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 5 or so years I have been employed in 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 patients.  There was a minority of patients whom we did not know who were referred in 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 eliminating the need for an endoscopy.

Gallstones.

We don't permit patients to order their own gallbladder removals!

I do not schedule scope examinations at the request of patients I do not know to evaluate symptoms.  I will do so if the exam is being requested by a medical professional.  Acquiescing to a patient’s request for an upper scope test to evaluate ‘heartburn’ or abdominal distress leads 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.  Suppose the patient experienced a complication on the scope table?  Or, if the scope test is negative, and the patient suffers a cardiac event from ‘heartburn’ in the coming weeks, does the gastroenterologist bear some responsibility?  Having a medical professional directing traffic helps to guide and protect patients.  If the patient’s doctor wants the test, then I feel more secure that the exam makes good medical sense.

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

I may sound categorical but there may be instances in scope world when an exception is reasonable.  Indeed, I have done so.  But these are rare and special circumstances. But in general, when one is considering a test with some risk, I would leave it to the  professionals to arrange - not the patients.

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