Houston, we have a problem. Or as the astronauts aboard the Apollo 13 reportedly said: ”We’ve had a problem.”
We’ve had a problem with too much testing in medical practice for years–and it is getting worse.
There are three scenarios where excessive testing is particularly egregious:
- Testing that happens before a clinician takes a history or examines the patient
- Testing that doesn’t meaningfully change treatment
- Needless repetition of a test.
The key reason for excessive medical testing is the same one that is driving private equity to invest in health care: the tremendous monetary incentive to test. Some researchers estimate that billions of dollars annually are wasted on unnecessary testing and its ensuing clinical harms. These financial incentives result in undue pressure placed on physicians by medical systems to test. Additionally, aggressive marketing by medical device and laboratory testing companies may generate anxiety and misinformation that may lead patients to pressure clinicians into unnecessary testing. Lastly, another important factor driving excessive medical testing is the ever-present concern among clinicians around being sued for failure to perfom a test.
“Joe,” a client I advocate for, reached out to me in search of a diagnosis. He was experiencing new, debilitating constipation. Colonoscopy and extensive laboratory and other radiologic testing were unrevealing.
In his quest for answers, he had reached out to a famous tertiary health care system. The “World Famous Clinic” offered him an appointment.
“Do you think I need to be seen there?” he asked. “I am kind of shocked,” he added. “They have scheduled a bunch of tests for me, which is kind of wild because I told them nothing about prior medical history or tests/labs to date. So this must just be their routine workup for someone with chronic constipation.”
Joe was told he needed to obtain multiple quite invasive tests over the course of six days–before he would be formally seen by a physician.
The schedule he shared with me showed him set up for: an Enema Prep; Anorectal Manometry Procedure; General Imaging Exam; and a Nuclear Medicine GI Transit Scan followed by three days of nuclear medicine imaging with a Nuclear Medicine GI Transit Return Scan.
A common adage in the practice of medicine is that a test should only CONFIRM a diagnosis that is already in your doctor’s head.
Only in rare cases, when there is a perplexing or unusual presentation of disease, may testing take on the form of what some doctors jokingly refer to as a “fishing expedition.” But that should be a rarity–not the rule, because excessive testing can cause harm both due to direct side effects of the test, and because the test can falsely suggest that there is pathology where there is none–leading to more painful and unnecessary follow-on procedures and testing like biopsies.
In Joe’s case, a review of his medical chart suggested the cause–and cure for his symptoms. In fact, both were mentioned in the medical record by his doctors. The diagnosis and treatment may not have been clearly conveyed to the patient; but the answers were all there.
Interestingly, one of Joe’s diagnoses was what we call a “clinical” diagnosis: meaning–there is NO test for it. A clinical diagnosis means there is a classic constellation of symptoms that, when observed together, can confirm a diagnosis. Common examples of clinical diagnoses are Parkinson’s disease and dumping syndrome after gastrectomy.
In Joe’s case, all of his symptoms responded well to treatment. So in short–there was no need for further testing at all.
Another patient, “Carol,” was offered a very difficult to tolerate test, esophageal manometry, to look for esophageal dysfunction. However, there were three important aspects to the decision to test: a/ the patient already HAD a diagnosis of esophageal dysfunction based on another test and 2/ this is a difficult to test to tolerate; and 3/ there were no great treatment options for a positive test. When the test did in fact confirm the diagnosis– the patient was told–”Well, there is really not much treatment for this.” The clinician suggested some simple dietary changes that the patient had already tried.
Some patients might wish to know these things BEFORE submitting to an exceptionally difficult to tolerate test.
Excessive testing is particularly egregious when radiation exposure is involved or the same test has been unnecessarily repeated at two different medical centers.
“Barbara” went to an excellent hospital where she was given a chest x-ray to evaluate her for a chronic cough she had been bothered by for many months. She then crossed the street, the same day, to go to an appointment at a clinic in a different medical system. The second clinic couldn’t find the chest x-ray because their electronic medical records could not communicate with the system used by the first clinic. The clinician told Barbara that it was necessary to repeat the test.
“And expose my elderly mom to all that excess radiation?” her son exclaimed. “Why not just find out the results of the earlier test?”
When the medical record from the other clinic was duly obtained, the son learned that the first test had been normal. So Barbara would have needlessly been exposed to radiation twice– only to find out that both tests were normal and therefore the second test wholly unnecessary.
In Sum
This worrisome trend is worth drawing attention to because the only way to counterbalance it is for patients to ensure that they ask plenty of questions when a test or procedure is suggested.
The following questions can help inform any discussion about medical testing or a medical procedure.
- Why do I need this test? What specific information will this test provide?
- If the test is positive, will it change my treatment? How? What are the treatments that I might receive based on the results; and importantly–can I safely receive that treatment?
- Can I be treated without getting the test? Can this diagnosis be treated empirically? Sometimes, if treatment is very simple and easy to tolerate and a test is complicated and expensive or painful–this may be a legitimate option to consider.
- Have I had this test before? What did it show? Why do I need to repeat it now?
- What does the test involve? Ask your clinician to walk you through it. Does it meet Dr. Brita’s “Is the juice worth the squeeze” criteria–ie, can I tolerate it? Is it painful? Is it safe for someone my age?
- What are the risks of this test? Every test comes with some risk. Your doctor is required to explain those risks so that you can make an informed decision about whether to have the test.
- What other tests are available to diagnose this condition?
- What happens if I don’t have the test?
- How much does this test cost? You need to ask your insurance company about deductibles, co-pay, co-insurance amounts, etc. before you have the test. Also: your clinician may not know if your insurance covers it, but they will know if the test is generally not covered by insurance and must be paid for out of pocket.
And don’t forget–you can always say no to a medical test, as Stanford professor Dr. Walter Bortz once said. Saying no does not mean you are a difficult patient–it may in fact mean that you are a better informed and ultimately, a healthier and wiser patient.
Resources
Helping Doctors Do No Harm by addressing medical test overuse.
Unneeded Medical tests: is it time to just say no? Choosing Wisely: Nine medical Societies have identified 45 common medical tests and procedures that they are encouraging doctors to use less often, and patients to demand less often.
Epstein, Helene, Medical testing’s dirty little secret and how you can protect yourself. Society to improve Diagnosis in Medicine.
Medical Disclaimer:
All patient and family names have been changed to protect patient confidentiality.
The suggestions given here are not intended as a substitute for the medical advice of your physician. The reader should regularly consult a physician in matters relating to his/her health and particularly with respect to any symptoms that may require diagnosis or medical attention. For additional questions, please call your healthcare provider for reliable, up-to-date information on testing and symptom management of all medical concerns.
Photo credit: We would like to thank Anni Kolleshi; from Unsplash.com, photos free to use and share.
