Ordering tests just to reassure patients doesn’t work

Ordering tests just to reassure patients doesnt work

Every primary care doctor has been faced with this situation. A patient reports vague symptoms and is very worried that they are a sign of a catastrophic illness. The symptoms aren’t even slightly suggestive of the disease the patient is worried about, but the patient’s neighbor’s brother-in-law was just diagnosed with the same disease, and so the patient is pretty sure that he has it too.

The doctor is not at all suspicious that the patient has this disease. The doctor believes that the patient is simply anxious, and that his symptoms are either caused by his anxiety or are normal bodily sensations that are being magnified and given lots of attention because of the news about the neighbor’s brother-in-law.

What can the doctor do? One option is to order a test — a CT, a MRI, blood tests, whatever would rule out the specific disease the patient is worried about. The doctor is not ordering the test because he is actually curious about the results. He thinks the probability of an abnormal result is extremely low. He is ordering the test simply in the hopes that a normal result will reassure the patient, decrease the anxiety, and maybe even lead to the resolution of the symptoms by letting the patient focus on something else.

The temptation to order the test is pretty great (especially if the doctor owns the testing equipment). But will it work? Will the normal test result fix the problem?

A study published in JAMA Internal Medicine attempted to answer that question. Researchers compiled all previous published randomized trials that assessed diagnostic testing done for symptoms that were unlikely to represent serious illness. They found that on average the patients’ reported anxiety and symptom severity did not decrease after the result was normal.

So when the disease being investigated is very unlikely, ordering a test just to reassure a patient doesn’t actually reassure the patient.

It might be more effective to take the time to understand the cause of the anxiety. Perhaps the patient is actually very close to the neighbor’s brother-in-law and is himself devastated by the bad news and simply needs to express how sad he is for his friend. Or perhaps he has health anxiety (hypochondriasis) and has been to a dozen doctors in the last six months with different symptoms getting myriad normal tests. The former just needs some sympathetic listening. The latter needs cognitive behavioral therapy. Neither benefit from diagnostic testing.

Another reason to avoid testing for a disease that is very unlikely in a given patient has to do with math. I wrote last year that screening for most diseases is not helpful. One of the reasons is that no test is perfect. If the likelihood that the disease is present is extremely small, an abnormal test is more likely to be caused by a test error than by the disease being present. So testing patients that are almost certainly healthy raises the possibility of false positives due to test errors. That won’t reassure anyone and will likely lead to more tests to pursue the spurious abnormal result.

Doctors need to learn to say to patients, “That doesn’t sound worrisome, let’s just keep an eye on it,” without being dismissive. Patients need to learn that a system that pays more for testing than listening will deliver more testing than listening.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

Image credit: Shutterstock.com

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  • Suzi Q 38

    I can undertand this thinking, but in my case NOT ordering the MRI of my spine (in spite of persistant but decreasing and increasing symptoms), caused signal changes on my spinal cord because too much time had passed to get much needed treatment.
    My neuro and gyn/oncologist thought I was a hypochondriac.
    Now I have limited walking function and am barely weight bearing when I stand. I wake up in the middle of each night in pain.

    Sometimes, if it is persistent, it is worth the MRI that costs $5K.
    Listen to your patients.

    • http://twitter.com/AlbertFuchs Albert Fuchs

      Suzi: The study I wrote about had to do with patients who did not have signs or symptoms of the disease they were worried about. Patients who have symptoms or signs of a disease should have the appropriate tests, of course.

      • Suzi Q 38

        My apologies, doctor, but how often do you come in contact with patients that exhibit NO signs or symptoms of the ailment(s) that they are concerned about?
        Every month? week? or year?

        • PCPMD

          Corollary – an overwhelming majority of symptoms are not related to true, or at least defined, disease.

          Now we’re really having a discussion – if a huge percentage of people who come see the doctor have either nothing wrong, somatization, or self-resolving conditions, how do you propose doctors figure out the “real” from the “imagined or harmless”?

          • Suzi Q 38

            I would guess that it would have to be a very small percentage.

            To see the doctor takes time and money. I personally don’t like to part with money, even if my insurance is taking care of it. I pay way too much per month for PPO insurance to risk getting canceled for being labeled a hypochondriac.

            Yes, maybe the patient is lonely or has psychological issues, but this is not likely. I have nothing to support my ideation that these hypochondriac patients are few and far between.

            If I am wrong, I am asking the physician/author to kindly support his claim with a link to a reliable study involving a fair number of patients.

  • wiseword

    If a medical doctor says it’s “in your head,” then you can be pretty sure it’s in your body.

  • http://twitter.com/gcgeraci Gaspere (Gus) Geraci

    Diagnosis is a process, not a one time stab. Taking a full history and listening, also consists of asking the right questions. “You’re the fifth doctor I’ve seen for this,” is rarely reassuring unless you ask the right question. “What are you afraid you have?” is a very telling question. A specific answer, “I’m afraid I have cancer in my bone, because….” can absolutely be reassured by a test. “I just feel these is something wrong,” needs much further exploration. We also need to be clear to patients that diagnosis is a process. “We are not finding anything right now, but if you get worse, or new symptoms develop, we can always look harder. Meanwhile, let’s talk about how these symptoms are affecting you…”

    • http://twitter.com/AlbertFuchs Albert Fuchs

      Completely agree. Well said.

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