Case Study
A 63-year-old patient was at his primary care physician’s office for an annual physical exam. The patient told the physician that he wanted “a whole-body MRI to make sure I don’t have any treatable cancer before it’s too late.” The patient noted he had recently seen cancers in several of his friends and colleagues: a retired coworker died of a glioblastoma multiforme one year after retiring, another coworker was diagnosed with inoperable pancreatic cancer, and a friend had returned following a month of recovery from excision of a renal cell carcinoma that was discovered incidentally on a CT scan performed for kidney stones.
The patient noted that he was in excellent physical health, felt great, and didn’t want to die of a curable cancer that could be caught early by an MRI. When the physician attempted to explain that he would not order the requested imaging because there was no scientific evidence that a routine screening MRI is of any benefit to asymptomatic individuals and may actually be harmful due to false positive findings, the patient became visibly frustrated and said, “Tell that to all my friends with cancer!”
The patient also told the doctor that if he did not order the MRI, then he would report the physician to the state medical board for incompetence and find another physician, “more interested in preventing disease than treating it.” This was very upsetting to the physician because he thought he had an excellent relationship with the patient, believed he had been sensitive to the patient’s concerns, and had done a good job of explaining pre-test probability and the risks of false positives in screening imaging. The physician had never been reported to the medical board and didn’t know the associated risks. The physician called Copic and asked whether he was doing the right thing.
This case illustrates several of the issues that may arise when patients demand unnecessary tests. A list of common questions and general advice follows:
What am I obligated to do for a patient who demands a test that I think is unnecessary?
A simple answer to this question is that, in any given scenario, physicians are held to the medical standard of care. This is generally defined as “what a reasonable and prudent physician with the same or similar training in similar circumstances would be expected to do.” As experienced physicians may know, each situation can have myriad complicating factors so that when there is a judgment call regarding a cognitive medical decision, there actually is a “range of acceptable practices.” However, in our relatively uncomplicated case study, the physician is held to the standard of care to refuse providing unnecessary medical services (see AMA Code referenced below.)
What if the patient is persistently demanding and will not accept my refusal to order a requested test?
Although it is next to impossible to reduce the complexities of how to handle such an encounter to a single piece of advice or a simple algorithm, a physician should understand that, foremost, he or she is an advocate for the best care for their patients. Sometimes, the best care is not necessarily what the patient demands. It is important to understand the patient’s underlying reasoning for wanting the test in the first place since addressing this may put the patient at ease. For instance, it would be helpful to have a discussion in the above case where you acknowledge that seeing three closely occurring cases of cancer in friends would be unsettling and prompt most people to ask if they should be doing more to screen themselves. If the patient persists despite reasonable efforts to educate a patient as to why you decline to order a requested test, then it may be reasonable to refer the patient to another physician for a second opinion.
What if, despite my best efforts to convince a patient that he or she does not need a test, I give in and order a test that I believe is unnecessary?
If it is not obviously harmful and could reasonably be justified that in a particular scenario it is within the “range of acceptable medical practices” to order a particular test, then that might be considered within the standard of care. In such a case, it would be useful to outline your thought process as to why you are ordering the test despite believing it is unnecessary such as “…although I discussed the risks with Mr. Jones of ordering an MRI, including incidental and benign findings that might lead to more and risky testing and that the best science tells us that the test is not valuable and may be harmful, I think he has significant and ongoing anxiety about not being tested which is having adverse effects on his health, and in this case, it is reasonable to order the MRI since he clearly understands why I recommend against it.”
An informed consent discussion with a patient where you outline why the test is being done, the potential risks to the patient, your reasons for advising against it, and your reasons for ordering the test anyway might be helpful to have in the patient’s chart in the event of adverse downstream events.
What if a patient threatens to complain to the medical board if I refuse to order a test he or she is requesting?
The medical board holds physicians to professional standards of care and conduct. However, if the physician behaved professionally during the encounter, the medical board does not look for reasons to interfere with physicians who are providing reasonable and appropriate medical care. Also of note, your Copic policy covers attorney assistance for medical board complaint issues (when a complaint is received), so the physician in this case could call Copic to request an attorney to assist in responding to the complaint.
Do any medical organizations have statements regarding unnecessary tests?
The AMA’s Code of Medical Ethics1 states that “Physicians should not recommend, provide, or charge for unnecessary medical services.”
In summary, the medical standard of care is shaped by our practicing peers and professional organizations, not by patient demands. However, with direct-to-consumer marketing, media reports of celebrities with diseases who then advocate for testing for them, and with personal anecdotes from friends and family with medical conditions, patients may request and even demand unnecessary tests. Even though it may create complex and even difficult interactions, physicians are not obligated to order a test simply because a patient demands it.
1 https://code-medical-ethics.ama-assn.org/ethics-opinions/fees-medical-services
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 4Q24 Copiscope.
