Neurologist Dr Andrew Wilner presents a case in which a patient requested a seemingly unnecessary test and then walked out before receiving the results. Psychiatrist and bioethicist Dr Ronald Pies responds with his thoughts on a physician's ethical responsibilities when a patient demands an unnecessary or questionable medical test or treatment.
Wilner: I recently saw a 21-year-old woman complaining of intermittent numbness and tingling all over her body for the previous 10 days. She believed her symptoms were similar to her mother's, who was diagnosed with multiple sclerosis 15 years ago and is now in a wheelchair.
A few days after the symptoms started, the patient went to an outside hospital. In the emergency room (ER), her examination was normal. Despite the patient's request for an MRI of "her entire body," she was told the "emergency room is for emergencies" and referred to a local neurologist for an outpatient workup.
The soonest appointment she could get was in 6 weeks. Because symptoms continued, she came to our emergency room, insisting on an MRI scan.
While her mother looked on in grave concern from her wheelchair, I completed a detailed physical and neurologic examination. I reassured the patient that her examination was normal.
Notwithstanding my assessment, the patient and her mother again demanded an MRI scan of her entire body. I explained that an outpatient workup for multiple sclerosis would include an MRI of the brain and possibly cervical spinal cord, but rarely the entire neuraxis. Such a scan would take several hours to complete, would likely not be well tolerated, and would tie up our scanner, which was urgently needed for patients with stroke and other life-threatening illnesses.
However, in the interest of quelling the patient's concerns, and because she would probably eventually obtain the scans anyway as an outpatient, I acquiesced to an emergency MRI of her brain and cervical cord.
Later that afternoon, the harried radiology department reported that the MRI scans were normal. I returned to the emergency room to deliver the welcome news, but the patient had signed out against medical advice.
This challenging encounter raised a number of questions regarding the "patient–physician–healthcare-system" relationship. As similar clinical situations commonly occur, it seemed worthwhile to explore these issues:
1. In my medical judgment, the patient did not need urgent MRI scans to investigate the possibility of multiple sclerosis. However, I felt bullied into ordering them. What are my ethical responsibilities to the patient, my profession, and the "healthcare system" when it comes to appropriate resource allocation?
2. How can the healthcare system protect itself against patients who overutilize services by "doctor shopping?"
3. What are the medical–legal implications of refusing a patient's demands?
4. Was I unconsciously practicing "defensive medicine," motivated by the miniscule chance the patient really did have multiple sclerosis?
5. This patient may have had some type of psychopathology driving her demanding behavior. How should this be addressed?
6. I'm embarrassed to admit it, but I also acquiesced to avoid a patient complaint, which, however unjustified, would reflect badly on me. This realization raised 2 more questions: How much influence should the hospital administration have in determining "quality care"? Second, is the current administrative preoccupation with "patient satisfaction" driving up hospital costs?
What are the physician's ethical responsibilities when a patient demands an unnecessary or questionable medical test or procedure? Dr Wilner's case vignette raises this question in the context of a 21-year-old woman with a 10-day history of intermittent numbness and tingling who feared she had multiple sclerosis. Although Dr Wilner's neurologic examination was within normal limits, both the patient and her mother demanded an MRI scan, which Dr Wilner believed was unlikely to reveal significant pathology. Nevertheless, in the face of the "extremely demanding" patient and mother, the MRI was ordered—and, as anticipated, showed no significant abnormalities.
The questions raised by this case occur in the context of a broad, societal problem in the US, namely the excessive use of medical tests and procedures that waste the precious resources of time and money. According to one report, "Some experts estimate that at least $200 billion is wasted annually on excessive testing and treatment. This overly aggressive care also can harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year."
This trend is often said to be driven by "defensive medicine," attributable to physicians' growing concerns over legal liability. That is, "As medical liability and malpractice risk rise to crisis levels, the medical–legal environment has contributed to the practice of defensive medicine as practitioners attempt to mitigate liability risk."
Indeed, in a survey of 824 physicians, nearly all (93%) reported practicing defensive medicine, with 43% reporting the use of imaging technology in "clinically unnecessary circumstances."
Similarly, in a survey of neurosurgeons (N = 1028 completers), Nahed et al found that 72% of respondents ordered imaging studies, 67% ordered laboratory tests, and 66% consulted other physicians solely for defensive purposes.
