Practice varies around the United States and across each institution, but I would bet that every reader could give multiple examples of situations in which tests are ordered automatically before talking to or examining a patient. There are situations in which ordering tests before examining a patient is reasonable and promotes efficiency. Primary care physicians often order tests before sending a patient to a specialist. These tests are based on the primary care physician’s history and examination, sometimes with advice from the specialist, and tailored to the individual patient’s case. It would not make sense to send a patient to a pulmonologist for a chronic cough without first obtaining a chest x-ray. It is also reasonable for clinic protocols to include specific tests based in intake or triage information, such as an electrocardiogram for any patient presenting to the emergency department with chest pain and shortness of breath. These tests are based on consideration of the patient's symptoms and driven by well-accepted clinical practice.
However, as in the Perspective by Sah1 in this issue of JAMA Internal Medicine, we all know of many situations in which tests are performed automatically for every patient with little consideration of the patient's history, findings, or goals of care. For all the reasons eloquently elaborated by Sah,1 this is generally a marker of poor practice that is wasteful, potentially harmful, and disrespectful of the patient as an individual.
Here’s a challenge: identify cases of inappropriate testing before examination in your own practice or in the practice of those physicians to whom you refer patients. Then implement a more patient-centered process.
Conflict of Interest Disclosures: None reported.
Grady D. Testing Before Seeing the Patient. JAMA Intern Med. 2015;175(3):343. doi:10.1001/jamainternmed.2014.7607