my own clerkships.
A patient recently came into the inpatient psychiatric ward with multiple delusions. Most pertinent to this discussion, this patient was convinced that she was pregnant. When a patient states they believe they are pregnant, we do not often paint this as a delusion. But with this patient, who was a male-to-female transgender, it was biologically impossible. Presented without further discussion on rounds, her belief was immediately labeled a delusion — and rightfully so. But against all sound reasoning, a pregnancy test was ordered. When asked, the attending would say that it was to reassure the patient; when pressed further, it was admitted that it was just easier to order the test than it was to have to really get to the bottom of this delusion.
This extreme example illustrates our own blame within the system. Many times we protest that we are ordering these tests we know to be unnecessary to escape the specter of some legal action. Perhaps there is sometimes a more innocuous explanation. Namely, it is sometimes just easier to click “order.” Faced with increasing time constraints, growing patient lists, and the demands of multiple responsibilities, ordering a test means little to me in terms of real opportunity cost. When I am presented with a menu of options for the latest and greatest in medical testing, I do not see the associated costs of ordering that extra anti-nuclear antibody test. With these costs hidden from my own sight and mind, it is often easier to order the test, but that says nothing about whether or not it was right to do so.
Corbin Rayfield is a medical student and can be reached on Twitter @CorbininChicago.
