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 Step-By-Step Guide
Tips and Traps
Resources
Step-By-Step Guide
How to Choose Additional Tests
As the next step in the case review, you have been asked to critique Dr. Chang's work in ordering additional tests. It is your job to evaluate whether Dr. Chang chose the appropriate diagnoses for further investigation, whether she chose the correct tests, and whether she used the correct reasoning.
When a physician reaches the limits of what he can determine through questioning, observing, and examination, s/he can take advantage of the many technologies available to “see” inside the body. While the tests available today can do some amazing things, not every patient needs every sophisticated, and often expensive, test. Some physicians are more selective in choosing tests, by being clear about what they really need to know and when they need to know it, by being familiar with what each test can tell them, and by balancing the cost (in terms both of financial and physical risk to the patient) of the test against the need in each case.
Use the step-by-step instructions that follow to critique Dr. Chang's choices for further testing at this time and her rationale (or reasons) for these choices.
Getting Started
- Get prepared to do your work in this task. Go to the email sent to you by Dr. Mendoza and download the attachments. You will need the following throughout the task:
- Additional Tests Form - This form contains Dr. Chang's list of diagnoses from the differential that she considered necessary to test at this time. First, Dr. Chang provides her reasons for choosing some diagnoses to explore further with tests. Then, she describes her reasons to choose particular tests over others.
- Critique Template of the Additional Tests - This is the form that physicians at Lakeshore Hospital use to critique a fellow physician’s choices of tests in a case; it contains questions for you to answer about each of Dr. Chang's choices.
- In addition, you may need to refer back to materials from previous tasks. For example, you may want to review what information Dr. Miller already has about this patient's injury and what information he still needs. The Differential Diagnosis Form can be particularly useful.
- Carefully review the email from Dr. Mendoza to become familiar with the goals of this task.
- Read through the Additional Tests Form and the Critique Template to familiarize yourself with the contents of each.
- Work with your teammates to create a quick list of the questions that you have about how physicians decide which tests to do; they should be questions that you would like answered as you complete this task. These questions may help you to focus your thought process throughout this task.
- Read about the thinking process physicians use to test the diagnoses in a differential.
- Read section 4 of the Diagnosis and Treatment Process document: Test the diagnoses to confirm or disconfirm them . This section explains the process a physician follows when testing the diagnoses s/he hypothesized in the differential. It will also be helpful to review the introduction to this document, which contains some important comments that are relevant to testing.
- Explore the resources related to Ordering Additional Tests in the Resources (above).
- It is a good idea to take notes on any material you find that answers the questions you raised or that you believe may help you to critique Dr. Chang's testing choices.
- For additional guidelines that physicians follow, see the Tips and Traps (above).
- Organize your team to do the critique.
- If you need a refresher on getting organized, refer back to the step-by-step in Task 1.
Completing the Critique Template: Section A (Do you agree with Dr. Chang's rationale for wanting to test further?)
You will notice that Dr. Chang did not order tests for every diagnosis in her differential. Instead, she selected the diagnoses for one of four reasons:
- The condition is a “must-treat” condition—one that must be detected as quickly as possible to protect the life and limb of the patient
- The condition is very common, suggesting that it is a likely candidate as a diagnosis for this patient
- The condition can be tested inexpensively (or can be detected using a test already being used for another condition)
- The condition is highly likely based on the initial findings
To determine whether you agree with Dr. Chang's selections, look at the diagnoses she chose to focus on. For each diagnosis, ask yourself the following questions:
- Is this a diagnosis that must be taken care of right away?
- Is this a common condition?
- Is this a diagnosis that is simple and inexpensive to test?
If the answer to the first question is yes, the relevant test will need to be ordered regardless of cost. If the answer to the first question is either less clear or “no,” a judgment call must be made. The steps below will help guide you through this decision.
- First, do research to make a decision about the level of urgency for each diagnosis. You'll need to revisit the resources available for each diagnosis, including the DATA (Diagnosis and Treatment Archive), websites, and your notes, and do some research. The following are questions that you should consider for each diagnosis:
- What is the typical progression of this illness or condition? For an injury, what is the average healing time?
- Are there any consequences of going without treatment or getting the wrong treatment for a period of time? How serious are they? Are there any potential complications?
- How quickly does proper treatment need to be implemented in order to be effective?
- A condition is a must-treat if it could endanger the patient if left alone, even for a short period of time, or that would cause lasting damage to the patient if left untreated.
- In other cases, decisions can be less clear-cut in terms of urgency to test and treat. Perhaps missing or delaying the diagnosis could cause the patient to have a longer period of healing and pain, but would not be life-threatening. The lifestyle and values of the patient and family could play a role as well. For example, what if a certain injury, while just a nuisance for most people, could seriously interrupt a competitive athlete's career? A physician must weigh such concerns along with the financial costs and risks of high-tech testing.
- If testing is relatively simple, easy, and inexpensive, the physician can go ahead with testing, if s/he has ample reason to suspect a diagnosis.
- If testing is very expensive and waiting will not harm the patient over the long term, it may be appropriate not to test a certain diagnosis, but instead to see how the patient's condition improves or deteriorates over a period of days or weeks.
- Go through the diagnoses that Dr. Chang considered for testing. See if you agree with her choices to test now (or not to test) and if you agree with the justifications for her choices. State whether you agree or disagree and explain why. Whether you agree or disagree, provide evidence from your research to support your opinion.
