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Sunita Sah Ph.D., M.D., M.B.A.
Sunita Sah Ph.D., M.D., M.B.A.

The Problem with Investigation Before Examination

There is a flaw in the sequence of events within the practice of U.S. medicine.

Recently, I experienced a vaccination injury to my left shoulder which caused me considerable pain. As the weeks progressed, and the pain increased, the range of movement in my left arm decreased until it became difficult to perform even simple tasks such as opening doors. As a physician myself, I knew that chronic inflammation was the most likely cause of the pain. My plan of action was either a course of anti-inflammatories or to undergo physical therapy and I decided to visit my doctor to address the issue.

Before seeing the doctor, I was told I needed an x-ray as this was the common practice for all patients in the clinic. Since inflammation does not show up on an x-ray, I considered the x-ray unnecessary before speaking with the doctor and I refused to follow the clinic protocol. I wrote about my encounter with the U.S. healthcare system in an article published in JAMA Internal Medicine.1

My personal encounter highlighted to me greater systemic issues in the U.S. healthcare system. As a physician, we are taught that a detailed history and examination are the first steps in evaluating a patient. After this you create a list of potential diagnoses and finally conduct investigations to confirm or rule out diagnoses and to ascertain clinical management. However, for many, scanning first and asking questions later reflects the real world of imaging in the U.S.

My encounter drew my attention to two particularly disconcerting issues:

First, the U.S. culture of overworking and over-treating patients can result in ‘Investigations before Examinations.’ Imaging should be ordered when indicated. Instead we see physicians crippled by their reliance on tests over patient histories and examinations. Some patients equate more tests with higher quality care but we know that over-testing and overtreatment is wasteful, potentially harmful and can lead to a cascade of other problems. 2 In medicine, often less is more.

Second, my experience accentuated the difficulty of incorporating the ethos of patient’s ‘Choosing Wisely’ (an admirable initiative of the American Board of Internal Medicine Foundation to promote conversation between providers and patients). Questioning medical protocol or your physician’s judgment signals distrust and most people wish to maintain harmonious relationships. The role of the patient is to be compliant, not combative. This discomfort in signaling distrust is so strong that people will often take obviously poor or biased advice to avoid rejecting advice in front of their advisor. 3–5 For patients to ‘choose wisely’ their physicians must start the conversation and ask “What are your goals for care?” “How can I can help you achieve your goals?” A patient-centered approach to care is more respectful, less wasteful and less harmful. If current medical incentive structures such as the fee-for-service model (the predominant form of physician reimbursement in the U.S.) do not change however, such an approach means physicians must deliberately place patients above profits.


1. Sah S. Investigations before examinations: This is how we practice medicine here. JAMA Intern Med. 2015;175(3):342-343.

2. Sah S, Elias P, Ariely D. Investigation momentum: The relentless pursuit to resolve uncertainty. JAMA Intern Med. 2013;173(10):932-933. doi:10 .1001/jamainternmed.2013.401.

3. Sah S, Loewenstein G, Cain DM. Insinuation anxiety: Fear of signaling distrust after conflict of interest disclosures. Work Pap. 2014.

4. Sah S, Loewenstein G, Cain DM. The burden of disclosure: Increased compliance with distrusted advice. J Pers Soc Psychol. 2013;104(2):289-304.

5. Sah S. Conflicts of interest and your physician: Psychological processes that cause unexpected changes in behavior. J Law Med Ethics. 2012;40(3):482-487.

About the Author
Sunita Sah Ph.D., M.D., M.B.A.

Sunita Sah, Ph.D., M.D., M.B.A., is a Research Fellow at the Ethics Center of Harvard University and a former Professor of Georgetown University.

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