Academic physicians' views on low-value services and the choosing wisely campaign: A qualitative study

Why do clinicians overtest? A narrative review and workshop group discussion exploring influences on clinician overtesting as possible causes of overdiagnosis

“…If you really mess things up, so that the patient switches to another doctor, that's what affects me" [37] ""So they see it as their right to have it" [46] "I guess I do it because...I want my patients to perceive that I practice good medicine...you do have to be seen to be proactive" [46] "There is a demand from patients for testing or medication or imaging that they've read about or they feel that they should get in order to be satis ed that they've been adequately cared for" [47] "Patients absolutely drive test ordering..." [47] "Patients come in and they say, 'Oh, I have this, and I want a CT scan done.' They'll tell you what they want done" [51] "If we order more tests and we make sure we have every test ordered that might possibly be needed, the patient's happy and leaves in their ED [emergency department] stay" [51] "I'll say "well you just had one two years ago, you're on treatment, it was stable from the year before, and I don't think you need one"… what does usually happen is that they usually win" [64] "Can improve relationship between patients and doctor" [65] "Check-ups are largely patient driven secondary to media/public health generated anxiety" [ "There are situations where I've ordered an echo when I otherwise would not have because guidelines mandated" [29] "I think there's more, as much as we've developed these decision rules-I think there's a lot to be said about just experience" [39] "I think people are wary of practicing not in line with that and then they have potential then for criticism" [46] "There's plenty of guidelines, but they're all different and there's nothing o cial...there's no hard and fast rule" [46] "Because I work in a teaching practice, my residents are very devoted to guidelines. A lot of them are driven by the more recent guidelines" [64] Financial incentives 20 articles "Well, often the supervisor just says to run some tests, and I just accept that without question" [3] "I recently ordered a lipase, but then the gastroenterologist called me and said: in this hospital, we always combine it with an amylase."…”

“…But how must I say "you have to accept it" if the neurologist says that perhaps the patient should be looked at by someone else" [37] "If I get a letter from the diagnostic centre with the comment "You request 10% more than the average GP in Maastricht", then you get critical. You wonder if we should wait a bit longer with this patient" [37] "If you're not going to order it, the next doctor will" [51] "He would see the cardiologist every three months and would get a stress test every year...When he came to see me...I had to tell him 'I don't think that that's necessary" [51] "A lot of tests get done that probably don't need to get done because our residents are afraid of not ordering something because they'll disappoint us" [51] Factor Articles Illustrative quotes Time constraints, (physical vulnerabilities and language barriers) † 13 articles [3,16,26,29,37,39,44,47,49,51,57,65,68] "Some days patients want tests that I feel are not necessary but I want to avoid discussions or I'm tired and I will order tests anyway" [29] "You see many exams ordered, "Rule out PE [pulmonary embolus]," and that's all that you have… we often just go ahead and do the exam, to be honest, because it ends up creating a lot of lost time" [39] "If you had enough time to do a thorough historytaking of all these people… People would say '"I think I've been well understood, listened to, and examined", and need far fewer further investigations. But that is much too time consuming" [37] "If I'm really busy and I have ten people in the waiting room, and if I feel pressured and overwhelmed, I can say,'Yep, here is a requisition for the MRI [magnetic resonance imaging], let's get it done and move along."…”

“…[47] ""They do a lot of catscans because they don't have time to observe patients… work them up, get them out the door." [51] "A major concern that it could increase workload which would diminish time for treating ill patients" [65] Availability, ownership and ease of access to tests 11 articles [3,15,28,29,30,44,39,37,69,75,77] "Checking boxes on the lab form, I often go, let's do this one too, and that one" [3] "When you're ordering lab tests, it is easy to just order some more tests" [3] "The patient is already being sent for another test to the diagnostic centre, which creates a low threshold for doing more testing… so why not?" [37] "I think for any test if it's very, very available and it's fast and it's easy to do and it doesn't take a lot of time and there's more turnaround on the report-then we're just more likely to use it more."…”

“…[37] "I think for any test if it's very, very available and it's fast and it's easy to do and it doesn't take a lot of time and there's more turnaround on the report-then we're just more likely to use it more." [39] "It would probably be valuable to make the process less convenient because the threshold is so low to order CTs" [39] Factor Articles Illustrative quotes Pre-emptive testing for subsequent care 10 articles [26,29,43,46,47,51,[63][64][65]73] "I am glad that I can refer to something… And you could describe that as medical overuse to some extent. Because we are talking about tests which were not totally urgent or rather luxurious given the speci c symptoms at that time.…”

Screening for thoracic aortic pathology: Clinical practice in a single tertiary center

“…The goal is to provide evidence‐based care which is free from harm and truly necessary. Overuse of low‐value services is a significant problem . To choose an appropriate imaging approach for screening in patients at risk for aortic pathology, the advantages and disadvantages of each imaging modality must be carefully considered.…”