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.