How do physicians respond to patient's requests for costly, unindicated services?
OBJECTIVE
To determine how physicians respond to a request for an expensive, unindicated test.


METHODS
Cross-sectional observational study.


METHODS
Four sites of a group-model HMO.


METHODS
Thirty-nine internist volunteers.


METHODS
A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unannounced into physicians' regular schedules. The patient's only complaint was fatigue with no neurologic symptoms.


RESULTS
Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians "had no idea" that the patient they saw was the standardized patient, and the remaining four participants (10%) were only "somewhat suspicious." Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future. All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%) also cited the test's expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized patient's concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patient about their friend's experience with MS. A few physicians appeared to dismiss the patient's concerns, such as by telling the patient they were being "paranoid."


CONCLUSIONS
Few physicians agreed to a standardized patient's request for a medically unindicated MRI, but more than half agreed to refer this patient to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction.
Gallagher
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Robert Wood Johnson Clinical Scholars Program, Department of Medicine, University of California, San Francisco, USA.
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Chesney
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Christensen
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D000328:Adult; D003142:Communication; D016265:Conflict of Interest; D005260:Female; D006279:Health Maintenance Organizations; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000175:diagnosis; D016544:Patient Simulation; D010817:Physician-Patient Relations; D019564:Unnecessary Procedures / Q000191:economics