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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Medically Necessary Interventions

When you are evaluating and treating patients, one way to keep the process simple and relevant is to ask yourself “Is what I am doing medically necessary?”

What does that even mean? 2 things:

  1. Will the intervention change the outcome?
  2. Will the intervention reveal unnecessary information?

Often, providers of all types will perform interventions that are completely unnecessary. You need to ask yourself if what you are doing even matters in the grand scheme of your patients outcome.

Providers order unnecessary radiological imaging, labs, medications, supplies, and referrals all the time. Why is this? I think it is due to multiple things including laziness, defensive medicine, and just not understanding the broad picture.

It results in wasted money, time and exposing your patient to unnecessary dangers with over treatment.

So, what are some examples of unnecessary interventions that do not change the outcome for your patient? (Remember, use your clinical judgement. There are always multiple variables with every presentation that need to be accounted for).

  • You hear crackles in the right lower lobe of a 40-year-old male who has a low-grade fever, congestion and cough for 10 days. He is mildly ill but still ambulatory and looks fair. Is a chest x-ray necessary? I argue that it is not. It sounds like pneumonia, treat it. Are you not going to treat the patient if the chest x-ray comes back normal? That would be ill advised. You hear the crackles, right? I have seen normal chest x-rays and then seen a subsequent chest CT that showed the pneumonia. It was documented that crackles were in the lungs. It just should have been treated from the start. This would have saved money and prevented unnecessary radiation exposure.
  • A 30-year-old female comes in who has 2 children and a husband that tested positive for influenza A. She has body aches and congestion that started the morning of presentation. She essentially has a normal examination. Is testing her for influenza necessary? I would argue that it is not. She has exposure and symptoms, treat it for influenza if her exam is normal otherwise.
  • A 16-year-old male complains of sore throat and fever that started last night. Exam reveals +3 bilateral tonsillar swelling with exudate, an erythematous pharynx, and tonsillar lymphadenopathy. Is a rapid strep necessary? Again, I argue that it is not. It looks like strep with an acute onset, treat it.
  • A 50-year-old healthy male has abdominal cramping, nausea, vomiting, and diarrhea. He has co-workers with similar symptoms. Are stool studies, lab work, or imaging necessary? I do not think so. Symptomatic treatment and watchful waiting would result in the same outcome.
  • Referring everything out. A finger sprain does not need orthopedic intervention. A splint placed in your office is sufficient. The outcome does not change. Sending mild asthma to a pulmonologist is total over kill. You can prescribe the first line treatments. The outcome would not change. Unnecessary referrals delay treatment and waste your patients time and money.
  • Administering 8mg dexamethasone injections for allergy symptoms after the patient has exhausted other allergy medications. Did you know one 50mg prednisone tablet is just as effective? It is also cheaper and safer.

Critically think about what you are doing. Will the intervention you order change the outcome? Often times, it will not.

If a patient presents with a classic presentation of an illness, you can treat it without ordering unnecessary diagnostic tests. Remember, if it smells like cheese, looks like cheese, and tastes like cheese, then its cheese!

Do you know what the best treatment is for a large portion of the complaints you see? TIME. Give it some time. Your body is amazing at healing itself.

What about revealing unnecessary information that does not change the outcome?

  • An individual with terminal cancer has chest pain. This person is a DNR. Is an exercise stress test necessary? Does it change the patient’s outcome? If the subsequent treatment results in more life and is what the patient desires, then yes. But if it does not, it is unnecessary.
  • Referring out a patient with a PSA of 4.5 to urology for a biopsy. Would it not be more cost effective and safer to just recheck the PSA in 2 months? Prostate cancer is usually not aggressive and slow growing. A prostate biopsy carries a lot of risk with it. Would it really change the patient’s outcome?
  • Ordering a follow up lumbar x-ray from 6 months ago on a patient who has degenerative disc disease and arthritic changes of the lumbar spine. Does this provide any necessary information that will change the outcome or how you treat the patient?
  • Ordering a viral panel on an acute illness. Ok great, you discovered the patient has a specific virus. Does that change anything? Probably not, the outcome will be the same.

These lists could go on and on. The point is to rewire your brain to think about what is and what is not medically necessary. Ask yourself “will this change the outcome of what I am going to do and for the patient?”

I used to ask this question all the time during the first 2-3 years of my career as a nurse practitioner. I was trained by multiple “old school” physicians and providers who were very conservative with their treatment plans. The two principles that developed through my experience practicing all over the country are:

Don’t ask the questions you don’t want the answer to.

Don’t order interventions that do not change the patient’s outcome.

Ingraining these principles into your brain will save your patients time, money, and the risk of unnecessary medical interventions.

It is a double-edged sword for the medical provider though. On one side, you are not going down a never-ending rabbit hole in search of information that is irrelevant and performing a medically unnecessary intervention that could result in injury. On the other side though, ordering a gambit of tests could reveal the hidden piece that covers you medicolegally. This is where developing sound judgement comes in. The only way to do this is through experience.

Be conservative but don’t be dangerous and overconfident. Try to think an intervention through before you order it. Always think of the outcome. If you do this, you will be a more efficient and competent elite nurse practitioner.

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