Yet more on unnecessary testing

From the New York Times:

In a move likely to alter treatment standards in hospitals and doctors’ offices nationwide, a group of nine medical specialty boards plans to recommend on Wednesday that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often.

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States. [emphasis added]


The question of unnecessary testing is one I’ve raised before, and it’s one that continues to vex me.  My previous discussion, however, centered around the specific issue of tests that are deemed unnecessary by the provider but are desired by the patient.  The recommendations released this week concern the opposite: tests or treatments that doctors are ordering because they erroneously think they are of benefit or for their own enrichment.  (More on that last in a moment.)

Before I go further, I should stipulate that I am not an internist, and these recommendations were issued by the American Board of Internal Medicine Foundation regarding treatment of adults.  Outside of the occasional “Is there a doctor in the house?” situation, I haven’t laid hands on a grown-up patient since the late 90s.  Thus, my ability to pronounce of these recommendations with authority is a bit limited.  I did lots and lots of internal medicine back in school, but the more time passes the mistier my recollections grow and the more outmoded what I was taught becomes.  Make of that what you will.

That said, these recommendations seem perfectly reasonable to me.  I was relieved to see that, with one exception to be discussed below, there was nothing that had a pediatric equivalent that I order routinely.  It is high time someone started discussing the problem of over-treatment in a serious manner.  I applaud the effort.

But let’s spend a little time mulling that word I bolded up there, shall we?  “Profitable.”  Heavens!  How did that word get in there?

From the same article:

“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”

That quote makes me throw up in my mouth a little.

There is, to my mind, one reason to order a test or treatment and one reason only  — it helps the patient.  It may help in detecting, preventing or curing disease.  I have raised the question of whether it could be considered sufficiently “helpful” to order something knowing it is “unnecessary” from a strictly medical perspective but for the purpose of creating peace of mind.  (I don’t necessarily endorse that view, but think one could mount the argument.)  I can think of no other defensible reason to order something than helping patients.  “Because it profits the provider” is not even close.

Now, obviously we can’t wholly remove the potential for undue profit from medical decision-making.  If I refer a patient to an ENT surgeon for evaluation, there’s a lot more money made if the patient goes to the OR than if the doctor looks in her ears and says “they look OK to me.  Come back in six months.”  There will always be some potential for unethical physicians to recommend interventions because of financial gain.  It makes my lip curl to say so, but them’s the brakes.  However, I have long been astounded by the obvious conflict of interest that arises when physicians are allowed to own a stake in a business that provides services they prescribe.  An easy example is a radiology suite, which gives physicians the opportunity to make money from every X-ray they order.  That this happens when it seems so elementarily unethical confounds the dickens out of me.  Obviously I don’t have a problem with doctor’s offices owning some of their own diagnostic equipment (an EKG machine is fine, for example), but when you’re ordering EKGs for patients because it pads the bottom line then you’ve crossed a pretty blindingly bright line.

I should stop to clarify that I don’t think most doctors order these unnecessary interventions because it profits them to do so.  On balance, I believe that the majority of physicians are ethical professionals who are generally intent on providing for their patients’ welfare above all. Most of these needless tests and treatments are probably ordered due to a combination of holding on to obsolete clinical practices and defensive medicine.  That doesn’t make the choice to order them right, but it does save it from being contemptible.

The recommendations also include an urging to patients to question when those interventions are ordered.  Any physician who is ordering these things for a good reason should be able to explain why to the patient’s satisfaction.  Hell, even for interventions that aren’t on this list physicians should be explaining their reasoning to their patients anyway.  But knowing that these tests and treatments are often ordered for no good reason may make those seeking care (who are, much as I dislike to think of them this way, consumers after all) more savvy about what they’re getting and less credulous when the provider’s motives are shaky.

This post is already long enough as it is, but I do also want to touch on the one intervention I do order commonly that ended up on this list.

The list of tests and procedures they advise against includes… antibiotics prescribed for mild sinusitis

I prescribe antibiotics for sinus infections relatively commonly.  I would gladly stop, and if these recommendations actually have an impact and people stop wanting them I would be delighted.  The truth is that almost all sinus infections would resolve without my doing anything at all, and I’d be inclined to let them.  Why do I order antibiotics, then?  Anyone want to guess?

