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.
Obviously, I’m not a doctor. But what I think would bother me in this hypothetical would be the extent of risk the patient undergoes by taking these more or less unnecessary tests. In a sense, the doctor is signing off on something he or she knows to be risky, and is thereby participating and enabling a decision that might harm the patient. If I were a doctor and did not sign off on these tests, that would probably be the reason: I would not want to be complicit in a decision–even one in which the patient is well aware of the risks–that is so detrimental to the patient’s health. (In one way, this reminds me of early induced pregnancies, because that is a procedure that patients sometimes ask for even when it is contraindicated*; of course, there are other considerations, such as the health of the newborn, that enter into consideration with early inducements.)
However, I imagine it is all a balancing act. It is unlikely the tests would find anything, but what if they did? How much does the risk of undergoing the tests measure up to the unlikelihood of getting any benefit from the tests?
Finally, the hypothetical suggests the patient might have some hypochondriacal neurosis that prompts him to keep asking for tests. Perhaps that is also another reason not to issue the tests: it would enable and ultimately aggravate this patient’s unhealthy attitude to getting reassurance of his health. (I realize you didn’t advance this hypothetical principally to discuss this aspect–and since I’m not a doctor, I can only speculate on how important such a consideration would be–but I thought I’d mention it.)
*I sure hope I’m using that word correctly.
Oh, goodie. A taker.
Indeed, there are certainly risks to being exposed to the radiation from a CT scan, which will only accumulate over time. But suppose those risks have been thoroughly explained and the patient convincingly expresses understanding. To what degree does the patient’s responsibility to assume his own risks and costs supersede my obligation to prevent them if I consider them needless?
And the hypothetical patient I describe almost certainly has an anxiety disorder. (I believe the psychiatric community now avoids the term “neurosis,” but the sense is the same.) As I have constructed things, this has been previously identified, and hasn’t improved with standard treatments. Suppose I give in an order one CT scan, and he returns in six months to say “The past six months have been the least anxious of my adult life! Thank you, thank you! But it’s been too long since the last one for me to consider it reassuring any longer. I want another.” Certainly nobody would view serial CT scans as appropriate “treatment” for anything, but in his case they alleviate the symptoms of his mental health disorder. Should I keep ordering them?
I don’t know. I imagine my answer would be another questions: to what extent would ordering new tests be like buying an alcoholic a bottle of booze? The alcoholic would probably get hold of the liquor regardless, but do you want to be an agent to that, especially if you as a doctor have a sort of “gatekeeper” role (maybe some doctors would order the test)?
Of course, my analogy is not perfect, but to the extent that the analogy does work, I would say I shouldn’t order the tests. To the extent that the analogy does not work, then I should say my decision not to order the tests would be less justifiable, at least when it comes to the grounds I’ve been arguing from.
I see your objection. However, with an alcoholic the harmful effects of drinking are concrete and immediate. (If there are no harmful effects of drinking, it calls into question whether the person is truly alcoholic.) With my hypothetical patient, the effects are abstract and may not manifest for many years.
If there really were a situation like Hi’s, then I think respecting patient autonomy nearly demands that the doctor order the scans upon the doctor’s satisfaction that Hi understand the risk of radiation exposure.
But it’s hard to swallow that outside of a thought experiment, such a situation will actually exist — not the hypochondria, but the external pressures like third-party demands on the radiology lab and the patient’s financial wherewithal to actually pay for every penny of the treatment himself.
Indeed, a situation like Hi’s is relatively unlikely (though I wouldn’t be surprised if so-called “boutique” or “concierge” medical offices don’t face questions like this more commonly than one might think).
But what about some of the other questions? Suppose a less risky and less costly test like a blood test to screen for “chronic lyme disease,” an illness that does not exist according to the Infectious Disease Society of American. Checking a titer would be wholly useless from my perspective, but suppose a patient demands it. Should I have the option of saying “I’ll order it if you’ll pay for it”?
I have similar issues in my law practice. About one in ten eviction cases that make it to trial go, with minor variances, like this: Tenant stops paying the rent. Landlord wants tenant evicted. The day we get to court, the tenant hands me the keys and walks out of the building before the case is tried. Landlord wants to obtain an obviously uncollectable judgment to “put it on the Tenant’s credit,” as though that somehow benefitted anyone, and because the Tenant might hit the Lotto one day. I do it anyway despite what I see as the obvious futility of the exercise. My client demands it and has paid for it. And yes, tax dollars do subsidize this exercise in empty vengeance so I’m guilty of abetting litigant draining public resources for no objectively good reason. After all, there is a infinitesimally-small, but greater than zero, chance that Tenant will hit the Lotto.
