201606-Lean-thinking-medicine-doctore-Poll: Overdiagnosis and Over-testing

Q: How do clinical guidelines or other reputable consensus statements affect your discretionary powers to make decisions for patients?

Increase my powers                                                        49%

No effect                                                                          25%

Decrease them                                                                 15%

Uncertain                                                                          11%

ED: The big unanswered question is whether increased discretion is applied inside or outside guidelines.

Q: Will most patients accept advice from their doctor to ‘wait and see’ when exploring a problem?

Yes                                                                                   64%

No                                                                                     28%

Uncertain                                                                          8%

ED: We suspect this figure would if increase if patient moiety payments increased.

Q: Do you think diagnostic tests are over-used?

Yes                                                                                   81%

No                                                                                     11%

Uncertain                                                                          8%

Comments

We asked doctors to comment on the issue of overdiagnosis, from their own perspective…

Legal issues overrule

“The issue of litigation by patients and the powers of the medical board in favour of patients and demonising doctors drives over-diagnosis through investigations.”

“No one will take me to court for over investigating/over-diagnosing. But who will defend me for the perception that I have under-investigated and not gone to the nth degree to solve a patient’s issue? We are all working under a cloud of fear generated by the threat of litigation as well as a fear of missing a diagnosis for our patients.”

Patient-led diagnosis

“Patients should have a co-payment that would sort out unnecessary tests.”

“Many patients wish for a simple “cure” and want lots of test done to find the “reason” for the problems they have. They read the internet and come to their own conclusions.
I find the best way to deal with them is to listen, examine them properly and then ask them what they think is wrong. Unless you know their agenda you cannot get anywhere. If they are not happy they simply go somewhere else. I will be happy when patients have to pay for pathology etc and even happier when results are available on their digital health record.”

“Most patients don’t care about guidelines and evidence-based medicine. They just want to be made better – now. Hence, over-servicing and over-investigation.”

System control

“Ambulatory endoscopy at Osborne Park Hospital has outstanding forms to complete for assessment of patients for gastroscopy and colonoscopy. If the criteria are not met, the patient is not accepted. I suggest that this model be modified and applied to pathology tests and imaging requests as well.”

“The more experienced we are, the fewer tests required.”

“Not enough time for risk/benefit counselling and pre-screening. “

Down the chain

“Every month the kidney team demands bloods be done on their patients as well as three-monthly bloods for chronic disease management. The rheumatic heart team all want their patients rounded up and echoed etc as well as the leprosy people wanting theirs dragged in for biopsies and not forgetting the orthos wanting everything x-rayed and CT’d and the urologist wanting sequential multiple PSAs and the antenates, all their bloods and scans and whoops. What about all the STI screens because all our patients are high risk.”

“The ability of other health professions to request diagnostic tests is of concern, and these are often done before I get to see the patient for the first time and results are not shared. Of particular concern is the easy availability of x-ray imaging to chiropractors and physiotherapists, often unnecessary or inappropriate and raises the concern of radiation dose to patients.”

“Specialist groups widen their criteria for diagnosis within their own area, which leads to increased drug use and cost without concern for all the other specialty groups doing exactly the same. There is therefore an increase in the drug burden and risk of interaction for the individual, and a colossal increase in cost burden to the PBS. This is particularly true in the elderly. The actual evidence base for most guidelines is almost non-existent for patients over the age of 75, often excluded from randomised trials on the basis of age. The art of the GP is to treat the patient, and avoid iatrogenic hospital admissions, despite the guidelines. This is why every jurisdiction which has more specialists than GPs have worse population outcomes for higher overall costs.”

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