I order them because patients demand them.  And it would be great if they’d stop.

From a different but related piece in the Times:

While diagnosing bronchitis, a common respiratory infection, is often easy, treating the condition is more difficult. Medicines may calm the symptoms, but the only cure is time. Most notably, antibiotics, though commonly prescribed, are no better than a placebo for bronchitis. Yet discussing this can be a bit of a minefield for physicians, particularly when patients are used to antibiotics for such infections. So when I sat down to talk to my patient, I was surprised when she cut me off.

“If it’s O.K. with you” she said, wiping her nose with a tissue, “I’d like to avoid antibiotics, with all those side effects.”

I do have plenty of patients/parents who are perfectly content with avoiding antibiotics for infections that I am confident are viral.  I am genuinely grateful for them.  But I will buy you the cold beverage of your choice [note: claims must be redeemed in Las Vegas in late May] if you can find a medical provider who hasn’t tried their best to talk a patient out of a prescription for an antibiotic and failed.  Then it becomes a decision about how much you’re willing to piss off your patient in order to avoid an unnecessary course of antibiotics.  I would be lying if I pretended that I didn’t cave.  Usually I can find something to hang my hat on when calling it a “sinus infection” instead of an uncomplicated upper respiratory infection, but the cases where I’ve genuinely suspected a bacterial source are a distressingly small proportion of total antibiotic prescriptions I’ve written for same.  Feel free to shame me for my pusillanimity in the comments.

For patients to start questioning their doctors when they write out a prescription for antibiotics to treat a sinus infection would be a pretty big change from the status quo.  Which isn’t to say it wouldn’t be appropriate and salubrious to do so.  Just that I think it’ll take more than a set of recommendations to make it come to pass.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Two responses:
    “However, I have long been astounded by the obvious conflict of interest that arises when physicians are allowed to own a stake in a business that provides services they prescribe.”
    When I recommend to parents that they seek an evalutation for their child, I always advise that they use an evaluator outside of the group they would seek therapy (if deemed necessary) from, for just this reason. I also make clear that I have zero affiliation with any evaluator or therapist I recommend outside of confidence in their work and/or a good working relationship.

    However, isn’t there bound to be some cost shifting? If doctors are ordering far fewer of these high-profit tests, won’t they just seek to make up the difference elsewhere? Overall, care may improve as their are costs to tests beyond simply monies from patients or their insurers. But I don’t know that this will make a difference ultimately in healthcare costs. I thought about this when reading your posts on doctor’s notes for schools, wherein you mentioned that unnecessary visits help you stay in business. If people only went to the doctor when absolutely necessary and only pursued medically necessary treatments, wouldn’t everything just become more expensive? Or would we simply see fewer doctors in the world?

    • I have much less problem with parents/patients opting for unnecessary visits than I do with them being directed toward unnecessary care that they wouldn’t have otherwise chosen. Coming up to a holiday weekend, I’ve had a steady stream of people bringing in their kids just because they’ve had a cold and they want to make sure there’s no smoldering ear infection before they go out of town for Easter or Passover. They implicitly acknowledge that they don’t need to be there, but choose to come in for the peace of mind. I have no objection to this. They’re seeking a service, and I’m providing it, even if it’s not “necessary.”

      If I directed them to a radiology suite for a useless CT of the sinuses, that would be a different kettle of fish. If I directed them there because I owned a stake in the radiology suite, the fish in question would be rotten.

      • Russ-

        Oh, yes. I didn’t mean to conflate the two. My point was only that if we make our healthcare system more efficient and more ethical by cutting down on unnecessary visits, tests, and treatments (especially so when they are recommended by doctors to increase profits), profits will be sought elsewhere. Either that, or we’ll have fewer doctors. If a doctor stays in business by recommending unnecessary tests and then ceases to do so, he either goes out of business or increases prices elsehwere. Am I missing something?

        • I suppose it ridiculously naive for me to hope that, rather than trying to compensate for the loss of profits unethically reaped, certain doctors might choose to make less money more honestly. I do just fine without the need to pad the bill with unnecessary tests. If a practice needs those tests to stay open, then there’s something very wrong with how they’re taking care of their patients.

