With COVID-19 restrictions lifting and traveling becoming a norm again, there seem to be more and more patients electing to seek investigations and medical care abroad. In my opinion, many patients are seeking over-investigations and providing us with full-body MRI reports and a panel full of lab results to dig through and deem what is necessary for follow-up in our publicly funded system.
The issue is multifaceted. Patients traveling for medical care and paying out of pocket expect thorough examinations and specific tests or scans. The providers ordering the tests do so because that’s what patients expect when they present to their clinic or hospital, especially when patients may have other places they can choose to go. With advances in medical technology, it has become easy for providers to order a wide array of tests and scans without having to ask questions about medical symptoms or putting things in context. Often, the more tests ordered, the more financial incentives there are as well.
Patients then bring back long reports of their findings from different countries, and as family practitioners we are obligated to follow up on pertinent findings. The difficulty lies in identifying what is medically necessary and balancing that with patient expectations and wise use of resources. With our medical system already strained, over-investigation contributes to increased health care costs and allocation of limited resources. In turn, this can divert resources away from patients who require more urgent care. Excessive testing can also lead to high rates of false positives, leading to more invasive procedures or treatments that may not be needed, potentially causing physical harm and unnecessary anxiety. Not to mention the limited time we have in the office: a 15-minute appointment is not sufficient to address the multiple concerns these reports can highlight. I struggle to be efficient when trying to interpret these medical reports, and it can be time-consuming to explain to patients what is and isn’t deemed necessary. As a clinician, it has been helpful to use evidence-based medicine and support from various practice guidelines to guide these discussions. For example, I found the Choosing Wisely Canada campaign (https://choosingwiselycanada.org) helpful in guiding my clinical decisions about whether to pursue certain tests.
In the end, what matters most is patient health outcomes. Has over-investigation been shown to lead to better health outcomes? Not necessarily. Although the comparison is obviously more complex, as an example, in the US, where there is a multipayer system and patients with the financial means can easily access tests and scans directly, it has not been shown to improve life expectancy on a population level. As per World Health Organization data, the healthy life expectancy at birth is 71.3 years in Canada, compared with 66.1 years in the US. This highlights the importance of focusing on health outcomes rather than simply the availability of tests and scans.
Even armed with knowledge and evidence to support clinical decisions, it is still a delicate balance between patient expectations, evidence-based medicine, and resource management. Often it feels impossible to fulfill all aspects, especially given the constraints of our medical system. The problem of seeking over-investigations has impacts not only at the patient level, but also for clinicians and the system as a whole.
—Yvonne Sin, MD
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1. World Health Organization. Healthy life expectancy (HALE) at birth. Accessed 30 September 2023. www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-hale-healthy-life-expectancy-at-birth.
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