Testing to the Nth degree

When a healthcare provider orders a test, it may be opening the flood gates for further testing. And it's really really really hard to scramble back and undo an unnecessary test after the fact.

When a healthcare provider orders a test, it may be opening the flood gates for further testing. And it's really really really hard to scramble back and undo an unnecessary test after the fact.

Every week I save articles about overtesting, overtreatment, "right care," how to fix out health system, and so on. Today I present:

Four examples of outrageously unnecessary tests

1. An Egregious Example of Ordering Unnecessary Tests
- Patient: 21 year old healthy male for a general annual exam
- Cost: $3682.98 ($13.09 covered by his insurance), confusion, worry
- What happened: The doctor ordered a tonne of lab tests including some I've never even ordered, a stress test (unprecedented in a healthy 21 year old!), etc.
- Comment: The blog writer is appropriately flabbergasted as basically every test ordered was unnecessary; however, he doesn't take it far enough - Routine Physicals themselves are not recommended; annual exams have no scientific value.

2. False-Positive Results From a Diagnostic Colonoscopy
- Patient: a middle-aged man with occasional blood in stool
- Cost: unnecessary colonoscopy, exposure to risks, worry/grief about having cancer
- What happened: Although the primary care provider thought the patient had irritable bowel syndrome (IBS) and an ano-rectal source (eg. hemorrhoids) for the occasional blood in the patient's stool, a colonoscopy was ordered. It showed a polyp and the pathology was positive for lymphoma. The patient underwent extensive testing which revealed nothing. The diagnosis of lymphoma was questioned and the patient was diagnosed with hemorrhoids and IBS or food allergy.
- Comment: It's not a bad idea to tell the patient what you are thinking and why you suggest certain things:

"After this experience, the patient stated he would have agreed to an elimination diet, rectal examination, and anoscopy if he had understood what information his physicians could have obtained from these initial tests, prior to pursuing a more invasive option."

3. How the CA-125 became a $50,000 blood test
- Patient: middle-aged female given a CA-125 blood test as "screening" for ovarian cancer
- Cost: $50 000 if you include all the sequelae from that first test
- What happened: The doctor suggested being "safe" and using a test that is not meant for screening as a screening test. When the test was slightly elevated, the doctor suggested further tests. Ultrasounds, CTs, surgeries, etc.
- Comment: I can't say it better than the blog writer when he sums up the costs:

"Five months of mounting worry, loss of several organs, and a simmering distrust of doctors and their tests:  incalculable."

4. Stop hunting for zebras in Texas

- Patient: young man hit in the head with a baseball bat, may be given 2nd CT scan
- Cost: more than necessary
- What happened: A young man who was struck with a baseball bat had a CT scan that showed a Subarachnoid Hemorrhage (SAH). Dr Watson suggested he have another CT (angiogram) scan to see if a brain aneuyrsm was the cause of the bleed. Dr Jha suggested that perhaps the blow to the head was the cause of the bleed in the brain (duhhh!). Dr Watson was "hunting for zebras," i.e. looking for a rare cause to explain the problem rather than the pretty obvious, straightforward one. He thought he had to "rule out" or exclude the rare diagnosis. Dr Jha applied Occam's Razor,  suggesting that while a rare cause was possible it would be far more likely for the simple/obvious cause to be the case.

"Watson’s rationale for fishing for rarities—“can’t be ruled out”—is unfalsifiable. This phrase cannot be disproved. It smashes Bayes’ theorem and Occam’s razor to smithereens. It is kryptonite to clinical acumen . . .
. . . there is wrong: falsely declaring disease in a healthy person—a false positive. And there is (really) wrong: falsely declaring health in a diseased person—a false negative. . . [M]any doctors have chosen being wrong over being really wrong."

- Comment: To "err on the side of caution" seems best at first blush. But being careful has consequences too. In this case, extra radiation (which increases the chance of developing cancer), potential reaction to CT dye (anaphylaxis, kidney failure), the finding of things no one was looking for ("incidentalomas") and further testing required to make sure they aren't bad things, the financial and time cost of the CT scan, etc.

See the article for an excellent narration of the thought process behind this kind of decision-making.

Coccidiomycosis and other "Zebras" in Medicine; reconciling with Less is More

This is the first time I've had a peer-reviewed article published. Shortly after I wrote an email to the patient, the subject of this case report, to let him know, I was looking through my other emails and realized not only was it published, but that it had become the cover story for this of the British Columbia Medical Journal (BCMJ)!

Read the article here: A textbook case of coccidiomycosis (web version or a PDF version).

Ok, perhaps I shouldn't be so proud as it's not the Lancet or BMJ, but I think the BCMJ is pretty darn good and it was exciting for me to get to share this case in so doing, to make good on a promise to this patient to educate others about his diagnosis. It was also great to work with a friend, the very smart Dr Barlow!

I also liked the reflective exercise of thinking about how a "Less is More" kind of doctor could still diagnose exotic conditions.

The article is about an uncommon fungus (coccidiomycosis) that a patient I saw in on Vancouver Island had acquired. There's an expression in medicine:

"When you hear hoof-beats, think horses, not zebras."

One should never jump to the exotic diagnosis. However,  occasionally, people do have exotic diagnoses.

Even though I had to order some specialized tests to find out for sure what he had, this practice is still consistent with the "Less is More" philosophy. The idea is that in avoiding all the unnecessary stuff, we can use our time and resources wisely to order the RIGHT tests and treatments. It also helps immensely when patients are aware of their own health and can tell us their story clearly.

It all worked out because we had:

- A clear patient, advocating for himself, open-minded & contributing to my assessment and plan
- A doctor with time to hear the patient's story, medical knowledge appropriate for the situation
- Judicious ordering of tests (wrong test for most people, the RIGHT test for him)
- Confirmation of a suspicion gained from the history and reviewing the labs/xray that were already available

This was a highly satisfying case. I'm rarely clever, and rarely have a patient who is as good a historian as he. It's a wonderful illustration of a working acute care system, the benefits of being a patient who takes ownership for his health, and that some obscure knowledge is tucked away in my brain which will sometimes emerge when needed!