Ordering More Is Not Caring More: Confronting the Hidden Harms of Diagnostic Overreach

In American medicine, the instinct to investigate is deeply ingrained. Ordering an additional imaging study, running one more panel, or referring to yet another specialist can feel like thoroughness. In reality, when driven by uncertainty rather than clinical reasoning, this pattern represents one of the most underexamined threats to patient safety and healthcare sustainability in the country today.

The phenomenon has no single, dramatic face. It accumulates quietly—in emergency departments where low-probability pulmonary embolisms trigger full CT angiography workups, in primary care offices where nonspecific fatigue prompts exhaustive metabolic panels, in oncology suites where ambiguous findings cascade into invasive biopsies. Each individual decision may appear defensible. In aggregate, they constitute what researchers are increasingly calling a silent epidemic of diagnostic overreach.

The Scale of the Problem

The numbers are difficult to ignore. The National Academy of Medicine has estimated that diagnostic errors contribute to approximately 40,000 to 80,000 deaths annually in the United States, yet a parallel and equally damaging problem—overdiagnosis and the overtreatment it generates—receives comparatively little attention. Studies published in peer-reviewed journals, including work featured in JAMA Internal Medicine and The BMJ, suggest that somewhere between 10 and 30 percent of medical care delivered in the US may be unnecessary, with downstream costs exceeding $200 billion annually.

For patients, the consequences extend well beyond financial burden. Incidental findings from imaging studies generate anxiety, follow-up procedures, and sometimes irreversible interventions for conditions that would never have caused clinical harm. Unnecessary antibiotic prescriptions accelerate resistance. Overdiagnosis of thyroid microcarcinomas and low-grade prostate abnormalities has exposed thousands of patients to surgeries carrying genuine morbidity—all for disease that would never have shortened their lives.

The root cause, in a significant proportion of these cases, is not incompetence. It is uncertainty—and a clinical culture that has not adequately equipped physicians to tolerate it.

Fear as a Clinical Variable

Medical training in the United States has historically rewarded exhaustive investigation. The missed diagnosis is the subject of morbidity and mortality conferences; the unnecessary test rarely is. Medicolegal anxiety compounds this dynamic. Surveys of US physicians consistently show that fear of litigation ranks among the primary drivers of ordering behavior, often prompting testing that the clinician's own clinical judgment would not support.

This is not a character flaw. It is a systems failure. When the professional and legal environment penalizes omission far more harshly than commission, clinicians rationally adapt their behavior accordingly. The result is a healthcare system in which the precautionary principle has been distorted into a mandate to investigate everything, regardless of pretest probability or the realistic benefit-to-harm ratio for the individual patient.

Addressing this pattern requires more than individual resolve. It requires institutional frameworks that support diagnostic confidence rather than punishing diagnostic restraint.

Evidence-Based Frameworks for Diagnostic Discipline

The clinical literature offers well-validated tools that, when systematically applied, reduce unnecessary testing without compromising diagnostic accuracy. Structured pretest probability assessments—such as the Wells criteria for venous thromboembolism, the Ottawa Ankle Rules for fracture evaluation, or the HEART score for chest pain risk stratification—allow clinicians to quantify clinical suspicion and calibrate their investigative response accordingly.

These frameworks do not eliminate uncertainty. They make uncertainty explicit and manageable. A clinician who can articulate that a patient's Wells score places them in a low-probability category for pulmonary embolism is not guessing; they are applying validated science. That distinction matters both clinically and, increasingly, legally.

Clinical decision support systems (CDSS) embedded within electronic health records represent another lever. When thoughtfully designed and implemented, CDSS tools can prompt clinicians to consider pretest probability before ordering advanced imaging, flag duplicate testing, and surface evidence-based guidelines at the point of care. Research from institutions including the Brigham and Women's Hospital and the Veterans Affairs healthcare system has demonstrated measurable reductions in unnecessary imaging when such systems are deployed with adequate clinician engagement.

Critically, the most effective implementations treat CDSS as a collaborative tool rather than an administrative gatekeeper. Clinicians who perceive decision support as an obstacle to care disengage from it quickly. Those who experience it as a resource aligned with their professional values are far more likely to integrate it meaningfully into their practice.

Rebuilding Diagnostic Confidence as a Professional Competency

For AAPTS members, the opportunity—and the obligation—extends beyond individual practice. Professional associations play a decisive role in shaping the cultural norms of a specialty. When AAPTS promotes educational programming that explicitly addresses uncertainty tolerance, when it advocates for malpractice reform that creates safe harbor for evidence-based restraint, and when it develops peer benchmarking tools that help members understand their own ordering patterns relative to validated standards, it shifts the entire field toward more defensible and more humane care.

Residency programs affiliated with AAPTS member institutions should consider incorporating structured diagnostic reasoning curricula that move beyond pattern recognition to include formal training in probability assessment and shared uncertainty communication. Patients, it turns out, respond more positively than many clinicians expect when uncertainty is acknowledged honestly and transparently. Research consistently shows that patients prioritize trust and clear communication over the false reassurance of exhaustive testing.

The goal is not to discourage investigation. It is to ensure that every test ordered serves a patient's genuine clinical need rather than a clinician's anxiety management. That distinction—between care driven by evidence and care driven by fear—is precisely the scientific and ethical standard that AAPTS exists to advance.

A Call for Institutional Accountability

Health systems, payers, and professional bodies all share responsibility for creating conditions in which diagnostic discipline is rewarded rather than penalized. Value-based care models that incorporate appropriate-use metrics, peer review processes that examine overtesting alongside undertesting, and transparent reporting of overdiagnosis rates within specialty fields are all mechanisms that move the system in the right direction.

None of this will happen without organized advocacy from associations like AAPTS. The science supporting diagnostic restraint is robust. The clinical frameworks exist. What has been missing is the professional will to treat unnecessary testing as the patient safety issue it genuinely is—and to hold the entire care delivery system accountable for the harm it causes.

Ordering more is not caring more. Advancing that truth is among the most important contributions AAPTS members can make to the patients they serve.