I was working a shift in our freestanding emergency department (ED), seeing a bounceback patient with worsening abdominal pain. During her visit two days ago, she had decided to hold off on imaging in lieu of watchful waiting, but now she had returned with worsening RLQ pain, and we had made the decision to get a CT scan. As I went about my usual routine of running the board, I noticed she still hadn't gone for her CT, despite it being ordered about two hours earlier.
We weren’t particularly slammed that day, so I called over to radiology to get an ETA. The CT tech informed me that I hadn’t ordered a urine pregnancy test, and that was why they had not come to get her for her scan yet. Despite my protesting that she had a documented negative pregnancy test less than 48 hours ago, it was hospital policy that a new test be ordered since it had been more than 24 hours since her last visit. What should have been a quick visit turned into a half-day mess, all because of an arbitrary policy that is part of a much bigger problem in the world of defensive medicine we all practice in the US.
Waste in healthcare is like an Amazon box. The tiny thing that you needed, surrounded by a bunch of bloat that you didn’t. We are all guilty, because we all do it. Reflexive daily labs because more data equals better care, right?
Fear of missing something drives illogical protocols based on highly unlikely clinical scenarios, or massive overcorrections due to a sentinel event. Patients are transferred from an outside facility with a full workup, which we then go and completely repeat; because who is going to trust the diagnostics of a different hospital? This kind of overuse is everywhere once you start looking for it.
Some of it is driven by patients' expectations and the transactional nature of our healthcare system.
I was seeing a young healthy male in his 20s for what was surely viral gastroenteritis. Other than his episodic scromiting, he was otherwise well-appearing with stable vital signs. I ordered my usual cocktail of Ondansetron and a bag of Ringer’s, along with a CBC, a BMP (+Mg of course), and a lactate. I gave my attending a quick rundown as we crossed paths in the hallway. He nodded in agreement, but then asked me why I was ordering the labs.
“Are you worried he has an AKI? His vitals look good, he's not tachycardic, and his pressure is perfect. Do you think labs are going to change anything about your plan?”
In a moment of reflection, I couldn’t think of any reasonable problem I was expecting to find in his blood tests. I was reflexively ordering basic labs because it's just what we do. It's part of the transaction that patients expect. Part of the visit must include me looking intently over his benign labs as I reassure him that all is well.
I confessed to my attending that I didn’t really need the labs, and I would cancel the orders. The thing was, we weren’t really even that busy. There were still a few open beds and a totally manageable number of boarders, with an almost empty waiting room because it was still early in the shift. But to my attending, the census never dictated the care. Whether we had 2 patients or 200, his clinical decision-making process was always the same. An unnecessary CBC and BMP only added maybe 20-30 minutes to a visit, but multiply that by X patients per day, and now you are looking at very real impacts on throughput.
He was a great attending, trained at a busy level 2 where the EM residents ran the ship. He had a mantra to always “practice how you play,” and part of that meant being a good steward of tests and resources. You never know when the waiting room is going to blow up, so having confidence in your clinical skills and gestalt is the greatest tool an EM clinician can have. The foundation of emergency medicine as a specialty centers around the specific skillset of caring for the undifferentiated patient.
The consequences of over-testing have a much bigger downstream impact than throughput. Increased testing often leads to additional follow-up imaging, invasive procedures and increased healthcare costs, all without clear improvement to patient outcomes. The phrase “just to be on the safe side” means something very different when the “safe side” means painful and invasive testing at a high financial and emotional cost to patients.
MDcalc is probably one of the most-used medical apps on my phone.
Whether it's Wells, PERC, HEART, or one of the many great tools Canadians have given us, I try to reach for a clinical decision tool whenever I can to help decide whether a lab test is really necessary. I usually go through the decision tool with the patient so they can see where the information is coming from and get a small insight into what a clinical decision tool is and what it means. It takes a few more minutes up front, but I do think it's had an overall net positive impact on my productivity.
Now obviously we can’t rely on clinical decision tools for every decision. I have personally seen two people close to me almost die from a sinus venous thrombosis. I also fully admit that I have ordered a few CT venograms on patients because of it. Clinical rationalization and gestalt will always have their limits, and gray areas will always exist.
Whenever a learner or new grad is struggling with a decision about a test or treatment, I ask them one question: “Are you going to worry about this on the drive home?” I call this the driveway test, and it’s a simple yes/no. If you are going to be sitting in your driveway with regret, then it's time to stop overthinking it and order the test. I've definitely been there, logging into the EMR on my day off to see if the patient ended up as a bounceback.
We all order “routine” labs when they really aren’t needed for a variety of reasons. In the end, it's usually because we want to take good care of our patients and avoid the risk of missing something. Unnecessary testing is deeply ingrained in medical dogma, and it's a hard habit to shake.
Check out this clip below from a September episode of ERcast: Clinical Perspectives to dig deeper into the issue of unnecessary testing with Dr. Tiffany Proffitt and Dr. Manny Singh.