          • I have no idea how the health care industry works, so I defer to your expertise (my wife is a nurse but doesn’t really have anything to do with billing and all that). I assume, hopefully wrongly, that it does not adhere to the same profit motive as other industries. Of course, the need for such recommendations implies otherwise (insert obvious caveat anout broad brush strokes and the likes).

            In the event that these docs do chase the same profit margin, driving up prices, we have an ugly siuation on our hands.

          • In the event that these docs do chase the same profit margin, driving up prices, we have an ugly siuation on our hands.

            Indeed. It would be very ugly, and one I’d find particularly repellent.

          • To that end, do you find it more repellent than other industries driven solely or primarily by the profit motive? If so, why? Thanks!

          • Indeed I do. Physicians have a special responsibility to their patients, and occupy a unique position of trust. For the same reasons I discussed in my post about why doctors mustn’t lie to their patients, they must not abuse the faith their patients have in them by fleecing them.

            Other industries that are motivated by profit make their money openly. Charging patients for things they don’t need is tantamount to fraud.

          • I don’t know about New England, but in my portion of the world (Los Angeles), it is a commonplace for doctors to have an ownership stake in laboratories. And while I’m sure that these doctors think of themselves as ethical, caring, and patient-centered, they tend to do considerably more lab referrals than doctors without the ownership stake.

            Ethics is hard, and it’s just that much harder when we have a personal stake in the outcome of a decision. I’m not saying that doctors refer out lab work in direct contemplation of the extra income; but I do think that the extra income makes a doctor more likely to see merit in additional testing, prescriptions, referrals, etc. that would redound favorably on themselves.

            I’ve seen studies (which I cannot currently find on Google) that suggested that doctors with a financial stake in a lab or medical group are 35-40% more likely to refer patients for outside services. Added to which, paranoia about malpractice leads to 1.74 buttloads of extra medical expense (notwithstanding the fact that malpractice costs are less than two percent of medical spending).

            I’m not sure what the solution is, but the dilemma is real.

          • they tend to do considerably more lab referrals than doctors without the ownership stake.

            Of COURSE they do. Even if they believe their decision-making to be completely untouched by their financial well-being (a view I will charitably describe as naive), of COURSE additional testing will gain some lustre when it comes with the added plus of a few more dimes for the ordering physician.

            I have a huge problem with it. It is a flagrant conflict of interests.

          • So would you prohibit doctors from referring to entities in which they have a financial stake? Make such referrals verboten in professional codes of ethics? Or simply acknowledge a problem without necessarily proposing a solution?

          • One of the things that doesn’t get discussed enough is how much it can differ from one place to the next. When my wife was first looking for work, it was astonishing how much the pay-scale varied. There were a about three clusters. The first and largest was in the $120-180k range, the second around $250k, and then there were jobs that paid around $350-400k. Now, how do you suppose those in the second group can afford to pay that much more than those in the first? We’re talking in the ballpark of two to three *times* as much. My guess is that they have the McAllen model followed right down to the schematics (indeed, one of the jobs was in McAllen). I fear that some people look at the problem like there is a universal tendency to order an unnecessary test here and another one there. And there may be some of that. But it sure looks to me like we have certain practices and certain medical cultures in certain places that specialize in ringing up large tabs.

            (My wife took a job from the first group. It’s possible that, if she were to continue doing what she’s doing, she’d look at some in the second group. She wants nothing to do with the third.)

          • Make such referrals verboten in professional codes of ethics?

            This. I am theoretically in favor of prohibitions on such behavior, but I am also a little bit chary of the unintended consequences that sometimes redound to regulations of this kind. I’m just not strong enough on policy to support an outright ban. But I think it should be strongly, strongly discouraged within the realm of medical ethics.

          • Ah!

            I read that when it came out last year. Incipient Alzheimers wiped it from my memory…

  2. Thank you very much for pointing these out, in specific. My husband has chronic sinus infections, but doesn’t tend to get antibiotics unless they’re “really bad” (twice in ten years) — the antibiotics seem to help.
    It’s rather relieving to know that most sinus infections really should just clear up on their own.

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