title: What are tests for? The implications of stuttering steps along the US patient pathway.
abstract: This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense.
authors.affiliation: Department of Sociology and Public Policy, Aston University, Birmingham B4 7ET, United Kingdom. Electronic address: Jonathan.tritter@aston.ac.uk.
authors.forename: Jonathan Q
authors.initials: JQ
authors.lastname: Tritter
authors.affiliation: Department of Health and Behavioral Sciences, University of Colorado, Denver, United States.
authors.forename: Karen
authors.initials: K
authors.lastname: Lutfey
authors.affiliation: New England Research Institute, Boston, United States.
authors.forename: John
authors.initials: J
authors.lastname: McKinlay
mesh_terms: D057210:Delayed Diagnosis; D003695:Delivery of Health Care / Q000458:organization & administration*; D003955:Diagnostic Tests, Routine / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D018802:Patient-Centered Care; D010821:Physicians, Family / Q000523:psychology*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D017009:Professional Autonomy; D036301:Qualitative Research; D011787:Quality of Health Care; D014481:United States
keywords: Diagnostic testing; Evidence based medicine; Health insurance; Patient-centred care; Physician autonomy; Uncertainty; United States