Why Low-Value Testing Outlasts Every Campaign Against It
Physicians generally know which tests rarely help. They order them anyway, for reasons that have more to do with defaults, habits, and fear than with knowledge.
Ask a room of physicians whether routine preoperative labs help healthy patients having low-risk surgery, and most will say no. Look at the order sets in that same hospital and you may find those labs built right in. The gap between what clinicians know and what they order is one of the most persistent puzzles in medicine, and education alone has rarely closed it.
The real drivers
Low-value testing survives because it is easy, it feels safe, and it is rarely punished. The forces behind it tend to fall into a few categories.
- Defaults. Order sets and panels bundle tests together, so the path of least resistance includes things no one consciously chose.
- Fear of the miss. A normal result feels like protection, even when the pretest probability was already very low.
- Patient expectation, or what clinicians assume patients expect, which is not always the same thing.
- Fragmented care. Without easy access to recent outside results, repeating a test can feel simpler than hunting for it.
Campaigns like Choosing Wisely gave clinicians shared language for these conversations. They work best when paired with changes to the environment in which orders are placed.
Change the defaults
The most effective interventions often involve the least persuasion. Remove unnecessary tests from order sets. Require a brief indication for tests that are frequently overused. Show recent prior results at the moment of ordering. Let clinicians see their own ordering patterns compared with peers, framed as information rather than punishment.
Each of these makes the right choice slightly easier and the reflexive choice slightly harder. That small shift, repeated across thousands of orders, is where stewardship actually happens.
Talk about the downstream
The strongest argument against low-value testing is rarely cost. It is the cascade. An unnecessary test can produce an incidental or borderline result, which prompts another test, a referral, sometimes a procedure, and a great deal of worry. A test ordered to relieve anxiety tends to create more of it when the result comes back borderline.
A test ordered to relieve anxiety tends to create more of it when the result comes back borderline.
Explaining this to patients works better than many physicians expect. "This test is more likely to find something harmless that worries us both than something that helps" is honest, and many patients appreciate the candor.
This week, pick one test you order out of habit. Before each order, ask what result would change your plan. If the answer is none, you have found your first stewardship project.
Dr. Okafor is a general internist and contributing editor who writes about primary care redesign and the economics of the exam room.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
