Not so long ago I posed a question about whether patients should be able to obtain lab tests for themselves without my ordering them. And lo:
You could call Michael Brooks a supplement junkie. He pops exactly six pills a day, three times a day, not to mention powders and shakes and chews. “A multivitamin, vitamin C, omega-3s, alpha lipoic acid,” he says. “I’m taking a digestive enzyme.”
Brooks is a personal trainer in Birmingham, Ala. He’s healthy and fit, but he almost obsessively wants to know more, which is why we find him here, a few doors down from a sandwich shop and a nail salon, at a storefront lab called Any Lab Test Now.
When you get your cholesterol or blood sugar checked, chances are your doctor ordered the tests. But as insurance companies pass along more of the cost of lab work onto the consumer, retail lab owners are seeing a niche. But there are some concerns.
Brooks is having a micronutrient test done to tell him where he’s deficient. The test costs $399, but Brooks figures his nutritional supplements aren’t cheap either.
“So even though there’s a cost to this test, I feel like if I can maybe find a few things I don’t need to be taking, so in the long run I’ll save money,” he says.
[snip]
At Any Lab Test Now, co-owner Anthony Richey pulls out a long sheet of paper with all the different tests his lab offers. There’s everything from an HIV screening to a “fatigue” panel. It looks like a sushi menu.
“You say, ‘Well I want to check my diabetes, I want to get a hemoglobin A1C, and maybe I’ll check my lipid panel. And I’m a male over 40 so I’ll get my PSA checked,’ ” Richey says.
My, my, my. Where to begin?
Mr. Brooks seems to be the kind of fool who is eager to speed the inexorable process of parting with his money. It surprises me not at all that someone who would avail himself of nearly four hundred dollars worth of unnecessary blood tests is also devoted to worthless supplements. Without the benefit of a single test, I could tell him that he needs to be taking none of them. I would happily sell him a tincture of my own toenail clippings for a fraction of the cost of those supplements, with a guarantee that there would be no measurable difference in benefit.
But I digress…
It should come as no surprise that I take a dim view of labs like these and the services they provide. My head swims just trying to think of what worthless woo is offered in that “fatigue” panel. And the lab owner’s mention of a PSA test forces a wry smile, given the shiny new recommendations against ordering them because they lead to unnecessary further testing, treatment and side effects in otherwise asymptomatic men. Which brings us to the major reason not to order tests like these:
[T]hat’s what is dangerous, says Michael Wilkes, professor of medicine at the University of California, Davis. He says false alarms come with the turf.
“If you order enough tests, something will eventually come back positive,” Wilkes says. And without a doctor’s input, he says, that can send someone into a panic. What’s more, ordering tests can drive up health care costs. That’s because a positive result, Wilkes says, is usually followed by a doctor’s visit.
“And now a doctor most likely has to repeat the test. And then there’s a whole list of cascade of new tests to confirm or go against what the tests show,” he says.
Just so. As I was taught in medical school, the more things you look for, the more things you find. The broader the panel of tests you order, the more likely you are to detect something randomly abnormal and almost certainly meaningless. It happens often enough even during totally appropriate routine screening. The correct approach is to repeat the test to be sure the first result wasn’t erroneous. Ordering a whole pile of totally worthless tests makes it much more likely that some kind of noise will emerge, and thus require a doctor’s visit and further testing to sort out. Mr. Brooks may pay out of pocket for that first round of tests, but if he shows up in a swivet at his doctor’s office (an emotional condition for which I would have little sympathy) then suddenly he’s contributed to everyone else’s health care costs, too.
That is my only real objection to these labs. Otherwise, I don’t really care. For people who feel overburdened by blood and money, and who wish to relieve themselves of both, I don’t feel compelled to stop them. If they fly into a panic because of something (likely clinically insignificant) that they found, it’s a panic they bought and paid for themselves. I don’t see why I would mind.
The only caveat I would add to this regards children. If grown-ups want to exsanguinate themselves and pay for the privilege of doing so, I’m pleased to let them. But children should only be put through the pain of blood testing when genuinely indicated, particularly since it is often much more difficult to draw blood from a child. Repeated needle sticks for no reason create a harm with no benefit, and could potentially create even more anxiety around legitimate medical exams, which is already enough of a problem. These labs have no place in pediatrics.
But for adults? I couldn’t care less.
Yes, it’s much better when a special group of smart, trusted men get to make all the decisions for everybody. It’s okay, you can trust them; they’re special and smart. They have a paper on the wall that says so.
