An Intervention to Reduce Use of Low-Value Imaging Tests

The problem of overuse of medical services is receiving increasing attention, in our Less Is More series and other venues, as well as many thoughtful programs sparked by the ChoosingWiselycampaign. In this issueofJAMAInternalMedicine, Fentonet al1 describe an innovative and novel intervention to reduce use of lowvalue imaging tests, such as screening dual-energy x-ray absorptiometry in low-risk women or spinal magnetic resonance imaging for subacute back pain. Calling these tests “low-value”may be generous because it is more likely that in these clinical scenarios, the tests were actually harmful. The possibility of benefit was tiny and remote, while the possibility of triggering a cascadeof further diagnostic tests and treatments incurring further risks was substantial. This single-center study used standardized patient instructors, a creative intervention, andwewere surprised and disappointed that it was not more successful in reducing diagnostic test ordering. The instantaneous feedback fromstandardizedpatient instructors, coupledwith training inapatientcentered approach for explaining topatients thedownsides of unnecessary testing, has the feel of an effective intervention. However, the problemof excessive use of diagnostic tests and imagingmaybe toodeeply ingrained inmedical and training culture to be improved by episodic interventions. A few educational sessions on low-value or no-value care and unnecessaryorderingare easily forgotten inanenvironment that is geared to alwaysdoingmore testing, andassuming that earlier andmore information is always better. All of us who take care of patients and those who teach residents need to consistently discuss risks andbenefits for diagnostic tests and include the potential harms of testing and downstream consequences in the calculation. We need to educate our trainees in patient-centered testing and not encourage pursuit of every problem in the differential diagnosis, no matter how remote. This questioning of medical tests needs to become an integratedpart ofmedical training,modeled everyday, rather than aone-timeeducational intervention. It is encouraging to see initiatives aimed at culture change, such as the Costs of Care,2 from a young generation of leaders in medical education. We all must play a role to be successful in our efforts to bring patients medical care that is of high value.