Do Doctors Say No To High-Dollar Requests?

November 10, 1997

A young woman with fatigue worries that she has multiple sclerosis, like her friend. Because of these concerns, she asks the doctor for a magnetic resonance imagery (MRI) of her head or a referral to a neurologist. Her history and physical examination make MS very unlikely.

How do physicians respond to requests for expensive tests that are likely to have very low yield?

To find out, researchers inserted into the schedules of 39 physicians an actor trained to present the same scenario to each doctor. While the physicians agreed to participate in the project, they did not know who the standardized patient was.

Thomas H. Gallagher, MD, of the Washington University School of Medicine in St. Louis, and colleagues at the University of California San Francisco and The Permanente Medical Group of Northern California, published their results in the November Journal of General Internal Medicine.

They found that only three of the 39 physicians agreed to order the MRI, but eight told the patient they might order one in the future. More surprising, 20 of those who refused the MRI request did agree to refer the patient to a neurologist, also not strictly medically indicated.

Few physicians used recommended communication skills, however. Only 10 percent of them asked the patient to say more about her friend's experience with MS, only 25 percent verbalized that MS is scary, and only 33 percent encouraged the patient to call back with questions or concerns.

The researchers noted that their sample size was small, but sufficient to warrant a caution to physicians that they should respond to such requests in ways that provide high quality care and contain costs, while also maintaining patient satisfaction.

They urged physicians to respond to requests for unnecessary services by communicating with empathy and by expanding patient involvement in the plan for care.

The project was supported by grants from the Walter and Elise Haas Fund and the Robert Wood Johnson Clinical Scholars Program.

The Journal of General Internal Medicine (JGIM), a monthly peer-reviewed journal and the official journal of the Society of General Internal Medicine, publishes original articles on research and education in primary care. For more information about JGIM, contact: Margo Alderton, (215) 823-4471.

Posted by the Center for the Advancement of Health ( For information about the Center, contact Richard Hebert, 202-387-2829,

Center for Advancing Health

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