Responding to requests for unnecessary tests

Most patients come to see you for the benefit of your clinical expertise – but what happens when they present with a shopping list of referrals, or perhaps ask you to provide clinical care that may be unsafe?
 
Case study
Jenny is a new patient. She has booked a double appointment, which leaves time to discuss her past medical history and address her presenting problems. Jenny is polite, on time, and hands you a piece of paper as she sits down.
 
‘Hi doctor – I know you’ll want a full medical history, but it’s a waste of your time and mine. My friend is a naturopath, and she understands my symptoms. I need you to order the tests because I can’t pay for them privately.’
 
You glance down the long list of obscure tests – most of which you’ve never ordered before. You try to elicit more information, but Jenny is having none of it.
 
‘Look, I just want the tests. And while I’m here, can you cannulate me and administer this,’ she says, pulling out a bag of orange fluid with foreign writing on the side.

You ask what it is, with some trepidation.
 
‘It’s a special vitamin mix I ordered online from Europe.’
 
Discussion
There is a good reason why you will often see the word ‘necessary’ when it comes to the provision and funding of medical services.
 
Good medical practice: a code of conduct for doctors in Australia encourages doctors to ensure ‘the services you provide are necessary and likely to benefit the patient’, as noted under Section 7.2: Wise use of healthcare resources.
 
This in turn references Choosing Wisely Australia – an NPS Medicinewise initiative hosted by the Australian Commission on Safety and Quality in Health Care, which aims to reduce unnecessary tests, treatments and procedures through better education.
 
Doctors should exercise clinical judgement when it comes to requesting tests under the MBS.
 
Explanatory note PN.0.2 of the MBS defines an ‘Excessive Pathology Service’ as ‘a pathology service for which a Medicare benefit has become or may become payable and which is not reasonably necessary for the adequate medical or dental care of the patient concerned’.
 
Pathology referrals are monitored by Medicare and, if pathology ordering is found to be excessive, you could be referred to Professional Services Review.
 
Follow-up can also be problematic. If a patient is reluctant to engage with you clinically, how can you adequately follow up any abnormal results? It is also inappropriate for a patient to add their own tests to your pathology form.
 
And, as for administering an unknown orange substance, we recommend you only ever administer medications that you would prescribe.
 
If in doubt, contact our Medico-legal Advisory Services team for advice.
 
The RACGP also has some excellent resources on responding to patient requests for clinically inappropriate tests.
 
The case study is fictitious. Any resemblance to real persons, living or dead is purely coincidental.
 
This article is provided by MDA National and has been independently reviewed by newsGP. They recommend that you contact your indemnity provider if you need specific advice in relation to your insurance policy or medico-legal matters. Members can contact MDA National for specific advice on freecall 1800 011 255 or use the ‘contact us’ form at mdanational.com.au.

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