Patient – Initiated Testing

AMNews: May 5, 2003. Do-it-themselves diagnosis: Patients pick their tests

 This atricle from American Medical News highlights several intersting and problematic issues, yet overlooks the "patient-initiaed-testing" that occurs behind the closed doors of the physician's office.

"Doc .. I think I need an MRI" says the man with a headache.

He may .. but then again .. he may not.  Depending on the patient and the physician .. the decision to order the test or not will vary – even in the context of identical presentations of signs and symptoms.

A few weeks, ago, I saw a 39 year old for a sore throat.  He'll be 40 in a few weeks, and scheduled a visit for this event.  "I'll see you in a few weeks, Doc"  He says … "I'll need a full work-up at 40 .. y'know .. exercise stress test, chest x-ray, EKG, CBC and complete chem panel."

"oh boy" .. I says to myself … I'd better get the screening guidelines ready. 

So it gets tricky.  I do want to reassure him that he's healthy.  And I certainly want to do my best to keep him healthty.  But these tests simply aren't indicated. 

I usually bring up a copy of the guidelines on the web in the exam room so that we can discuss them.   Traditions die hard, though … and it's hard to educate away a fixed belief that something that was "essential" 10 years ago is no longer necessary.

Barbara Starfield has written about the importance of primary care .. but one of her most often cited papers is from 1994 in which she determines that lower cost care often provides the same quality of case as high cost care.

 .. and … in the context of last week's post on the Futures of Family Medicine project, Dr Starfield's lectures provide a wonderful outline of the reasons that Primary Care is better for a community than specialty care:

• New Paradigms for Quality in Primary Care
• The Primacy of Primary Care in Health Services Systems
• The Primacy of Primary Care in Health Services Systems
• Primary Care: 21st Century Challenges to Quality

The last one is a fantastic overview of the complex pressures on health policy.  The 2nd half of the presentation includes a classic slide. Take a look at it carefully.  The Question it asks: should we do an exercise stress test on our patients before they begin jogging?  The answer:  No.  Doing the test may in fact expose them to greater risk than not doing the test. 

This is a concept that patients often find hard to grasp.   It comes up in the dicussion of PSA testing, of course … a discussion for another day.