New study examines issue of assertive patients demanding tests

February 23, 2015
by John W. Mitchell, Senior Correspondent
Dr. Scott Rich, an internal medicine specialist who is now a hospitalist at St. Marys in Grand Junction, Colorado, like all doctors, regularly fielded requests from patients for specific diagnostic tests, usually imaging studies.

“Patients with back pain often request an X-ray or MR. Family or friends have suggested they ask for it or they have read it on the Internet,” Rich told DOTmed News. “But 90 percent of the population gets unspecific back pain at some time. The protocol is to wait two months because 80 percent of such outpatients get better regardless of what we doctors do.”

Now a new study, "Patient Demands and Requests for Cancer Tests and Treatments", by authors Dr. Keerthi Gogineni, Katherine L. Shuman, Derek Chinn, Nicole B. Gabler, Dr. Ezekiel J. Emanuel,out this month in JAMA Oncology, has addressed the longstanding issue of “assertive patient behavior” and testing.

The study looked at oncology patients — who are typically not cared for during treatment by primary care physicians such as Rich — and found that they are not as demanding as oncologists had anticipated.

In the study patients requested a test or treatment, about 50 percent were imaging, in nine percent of encounters with clinicians. The authors wrote about the study, "There were 5050 patient-clinician encounters involving 3624 patients and 60 clinicians. Overall, of the 5050 encounters, 440 included a patient demand or request for a medical intervention. In only 50 of the 440 encounters with demands did the patient demand or request clinically inappropriate interventions."

A related earlier study in 1999 on “assertive patient behavior" ("Patient assertiveness and physician decision-making among older breast cancer patients") found a tendency in physicians to order full tumor staging in older breast cancer patients from socio-disadvantaged backgrounds who insisted on the test.

However, unlike the recent study, the earlier study was not compiled from actual patients, but various scripted patients who were pre-recorded on videotape for physician review.

Avoiding unnecessary imaging tests reduces patient exposure to radiation and helps control health care costs, Rich recommended.

He advised that doctors, who know more about the cost- and risk-to-benefit ratios of tests, behave differently from such assertive patients.

“Cancer, pulmonary and heart patients are bit different, but I saw all of these type patients either pre- or post-treatment,” said Rich. “In general, based on my own experience caring for doctors, as well as studies that have been done, physicians who are patients are much less likely to ask and instruct their doctor about the specific care and testing they should receive. This is true for themselves and their families.”