A good doctor should rarely be surprised by test results

I got into medicine because it is fun, and, of course, to help people. I think most of my colleagues did so as well. I get up every day and I get to go to work and figure out puzzles all day. How cool is that? Sure, it may not always be unwarranted or a bad thing, but testing and more testing can definitely take the fun out of taking care of patients.

I want to figure out your problem the old-fashioned way with a good old history and physical! Then and only then, get a test if it is warranted. This is the correct way, and the safe way, to help improve your quality of life.

So why else am I in favor of the Choosing Wisely (and the mentality behind it)?

Our over-testing can place the patient in harms way, especially if your doctor is not vigilant. There are only three results that can come from any medical study or test. You might find what you are looking for, find nothing (negative/normal result), or a result that is unexpected. A test that shows what you are highly suspecting should be the most common result. Testing that shows nothing or is “normal” should be far and few between. Warranted screening testing or similar testing is not what I am talking about here – I am talking about a patient who has a problem for which an active diagnosis is being sought. On the other hand, we would all hope the any and all screening testing would come up normal.

Tests that show something unintended are where it can get scary folks. And this is something few ever really think about. It is sort of “beware of what you ask for.” Of course, an unintended result such as serendipitous finding an early case of early leukemia or similar is a good thing. Nobody can deny what that discovery can mean to that person and their family.

But what about information that is discovered that might be something, or not? What do we do with that information? Let me say with pure clarity, it is my job to interpret and clinically correlate any and all findings. Clinical correlation is medical jargon for connect the dots, which is vitally important. Furthermore it is a bit of a lost art in my opinion.

A vital part of connecting the dots is whether the “finding” is relevant to your problem, and whether this is really there. I deal mostly with imaging tests (MRI, bone scans, ST-scans, etc.) and I can assure you that radiologist love to find all kinds of things, whether they are actually there or not. It is my job to determine if that extra finding is relevant.

So here is a piece of very good advice: ask your doc if they actually read the test themselves, and not just the report. If they do not read your test themselves, run!

The only way I can answer what to do with this extra information is by way of a story. This is only one of many such yarn I could spin. Sorry to keep bashing the MRI, but it’s so easy. In the past ten years I have seen several patients presenting with ankle pain after an ankle reconstruction surgery with a history of only heel pain or plantar fasciitis prior to the surgery. In each case they had never had ankle pain or a history of ankle injury. For any or all reasons noted above, an MRI was obtained and the read was “chronic rupture of the ATFL” or ankle ligament rupture. In my experience, approximately 80% of all MRI’s that include the ankle region note this finding. In most of these cases (hundreds) the ligaments are not an issue and do not represent a dot.

Well, as you would guess, the surgeon probably did not know what they were looking for, looked at the report, did not read the study for themselves, did not connect the dots, and the patient got an ankle reconstruction. And they still have heel pain. So, even if all these MRI reports were correct, the information was used unwisely. The dots were not connected.

What I want you to takeaway is this: I have been taught as a doc, that when you get a test, you should know what it will show. This was true then and it is true now. When a good doctor sits down with you, obtains a good history and physical, and then judiciously orders a test on you, I can guarantee you they will rarely be surprised by the results because they already know.

“Angry Orthopod” is an orthopedic surgeon who blogs at his self-titled site, The Angry Orthopod.

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