“Doctor, can I get an MRI?” ... Not so fast


In today's complex and often chaotic world, there is more of just about everything—more information, more choices, more products, more news, and more decisions to make. But as the old adage goes, sometimes less is more. When it comes to unnecessary screening and testing, this adage in many cases holds true. I am certain that you have had patients present to you with the latest information that they have uncovered from “Dr. Google,” or patients who feel that whatever their health plans cover, they should get without question. Or even more commonly, you have had to repeat a test previously done elsewhere but whose results are not readily retrievable in the middle of the night or on a weekend.

ACP has long been a proponent of practicing high-value care. Our broad High Value Care initiative addresses cost-of-care issues and pushes for the elimination of overtesting and assessment of the benefits, harms, and costs of an intervention to determine whether it provides good value based on the best available evidence. The College has been addressing these issues from a broad platform using various angles for physicians, medical students, and residents. This includes developing clinical recommendations and best practice advice papers and addressing public policy, performance measures, and ethical issues, too. Other educational resources include online cases and a care coordination toolkit, results of collaboration among ACP, ACP's Council of Subspecialty Societies, and patient advocacy groups to facilitate more effective and patient-centered communication between primary care and subspecialist doctors.

ACP's goal is to determine whether diagnostic tests and treatments for various diseases provide good value, i.e., medical benefits that are commensurate with their costs and outweigh any harm. Recently, I had the honor of acting as primary spokesperson for the release of ACP's policy paper—part of our HVC initiative —on screening for 5 common cancers. It was an illuminating experience, speaking to reporters on the topic of this particular paper and on HVC in general. My takeaway was that the media are starting to “get it.” They are writing about the topic on a regular basis and are asking the right questions to formulate their articles. While this is encouraging, where we really need to continue to press on is in the examination room in our interactions with our patients. We need to educate constantly, encouraging shared decision making with patients and not ordering screening tests out of habit.

And how can we possibly begin to “practice what we preach” if we are not training our students and residents and modeling best practices around this issue? As noted in a recent MedPage Todayarticle, an ACP survey found that only about 25% of internal medicine residents said they know where to find cost estimates for tests and treatments. The survey was designed to determine the knowledge of, attitudes toward, and self-reported practice of HVC among U.S. internal medicine residents. We must continue to work toward improvements in these areas, and, in fact, ACP collaborated with the Alliance for Academic Internal Medicine to develop an HVC curriculum for educators and residents. ACP has also worked with MedU on a curriculum for medical students. These are strong steps in the right direction, but more can be done.

The elephant in the room around this issue can be captured in 1 word: cost. It is a real issue that unless addressed will send our profession and even our society into a financial tailspin from which we'll never be able to dig out. ACP is committed to doing our part to help bend that cost curve and to reduce the unsustainable financial burdens to our health care system.

While the College has been a leader in encouraging cost-conscious care, the concept has also gained traction within the medical community at large, and other medical societies have put their weight behind these issues, too. Recently, the American Society of Clinical Oncology (ASCO) published an ASCO Value Framework that assesses the value of new cancer treatment options based on clinical benefit, side effects, and cost. Standardized tools will help physicians talk with their patients about the value of new cancer therapies compared with established treatments.

We have a real opportunity as internists and physician leaders to change the way health care dollars are spent, to provide the best possible patient care, and to educate our patients about the benefits, harms, and costs of health care. We can stem the tide of overtesting and overtreatment and make doing so our practice, every day and with every patient. Together, along with our patients, we can pursue care that improves health, avoids harms, and eliminates wasteful practices. I am personally committed to this and urge you to join me on this important and worthwhile journey toward a better way of practicing medicine, for our own sake, to sustain our profession, and, mostly, for our patients' sakes, so that they can benefit from the care they deserve: high-value care.