Safety of care
The right test at the right time: Striking the proper balance
Originally published September 2014 / Revised April 2017
In an era of fiscal prudence, combined with ongoing efforts to improve the safety of care, the efficient and effective utilization of healthcare resources remains a priority for governments, health authorities, administrators, and healthcare providers. Within this context, physicians must reconcile their obligation to act fiscally responsibly while also providing safe care.
It is increasingly recognized that excessive or unnecessary medical tests and procedures do not benefit patients, and can detract from sparse healthcare resources. It is challenging for doctors to strike the proper balance when ordering tests and carrying out procedures. When responding to fiscal realities while also providing safe care, doctors will want to rely on their knowledge, clinical judgment, and the best available evidence to guide their decisions.
Growing interest in medical tests and procedures
While clinicians have experience with and routinely evaluate medical tests and procedures, current resource constraints are imposing an added complexity to the provision of care. In 2013, the interprovincial Health Care Innovation Working Group began to re-evaluate and set new guidelines for a number of procedures including MRIs, joint replacements, and cataract removal. Acting on the recommendations of the working group, Canada's first ministers adopted guidelines for the appropriate use of medical imaging for lower back pain, headaches, and minor head injuries. At the same time, some health authorities introduced guidelines on the appropriate use of certain diagnostic tests. Amidst these initiatives, the delegates at the Canadian Medical Association's 2013 Annual Meeting voted to strike a working group to develop a list of tests and procedures which pose risks, unnecessarily consume resources, and do not advance patient recovery. These and other initiatives highlight the increased focus on resource utilization in healthcare.
All physicians practising in Canada must "consider first the well-being of the patient."1 This includes ordering the right tests and prescribing the right treatment based on each patient's condition and circumstances. Physicians also need to engage in meaningful discussions with patients about the risks and benefits of any test or procedure, and these discussions should be documented in the medical records.
As part of the Choosing Wisely Canada (CWC) campaign, more than 220 evidence-based recommendations of tests, treatments, and procedures that patients do not need have been released across 37 specialties by participating national medical professional societies.2 The initiative is primarily intended to help doctors and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care. Unnecessary tests and treatments do not add value to care. In fact, they take away from care by potentially exposing patients to harm, leading to more testing to investigate false positives, and contributing to stress for patients. And, of course, unnecessary tests and treatments put increased strain on the resources of our healthcare system. Physicians are not obligated to follow the CWC recommendations in all cases but should familiarize themselves with the relevant lists of tests and procedures. The CMPA sees the campaign as an innovative example of physician leadership on the challenges of practising good resource stewardship and preventing patient harm from unnecessary clinical care
While some diagnostic tests may be overused, there may be cases when items on the CWC lists are required for specific patients in particular circumstances. To practise good medicine, physicians must use their knowledge and judgment, along with sound evidence, when recommending the most appropriate tests and procedures for patients. Physicians are ultimately responsible for accurate and timely diagnosis, and for discussing appropriate treatment options and recommendations.
In today's wired world, patients have access to more medical information than ever before. This can lead to patients requesting a number of inappropriate or unnecessary tests or procedures. This greater access to medical information can also lead patients to decline tests and procedures based on their interpretation of what is considered "unwise." In addition, as new medical technologies (including medications) expand, both physicians and patients can be lured by these innovations. Physicians generally recognize the diffusion of some of these advancements is not always well-controlled, and doctors must assess the impact of new tests and procedures on the patient's treatment or likely outcome.3
When considering the most appropriate tests and treatments, physicians should communicate clearly with patients and involve them in discussions about options and preferences. The risks and benefits of a diagnostic test, as well as the nature and anticipated effect of a proposed treatment, should be discussed. Not all patients may realize that too much testing and treatment can be harmful, and that most tests carry risks of possible complications, physical discomfort, emotional stress, or false results. Doctors should always give patients the opportunity to ask questions, and inform them about the consequences of leaving the ailment or condition untreated. Ultimately, physicians must respect the right of a competent patient to accept or reject any medical care recommended.
Managing risks associated with recommending tests and treatments
Physicians ordering tests or treatments can fulfill their responsibilities and manage the associated risks by doing the following:
- Be knowledgeable about the tests and treatments commonly recommended, including up-to-date evidence.
- Discuss the test or treatment with the patient, including the reason it is recommended and the anticipated outcome. Benefits, significant risks, and available alternatives should also be communicated.
- Communicate the possibilities associated with negative side effects and unlikely outcomes to the patient.
- Obtain the patient's informed consent before any test or treatment is administered to the patient.
- Document the information shared with the patient in the medical record, including (as required) rationale supporting decisions about tests or treatments. If appropriate, physicians should also document the differential diagnosis.
- When necessary, obtain the opinion of a second physician to gain another perspective about a test or procedure under consideration.
Making the best decision
Patients rely on their physicians to recommend the right tests and procedures based on their specific clinical needs. Doctors should use their knowledge, clinical judgment, and the best available evidence to guide their decisions, and they should speak with their patients about the appropriateness of specific tests and treatments. Physicians are called upon to use healthcare resources prudently, exercise appropriate judgment, and help their patients make informed decisions about their medical care.
- Canadian Medical Association, Code of Ethics, 2004 (reviewed March 2014). Retrieved on April 8 2014 from: http://www.cma.ca/code-of-ethics
- Choosing Wisely Canada. http://www.choosingwiselycanada.org/ The Canadian Medical Association is a lead partner in the campaign, and more than 50 Canadian medical professional societies are at various stages of engagement in the initiative. The initiative mirrors the U.S. campaign Choosing Wisely.
- Wolfson, Michael, "Saving our health system means reigning in costs for doctors, tests and drugs," EvidenceNetwork.ca, 2013. Retrieved on April 8 2014 from: http://umanitoba.ca/outreach/evidencenetwork/archives/14632