{"id":1092,"date":"2013-12-11T11:50:56","date_gmt":"2013-12-11T16:50:56","guid":{"rendered":"http:\/\/blogstemp2.wpengine.com\/?p=1092"},"modified":"2013-12-11T11:50:56","modified_gmt":"2013-12-11T16:50:56","slug":"making-value-based-decisions-about-ordering-tests","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2013\/12\/making-value-based-decisions-about-ordering-tests\/","title":{"rendered":"Making Value-Based Decisions About Ordering Tests"},"content":{"rendered":"
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Every day, piles of money are spent on needless tests and treatments in training hospitals and clinics.<\/p><\/div>\n

As Dr. David Green reported this week in NEJM Journal Watch<\/em><\/a>, the American Society of Hematology is the latest society to comment on appropriate and cost-conscious care in the ABIM Choosing Wisely campaign. I\u2019ve followed the Choosing Wisely<\/a>\u00a0campaign closely and have been using it on the wards and in clinic as academic ammunition.\u00a0A specialist society\u2019s public advice about showing restraint is an excellent means to challenge the dogma of our so-called routine practices.<\/p>\n

I know every conscientious practitioner has struggled with the high price of medical care. Our training environments are currently breeding grounds \u2014 and battlegrounds, for that matter \u2014 for ideas on how to solve our nation\u2019s cost crisis. I have often wondered how we might change the way we train our residents and teach our students to exhibit financial diligence.<\/p>\n

Of course, we are all part of this economic mess, and residents rightly share some of the blame. As na\u00efve practitioners who lack confidence in diagnosis and management, residents tend to overorder and overtreat. I certainly have checked\u00a0a thyrotropin (TSH) level in the inexplicably tachycardic hospitalized patient, despite my own knowledge that it was probably worthless. And I\u2019ve seen colleagues get echocardiograms \u201cjust to make sure\u201d they could safely administer large amounts of IV fluid for hypovolemic patients with hypercalcemia or DKA. When residents don\u2019t have years of experience, they use high-tech diagnostic testing as a crutch.<\/p>\n

Then again, the expectations of the learning environment also contribute to the epidemics of excessive echocardiograms and needless TSH levels.\u00a0 First of all, trainees are expected to have their patients presented in neat \u00a0little bundles, devoid of any diagnostic uncertainty. Additionally, they have been trained through years of positive reinforcement for broad differential diagnoses and suggesting additional testing for unsolved clinical problems.<\/p>\n

Although the Choosing Wisely campaign speaks to me and many of my generation, it is only a start. It alone cannot stand up to the decades of decadence and our culture of waste. How can we encourage trainees to truly choose wisely in the training environment? I propose the following:<\/p>\n