Can a Doctor Deny Diagnostic Testing?

Here’s a scenario that I face fairly regularly in my endoscopy and colonoscopy practice. As readers know, over the past 7 or so years, I have been employed by a rather well-known Cleveland-based health care institution. Prior to that, I was a private practitioner.  During those earlier days, I personally knew most of our scope clientele as they were our existing patients.  There was a minority of patients whom we did not know who were referred to us by their doctors for routine scope exams.  In contrast, in my current employed role, nearly all the scope patients on my schedule are meeting me for the first time.

From time to time, a patient who is scheduled for a colonoscopy will call my office asking if an upper endoscopy can be performed at the same time because their heartburn or some other symptom has been active. Which of the following responses are most appropriate?

• Yes we will gladly add on the extra scope test to assess your stomach and esophagus as this would be an opportune time to do so.
• Our schedule is very tight that day so we request that you return on another day when the upper endoscopy can be performed.
• A review of your chart indicates that an upper endoscopy was performed last year so there is no reason to repeat the exam.
• We cannot schedule you for the requested exam without an order from a medical professional.
• We recommend that you take an over-the-counter heartburn pill, which might cure your heartburn and eliminate the need for an endoscopy.
• I'd like to order an ultrasound exam first.  You may be suffering from gallstones.

If gallstones are present, then no need for a scope!

I do not schedule scope examinations at the request of patients I do not know. This is not even a close call. I will do so, of course, if the exam is requested by a medical professional.  Acquiescing to a patient’s request for an upper scope test to evaluate ‘heartburn’ or abdominal distress is a low-quality shortcut move that can lead to a potential minefield.  What if the ‘heartburn’ is really cardiac pain?  Clearly, a scope exam of the esophagus and stomach would not be the next best medical move.  If the scope test is negative, and the patient suffers a cardiac event from ‘heartburn’ in the coming weeks, does the gastroenterologist bear responsibility?  Suppose the patient experienced a complication from a procedure that we casually added on without necessary due diligence?  How would we explain this?   Finally, agreeing to perform a test that has risk to satisfy a patient's request communicates that we sanction this irregular process.  Having a medical professional directing traffic protects patients from these misadventures.  When a professional requests a test, I feel more secure that there is a medical basis for the exam.  Doesn't all of this just make sense?

Similarly, we do not permit (yet!) a patient to order his or her own CAT scan.  A medical professional has to pass judgment first on this.

Would we be comfortable if a patient contacted a surgeon and asked to be scheduled for a gallbladder removal based on the patient’s self-diagnosis?  

Although I am coming off here as categorical, there may be instances in scope-world when an exception is reasonable.  Indeed, I have done so.  But these are rare and have special circumstances. In general, I advocate that the practice of medicine be reserved to those who have been trained to do so. 

I'm all for patient empowerment and autonomy.  I practice shared decision-making with my patients. But at least for now, I do not support patients being permitted to schedule their own surgeries, request their own endoscopies or prescribe their own medications.   Will Doctor AI change this paradigm?  Buckle up!  Significance turbulence ahead!