How do physicians respond to patients’ requests for costly, unindicated services?

Objective  To determine how physicians respond to a request for an expensive, unindicated test. Design  Cross-sectional observational study. Setting  Four sites of a group-model HMO. Participants  Thirty-nine internist volunteers. Intervention  A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unanncounced into physicians’ regular schedules. The patient’s only complaint was fatigue with no neurologic symptoms. Measurements and main 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 patients, 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 patients 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 patients to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction. Presented in part at the Robert Wood Johnson Clinical Scholars Program national meeting, November 1995 and the Society of General Internal Medicine national meeting, May 1996. Supported by grants from the Walter and Elise Haas Fund and the Robert Wood Johnson Clinical Scholars Program.