In other cases when I’ve been asked to do more elaborate litigation for similarly barren prospects, I’ve demanded that my clients sign off on disclaimers saying “While the lawsuit you have asked me to file has the minimal evidence necessary for me to avoid liability for malicious prosecution later, it nevertheless has very low odds of ultimate success. Further, the person you wish to sue appears to have no way to pay any judgment in the unlikely event that you do win, and would likely be able to discharge any such judgment through bankruptcy. If you change your mind in the middle of the case, it will be difficult to extricate you from it cleanly. Finally, the amount of any judgment you receive would be significantly smaller than the fees you would pay me. I will only proceed if you place my entire anticipated fee on deposit with my firm in advance, and sign below, acknowleding for my file that I’ve advised you that I believe filing this lawsuit is a mistake and counseled you not to do it. If you do that, I’ll start work after your check clears.”
Mostly, that works. Not always.
In the case of a “chronic lyme disease” screen or other test for a fictitious disease, I might be able to rationalize it on grounds similar to the “recently-evicted tenant might hit the Lotto” thining of my practice — if such a blood test contains even a minimal chance of revealing some sort of useful information.
In the case of a wholly useless test (checking a titer), I’d say your response could acceptably be “I’ll order it if you’ll pay for all of it and if you sign this form that says you acknowledge my advice that this is 100% certain to be a waste of time and money.”
The odds of the lyme titer being in any way clinically useful are closer to the “recently-evicted tenant hitting the Lotto” scenario. It is highly, highly unlikely it will yield a result with which I would do anything at all, but not entirely zero. When I have been dragooned into ordering one, I always precede the blood draw with a statement along the lines of “there is essentially no result likely to come that will in any way inform a clinical decision on my part.”
First, I’d like to say that I think I’d enjoy having you as my doctor.
Beyond that, I think as long as you’ve clearly explained the minimal benefit and increased risks to the patient, and the patient is in a position to give voluntary informed consent, I think you can be right to order extra tests. I’d be more squeamish in the cases you indicated were most common–when the tests are really for children, to alleviate the parent’s anxiety. But if the risks are minimal, and you’ve done all the ‘splainin’, I don’t think you’d do wrong to order the tests.
I’ve read about parents who demand that doctors put their children on prophylactic antibiotics. Bizarrely, it’s more educated parents who tend to do this. I had a friend who knew full well that the doctor couldn’t do much for a viral illness, but enjoyed going to the doctor and demanding a prescription for antibiotics every time he got a cold. I hesitate to condemn a doctor who is puzzled by how to deal with such people.
And of course medicine, so far as I understand, still involves a large element of dealing with people’s emotional states. I doubt most physicians get as much medical-school training in that as they do in the more certain physical side of things. To say a doctor should just ignore that emotional side and never order a test that is unnecessary is to say that a doctor should ignore something that is in fact important to his patient’s health, as stress not only makes us emotionally unhealthy but can (or so I’ve heard, and tend to believe) have a negative effect on our immune system.
In the prior thread, Density Duck said,
so your attitude is that your patients are petulant children who need placebo testing in order to feel like the doctor “fixed” something and therefore things are better?
But to simply ignore a patient’s emotional needs is much more like treating them as petulant children, telling them they just need to toughen up. To pay attention to their emotional state is to treat them as human individuals, with a very real interior life, rather than as just another widget coming through the examining room assembly line.
I’ll start by thanking you for your kind words. One of the things I’ve learned in my relatively short career thus far is that you “click” with some people, and you really, really don’t with others. For some patients/parents, my bedside manner of goofy irreverence works great. For others, not so much.
Having now worked as an attending physician in two very different practices with two very different patient populations, the requests for diagnostically unnecessary tests have been much more frequent in the more affluent area. However, the requests (read: demands) for antibiotics have been about the same. During the present season, I’d estimate that at least a third of my patient encounters entail at least an explanation of why antibiotics are not indicated, with varying degrees of reception.
What I’m really getting at in my question, and which speaks to your point, is whether it’s more helpful to think of these tests as “therapeutic” rather than “unnecessary.” Assuming neither personal benefit from ordering the tests (which raises obvious ethical questions) nor simple laziness on the part of the providers, these tests are ordered for a reason. Lord knows I would never order them if I didn’t feel that in some way I had to.
Could you feel comfortable prescribing a placebo in place of an antibiotic?
No. I would consider that undeniably unethical.
see… at least for me, I wouldn’t. It’s not just the person’s own life they’re risking, when they beg for antibiotics they don’t need. And if you give them a placebo, there’s the convenient excuse that “it must of been resistant” if there actually is a bacteriological problem.
Again, this is just me. And I’d want to inform the patient about the risks of over-prescribing antibiotics.
A sugar pill will accomplish everything that a “therapeutic test” would, with the added benefit of not costing hundreds of dollars or promoting antibiotic resistance.
hmm… were I the doc, I’d send him to a psychologist — get a workup on exactly how much this is effecting him (including the cumulative effects of stress), and then lay out the facts to him as I know them.
I’d feel comfortable ordering it — in the same way that doctors give placebos. But in this case, he’d be much better informed than sugar-pill users tend to be.
I might strongly advise against it. Or it might actually be beneficial to his health (if he’s that anxious, there are substantial correlations to poor outcomes of other diseases, and if he’s prone to certain ones, he may be at risk for suicide)