97% of ED Physicians Order Unnecessary Imaging Tests

The fact that nine out of 10 emergency physicians admit to ordering medically unnecessary tests indicates that existing protocols and safeguards to prevent overuse clearly aren't working, survey results suggests.

Nearly all of the 435 emergency physicians in a recent survey admitted to ordering too many diagnostic tests, but said they did so out of fear of error, uncertainty, and non-medical reasons.

The survey, published this month in Academic Emergency Medicine, focused specifically on the use, and over-use, of imaging tests. More than 85% of the respondents said they believe that too many tests are ordered in their own departments, and 97% admitted they ordered "medically unnecessary" radiology tests, which were defined as imaging the physician ordered in response to external pressures and not for optimal medical care.

"I am not surprised by the findings," says Hemal Kanzaria, MD, the lead author of the study, and an emergency physician practicing at UCLA Ronald Reagan Medical Center, and VA West Los Angeles Medical Center. "I face these issues every time I work in the emergency department and I agree with the collective response from my colleagues that there are many aspects of the practice environment that drive over-diagnoses."

"A lot of what I heard from our survey respondents regarding a fear of being wrong, or missing a low-probability, but potentially life-threatening diagnosis resonates with my own clinical practice, says Kanzaria, who is also a clinical scholar with the Robert Wood Johnson Foundation, which funded the study with the Department of Veterans Affairs.

The fact that nearly every emergency physician admits to ordering medically unnecessary tests indicates that existing protocols and safeguards to prevent overuse clearly aren't working, survey results suggests.

"Overall, I interpret our results to suggest that over-testing is not due to physicians' lack of knowledge or lack of insight or poor medical judgment, but reflects a cultural response both within and outside medicine to uncertainty and error," Kanzaria says.

"I personally think that to overcome over-testing we need to address our collective intolerance of uncertainty both within medicine and within society at large as well as this culture of blame that triggers the malpractice system."

When asked how they'd address the problem, the physicians in the survey suggested several approaches including tort reform, increased adoption of shared decision-making with patients, feedback to physicians on test-ordering metrics, and improved training on diagnostic testing.

"There is not one magic bullet. I don't think that any isolated approach to curbing over-imaging exists," Kanzaria says. "There is one idea that is being discussed right now, the idea of safe harbors. Using clinical practice guidelines to determine the local standard of care might help physicians follow both evidence based guidelines and offer some protections from malpractice and could potentially result in fewer medically unnecessary tests."

More feedback on test orders and behavior also would give emergency physicians a better sense of where they stand in relation to their colleagues. "This type of benchmark does not get at appropriateness, but it still would begin a discussion about use and overuse," Kanzaria says.
Another big driver for imaging overuse is pressure from patients, who are often arrive at the emergency department in pain, afraid, and with unrealistic expectations.

"The first step is recognizing for yourself and your patients that uncertainty exists and that we might not figure out the answer today, and acknowledging that there are potential harms and benefits with every test," Kanzaria says.

"Acknowledging that uncertainty exists both for the physicians and for their patients may be a good first step," he says. "Beyond that, addressing our low tolerance for uncertainty on the part of physicians and patients will really require addressing a number of widespread beliefs that are held in society, including the perception that error is the cause of any bad outcome, or that technology can solve all of our problems, or that catching things early is always beneficial. Myths like that we will have to address."