Unnecessary clinical tests in ophthalmology

To define and discuss unnecessary clinical tests in ophthalmology, review the justifications commonly given by clinicians for obtaining unnecessary clinical tests, and suggest a more rational approach to clinical testing in the future. The author defines an unnecessary clinical test as a test on a human subject that is unlikely to influence that patient's diagnosis, prognosis, or management or is performed exclusively, primarily, or in large part for research purposes. Examples of clinical tests the author categorizes as unnecessary are tests performed to evaluate a new or nonstandard diagnostic instrument or method; tests performed to evaluate sensitivity, specificity, and predictive value of a new instrument or method; tests obtained to provide images or data for future analysis, presentation, or publication; tests obtained routinely in patients of a certain class or category without regard to the individual's personal characteristics, recent clinical history, or clinical signs; and duplicate tests performed without retrieval and review of recent prior tests of the same types and determination of the quality of and findings revealed by those tests. Several justifications that are commonly given by clinicians for their ordering of unnecessary tests are presented, and each of these justifications is critiqued. The principal problems with unnecessary testing are increased costs of medical care, worsening rather than improvement in patient outcomes, and unethical practice. Unnecessary testing is perhaps an unavoidable aspect of current clinical ophthalmic practice in the United States. In spite of this, clinicians (especially academic ophthalmologists) need to be aware of this issue and take appropriate steps to minimize such testing.