“What is the one best test?”

A test-taker’s frustration boils over as they read this prompt and think, “in real life we would do all of the above.”  And for the most part, they are correct.  In the United States, medical trainees are taught for exam purposes to answer the one best test for diagnosis or the one best procedure for management.

However, in practice the same trainees watch our role-models take a “do everything at once” approach, often just because we can.  We hear voices in a fog lamenting the problems with our broken expensive medical system, the high cost of insurance, and patients undergoing too many tests.  But often we are too far removed from the actual money exchanging hands to see the necessity in practicing cost-effective medicine.

In the United States, the Institute of Medicine, reports there is an estimated $700 billion of health care waste annually, $250-325 billion in unwarranted use, additionally, missed prevention opportunities account for another $55 billion.  What causes this disconnect from learning the right thing to do and practicing the wrong thing?  For residents, the following reasons were identified:

1. duplicating role modeled behavior
2. desire to be complete
3. pre-emptive ordering/rushing an evaluation/unnecessary duplication of tests
4. discomfort with diagnostic uncertainty
5. curiosity
6. lack of knowledge of the costs and harms
7. defensive medicine
8. patient requests
9. faculty demand
10. no training in weighing benefit relative to cost and harm
11. ease of access to services when patient is hospitalized

Over the past few years, the medical community has attempted to address these issues. Residency programs have begun to remedy these reasons through curriculums targeting cost-effective medicine.  The American College of Physicians has created a High Value Cost Conscious Care curriculum through which they hope to inspire programs to engage in cost-conscious quality improvement initiatives.

Choosing Wisely is part of an effort of the ABIM Foundation to help physicians be better stewards of finite health care resources. Many medical specialty organizations have identified five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.

The resulting “Five Things Physicians and Patients Should Question” aims to “spark discussion about the need — or lack thereof — for many frequently ordered tests or treatments.”

In my own internal medicine program, one monthly noon conference is devoted to addressing the test-by-test cost of hospitalization as teams compete to get to the diagnosis and treatment plan using the least amount of dollars.  However, it is unclear if knowing the dollar amount associated with each test can really be a deterrent to over-ordering.  After the first shock value of the cost of a basic metabolic panel, the shock wears off and the ordering of daily labs reoccurs.

“What is the one best test?” asked my senior resident during my internal medicine rotation in the Philippines regarding my patient with suspected thyroid storm. In this situation, the question became more than just an intellectual exercise as depending on my answer we would then ask the patient to hand over the cash to pay for the test. In a resource-poor setting, my patient would not be able to afford the array of tests we would order at an institution in the United States. More importantly, the tangible dollars exchanging hands was an image now burned into my memory.

Now, as a senior resident myself, I hope to role model appropriate stewardship of finite health care resources.  As I discuss my expectations with my team, I ask my interns to question what labs we order on a daily basis and I task my medical students to identifying potentially wasteful tests.  And proudly, as part of the the public health committee of the resident and fellow section of the AMA, our committee identified this topic as an important issue for medical trainees.  We challenged the participants at the recent interim meeting to identify high-value care as identified by the US Preventive Service Task Force.

The resources available to medical trainees is incredible, and often the problem in overwhelming our decision making, however the medical culture in the US is showing signs of change and I hope everyone will hear the question echo, “What is the one best test?”

Sharon Rikin is an internal medicine-pediatric resident and a member, public health committee, resident and fellow section, American Medical Association.