I am a physician in the US. I think the article has valid points (esp. inpatient glucose control) but it also oversimplifies and glosses over some of medicine's more arcane aspects.
To give a tangible example I'll start with the unnecessary ankle x-ray. There is a set of guidelines called the Ottowa Ankle Rules[1] which we use to justify ordering plain films for a suspected fracture, but there are plenty of reasons why a doctor would still get them if the criteria weren't met.
One reason is clinical judgment and experience. Guidelines are just guidelines. Ultimately the doctor is the one making the call, as well as suffering the blame for that call if things go sideways. If everything were as simple as following algorithms and checklists, medical training wouldn't take 7+ years of post-undergraduate work.
But probably the most important reason has to do with the "patient satisfaction" (customer service) aspect. Ideally medicine wouldn't be a business, but it is and there's not much we can do about that.
Patients who present to an urgent care center or ED generally carry an implicit "something is seriously wrong with me or I would have just made an appointment with my PCP" vibe. These patients often don't like it when you explain that based on your history and exam, they most likely have a sprain/strain injury and an xray is not appropriate since we want to avoid unnecessary costs/radiation exposure-- as opposed to being relieved that they only suffered a minor injury. Even when spoken in a compassionate, straightforward manner, this explanation can come across to the patient as "nothing is wrong with you / you are malingering / your concerns aren't valid / I don't care about your symptoms", etc.
Sometimes patients outright demand tests, or worse, they'll say nothing but then complain to your employers that you medically neglected them, or you are incompetent, or what have you. Now if they had the audacity to file a malpractice suit, you'd (ideally) have no problem justifying your actions in a courtroom or deposition. But say they complain to the MBA (or some other person with no medical training) who runs the clinic or care center employing you. Your argument will likely fall on deaf ears, and be countered with some diatribe about how you're causing them to lose money. In that case it's a lot easier to just order the unnecessary xray.
Basically, the squeaky wheel gets the grease. There are plenty of other examples like this, and they all come down to choosing your battles wisely. I think it's kind of hard to blame the over-worked and behind-schedule doctor who orders something like an xray or lab test rather than taking an extra 10-15 minutes discussing the pros and cons with the patient, after which the patient might still not be convinced.
Having said that, there is a problem with superfluous testing in EDs, especially ones that rely on "standing orders" where e.g. virtually any patient presenting with abdominal pain might get a CT scan before the physician even sees them (something I strongly disagree with and can't think of a legitimate excuse for).
[1] http://www.theottawarules.ca/ankle_rules
To give a tangible example I'll start with the unnecessary ankle x-ray. There is a set of guidelines called the Ottowa Ankle Rules[1] which we use to justify ordering plain films for a suspected fracture, but there are plenty of reasons why a doctor would still get them if the criteria weren't met.
One reason is clinical judgment and experience. Guidelines are just guidelines. Ultimately the doctor is the one making the call, as well as suffering the blame for that call if things go sideways. If everything were as simple as following algorithms and checklists, medical training wouldn't take 7+ years of post-undergraduate work.
But probably the most important reason has to do with the "patient satisfaction" (customer service) aspect. Ideally medicine wouldn't be a business, but it is and there's not much we can do about that.
Patients who present to an urgent care center or ED generally carry an implicit "something is seriously wrong with me or I would have just made an appointment with my PCP" vibe. These patients often don't like it when you explain that based on your history and exam, they most likely have a sprain/strain injury and an xray is not appropriate since we want to avoid unnecessary costs/radiation exposure-- as opposed to being relieved that they only suffered a minor injury. Even when spoken in a compassionate, straightforward manner, this explanation can come across to the patient as "nothing is wrong with you / you are malingering / your concerns aren't valid / I don't care about your symptoms", etc.
Sometimes patients outright demand tests, or worse, they'll say nothing but then complain to your employers that you medically neglected them, or you are incompetent, or what have you. Now if they had the audacity to file a malpractice suit, you'd (ideally) have no problem justifying your actions in a courtroom or deposition. But say they complain to the MBA (or some other person with no medical training) who runs the clinic or care center employing you. Your argument will likely fall on deaf ears, and be countered with some diatribe about how you're causing them to lose money. In that case it's a lot easier to just order the unnecessary xray.
Basically, the squeaky wheel gets the grease. There are plenty of other examples like this, and they all come down to choosing your battles wisely. I think it's kind of hard to blame the over-worked and behind-schedule doctor who orders something like an xray or lab test rather than taking an extra 10-15 minutes discussing the pros and cons with the patient, after which the patient might still not be convinced.
Having said that, there is a problem with superfluous testing in EDs, especially ones that rely on "standing orders" where e.g. virtually any patient presenting with abdominal pain might get a CT scan before the physician even sees them (something I strongly disagree with and can't think of a legitimate excuse for).
[1] http://www.theottawarules.ca/ankle_rules