As I entered the hospital to begin an Internal Medicine rotation, I was eager to make use of the array of diagnostic tests I had spent the past year analyzing in board review questions. The thought of, “Will this information change our care plan?” was not considered when the chance arrived to diagnose classic berylliosis in an elderly patient with lung disease and a history of work in the aerospace industry. As students, the opportunity to diagnose conditions we have read about in textbooks is thrilling, and erring on the side of restraint and reflection is often not our first response. Although the case is sometimes made to obtain a test “for the sake of learning,” uncritical ordering of tests may represent the beginnings of a more important issue: the unwitting embrace of medical overuse – that is, the provision of medical interventions where benefits do not outweigh the harms.
Daily labs are commonly ordered on hospitalized patients. While such tests may be indicated when patients are acutely ill and the clinical picture is unclear, there are many times when this is not the case. When a patient is stable and awaiting discharge, the plan from the previous day is often maintained, unaffected by the daily labs reported on rounds by a diligent student or intern. With countless other concerns related to patient care, I began to understand the appeal of “daily labs” and perhaps how it came to be so commonplace. The results were always there, but could be glossed over in stable patients. The practice made sense until I became aware of the unintended harms that can come from daily labs.
At the most basic level, daily lab draws means increased discomfort for patients. In addition, daily lab orders, which are intended to save valuable time and energy, require more of the team’s attention. Physicians must review the results of every test they order and are charged with the additional task of responding to unexpected abnormalities. Spurious results or unexpected changes, often reflecting clinically unimportant variations in human physiology, can lead us down a rabbit hole of further testing and cloud the clinical picture. Not only are health care workers impacted, but this seemingly benign practice is rarely regarded for what it truly is – an invasive procedure for which risks and benefits should be weighed. Patient discomfort along with the risks of bruising, thrombophlebitis, infection and hospital-acquired anemia should all play into the decision as to whether a given laboratory test is warranted. Additionally, the opportunity costs associated with time spent by nurses performing blood draws and the lab staff completing the tests are not inconsequential. With an estimated 750 billion wasted health care dollars spent annually in the U.S., the overall financial impact of this practice is considerable.
Some institutions have begun to tackle this issue. In 2016, Vanderbilt University Medical Center instituted a one-time twenty minute educational session on this topic for house staff on inpatient general medicine and surgical services. They taught about how to choose medical tests wisely and then provided each participant with weekly feedback on the number of labs they had ordered and their peers’ success in reducing recurrent lab orders. Health care providers were also given pocket cards to carry which detailed the financial cost of routine labs at their institution. This program was successful in reducing the number of routine labs ordered while also increasing the number of patient “lab-free days” without any negative impact on length of stay, ICU admissions, readmission rates or in-hospital mortality.
Other interventions have included adding a “labs needed for tomorrow” section in the daily progress note, as described in a study conducted at Massachusetts General Hospital. Clinicians were discouraged from writing recurring orders, and the new charting section provided a built-in check to encourage reflection about the necessity of each ordered test. The Royal Victoria Hospital in Montreal also instituted a “time-out” during evening sign-out as a period to actively engage in discussion about the lab work necessary for the next day. In the 14 months following this intervention, they were able to save $50,657 over the course of 985 admissions.
The mindset of health care providers also plays an important role in the overuse of health care interventions. An article recently published in JAMA Internal Medicine examined how different provider types view overuse of laboratory testing at Memorial Sloan Kettering Cancer Center. 54% of respondents reported that superfluous testing was done simply because they believed that their attending physicians wanted these tests to be done. Interestingly, 84% of attending physicians surveyed reported that they were comfortable cutting back on laboratory testing. This stark contrast illustrates how misperceptions of attending physicians’ expectations also contribute to unnecessary lab work orders.
There are many drivers underlying the overuse of daily labs in the hospital. They include inexperience of trainees, diagnostic uncertainty, time constraints, a lack of knowledge about cost and a culture of care promoting the idea that more is better. Although some institutions are beginning to address these issues, one area not commonly considered is the role medical students can have in shifting the culture of inpatient lab testing. A program at Medical College of Wisconsin trained third-year students to serve as “health value officers” and initiate team discussions about the value of the care being provided. This initiative led to a decrease in charge-master billing equaling an average of $53.80 per patient day and $269.10 per hospitalization. Perhaps more dramatically, 50% of faculty and 56% of residents surveyed said this experience would impact how they practiced in the future.
As students, we are responsible for fewer patients than residents and have more time to carefully consider the value of the lab orders placed for hospitalized patients. Acting as new members on a medical team grants students the opportunity to identify which clinical habits are driving overuse. By educating ourselves about the harms associated with over-testing and encouraging discussions about the value of the care we provide, medical students have the ability to ensure our patients receive the best possible care.