Dartmouth Study Looks At When Doctors And Patients Clash Over 'Unnecessary' Care

What happens when you want a test that your doctor thinks won't help? Has a national campaign against high-cost, low-value care helped physicians have these tough conversations? And what drives doctors to provide care that they don't think a patient needs?

These are the sorts of questions that researchers at the Dartmouth Institute for Health Policy and Clinical Practice sought to answer in a new study that came out Tuesday. The researchers surveyed clinicians at Atrius Health, Massachusetts' largest outpatient care provider, with over a million patients, to determine what drives physicians to order tests they don't think are in a patient's best interest, and whether doctors were interested in controlling costs.

While nearly all doctors (96.8 percent) in the survey agreed that they should "limit unnecessary tests," one in three thought that it was "unfair" to ask physicians to consider cost, and nearly one in three (30.7 percent) thought there was too much emphasis on cost. Primary care doctors were more likely to report being pressured by patients to order unnecessary tests, while surgeons were more likely to be concerned about malpractice.

Dr. Tom Sequist, one of the study's authors, said in an interview that the researchers found a big gap between physicians' desire to limit costly and low-value care, and their ability to do so.

"The thing that strikes me the most about this study is that over 90 percent of physicians said they were interested in reducing unnecessary cost, but only a third said they understood the role of cost in the system," Sequist said. "It's like saying, 'I'm really interested in physics, but I have no idea how physics works.' "

To fill the gap between physicians' knowledge about cost and desire to help control it, the American Board of Internal Medicine launched the "Choosing Wisely" campaign. The website has compiled hundreds of recommendations against "low value care," defined as care that has little benefit to the patient compared to the cost.

According to the Dartmouth researchers, there was low awareness of the "Choosing Wisely" campaign, with 59 percent overall reporting they did not know about the campaign. Of those who did, about two thirds (70.3 percent) found the campaign helpful.

The study brought back to my mind a tough patient interaction I had in my first year of residency. My patient, a Spanish-speaking man in his 50s, had seen me once before, for a routine physical. But then, a few weeks later, he returned, and I didn't know why.

After reviewing various test results, he told me: "Why didn't you check my prostate?" The man was an immigrant from Mexico, highly educated, and concerned that I had missed something. As far as he knew, a prostate exam was the standard of care for a man his age. I struggled to walk through the complex decision to not perform the test, which many medical organizations have recommended against. I found a handout, in Spanish, for him to read on the risks and benefits, and told him to come back when he'd made a decision. Then we ran out of time.

I never saw him again.

Should I have just ordered the test instead of talking through it with him? I still wonder.

The "Choosing Wisely" campaign offers four recommendations against screening for prostate cancer generally or in an elderly or sick populations. In their patient materials, they detail the risks and tell men 50-74 (the age group of my patient) to "discuss the PSA test" with their doctor. There are no materials in Spanish.

Like every test, the consequences of prostate screening are hard to know for a particular patient. Screening for prostate cancer can lead to severe infections and even unnecessary surgery, which may cause incontinence and impotence. Also, while the test itself is only around $40, if it's positive, costs and risks start adding up. On the other hand, screening does lower your risk of dying of prostate cancer (though not your risk of dying overall) and the American Urological Association says it should be considered for patients aged 55-69.

I am comforted that the authors found that my situation is not unique; nearly three in four primary care doctors reported feeling pressure from patients to order unnecessary tests. But the study doesn't address questions that linger over my particular interaction: If I deferred to his wishes and ordered the test, would I be doing my job as a physician? Did he think I was denying him care because of his ethnicity? More insidiously, since we know that physicians have strong racial biases, could cost-consciousness serve as a justification for providing less care for minority patients?

This study does suggest that physicians are more responsive to efforts to reduce unnecessary care than efforts to explicitly control cost. And physicians are not the only drivers of wasteful tests and treatments; as the authors say, "patients, regulators, and other stakeholders" contribute to the demand for low-value care. Maybe this could help reshape the "Choosing Wisely" campaign and encourage alliances with other cost-controlling efforts, but the true drivers of unnecessary care are still unknown.

I would love to have another discussion with my patient about this. If he ever comes back.