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LEARNING OBJECTIVES

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  1. To understand the rationale for physicians to address the stewardship of finite resources.

  2. To understand the dilemma physicians experience in caring for individual patients and simultaneously considering the use of resources.

  3. To learn specific communication skills for conducting conversations with patients about unnecessary tests or treatments.

  4. To learn the roles of teams, healthcare systems, and professional organizations in stewardship of finite resources.

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INTRODUCTION

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Donna Johnson is a 40-year-old woman who is the CEO of a small manufacturing company. Her job is stressful and she has a long history of headaches, but recently she feels the headaches are increasingly frequent despite her efforts to manage them with stress reduction. She has a neighbor who recently was diagnosed with a malignant brain tumor who also had headaches, and she is asking her family doctor, Dr. Hernandez, to order a computerized tomography (CT) scan to be sure she does not have a tumor.

Dr. Hernandez takes a detailed history and rules out any other neurologic symptoms. Her complete physical examination, including a careful neurologic examination, is all normal. Dr. Hernandez concludes that these are tension headaches and discusses this with the patient. Ms. Johnson would like a CT scan just to be 100% sure, but Dr. Hernandez does not think it is clinically indicated. Furthermore, the test is expensive, even though the patient has insurance that would cover it. Dr. Hernandez thinks to herself that it is just easier to order the test than try to explain the risks and benefits to a worried patient.

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Every day physicians make many decisions about whether to order, or not to order, laboratory tests and imaging procedures. This scenario and similar scenarios are very common in daily practice. Patients with symptoms are worried and want their physicians to use the best of medical science to quickly diagnose and treat a problem or to reassure them that nothing serious is wrong. Some believe that tests and x-rays are perfectly accurate and humans are not, so they equate an order for a test as better care than a careful clinical examination. Consumer advertising and Internet sites recommending non–evidence-based tests and treatments reinforce these beliefs.

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Physicians worry as well. Test ordering can be driven by a physician's concern that they might miss an important diagnosis and cause their patient unnecessary suffering. Worry that declining to order an unnecessary test might negatively affect their patient's satisfaction may also prompt decisions to obtain tests that are not truly indicated. Belief that test ordering represents the standard of care and thus is a defense against malpractice claims also drives this behavior. It is safe to say that we have a “more is better” view of medical testing, even when we know that these tests do not add value to patients' care and when these tests may even have some risks for patients. Even more concerning is the reality that current ...

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