The problem of overuse of medical services is receiving increasing attention, in our Less Is More series and other venues, as well as many thoughtful programs sparked by the Choosing Wisely campaign. In this issue of JAMA Internal Medicine, Fenton et al1 describe an innovative and novel intervention to reduce use of low-value imaging tests, such as screening dual-energy x-ray absorptiometry in low-risk women or spinal magnetic resonance imaging for subacute back pain. Calling these tests “low-value” may be generous because it is more likely that in these clinical scenarios, the tests were actually harmful. The possibility of benefit was tiny and remote, while the possibility of triggering a cascade of further diagnostic tests and treatments incurring further risks was substantial.
This single-center study used standardized patient instructors, a creative intervention, and we were surprised and disappointed that it was not more successful in reducing diagnostic test ordering. The instantaneous feedback from standardized patient instructors, coupled with training in a patient-centered approach for explaining to patients the downsides of unnecessary testing, has the feel of an effective intervention.
However, the problem of excessive use of diagnostic tests and imaging may be too deeply ingrained in medical and training culture to be improved by episodic interventions. A few educational sessions on low-value or no-value care and unnecessary ordering are easily forgotten in an environment that is geared to always doing more testing, and assuming that earlier and more information is always better. All of us who take care of patients and those who teach residents need to consistently discuss risks and benefits for diagnostic tests and include the potential harms of testing and downstream consequences in the calculation. We need to educate our trainees in patient-centered testing and not encourage pursuit of every problem in the differential diagnosis, no matter how remote. This questioning of medical tests needs to become an integrated part of medical training, modeled every day, rather than a one-time educational intervention. It is encouraging to see initiatives aimed at culture change, such as the Costs of Care,2 from a young generation of leaders in medical education. We all must play a role to be successful in our efforts to bring patients medical care that is of high value.
Corresponding Author: Kenneth E. Covinsky, MD, Department of Geriatrics, University of California–San Francisco, Box 111G, VAMC, San Francisco, CA 94143 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Covinsky KE, Redberg RF. An Intervention to Reduce Use of Low-Value Imaging Tests. JAMA Intern Med. 2016;176(2):198. doi:10.1001/jamainternmed.2015.6941