Do Doctors Perform Unnecessary Tests?

Some time ago, a patient arrived to my office prepared to enjoy the joy of colonoscopy. 

Many of the patients on my endoscopy schedule are scheduled by other physicians and gastroenterologists.  In other words, I meet many of them for the first time on their special day.  My task is simply to perform the procedure and to then refer them back to their medical professionals. 

In general, the system works well as we have many checks to assure that there are no safety barriers to performing the requested procedure in an out-patient setting.  Even when I schedule a procedure on one of my own patients, my patient’s medical record will be reviewed in advance by another medical professional.

While the system works well on the safety front, it is less effective on the medical necessity front.  When an endoscopy schedule is open to referring medical professionals, there will be instances when the medical necessity of the procedure is questionable.  This is a murky issue as professionals disagree often on whether a medical intervention is clearly indicated.  Medicine is an art and different practitioners have different points of view by virtue of their personal philosophies and experience.  I have certainly performed procedures requested by other doctors that I would not have ordered myself. This does not make me right or the other doctor wrong.

The patient who is the subject of this post was not due for a colonoscopy for 2 more years, as clearly appeared in the chart.  I surmise that the patient mistakenly thought she was due 3 years after the last exam instead of the doctor recommended 5 years.  She advised her primary care physician that she was due and the procedure was scheduled.

So, when facing this patient who had endured the colonoscopy prep, had taken a day off of work and had her spouse with her, which course of action would you have pursued if you were the gastroenterologist?

What would you do?

• Proceed with the procedure as scheduled.  This fulfills the patient’s expectation and avoids the embarrassment of divulging sloppy medical care.
• Advise the patient that I am willing to proceed, but that her insurance company may refuse to cover the procedure.
• Advise the patient that she should not undergo an unnecessary medical procedure and that she should absorb all of the resultant inconveniences.
• Offer to perform the procedure at no charge.
• Document in the chart a new symptom that the patient on reflection realizes she has been suffering so that the procedure will be covered by her insurance company.

This was an easy call for me.  Unnecessary procedures should not be done.  After doing my best to empathize with her, I explained why proceeding 2 years in advance of the due date is against her medical interests.  Beyond my philosophical opposition to proceeding, why risk a complication from a test that need not be done?   While this was not the outcome that she expected, I am hopeful that she and her husband felt that she received high quality medical care.  Perhaps, she’ll end up on my schedule again 2 years later.