Sunday, May 22, 2022

Justifying Unnecessary Medical Tests

Would a doctor ever order a diagnostic test that was not medically necessary?  I’ll give you a hint to this ‘yes or no’ question; the answer has 3 letters.

Of course, in a perfect medical world, every medication would perform flawlessly with no adverse reactions.  All medical tests would be justifiable and painless.  Physicians’ diagnoses would always be accurate.  Drugs would be affordable.  All patients would recover from whatever ails them. And doctors would never be late for their appointments!

Sound like the medical world you know?  I doubt it.  The medical universe that I inhabit is riddled with flaws and imperfections.  It is, after all, a human endeavor which guarantees variable outcomes. Sometimes, the patient just doesn’t get better.

So why would doctors like me at times order medical tests that are not necessary?  Wouldn't this violate my professional oath and code of conduct?

Years ago, when the plaintiff’s bar was on fire suing doctors, many physicians ordered questionably necessary tests thinking that this might protect them from a successful malpractice claim.  Thankfully, the volume of med mal litigation has diminished and so has the defensive medicine response.  This is a welcome development for doctors and their patients.

Trapped in a medical maze

Sometimes, patients feel trapped and need to be set free.

But often it is the patients themselves who drive the pursuit of unnecessary diagnostic testing.  Even when the doctor tries hard to reassure the patient that the test result will be normal, the patient is often not persuaded.  Nearly always the patients steadfastness originates from anxiety – the fear that a serious disease is lurking.  On a regular basis, for example, a patient will see me a year or two before his colonoscopy is due asking for the procedure because a neighbor was diagnosed with colon cancer. Or a patient may insist on a CAT scan of the abdomen, even though one done months ago was normal, worrying that something was missed.  Many times I have performed a scope examination of the esophagus to calm a patient who truly doesn’t need the test medically, but is worried because his grandfather’s esophageal cancer was found too late.

When doctors order such tests, is this fair to insurance companies who are paying for the studies?

Is this fair to society to be consuming finite medical resources?

Is it even fair to patients to expose them to the risks of medical testing?

I have come to think that a strict medical justification for a test is not the only criterion that merits consideration.  If a patient has a level of anxiety that is diminishing his quality of life, and a medical test can assuage it, then I think a case can be made to proceed.  I can’t define the precise anxiety level that needs to be present in a particular patient in order to proceed.  This judgment needs to be made by individual physicians and their patients.

And finally, even though the doctor may balk at the test, sometimes the patient ends up being right. Doctors, after all, are members of the human species with all of the flaws and frailties that define everyone.



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