Re: Pressed to test

Issue: BCMJ, vol. 55, No. 9, November 2013, Page 411 Letters
By: Robert Shepherd, MD

Dr Richardson asked if one would order cortisol levels because a patient told her that her naturopath said she needed them checked, order hormones for someone who wants to start bioidentical hormones, order X-rays of the back because someone’s chiropractor wanted them ordered, or order a cervical MRI because someone’s massage therapist wanted the imaging done [Pressed to test: How should GPs respond? BCMJ 2013;55:312].

What I would do for each of these patients is to try to generate a SOAP note for the original problem, then review what tests, if any, I would order for that particular assessment. I intervene (that is, order a test, request a consult, or even ask a question) if I am pretty sure the intervention is going to help the patient. If I don’t think the intervention is likely to help, I don’t intervene. If the patient described in the above four scenarios is healthy, I probably would not order the test. I would review with the patient that testing can cause harm. For example, if we find something on testing and the patient has a new diagnosis, we may feel obliged to follow up with more testing and perhaps also treatment. I don’t need to order a lumbar radiograph on a 60-year-old to know that he or she probably has disc space narrowing and osteophyte formation. Why give the patient a label that may cause worry, and which will not lead to useful treatment? If a patient insists I order a test that I don’t think needs to be done (commonly, PSA or lipids), I fill out the requisition for the test and mark clearly, “patient to pay.”

GPs in British Columbia have great freedom of professional action. Our colleagues in the United States express frustration because they are allowed to order a narrow range of tests and therapies for disease-related categories. It is not sustainable for health care spending to increase with every provincial budget. If we in BC manage patients in an empathetic, elegant, and slightly frugal manner, we can provide good care and hopefully not contribute to a situation in which the legislature feels compelled to limit the action of doctors in arbitrary and unhelpful ways.
—Robert Shepherd, MDCM
Victoria

Robert Shepherd, MD. Re: Pressed to test. BCMJ, Vol. 55, No. 9, November, 2013, Page(s) 411 - Letters.


Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.


For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

Leave a Reply