When patients demand tests and prescriptions, doctors should think twice

As an infectious-disease specialist, I often see patients who complain of a headache, nasal congestion and short-term fatigue. There is no fever or cough, and it appears the problem is sinusitis, which requires no further testing or treatment. But when I say, “Let’s wait and watch,” many of my patients seem disappointed. In some cases, it seems they are satisfied only if I prescribe an antibiotic or order a blood test or X-ray.

I understand where they are coming from: I often feel similarly let down when I take my daughter to the pediatrician for an earache and leave without a prescription for an antibiotic.

When we go to the doctor, most of us want something done, even if the benefits are questionable or marginal. Both parties are at fault: Many patients demand tests, and often doctors encourage them. How much excess care is being carried out is debatable, but some studies indicate that nearly 30 percent of U.S. health-care expenditures are unnecessary. That would be $700 billion of waste each year.

Choosing Wisely, a new campaign supported by several professional medical societies and consumer groups, is encouraging doctors and patients to kick this habit — to curb the overuse of tests and procedures, including the prescription of antibiotics and imaging studies for sinusitis within the first seven days of symptoms.

In April, the ABIM Foundation, which is affiliated with the American Board of Internal Medicine, published a list of 45 overused tests and procedures, including routine electrocardiograms during a physical and imaging studies for back pain.

The compilation was sparked by a 2010 article by medical ethicist Howard Brody, who called on physicians in every specialty to think about five overused procedures and offer “a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.” Nine professional societies helped assemble the list and are helping shape the Choosing Wisely campaign.

The ABIM Foundation has also joined forces with Consumer Reports to conduct a marketing plan that includes posters, videos and brochures. Like the recent CDC campaign to improve hand hygiene in hospitals, Choosing Wisely aims to first increase awareness, then change attitudes and finally change behavior. Using the playful slogan “When to say ‘whoa’ to doctors,” the materials offer patients a guide to common tests and encourage them to ask questions such as “What happens if I do nothing?” Some hospitals are reinforcing the message to doctors through screen savers on their computers and e-mail reminders.

As a doctor and, at times, a patient, I can appreciate the need for Choosing Wisely. I often come upon situations where the doctor-patient encounter feels like a push-and-pull dance, with both partners leaning toward overtreatment. As patients, we push for more tests, genuinely fearing a debilitating or fatal illness such as pneumonia, cancer or heart disease. Some of us do not understand that more testing can be harmful due to radiation, medication side effects or a spurious lab finding that begins a cascade of unnecessary and invasive diagnostic tests.