A 2 question strategy to assess the worth of medical tests

In the medical world, when a physician, a scientist, a hospital, a drug company or a panel of experts issues a report, the games begin. If one agrees with the statement or benefits from it, then the report is heralded as breakthrough brilliance.

If, however, the report suggests a new medical pathway that diminishes your relevance or reimbursement, then the report and its authors are regarded as misguided. Yes, I am generalizing somewhat here, but you get the point.

As readers of my blogs know, I am a conservative medical practitioner. I do not mean conservative as in supporting the NRA, prayer in public schools, self-deportation of illegal aliens (or should I say “undocumented residents?”), “clean coal” and lower taxes for millionaires and billionaires.

Conservative physicians describe those who are extremely judicious with regard to medical treatment and diagnostic testing. We don’t lurch to treat or test unless a high threshold of necessity and effectiveness is crossed. Before ordering a medical test, two questions should be considered.

  1. Will the results of the test under consideration potentially change the medical management of the patient?
  2. Is the change in medical management referenced above in the patient’s best interests?

Let me illustrate why the second question above is so critical.

For example, assume a surgeon orders an ultrasound on a patient with abdominal pain to determine if gallstones are present. This test seems reasonable as the result of the test may change the medical management of the patient — the point raised in question 1. So far, so good.

If gallstones are present, then the surgeon removes the gallbladder. But, if this is not the correct treatment (because the pain is not caused by gallstones), then the principle in question 2 has been violated.

In this example, the physician feels that the ultrasound test was needed as it led to gallbladder removal. He feels that the test changed the management of the patient — which it did — but it led him down the wrong path. So, the test was not reasonable and should not have been ordered in the first place.

I make this point as for years during medical training and afterwards, I have been told and have read that tests should only be done if they might change medical advice. This is true, but not the whole story. Left out of this medical maxim is the more important point that the new medical advice must advance the patient’s medical interest.

An oncologist may recommend a CT scan because if new cancer is found, then new treatment will be prescribed. Does this strategy pass the two question test I have raised here? Sometimes yes, and sometimes no.

Is there anyone out there who doesn’t believe that we are testing and treating patients excessively?

This same two-question strategy can be applied to a medical commentary blog to assess its worth.

Does the blog potentially change your point of view?

Is this new viewpoint enriching you?

As always, readers’ views are earnestly solicited.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

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  • rtpinfla

    Although I agree that both questions are valid when ordering a test and there is entirely too much unnecessary testing out there. But to conclude that a test was inappropriate after the fact isn’t necessarily valid. Since there is no way to know, in this example, that taking out the gallbladder is the wrong choice until after the gallbladder is removed, how can the surgeon possibly decide against doing the ultrasound? Lawyers may have the benefit of hindsight, but physicians do not. Had the US been negative, then the surgeon could have considered another diagnosis, and the US would have been appropriate- trouble is, there’s no way to know that until you know that.

  • Dr. Drake Ramoray

    I have always used three rules.

    1st do no harm

    2nd rule out badness

    3rd as you stated don’t order a test that won’t change what you do.

    Personally I don’t think your second question is necessary as treatment decisions involve the patient and implicit in that is would a treatment resulting from that test be in the patient’s best interest.

    I don’t biopsy thyroid nodules in 90 year olds because it won’t change what I do BECAUSE total thyroidectomy is not in the best interest of the patient.

  • Kaya5255

    It is difficult to determine if a test is necessary and appropriate. It seems to me that most tests are ordered to “rule out….”. Having said that, I must also say there appears to be a perception that if a provider doesn’t order a test, they run the risk of being sued. Best interest of the consumer, best medical practice, or CYA???

  • medicontheedge

    Today’s healthcare environment is not conducive to judicious and targeted tests based on assessment…. it is check off, cookbook, pathway based scattershot, and a cash cow for all of us in the business.