Remind me, Duck, where it was I stipulated the importance of gender in one’s medical provider. I seem to have forgotten.
Also, does your disdain for the education and resulting expertise of professionals extend across the board, or are doctors just lucky? Presumably your sneering contempt for the pieces of paper we hang on our walls, meaningless bits of frippery that they are, means you don’t bother with us when you’re ill.
*sigh* persons, then, rather than men, if you think that was the intent of my message.
You write about how awful it is that people can do all these tests, and how someone who misinterprets a result will cost everyone money. Meaning…what, exactly? That we shouldn’t allow people to order their own tests? That we shouldn’t let people see their test results? That everything should go through The Doctor and we should all just sit down and shut up and do as we’re told and only as we’re told because our lack of education and specialization means we’ll just screw it all up? If that isn’t the point of your post, then what is it?
You wrote “men,” Duck, and so to “men” I responded. If you think you’re deserving of more slack in my interpretation of what you write, try to remember how barbed many of your comments are.
Since you have somehow come to the conclusion that I don’t think people should be allowed to order their own tests when I tried to make the opposite point quite explicitly, I will lay it out for you again. I think people who order their own blood tests are likely to waste their money. Please direct me to anything I wrote that comes anywhere near the inflammatory and inaccurate “sit down and shut up and do as you’re told,” as I don’t believe I said anything of the sort. Rather, I think doctors, what with all our book-learnin’ and fancy bits of paper and such, can meaningfully advise our patients about what kinds of testing are warranted and likely to yield helpful information, and what kinds aren’t. I think people who go it alone are quite likely to spend their money on worthless data. And, as I believe I made abundantly clear, I think they should be free to do so.
From your experience — well, let me lay it out from my end, watching all these claims pour into BC/BS, trying to extrapolate meaningful stats — is there really a tendency among health care professionals to over-test in an effort to avoid malpractice suits?
Let me stipulate to the troubling statistical inferences of tests like PSA. Sure, we can say an elevated PSA is something to keep an eye on, but it’s no indicator of prostate cancer and doesn’t save lives, statistically. I’ve had to point this out to folks even within the BC/BS community, who up until quite recently were terribly conflicted about denying payment for some of these tests.
From your experience … is there really a tendency among health care professionals to over-test in an effort to avoid malpractice suits?
Yes. I think I posted something about this, back in the ether. Anyhow, I think any honest provider will admit to ordering tests they don’t think are medically indicated because of a combination of factors along the same spectrum, with fear of malpractice being a relatively rare concern at the far end.
It seems that when it comes up, the doctors I’ve known will rather quickly cite medmal as a big reason for overcare (not that they do it, necessarily). The more exposure to the medical community I’ve had, though, the more it seems strongly intertwined with a strong desire not to miss something.
I’m not a big fan of our medmal tort environment (and I can actually say this was the case before I met my wife), but I think its monetary effects are often overstated by its opponents. What I see most sharply (again, as an observer on the fringe of the medical community) is more psychological Culture of Fear it can instill. And not the sort of fear that necessarily makes doctors better doctors.
That’s quite informative, thanks, both of you.
I have this theory I’ve been kicking around lately. It goes along these lines. If health care professionals and insurance firms had some sort of feedback loop whereby the HCPs could take a look at the stats I generate about the effectiveness of a given test, they’d be able to make more informed decisions. I get to see how this stuff pans out, from the exam to the diagnosis all the way through the surgeries and post-op and recurrence, all the way to hospice. Blue Cross really does pay, and it knows what’s going on in terms of cost and benefit.
Granted, I’m sure every competent HCP stays current, but damn, from a statistical basis, the insurance companies have some useful data, none of which can be shared at present.
The Culture of Fear Will mentions, are more or less the explicitly-acknowledged mechanisms of tort law.
Now for some reason, few complain about the Culture of Fear imposed on supermarkets by greedy trial lawyers, which compels them to hire more clerks than would otherwise be necessary to sweep the floors and thereby raising the cost of bananas.
Few complain about the Culture of Fear in which tort law forces drivers to modify their behavior when behind the wheel and thus restricts individual freedom.
Nor, on balance, are most people terribly upset by the fact that a Culture of Fear compels restarauteurs to enforce cleanliness standards on their kitchens and bathrooms and to only serve wholesome food, again increasing costs and the hassle of operating a bedrock business of modern American commerce.
