This comment of James’ has brought to my mind the question of why I (more often than I’d like [which is never]) order tests I believe to be unnecessary for the detection or diagnosis of disease. As I said in that comment thread, I don’t really order them because I fear a lawsuit or contemptuously try to placate the unhappy. Sure, there is the niggling fear that occasionally surfaces when the illness is vague and the patient disgruntled, but most of the time I rest relatively easy in the knowledge that even unhappy patients rarely sue. I don’t really think that the CBC or lyme titer (perhaps the most nettlesome of unnecessarily requested test) is going to be the thing that keeps me from the courthouse.
But for some patients (which I will use as shorthand for the more cumbersome “parents of patients,” though technically more accurate in my case), the vagueness of the best diagnosis I can make is a source of obvious distress. For a great many pediatric illnesses or symptoms, a clear cause is elusive. The most authoritative diagnostic statement I can make is often “it’s probably viral,” with a plan to monitor for resolution over time. While this is a fundamentally unsatisfying answer, for most people it is good enough. In some circumstances, however, the patient is obviously quite worried that there is some more sinister diagnosis that is being overlooked, and my attempts at reassurance are ineffective. Further investigation is desired, and ordering a few simple blood tests can get them over the hump. These tests may not be “necessary” by my definition of the term, but from the patient’s perspective they are. Is it wrong that I sometimes order them?
Before I proceed with this little intellectual exercise, I should make a couple of things clear. I don’t make any additional money by ordering tests. I don’t own a stake in a lab, and I don’t have a share in a radiology suite. To use Christopher Carr’s terms, I have little personal incentive. Yes, on the one hand it’s good to have patients who are happy with you. On the other hand, concerned patients are more likely to come in a follow-up visit they may not need, in which case my practice collects more money. The real benefit to me personally is pretty much nil either way.
With that said, suppose a patient.
Let’s call our patient Hi. During the course of a routine and perfectly normal physical exam, Hi explains that he is beset with frequent bouts of crippling anxiety about his health. In particular, he is worried that he might get cancer of a type that is often undetected until curative interventions come too late, such as that of the pancreas or lung. He often becomes so preoccupied that he cannot sleep or attend to his work or recreation. He has tried both cognitive behavioral therapy and various medications, but his anxiety is refractory to both.
Hi requests that I order spiral CT scans of the chest and abdomen every six months to detect solid tumors while they are still small enough to be resected. He understands that doing so is well beyond even the most prodigal screening recommendations. He understands the significant cumulative radiation exposure and the potential risk thereof. He is an intelligent and otherwise rational man, and requests these scans because he believes they are the only thing that will allay his otherwise unremitting psychological distress.
Let us further suppose that Hi is a man of means. He would pay for these scans himself. All he needs from me is an order.
His money. His body. His risk. Any scans he undergoes will be scheduled in such a way that patients whose need is more obvious will always take precedence. The only costs to be borne are his.
So, is it my proper role to refuse? To accommodate his request? To protect him from unnecessary risk, even if he is willing to accept it? Is my role even truly necessary, there solely because of the protocols of contemporary medical care? Should he be able to obtain these tests without setting foot in my office? If it were you, would you order the scans?
Reality, of course, is more complicated. In the above case (and returning to Christopher’s approach to such questions), I’ve stripped away personal incentives and societal ones (in that nobody else has to pay for Hi’s scans). In real life, most people don’t have the wherewithal to pay for serial CT scans, and so a simple but compelling argument can be made that nobody else should have to pony up the cash for tests of questionable value.
But again, what about those times when I don’t think the test is necessary but the patient does? Should I have the option of telling them that I’ll order the test if they’re willing to pay for it? Should there be a box I can tick that says “ordered by patient request”? Would requiring patients to assume the cost of the tests I don’t think are necessary somehow make me more culpable if I miss something and the tests were deferred because the patient couldn’t pay out of pocket?
Your thoughts are welcome.