Reducing Unnecessary Procedures is Not as Easy as it Seems!

By | March 5, 2019
Shared decision making

With the initiative of Choosing Wisely, which was introduced to the healthcare community in 2012, there has been an intentional focus on decreasing unnecessary testing such as CTs, MRIs, and labs. Superfluous medical treatment, tests, and procedures lead to not only increased cost, but also the potential for higher incidents of unintended harm. Incidental findings frequently lead to further testing, patient worry, and risks resulting from possible interventions. Moreover, on an individual level, these events might have a low probability of occurring, however, when one considers the actual numbers involved, unequivocally harm happens.

With this push, primarily there is a focus on merely educating the physician and outlining the problem. However, numerous factors influence the potential of testing. For instance, physicians focus on ruling out specific issues that might be occurring as we are trained to create a differential diagnosis. Simultaneously, society also demands health care providers to “Make sure I do not have something bad.” Frequently there is a discussion of symptoms from a perspective of “This is what we now know it is not” versus, “This is the likelihood of what it is.” Since people are relational by nature, accompanied by their inherent desire to rule out what might be occurring, inevitably overutilization occurs. Further amplifying this situation is the desire for a strong physician-patient relationship and the disassociation of the consumer from the cost of treatment in our present insurance model.

In order to bring attention to the matter, many suggest devising general campaigns geared towards consumers, which is also fraught with similar dynamics, could be the answer. However, the solution, like most, is multi-pronged. Understanding the relativity of harm requires education beginning in medical school. Furthermore, a discussion concerning the pre-test probability of finding a cause for a complaint versus an incidental finding requires a sound grasp of knowledge when one contemplates offering a differential diagnosis.

From a consumer perspective, having a better understanding of the impact of testing from both a diagnostic and cost perspective is imperative. Moreover, shared decision-making requires the sharing of information as well as creates a space for conversations. For these to be effective, these must occur at a point of care when the testing is going to occur rather than through a general sharing of information. Without contextualization of the information to the individual or situation, it is difficult for them to understand the data.

Many human learning and teaching techniques aid in such communications. Flow charts, clarifying questions, speak back techniques, asking what the patient is most concerned about, are all such methods.

Thus, if we are to increase the value as well as decrease harm, addressing overutilization is imperative. Let us better understand the problem at hand and design interventions both on the provider and consumer side to create a bigger impact.