Takeaway
When patients request a test that you think is unnecessary, be curious and elicit why they feel this way. Then address their concerns about the condition being screened.
Lifelong Learning in Clinical Excellence | December 7, 2023 | 2 min read
By Pavitri Dwivedi, DO, MPH, Johns Hopkins Medicine
The last patient of my day pulled out her list of questions. Before she let me read it, my eyes quickly glanced at questions about tests. I saw in bold red ink: missing tests. All I could focus on was the word “missing.” She seemed proud of her diligent research on screening tests and imaging, waiting for my acknowledgment. She told me I should order them.
This was my first-time discussing overuse of screening tests in older adults and my first opportunity as a geriatrician to empower and educate my patient. Here are some pearls from our discussion:
1. Always use a patient-centered approach.
First elicit why the patient believes they need a screening test, what concerns they may have about the test or the condition that is being screened, what their understanding is about the benefits and harms, and whether it’s a test they have had in the past.
2. Consider the lag time to benefit for a screening test relative to the patient’s life expectancy.
Lag time to benefit is defined as the time between the preventive intervention to the time when improved health outcomes are seen; the lag time to benefit for breast, colorectal, and prostate cancer screenings are ten or more years but may be as short as two years for lung cancer screening. If the lag time to benefit for an intervention is longer than the patient’s life expectancy, then the patient is unlikely to benefit but likely to still be exposed to the short-term harms and burdens of the intervention. In such scenarios, suggest that the screening test is no longer necessary. Discussing that the patient may not need a test can be challenging. Helpful communication strategies include framing the conversation as shifting priorities to focus on other care that is more impactful and mentioning that the baseline risk for the screened condition is very low—this is because in a patient with limited life expectancy, they have a lower risk of developing the condition, such as a life-threatening breast cancer.
3. Emphasize that it’s ultimately the patient’s choice.
Additionally, emphasize that your recommendation is based on what you know of the evidence and of the patient as an individual. Have their best interest in mind.
As I sat next to her explaining my reasoning, I sensed a new level of calmness in her energy. To my surprise, her joy only grew more as she crossed out the missing tests on her list one by one. She left the visit with gratitude. I walked away with a smile.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.