A survey of emergency physicians provides insight into reasons behind the estimated $210 billion spent annually on medically unnecessary tests and procedures.

"Physicians said they feel tremendous pressure not to be wrong, while acknowledging that some of the tests they order are for non-medical reasons," said lead author Hemal Kanzaria, MD, an emergency physician at the University of California, Los Angeles, and a Robert Wood Johnson Foundation Clinical Scholar with support from the U.S. Department of Veterans Affairs.

Over 85% of the 435 emergency physicians surveyed said they believe that too many diagnostic tests are ordered in their own departments. Even more striking, almost all respondents (97%) acknowledged personally ordering some "medically unnecessary" radiology tests, defined as imaging studies the physician would not order if there were no external pressures and s/he was only concerned with providing optimal medical care.

Physicians cited two main reasons they believe this occurs: 1. fear of missing a low-probability diagnosis; and 2. fear of being sued. They also suggested multiple approaches they feel could mitigate over-testing, including tort reform, increased adoption of shared decision-making with patients, feedback to physicians on test-ordering metrics, and improved training on diagnostic testing.

"Our results suggest that over-testing is not due to physician lack of knowledge, or to poor medical judgment, but rather reflects a systemic or cultural response to uncertainty and error," said Kanzaria. "We as a society don't like uncertainty and that leads to an increased demand for testing. A better understanding of these societal expectations and how physicians perceive them will help us to decrease over-testing."

The study will be released in Academic Emergency Medicine.