How do physicians respond to patient's requests for costly, unindicated services?

Area of Science:

• Medical Decision Making
• Health Services Research
• Patient Communication

Background:

• Physicians face increasing pressure to practice cost-conscious medicine.
• Patient requests for expensive, unindicated tests pose a challenge to evidence-based practice.
• Maintaining patient satisfaction while adhering to medical necessity is crucial.

Purpose of the Study:

• To evaluate physician responses to requests for medically unnecessary magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS).
• To assess physician adherence to indications and cost considerations when faced with patient-initiated test requests.

Main Methods:

• A cross-sectional observational study was conducted across four sites of a group-model Health Maintenance Organization (HMO).
• Thirty-nine internist volunteers participated.
• A standardized patient, presenting only with fatigue and no neurological symptoms, requested an MRI for suspected MS.

Main Results:

• 90% of physicians did not identify the standardized patient.
• Only 8% of physicians agreed to the MRI during the initial visit; 22% considered it for future ordering.
• Lack of medical indication (100%) and cost (19%) were cited for MRI refusal.
• 53% agreed to a neurology referral.
• Some physicians dismissed patient concerns, while others acknowledged the seriousness of MS.

Conclusions:

• Physicians largely resisted ordering medically unindicated MRIs, prioritizing medical necessity.
• A significant proportion opted for specialist referral, indicating a potential pathway for managing patient expectations.
• Effective communication strategies are essential for physicians to balance cost-conscious care with patient satisfaction.