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 [9]].

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