In reply: As Murray notes, appropriate test ordering belongs firmly in the domain of quality care and clinical accountability. In his seminal article on clinical leadership of healthcare system improvement, Berwick lists appropriate use of testing and therapy as the first challenge facing people who wish to improve healthcare systems in the developed world.1

Murray also identifies the paucity of structured educational programs aimed at providing junior medical staff with the skills to exercise "knowledge and judgement" in test ordering. The Royal Australasian College of Pathologists is seeking to address this deficiency through the development of educational modules on test ordering.

It is unlikely, however, that education alone will curb the increase in test ordering in Australia. Educational programs for junior medical staff are notoriously resource-intensive and difficult to sustain. In addition, they rarely provide the point-of-care guidance that seems to be more effective in sustainably modifying behaviour. Such guidance may require test-ordering software that provides guidelines for ordering and feedback of individual performance, or the use of structured test-stratification programs such as that described by Stuart et al.2

Improved education, supervision and point-of-care guidance will prove ineffective if fears of litigation continue to drive the behaviour of clinicians. As Carter points out, concerns about litigation must be considered in any program aimed at improving practice. However, although litigation related to missed diagnosis is a recurring theme, this may relate more to time pressures rather than a failure to perform investigations. Indeed, many malpractice suits result from failure to adequately check and act upon the results of the barrage of tests ordered. Attempts to reduce medicolegal risk by ordering all conceivable tests may increase practitioners' risk unless they have extremely well-designed follow-up systems.

It is important that clinicians not sacrifice high-quality, evidence-based investigation and treatment in an attempt to minimise perceived litigation risks. By testing inappropriately, clinicians may in fact expose themselves to greater risks of litigation, as their patients are exposed to the risks of the tests themselves, the chance of false-positive results and inappropriate treatment, and the failure to follow up on investigation results.

It is unfortunate, and an indictment of our current reimbursement system, that the financial realities of community practice make it difficult for clinicians to take sufficient time to communicate with patients about the appropriateness of an investigation or treatment. If we continue to allow this to become the way we practise, we will continue to see a diminution of our professional role as we become merely booking agents for tests.

As Berwick says, "Efforts to reform the health system from the outside can help motivate and set the stage for improvement. Yet, if clinicians do not wish to make specific changes in their own work to better meet society's need for better outcomes and lower cost, no-one outside the health system can be clever enough or powerful enough to make them do it."1