Some people are simply sociopaths who will do as they please, acting as carelessly as they choose, until and unless the law steps in and creates a disincentive to particular kinds of undesirable behavior. Why should doctors (or lawyers, or accountants, or any other members of any learned profession) be treated with less mercy? Do unregulated professional sociopaths somehow do less harm to society than do unregulated sociopathic restarauteurs, drivers, or grocery store managers?
Hmmmm. I honestly hadn’t thought of it in those terms. I’ll ponder this, and if another post springs forth, Athena-like from my skull, I’ll share it.
Fear can be a motivator for doing better, but it isn’t always so. In the case of doctors, I believe it is counterproductive.
Why is it different from other things? Maybe there are some other fields like it. I couldn’t say. But medicine is a liability magnet. Imposing that liability on providers is, in a sense, suggesting that they should carry the burden because they chose to devote themselves to something life-and-death. That, if they didn’t want the ever-present fear of lawsuits hanging over their head, they should have gone into something less risky. Less important, for that matter.
As I’ve mentioned before, one of the reasons that my wife’s hospital is short-staffed on obstetrical services is that one of the doctors refuses to deliver any more babies after a prolonged lawsuit (that he won). Rightly or wrongly, there is the perception among doctors that being sued is not in accordance with how careful you are or how good you are, but rather a game of roulette. Wrong patient (or patient family) + bad outcome = lawsuit. And once you’ve been sued, you’ve already lost. The only question is how much you have lost (maybe a little, maybe a lot).
I believe this to have a detrimental effect on care that outstrips the positive effect of “I’d better be a good doctor or I will get sued.”
I don’t know what the solution to actual malpractice and/or bad outcomes ought to be (outside of discipline boards and such for egregious and/or repetitive cases). But I question treating hospitals (where death and sickness and bad outcomes are a part of every day life) the same as truckers (where it’s easier to avoid death and bad outcomes) is optimal.
Will, I thought these remarks deserved a deeper exploration than I could give here.
someone had an article out blaming much of medical overtreatment on schemes like “doctors who own stock in the for-profit labs” (they linked to it on kos a while back)
Less flippantly: It seems to me that the first step, upon receiving a positive result from a medical test, is to re-do the test twice. Once to see if the problem recurs, twice to see if the first two times were flukes.
Anything that’s not killing you right away…isn’t killing you right away. You have time to verify.
Yes. If I were running such a “scam” I’m make sure that people knew about Type I and Type II errors before doing a test on them.
Before I read far enough, I was trying to figure out what sort of thing a “swivet” might be and how it would result from these tests — I was picturing it as some sort of medical equipment, like maybe a sling.
Otherwise, I agree regarding letting adults make their own choices for themselves. With children it’s complicated in ways that these things are always complicated.
I’ve always wondered about the ethics of treating the hypochondriac. Conversely, I’ve heard of enough cases where one doctor thought the patient was a hypochondriac and another doctor found an actual treatable medical condition.
A well-heeled hypochondriac could get himself some first rate expensive treatment. It’s sorta like that old urologist joke about the urologist giving one of the hospital board members a tour. They come into one man’s room, only to find him masturbating. The board member was appalled. “Oh, don’t worry, that’s part of the therapy,” said the urologist. “He has a serious prostate condition.”
They come into the next patient’s room, only to find a nurse fellating the patient. Completely outraged, the board member said “Now you’ve got to explain this one!”
“Ah, ” said the urologist, “Same condition, enlarged prostate gland again.”
“What’s the difference?”
“Self-pay”
I believe Aetna has limited payment for that condition to a swift kick in the yarbles.
ROFL! Everything on HCPCS G0102 gets routed down that therapeutic avenue.
I’m glad I found this. I’m going in for my annual check-up in a few weeks and I was going to ask for a PSA. I might still get the DRE (or Dreaded Rectal Exam as I call it. The first time I saw this I thought of Digital as opposed to Analog, not as Digits and was hoping that they had found a new less invasive way of testing. Boy, was I disappointed!).
Any specific tests that I (as a man of 59) should ask for?
Good luck with your visit, Jeff. I’m in no good position to offer advice to you, as I’m a pediatrician.
Details, details, details! Pretend I am 10 and extrapolate 50 years!
<a href="http://www.miamiherald.com/2009/02/11/427603/dave-barry-a-journey-into-my-colon.html"What to expect
Without the benefit of a single test, I could tell him that he needs to be taking none of them.
None of them? Isn’t the importance of adequate omega-3 intake fairly well established at this point?
Fair enough, I suppose. Though with sufficient consumption of fish in one’s diet, supplementation is unnecessary.