Will it change our management?
The most important question for doctors and patients
I was a resident when I was first asked some version of, “How will it change our management?” I thought it was a brilliant question, as it gets to the heart of both clinical reasoning and acknowledging that we can do many more things than we should. At some point, I got tired of the question. It had begun to sound empty to me. A crutch for those who didn’t have much to add to management discussions. I have now come full circle. In an era when too many people mindlessly defer to guidelines, when excessive care threatens both the health of our patients and our economy, when many doctors seem overwhelmed, and when many patients (unknowingly) are seeking more, rather than better, care, we can not ask the question enough.
In medicine, there is no reason to perform a diagnostic test if it has little to no chance of changing management. Such a test only exposes a patient to a risk of harm and the system to increased costs. Recently, I’ve prevented evaluations or referrals so often by asking this question that choosing a few to recount is difficult.
You are admitting this patient with an abscess for intravenous antibiotics. How will checking non-specific inflammatory markers (ESR, CRP) change your management?
This patient has declined statin therapy for primary prevention for years. Their LDL has always been about the same. How will checking a lipid panel change your management?
Your patient with diabetes has good blood pressure control on an ARB. How will checking their urine microalbumin change your management?
Clinically, this patient has mild intermittent asthma. You have their symptoms under perfect control. How will PFTs change your management?
Wait – I can’t stop. Let’s turn to patient requests.
I know you have an essential tremor. I have a plan for first-line (and even second and third-line) treatment. Seeing a neurologist will not change our management.
Clinically, you have a viral upper respiratory tract infection. There is no reason to test you for flu, COVID, and RSV. The results of the test will not change our management.
The treatment for your sciatica is time and physical therapy. I know exactly what an MRI will show, and nothing I would see on an MRI would affect our management.
We do not need to check your thyroid function again. You have been gaining weight steadily for 4 years, and we have checked your TSH twice.
Your ASCVD is 12%. You are on a statin. You feel good and exercise regularly. A CAC will change nothing.
An unnecessary diagnostic test or unnecessary referral represents low-value care. overuse. So why does this happen? I once heard a talk in which the lecturer attributed all overuse to stupidity, cowardice, or greed. This is a little harsh, but not too far off. Sometimes people are lazy, finding it easier to order tests than to think about the diagnosis. The thinking goes: abdomen pelvic CTs usually give me the diagnosis in people with abdominal pain, it is easier to just order one than to think about what diagnosis is most likely in this patient and, therefore, what evaluation makes most sense.
Sometimes it’s not laziness but a knowledge deficit or lack of experience. The doctor might not know that this presentation of abdominal pain is classic for cholelithiasis or that the test of choice to rule in that diagnosis is a right upper quadrant ultrasound. When the problem is a lack of knowledge, then asking the question will not help.
Sometimes the question is asked and answered, but the overuse still takes place because the doctor is overly cautious and inexperienced. “I know cholelithiasis is the most likely diagnosis, I know an ultrasound is the test of choice, but I am not confident enough to know that the CT will not change my management. Maybe I am wrong.”
This is where the question and diagnostic calibration overlap. Diagnostic calibration is the relationship between diagnostic accuracy and physician confidence in that accuracy. In general, a physician with a low level of confidence in his or her level of diagnostic accuracy will overtest, whereas an overconfident physician will under-evaluate patient concerns. I published a paper on diagnostic calibration and medical errors in 2017. It is one of my favorite publications of my career.
I’ve come full circle on the importance of, “Will it change our management?” Almost like a surgeon’s time out, doctors should pause before ordering any test or making any referral and ask the question. If the only honest answer is, “I don’t know,” it’s probably time to grab a colleague or do a little reading. Patients also should be open to conversations with their doctors about whether tests or referrals that they feel are warranted are necessary.
Excellent article. I can think of just one situation in which ordering a test did not affect management but still had a positive outcome on a patient’s healthcare. He was quite anxious about his risk of MI even though he had minimal cardiac risk factors, and presented to the emergency room multiple times with anginal type chest discomfort. Each time he underwent a nuclear cardiac scan, all normal. Even after multiple attempts by me and his cardiologist to reassure him, he remained convinced that the nuclear scans might have missed a significant coronary lesion.
I finally talked his cardiologist into performing a coronary angiogram, simply to reassure him that his coronaries were normal. As expected, his coronaries were completely clean. After that, his chest pain never reappeared, his ER visits stopped, and he stopped being exposed to so much irradiation.
Great article, Adam. I 100% agree with your assessment. One piece that often gets left out, though, is how many healthcare systems use patient satisfaction as a measure of physician quality. I’ve seen many cases where physicians are rated poorly simply for “not doing anything.” Thoughtful conversation and listening can help, but it doesn’t always prevent the hit to satisfaction scores. Is there data that shows doing less can actually improve these objective measures? Should we ignore patient satisfaction in healthcare systems when that feedback could be based on “being thorough.”