- If there are any other diagnoses that you think the physician should have investigated at this time, list them in the space provided in the table. Give your reasons why you think the diagnosis (or diagnoses) should have been tested. Provide convincing research evidence to support your opinions.
In order to do this, review Dr. Chang's differential to see which diagnoses Dr. Chang did not
consider testing at this time. If you suspect any diagnosis should have been considered for testing, put the diagnosis through the same series of questions posed in Step 1 above. If, based on your answers to these questions, you decide there is sufficient evidence to warrant testing for the diagnosis, list the diagnosis you feel was omitted in error and provide the evidence for your claim.
Completing the Critique Template: Section B (Do you agree with the test(s) the physician ordered?)
For each diagnosis, decide which test(s) you would recommend by following the steps below:
- Review what you know and what you still need to know about the patient with regard to the diagnosis. Decide what pieces of information, if any, are crucial for you to find out now.
- Investigate the different tests available that will help you to obtain the information you need. Some of the tests relevant to the diagnoses in this case include X-rays (radiographs), MRI, bone scan, stress X-rays, and CT scans.
- Use the DATA (Diagnosis and Treatment Archive), as well as other available resources, to find tests that help in determining each diagnosis. For each test, consider:
- What is this test best at revealing?
- When is this test most effective at revealing the information? (Can it detect a problem at the time of the patient visit, or must it be run after some period of time has passed?)
- Are there any other tests that are better at revealing this information?
- Are there any health risks associated with the test?
- What is the cost associated with the test, relative to other tests you might be considering?
- Decide which test(s), if any, will be best to order at this time.
- Remember, you should use the test with the least financial costs and health risks that will work sufficiently to give you the information you need. For example, you may not need the most detailed image of an injury if a less expensive test will provide the data you need.
- If a decision is not clear-cut, you can use decision-making strategies such as making a list of pros and cons, or creating a matrix in which you rate how well each test fits with your criteria.
If you determine that a test, while expensive and/or risky, is necessary, it is important to communicate well with the patient about the decision. In some cases, you may need the consent of the patient to proceed. This is called “informed consent."
- Compare your choice to the one the physician made, and write whether you agree or disagree and why.
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- If there were any other tests that you think should have been done for a diagnosis, list them and explain your reasons.
- If there are any other diagnoses that you think the physician should have investigated at this time, list them in the table. Fill in the test(s) that you think should have been done for each of the omitted diagnoses. Use the same rigor and detail in defending your own choices that you have just used to critique Dr. Chang's choice of tests.
Meeting to Exchange Feedback
1. Meet with your cohort (made up of all teams participating in the rotation) to discuss your findings and ideas. You will be assigned one or more sections of the critique form at the beginning of the meeting; your team will present your key ideas and lead the discussion of that section with the cohort
2. After incorporating any feedback you may have received during the cohort discussion, submit your work to your mentor. Be sure to save all of your work, regardless of whether you submit it to the mentor.
Tips and Traps
How to Order Additional Tests
- Physicians do test for conditions in the differential that might be life-threatening or harmful (cause lasting damage) if not promptly identified.
- Physicians do not generally look to start considering new diagnoses at this point in the process; they use the differential as a guide and look to identify the most likely diagnoses from among those listed. But if in considering a potential test an additional possible diagnosis is identified, physicians do account for this diagnosis in the differential.
- Once must-treat conditions are ruled out, physicians do not test every single condition until a definitive diagnosis is reached. Doing so in every case would be too expensive, incur too much wait time for patients and create an overwhelming demand for tests. Further, some high-tech tests might cause the patient discomfort or have health risks of their own.
- When planning what tests they will need, physicians do think about the diagnoses they hypothesized and identify what additional information will help them most. They think about what additional findings (beyond the interview and exam) ought to be present if a hypothesis is correct and then test for those. Or, they think about what additional findings should not be present and test for those as well.
- Physicians do stop testing when they are comfortable making a presumptive diagnosis, at least for the time being.
- Physicians do often stop when they know patients can safely wait a while to see if their symptoms improve.
- Physicians do think through the likely consequences of all of the basic options (test, treat without testing, or wait-and-see), especially the consequences of doing nothing/waiting, in order to help them decide what to do.
- Physicians do only order a test when it will affect their decision-making in some way. For example, if two diagnoses would receive the same exact treatment, it wouldn’t necessarily be worthwhile to use tests to find out which one the patient has. On the other hand, if a condition requires a specific treatment and that treatment should not be started unless the physician is certain about the diagnosis (for example, surgery to repair a structure or a medication with health risks), the physician does order the relevant tests.
- Physicians do communicate with the patient and family about the decisions to be made and consider the values of the patient and family when making decisions about testing.
Meeting to Exchange Feedback
- Do back up the points you make with your research and with strong, logical arguments.
- Do be open to hearing disagreement or different ideas from other teams. If your points generate some debate, then you know you have done your job well and hit upon an interesting issue. Both your team and other teams can learn from the discussion.
- Do listen carefully to the thoughts the other teams are sharing, and note how they are the same or different from your own. Remember that there is not necessarily a “right” answer that all physicians would agree with. Different physicians use different approaches.
- Do jot down notes to record what you learn in the discussion. Write any answers you found to the questions you and your teammates posed in the very beginning of this task. You may also note down any questions you still have about ordering tests.
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Diagnosis and Treatment Archive - Sports Medicine
What are the reasons for and against running an x-ray?