June 22, 2011
Sometimes, you just can’t win! In medicine, sometimes is way too often! “Doc, do I need that test?” (http://livewellthy.org/2011/02/10/doc-do-i-need-that-test.aspx), published in February, reviewed the issues surrounding screening colonoscopy exams. The dilemma is always the same. Do I order a test or don’t I?
If I order a test, there are consequences. Some are obvious; some are not. Tests cost money and money is in short supply. One consequence of ordering a test is that my patient may be held responsible for a big bill. Having to pay for the test may well stress my patient and his/her family.
A second consequence is that the test may not prove anything or help make a diagnosis. In this case, not only have I wasted hard earned money but I have frustrated my patient. Ordering too many tests that turn out normal shakes your patient’s confidence in your abilities as a doctor. It may also lead to the accusation of profiteering or practicing defensive medicine. In reality, a negative test helps remove items from the “Differential Diagnosis” list (http://livewellthy.org/2011/04/06/differential-diagnosis.aspx) and helps make an accurate diagnosis.
A third consequence is that a positive result may lead to more testing, more expensive and more risky procedures. PSA testing is used to screen for and diagnose prostate cancer. A positive PSA test is suggestive of a problem but certainly is not definitive. If your PSA is elevated and your digital rectal exam is normal, your doctor may simply repeat the test in a few months to monitor the situation. If there is any question of malignancy, your doctor will probably refer you to a urologist for further testing. Further testing often entails multiple biopsies of your prostate, painful and expensive procedures.
As a physician, you are really damned when the positive blood test leads to a biopsy and the biopsy is negative! Rather than being happy that he does not have prostate cancer, your patient is pissed that he had to have a biopsy and even more pissed that he has to pay for everything.
You are also damned if you don’t order a test! Fail to order a test that might have revealed a disease at an earlier date and your patient will be even more pissed! “Cyberchondria” (http://livewellthy.org/2011/04/10/cyberchondia.aspx) addressed a new phenomena in which patients read about illnesses on the internet and then convince themselves that they have those illnesses. They often come in requesting an assortment of tests, some expensive and some invasive in nature. While making your patient happy is preferable, ordering a barrage of tests without clinical reason is both wasteful and inappropriate. The patient who thinks they have “XYZ” disease wants an MRI of his/her brain. “XYZ” is extremely rare and present only in people of Asian origin and your patient’s family is from Hoboken, New Jersey, having come over on the Mayflower. Do you order the MRI? No! You explain that you see neither signs nor symptoms of “XYZ” and look for another cause for the patient’s ailment. The patient eventually finds a “real” doc who orders an MRI and is pleased to find that they don’t have “XYZ.” They tell everyone you are a “quack”, don’t listen to your patients, and don’t care.
You are really, really damned when the MRI verifies that your ex-patient is the first non-Asian in medical history to have “XYZ.”
So, as a physician, what do you do? How do you win? You partner with your patients. You make your patients responsible members of the medical team. You help educate your patients to the benefits, risks, limitations, and costs of testing and treatments. You listen to your patients and offer your best advice. You write a nightly column. Then you say a little prayer! May you be so blessed as to never know the disease you prevented.