However, in my view, the "defensive medicine" explanation is a bit simplistic, and ignores more humane and altruistic motivations when physicians are confronted with patients of the sort described in Dr Wilner's vignette. We are not given much background information on the patient's mental health issues, and I suspect such information was not available at the time she was assessed in the ER; eg, was there a history of anxiety or depression, outpatient psychiatric treatment, impulsive behavior, etc?
As a psychiatrist—given only the information in the vignette—I would have been concerned about the emotional stability of the patient, and whether a blanket refusal to order the MRI might have provoked various forms of "acting out"; eg, further "doctor shopping" (she had already been evaluated and cleared by one emergency department) or use of alcohol or drugs to deal with mounting anxiety. I believe most conscientious physicians would also worry about such unintended consequences of refusing the patient's request.
Does this mean that physicians ought to yield to a patient's unreasonable demands for imaging studies, blood tests, etc, when there is no evidence-based justification for such tests? In general, I believe the answer is no. But the decision is by no means a "slam dunk" when the patient is known to be at high risk of acting out in self-defeating or self-injurious ways—more on this shortly.
What does the American Medical Association (AMA) have to say about acceding to unwarranted demands for tests and procedures? The statement in the AMA's Code of Medical Ethics Opinion 11.3.1 is a model of clarity and concision: "Physicians should not recommend, provide, or charge for unnecessary medical services."
So, that settles it? Well, not exactly. In the AMA's Code of Medical Ethics Opinion 11.1.2, more nuance and balance are introduced, suggesting a kind of dialectic between two ethical obligations:
"Physicians' primary ethical obligation is to promote the well-being of individual patients. Physicians also have a long-recognized obligation to patients in general to promote public health and access to care. This obligation requires physicians to be prudent stewards of the shared societal resources with which they are entrusted. Managing health care resources responsibly for the benefit of all patients is compatible with physicians' primary obligation to serve the interests of individual patients.
The last sentence suggests that there is really no conflict between protecting the best interests of a particular patient and being a good "steward" of society's limited resources—such as time, money, and medical personnel. But is that really the case? Maybe in theory—but as Dr Wilner's vignette brings home, sometimes the patient's "interests"—as he or she perceives them—may conflict with good stewardship of medical time and resources.
This is where we may need to invoke a "third principle," namely the physician's expert judgment, knowledge, and experience. To put it bluntly: just because the 21-year-old woman and her mother are absolutely convinced that the patient ought to have a full-body MRI does not mean that the physician must concur or acquiesce, all other things being equal. As internist Caleb Alexander, MD, puts it, respect for the patient's autonomy "...does not necessitate that physicians abdicate their professional responsibilities or clinical judgment."
But sometimes, all other things are not equal. Sometimes, we have good reason to fear that a particular patient would be better served by our acquiescing in a medically unwarranted demand, provided the net benefits to the patient outweigh the net risks. It's possible this was the case with the patient Dr Wilner describes—though we would need more information to decide this. Suppose, for example, that the patient in question had a history of severe emotional instability, panic attacks, and self-injurious behavior—including alcohol and drug abuse. She is dealing with the terrifying prospect (however unsupported by the medical facts) that she has multiple sclerosis, like her mother.
Suppose, further, we have documentation that the last time a physician refused to order a (questionable) lab test for this patient, she had a series of severe panic attacks, which she "self-medicated" with alcohol. Knowing this, would a physician in the ER be justified in ordering the MRI, as the patient requested? I'm not sure there is a right or wrong answer. Dr Alexander addresses the issue by proposing an approach he calls "enhanced autonomy." He writes:
While respect for patient preferences is important, these preferences must be balanced with other considerations, including the medical indications, costs, and other contextual factors of the case. Only by carefully considering the entirety of the evidence in each of these domains can a physician act in a way that is in accordance with the patient's best interests and the physician's professional obligations.
Of course, in an ER setting, physicians almost never have "the entirety of the evidence" at their disposal. Hence, we must usually act on the best available information (including the scientific literature) and our clinical experience and judgment.
In the present case, consultation with a mental health professional might have been helpful—in theory. In practice, however, many patients presenting with somatic complaints that they attribute to a serious medical or neurologic disease (see below) are adamantly opposed to "seeing a shrink," and react to such referrals with anger and indignation (as in, "Oh, so you think I'm a head case, do you? How dare you!").
