Monday, May 9, 2011

Tales from the Representative Assembly II - Appropriateness of testing

A story in today's Star-Phoenix about possible overuse of CT scans in kids reminded me of some more discussion from the weekend's RA.

One doc spoke about his frustration in not being allowed to order certain tests for his patients, specifically CT scans.  In some health regions, only "specialists" can order CTs and MRIs.  Rationale: reduce overuse/misuse.  Side effect: delayed diagnosis for patients.  He felt that he had been practicing for long enough that his clinical judgement should be trusted.

The next doc to speak told the RA that it was nearly impossible for him not to order certain tests or treatments because patients demanded them.  He gave the example of PSA for prostate cancer screening in men aged 80 and over, multiple repeats of cholesterol testing, and antibiotics for viral infections - all of questionable value.  If he didn't order the test, then they would be angry at him, and just see another doctor to get them done.  

The juxtaposition of these views was puzzling.  On one hand, docs are feeling powerless to refuse requests from patients, even though their clinical judgement tells them the testing is not helpful.  On the other hand, docs are making a case for broader privileges to order more expensive, possibly risky tests.

I think these are different sides of the same clinical problem:  appropriateness.  Tests and interventions may be underused (insufficient use of a test that has been proven to be beneficial, like cervical cancer screening), but most inappropriate use falls into the category of overuse (like the CT scans in the SP article).  The restrictions to ordering CT scans that the first doc complained about are in place to reduce inappropriate testing.  Even with long years of experience behind him, I doubt that even the most clever doc would consider himself up-to-date on the indications for CT scanning in all subspecialties.  And, given the second docs comments about the pressure felt to acquiesce to patient requests for testing, we can expect that opening the CT floodgates would, in fact, bring a flood. 

So, how can we assure appropriate testing, based on best practice, yet allow timely access for patients?  

We can't all be experts, but we can have access to expert opinions.  But, rather than having family docs call up specialists to get "clearance" to order certain tests, there are clinical decision tools.  The Ottawa Ankle Rules are an example of validated guidelines that reduce unnecessary testing without negatively affecting outcomes.  Similar guidelines could be developed for situations that commonly lead the primary care physician to consider whether a CT scan is indicated.  If the guidelines/clinical decision tools were agreed upon by GPs, relevant specialists and radiologists, then patients could get the appropriate study done promptly without the wait and expense of seeing a specialist first.

Would docs feel it was an insult to their clinical acumen if they had to use a clinical decision tool?  No, they would understand the importance of appropriate decision-making for the benefit of their patient, and would not let misguided professional pride get in the way.  A well-crafted set of guidelines could also be a valuable educational tool for the second doc who was frustrated with patient "demands" for testing.  While he may feel he doesn't have enough time to give a thorough explanation of why he recommends against certain testing, he could send the patient home with the guidelines and ask them to reconsider after studying the expert opinions.


  1. Thanks for the post on 'appropriateness' - a timely issue in health care at the moment, particularly for diagnostic imaging. I think what you are referring to in your blog post when you speak of a 'well-crafted set of guidelines' is something the Canadian Association of Radiologists has already been working on for a number of years. As it states on their website 'The CAR has developed Diagnostic Imaging Referral Guidelines to help physicians order the most appropriate and effective diagnostic imaging procedure for specific clinical circumstances.' (These guidelines can be downloaded from their website.)Not only have they worked on developing these referral guidelines, they have undertaken pilot projects to test the impact of implementing the guidelines into electronic order entry systems to facilitate their uptake by physicians by incorporating them more seamlessly into physician workflow. The results have been interesting. I don't work for the CAR but I have followed their work on this over the past few years and I think any of your readers interested in the concept of guidelines for diagnostic imaging ordering may wish to look at the work that the CAR is doing in this area.

    Thanks again for your thoughtful look at access related issues. It is always interesting to see your take on various issues.

  2. Hi Kishore,

    I am new to Saskatchewan and find your blog very interesting. I am glad to see you playing a role of change leader.

    I searched briefly, but could not find, your contact detail!

    Is there anyway to send you an email or to share some ideas?

    Many Thanks,

  3. Thanks, everyone, for your comments and encouragement. Please email me at I look forward to sharing ideas with you.