'Appropriate' Diagnostic Testing: Supporting Diagnostics with Evidence-Based Medicine and Shared Decision Making

Abstract

Background: Evidence-based medicine is an important approach to avoiding care that is unlikely to benefit patients in both the treatment and the diagnostic context. The medical evidence alone may not determine the most appropriate care decision. Patient interests are best served when the advantages and risks of a diagnostic test are viewed through the lens of the patient’s values. That is, the paradigm of evidence-based medicine should be complemented by the paradigm of shared decision making.

Analysis: Diagnostic testing may offer physiological and psychological benefits. Clinicians should also discuss the potential harms, however, which may be physiological (e.g. radiation or scarring), psychological (e.g. anxiety), and financial (e.g. cost-sharing burdens). All three of these concerns are compounded by the risk of false positives or incidental findings that are not serious, but which require decisions about further testing or treatment.

Conclusion: We suggest that patient-centered decision making around diagnostic testing involves a two-step inquiry: (1) Is the test medically appropriate? Does the available evidence documenting short- and long-term risk and benefits support the test for its intended use, given the patient’s characteristics and symptoms? (2) Is the test appropriate for this patient? Has the provider initiated a conversation about tradeoffs that helps the patient evaluate whether the balance of risks and benefits is consonant with the patient’s own values and preferences? Potential benefits and harms to consider include the physiological, the psychological, and the financial.

Keywords: Shared decision making, patient-centered decision making, evidence-based medicine, diagnostic testing, medical ethics, bioethics