My patient, an educated, engaged patient in his 40s (with a doctoral degree in the sciences), came to me for “pre-op” before an orthopedic procedure. He’s pretty healthy, and doesn’t need any further risk stratification or blood work.
“I have some forms,” he began, pulling a sheaf of papers out of a folder.
“Oh, I know.” I laughed, which disconcerted him, and I hastened to explain. “You see, many doctors think that people need to get a whole lot of tests before an operation. Sometimes tests are necessary, and sometimes not. I’m always in a spot, here, and wanted to see what you think. Should I order you tests you don’t need, just to move things along, or should I try and stand my ground, so we don’t put you through anything you don’t need?”
“Well...you do what you need to do, doctor!” he said, obligingly.
He sat up on the exam table and I picked up the phone:
First, I called his surgeon, and a secretary said, “We just sent him to [Preop Center X] to get these tests.” “What do I do if I think he doesn’t need everything on the form?” I asked. “Bring it up with them.”
I called the number I was given, and got forwarded around a few times, till I reached a helpful PA. “Well, the surgeons want these tests to be done.”
I pressed. “But they sent him to *you* for preop testing!”
“Yes,” she said. “Everyone gets urinalysis before orthopedic surgery.”
“Why’s that?”
“Well, he’s getting hardware inserted, so if he has a urinary tract infection…”
“He doesn’t. I’m seeing him right now.”
“I don’t have decision-making power,” she said, pleasantly but clearly willing to get off the phone. “I’m just a lowly PA.”
“You’re not lowly at all!” I protested. “You’re being very informative and helpful.”
I put down the phone and gestured to the patient. “You see what I have to go through?”
“Sure,” he said, and gently corrected me. “Almost as bad as what I have to go through!”
***
I learned several things from this experience, or perhaps I just realized anew several things that were previously dormant.
What do we do about unneeded pre-op testing? It’s a big question, fraught with the same barriers that beset meaningful change for overuse in the US health care system writ large. And I am not sure that picking up the phone, this time, helped much. But it did activate my mind, and hopefully my patient’s mind, to be on the lookout for the assumption that testing is needed.
And if I pick up the phone the next time, and the next….? Or leave a polite note in the chart the next time, and the time after that? Will the issue be incrementally improved, or is a revolution needed? You might ask those same questions of health care in general.
“I have some forms,” he began, pulling a sheaf of papers out of a folder.
“Oh, I know.” I laughed, which disconcerted him, and I hastened to explain. “You see, many doctors think that people need to get a whole lot of tests before an operation. Sometimes tests are necessary, and sometimes not. I’m always in a spot, here, and wanted to see what you think. Should I order you tests you don’t need, just to move things along, or should I try and stand my ground, so we don’t put you through anything you don’t need?”
“Well...you do what you need to do, doctor!” he said, obligingly.
He sat up on the exam table and I picked up the phone:
First, I called his surgeon, and a secretary said, “We just sent him to [Preop Center X] to get these tests.” “What do I do if I think he doesn’t need everything on the form?” I asked. “Bring it up with them.”
I called the number I was given, and got forwarded around a few times, till I reached a helpful PA. “Well, the surgeons want these tests to be done.”
I pressed. “But they sent him to *you* for preop testing!”
“Yes,” she said. “Everyone gets urinalysis before orthopedic surgery.”
“Why’s that?”
“Well, he’s getting hardware inserted, so if he has a urinary tract infection…”
“He doesn’t. I’m seeing him right now.”
“I don’t have decision-making power,” she said, pleasantly but clearly willing to get off the phone. “I’m just a lowly PA.”
“You’re not lowly at all!” I protested. “You’re being very informative and helpful.”
I put down the phone and gestured to the patient. “You see what I have to go through?”
“Sure,” he said, and gently corrected me. “Almost as bad as what I have to go through!”
***
I learned several things from this experience, or perhaps I just realized anew several things that were previously dormant.
- Unnecessary preoperative testing is the fault of no one individual. The surgeon (or whoever) thinks the tests are needed by “them,” and the inertia of pre-existing protocols pushes the patient down the conveyor belt into the maw of potential harm. Everyone I talked to on the phone was responsive and helpful, and no one thought they had the authority not to order the unneeded testing. And me? in the end, I ordered the minimum I thought justifiable, but worried that if I ordered nothing, the patient would not get his procedure.
- The patient is always worse off than the doctor.
- People’s self perception (“lowly PA”) can help drive their incentive to support change.
What do we do about unneeded pre-op testing? It’s a big question, fraught with the same barriers that beset meaningful change for overuse in the US health care system writ large. And I am not sure that picking up the phone, this time, helped much. But it did activate my mind, and hopefully my patient’s mind, to be on the lookout for the assumption that testing is needed.
And if I pick up the phone the next time, and the next….? Or leave a polite note in the chart the next time, and the time after that? Will the issue be incrementally improved, or is a revolution needed? You might ask those same questions of health care in general.
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