'Sting' approach doesn't make young doctors cut back on low-value tests

In a study using surprise visits by undercover instructors posing as patients, the approach did little to deter trainee-doctors from ordering unnecessary tests or to better focus them on their patients' goals.

"In primary care and a lot of other areas of medicine, we know there is a problem of tests and procedures that are done that are probably medically unnecessary and not beneficial to the patient," said lead study author Dr. Joshua Fenton, of the University of California-Davis Health System in Sacramento.

In the new study of almost 60 second-year doctors, known as residents, a male fake patient requested magnetic resonance imaging (MRI) for lower back pain and a middle-aged woman asked for bone mineral density testing.

Both are considered overused tests according to the Choose Wisely program, which aims to avoid wasteful or unnecessary medical testing, treatments and procedures through education of both doctors and patients.

The undercover instructors eventually broke character and critiqued the doctors-in-training on their techniques for addressing the patient's concerns apart from just ordering the requested test.

Fenton told Reuters Health the study team theorized that fewer tests might be ordered if doctors were more patient-centered, which means providing healthcare that aligns with patients' wants, needs and goals.

To see if real-life challenges combined with feedback would get the message across, the researchers sent the instructors to visit 30 internal medicine and family medicine residents at two clinics in California, and to another 31 residents who served as a control group. Members of the control group did not receive feedback from their fake patients, but they got educational materials afterward.

Following the first trial, researchers sent the undercover instructors back for up to three unannounced visits to different residents over the following three to 12 months to request similar tests.

Overall, the residents ordered the low-value tests in about 27 percent of visits, and that rate didn't change across the trial.

The residents also didn't score higher on patient-centeredness or on the techniques used to address patient concerns during the trial, researchers found.

"Essentially, for the most part it wasn't an effective intervention," Fenton told Reuters Health.

It may be that overuse of diagnostic tests is too deeply ingrained into the medical culture to be improved by a brief intervention, write JAMA Internal Medicine editors Drs. Kenneth Covinsky and Rita Redberg of the University of California, San Francisco, in a note accompanying the new study,

"I think it speaks to the importance of discussing low-value and potentially harmful care across our discipline," said Dr. Wanda Filer, president of the American Academy of Family Physicians, who wasn't involved in the study.

One possible technique to avoid unnecessary and potentially harmful tests is to show patients on a document that a certain test is not recommended for their health problem, Filer noted.

"It's very important that the public understands when a doctor is not giving you antibiotics for this head cold today, it's partly because they don't want to hurt you," said Filer, who practices in York, Pennsylvania.

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As for getting doctors to become more patient-centered, an editorial accompanying the new study highlights the need for more research on medical education and patient-centered outcomes.

"The study of how to best teach the practice of Medicine is as important as the study of how to best practice medicine," write Drs. Patrick O'Malley and Louis Pangaro, of the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

"Aligning these missions more closely will not only improve the practice of medicine, but also the care of patients," they add.