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Reviews

Avoiding Unnecessary Medical Tests

Timothy B. McCall, M.D.

Medical tests cost money, often involve discomfort or inconvenience and can cause side effects. When necessary, the can save your life. Unfortunately, many tests are not necessary. Here are some tips to be sure you are not getting unnecessary tests or the wrong tests:

• Be sure your doctor begins with a thorough interview and exam to narrow the possibilities. An inadequate interview and exam increase the likelihood of inappropriate testing. Only after the interview and exam can a doctor make an informed guess about what’s wrong with you and recommend the appropriate tests.
  Beware though: to save time, nurses often obtain blood tests, EKGs or X-rays before the doctor evaluates the patient. Sometimes the nurses anticipate what the doctor wants, sometimes not. I’ve seen instances when a nurse sent a patient for a knee X-ray, when what the patient needed was an X-ray of the ankle. Other times, patients have had several tests when none was needed. The nurses’ intentions are good. They’re trying to save the patient and the doctor time but the result of this “Shoot first and ask questions later” approach is a load of unnecessary tests. Except in emergency situations, my advice is to politely refuse tests until you’ve has a thorough interview and physical exam.
• Use as few tests as possible to establish the diagnosis with reasonable certainty. Sometimes your doctor may feel fairly certain of your diagnosis but want to order more tests “just to be sure.” This may be appropriate when there is a lot at stake, as if they think you have cancer and are recommending chemotherapy. For most medical problems, the so-called “belt and suspenders” approach to diagnosis (to make doubly sure your trousers stay up) isn’t a good idea. Many doctors, however, seem to subscribe to the credo The more the better. When more data can be collected without major risk or expense, as with a careful interview and exam, this philosophy may be reasonable but excess testing comes at a cost, both financial and otherwise.
• The best test may be no test. Part of a doctor’s job is to decide when a patient’s symptom is serious and when it’s nothing to worry about. If a patient complains, “my right elbow itches every time I eat pastrami,” the doctor shouldn’t be ordering a lot of tests. Many people mention unusual symptoms that don’t sound serious and that no amount of testing is likely to explain. A healthy shrug of the shoulders is probably the best thing the doctor can do. If, on the other hand, the patient complains, “I get a sharp pain in my belly every time I eat pastrami,” a few tests to sort things out may be in order.

Occasionally, a symptom that doesn’t sound serious at first turns out to be significant. It simply isn’t prudent, however, to chase after every symptom with a battery of tests. In the early stages of many diseases, the symptoms may be vague, of short-duration and not point in any particular direction. Tests may not have had time to become abnormal yet. As time goes on, the picture becomes clearer and the diagnosis can be made.

Some patients have a million symptoms. It is impractical and inappropriate to do a test for every one. Instead, through careful follow-up questioning and a thorough exam, the doctor should order those few tests that may help to pin things down. If there’s reason for concern, it’s always possible to schedule a return visit. Sometimes the best course of action is watchful waiting or, as it’s sometimes called, “tincture of time."

Doctors are trained to think scientifically. Many of them expect there to be a physical reason for every symptom, definable by a number or by an abnormal test result. Given the litigious atmosphere in health care these days, doctors often feel they at least need to look for a physical reason for each symptom. In their scientific zeal, many doctors ignore the role of psychological and social factors in disease. If a young patient who is unemployed and having marital problems feels dizzy, performing a bunch of expensive tests may not be the best way to proceed.

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