Journal of General Internal Medicine

, Volume 23, Issue 10, pp 1547–1554 | Cite as

Older Patients Perceptions of “Unnecessary” Tests and Referrals

A National Survey of Medicare Beneficiaries
  • M. Brooke HerndonEmail author
  • Lisa M. Schwartz
  • Steven Woloshin
  • Denise Anthony
  • Patricia Gallagher
  • Floyd J. Fowler
  • Elliott Fisher
Original Article



Unnecessary exposure to medical interventions can harm patients. Many hope that generalist physicians can limit such unnecessary exposure.


To assess older Americans’ perceptions of the need for tests and referrals that their personal physician deemed unnecessary.


Telephone survey with mail follow-up in English and Spanish, conducted from May to September 2005 (overall response rate 62%).

Study Participants

Nationally representative sample of 2,847 community-dwelling Medicare beneficiaries. Main analyses focus on the 2,319 who had a personal doctor (“one you would see for a check-up or advice if you were sick”) whom they described as a generalist (“doctor who treats many different kinds of problems”).

Main Outcome Measure

Proportion of respondents wanting a test or referral that their generalist suggested was not necessary using 2 clinical vignettes (cough persisting 1 week after other flu symptoms; mild but definite chest pain lasting 1 week).


Eighty-two percent of Medicare beneficiaries had a generalist physician; almost all (97%) saw their generalist at least once in the past year. Among those with a generalist, 79% believed that it is “better for a patient to have one general doctor who manages most of their medical problems” than to have each problem cared for by a specialist. Nevertheless, when faced with new symptoms, many would want tests and referrals that their doctor did not think necessary. For a cough persisting 1 week after flu symptoms, 34% would want to see a lung specialist even if their generalist told them they “probably did not need to see a specialist but could if they wanted to.” For 1 week of mild but definite chest pain when walking up stairs, 55% would want to see a heart specialist even if their generalist did not think it necessary. In these same scenarios, even higher proportions would want diagnostic testing; 57% would want a chest x-ray for the cough, and 74% would want “special tests” for the chest pain.


When faced with new symptoms, many older patients report that they would want a diagnostic test or specialty referral that their generalist thought was unnecessary. Generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will need to address their patients’ perceptions regarding the need for these services.


geriatrics patient perceptions tests and referrals shared decision making 



The authors would like to thank Jennifer Snide for her assistance with manuscript preparation. Dr. Herndon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. This study was supported by a grant from the National Institute on Aging (PO1 AG19783) and from a Research Enhancement Award from the Department of Veterans Affairs. Dr. Herndon was supported by a faculty development grant from the Department of Medicine at Dartmouth-Hitchcock Medical Center. Drs. Woloshin and Schwartz were supported by Robert Wood Johnson Generalist Faculty Scholar Awards. The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

Conflict of Interest

None disclosed.

Supplementary material

11606_2008_626_MOESM1_ESM.pdf (103 kb)
Online Appendix (PDF 102 KB)


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Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • M. Brooke Herndon
    • 1
    • 3
    Email author
  • Lisa M. Schwartz
    • 1
    • 2
    • 3
  • Steven Woloshin
    • 1
    • 2
    • 3
  • Denise Anthony
    • 2
    • 4
  • Patricia Gallagher
    • 5
  • Floyd J. Fowler
    • 5
  • Elliott Fisher
    • 1
    • 2
    • 3
  1. 1.VA Outcomes GroupDepartment of Veterans Affairs Medical CenterWhite River JunctionUSA
  2. 2.The Dartmouth Institute for Health Policy and Clinical PracticeDartmouth Medical SchoolHanoverUSA
  3. 3.Dartmouth Medical SchoolHanoverUSA
  4. 4.Department of SociologyDartmouth CollegeHanoverUSA
  5. 5.Center for Survey ResearchUniversity of MassachusettsBostonUSA

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