That the patient in Dr Wilner's vignette wound up signing out "AMA" suggests to me that she would not have taken kindly to a "psych consult"—at least at that stage of her condition.
Managing Patients With Somatoform and Related Conditions
Most physicians have had experience with patients who periodically complain of somatic symptoms (pain, tingling, motor weakness, etc) but whose physical exam, lab tests, imaging studies, etc are repeatedly within normal limits or negative. It is risky to conclude from such negative findings alone that the person is suffering from a purely "psychogenic," "psychosomatic" or "functional" disorder—nor is the term "hysterical" appropriate in such circumstances. (As one of my teachers in residency used to caution, "Hysteria is the last diagnosis the patient will ever receive.")
Some seemingly "psychiatric" symptoms can conceal subtle, underlying medical/neurologic disease processes. A recent comprehensive review found that the reported rate of misdiagnosis of conversion ("non-organic") symptoms has been, on average, about 4% since 1970; ie, about 4% of patients thought to have conversion symptoms turn out to have covert medical or neurologic illnesses. Though a review of these issues is beyond the scope of this article, it is important to note a major change from the 4th to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The DSM-IV categories of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder were removed; and many individuals diagnosed with one of these disorders would now fall within the DSM-5 category of Somatic Symptom Disorder (SSD). Essentially, SSD is characterized by "...somatic symptoms that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings and behaviors regarding those symptoms" over a period of at least 6 months.
Importantly—unlike most of the "old" DSM-IV somatoform categories—SSD does not require that the patient's symptoms be "medically unexplained." That is, the patient's symptoms may or may not be associated with a specific medical condition. These changes from DSM-IV to DSM-5 have been quite controversial.
Moreover, as Kurlansik and Maffei note in an excellent review, "Somatic symptom disorder presents a problem for both the physician and patient because it puts patients at risk of unnecessary testing and treatment." These writers nicely summarize the optimal management of SSD patients in general and family practice settings:
"General treatment tenets for the primary care clinician include scheduling regular, short-interval visits to avoid the need for symptoms to get an appointment; establishing a collaborative, therapeutic alliance with the patient; acknowledging and legitimizing symptoms once the patient has been evaluated for other medical and psychiatric diseases; limiting diagnostic testing; reassuring the patient that serious medical diseases have been ruled out; educating patients about coping with physical symptoms; setting a treatment goal of functional improvement rather than cure; and appropriately referring patients to subspecialists and mental health professionals."
My colleague, Dr Annette Hanson, has noted that for patients with SSD and related disorders who make repeated, usually inappropriate visits to the ER—so-called "frequent flyers"—the primary goal "...is to protect the patient from any short or long-term risks of tests and treatments of uncertain value."
Dr Hanson noted the potential value of having the patient return for a scheduled re-evaluation, regardless of whether the patient is symptomatic,"...just to gain control of the [ER] visits." (A. Hanson, MD, personal communication; August 8, 2018).
Referral for cognitive–behavioral therapy may sometimes be useful, though many SSD patients may resist this recommendation.
Dr Wilner's case vignette highlights the complexities of dealing with inappropriate demands for medical testing. I believe that, among medical ethicists, there is a general consensus that "Physicians are not obligated to offer testing or treatments that are not medically indicated—even if patients demand them." However, I have suggested that there are sometimes extenuating circumstances, and that the patient's overall well-being must be the first consideration.
Assessing this means gaining as much information as possible regarding the patient's fears, motives, emotional stability, and risk factors for "acting out," while also weighing the physician's (secondary) responsibility to be good stewards of medical resources. With regard to the latter, however, the AMA recognizes that, "...individual physicians alone cannot and should not be expected to address the systemic challenges of wisely managing health care resources."
In the table below, I have provided a set of factors and questions to consider when faced with patients who make inappropriate demands for medical testing. In the end, though, every case requires an individualized approach—and there is no substitute for the wisdom, judgment, and experience of the physician.
Table. Factors to Consider When the Patient Demands a Medically Questionable Test or Procedurea
|a"Medically questionable" is defined as "Having some limited scientific justification (eg, uncontrolled observational data, case reports), but lacking a strong, evidence-based rationale, given the best available scientific data (eg, randomized, controlled studies; sound epidemiologic data).|
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Cite this: When Patients Demand Unnecessary Medical Tests - Medscape - Sep 05, 2018.