Tag Archives: Symptoms

Continuity of care is a good thing right?

There’s a wonderful video that illustrates the point I’m making this week. You can see it here.

It is assumed that continuity of care is a good thing. That if you consult the same doctor every time then you will benefit with better health. We all have relatives who insist on seeing the same doctor every time. No one but Dr. X will do. Yet doctor X has all sorts of interesting approaches to their problems and despite knowing Aunt Mildred for years hasn’t twigged that her latest symptoms may be a manifestations of some family drama. She might suddenly be more bothered about her aching hip because Uncle John is making her miserable or making her carry the shopping on their visits to the supermarket.

So, is there strong evidence that people who consult the same doctor at every visit are:

  1. Less likely to be prescribed inappropriate drugs or have unnecessary tests?- Maybe.
  2. More likely to have symptoms of life limiting illness recognised early?- Not really.
  3. More likely to be counselled about poor lifestyle choices addressed?- Maybe.
  4. More likely to be screened for chronic illness? – Maybe
  5. More likely to be immunised?- Maybe.
  6. More likely to have better outcomes from chronic illness?- Maybe

The evidence is equivocal at best. Even the most ardent supporters of continuity conclude that there is ‘lots more research needed’.

So what does that tell us?

Perhaps it suggests that simply because people choose to see different doctors does not necessarily mean they are opting for, or receiving, inferior care.

When it comes to test ordering ‘walk-in’ patients are not necessarily after tests and there is some evidence that those doctors who order tests in the hope of ‘satisfying’ the patient are misguided.

There is lots of evidence that ‘continuity of care’ increases trust in a doctor. As per the example of Aunt Mildred. But there is no evidence that Aunt Mildred will be better off trusting her doctor because ‘trust’ ( which isn’t consistently defined) does not guarantee better outcomes. If Aunt Mildred attends here GP presenting with symptoms of bony metastases and is referred for urgent investigation because her GP recognises the clinical signs then she will have been well served regardless of whether she attends Dr. X, Dr. Y or someone at another practice. The point is one of them should spot the moonwalking bear.

Picture by torbakhopper

How to get your doctor to do what you want

I had no idea who he was other than a name in the appointment book and an address on some street I had never seen. What did he do for a living? Who was his partner? What was his home like? Where had be been before with this complaint? What was he told? What were his hopes and expectations?

I could take his pulse, his blood pressure and his temperature. I could listen to his heart sounds and palpate his abdomen. But his ideas, concerns and expectations were a mystery other than what he honestly shared with me.

We know little or nothing about the people who come to see doctors in many parts of the country. It is said that almost one in three Australians choose to see many GPs.

It would be foolish to assume people haven’t asked someone for advice before they present. A google search for ‘patient health advice sites’ yields 124 million results in 0.46 seconds. People are talking to each other even if they don’t always tell us what’s on their mind when they finally consult.

  1. Getting a sick certificate when you are not actually sick:

Usually if you say anything in regards to the gastro-intestinal area, they can’t really say no. It’s too hard to find out what the issue might be, plus it could just be something bad you ate the night before, so they usually just give you the certificate.

2. Hypothroid testing: what you need to know and ask for.

Please help!!! I feel like im going crazy! Im tired all the time. I’ve gained over 30 pounds in the last year. Dont get me wrong i have always been big but never gained weight this fast. I had my gallbladder out in March of this year due to a very large stone. My doctors and I contributed my symptoms to the gallstone but nothing changed after surgery. I feel like something is just off with my body. My GP did a blood panel and said everything came back normal. I feel sick all the time. Very fatigued with brain fog. What do I need to do to get this under control? I’m 34 years old and I feel like I’m falling apart. I need help and the doctors seem to think that it’s in my head because all my tests come back normal. What should i demand to be tested or done?

3. How to talk to Dutch Doctors so that they’ll listen

I don’t know how many times I went to the doctor with a sick child only to be told to go back home and give them Paracetamol. My husband, however, always gets medicine when he needs it. I’ve been wondering how he does it. Many times, I send him to the doc’s office with whichever child is sick at that time and he comes back home, waving the prescription for antibiotics at me. For a long time, I wondered, how does he do it? What am I doing wrong? So I asked him. The insights he gave me are just too precious to keep secret. Apparently, Dutch doctors require a special mode of communication…

4. Will my Doctor prescribe me Duromine??

Theoretically you have to have a Bmi of 30+ to be able to qualify(?) for a script in Australia. However many doctors don’t like it at all and won’t prescribe. Mine said it was evil and caused more problems than it solved. Refused.  I ended up going to a bulk billing clinic as figured if this doctor said no at least I wouldn’t be out of pocket.  Said my Bmi nudging 30 and weight making me sad and depressed. Losing confidence. Also that I had signed up at the gym with a series of personal training sessions to start me off. (True). And would like to use it to kickstart losing weight, a healthier lifestyle and better eating habits. (True) And that I had used Duromine in the past and not had any issues re blood pressure or heart etc. (not true). Initially this doctor said no, hates the stuff, banned in America, very bad drug etc etc. After some discussion he ended up writing me a script for 1 month.

5. How to convince your GP to refer you to a specialist?

You feel like you don’t have the right to make your GP listen. What they say goes. That is not the case, and sometimes you really have to push the issue or go elsewhere. You may have to be pushy, and you may have to be blunt and pretty much say “I don’t think you are taking me seriously and I think you are making excuses”. If the doctor you have still isn’t listening, then you have a right to a second opinion. Exercise this right. Go to another doctor if necessary.

It is more than likely that some people will present with ideas about what they think they need to get better. It could be a day off, or a blood test, drugs or a referral. For each of the examples above we need to consider how to facilitate the best in consultations. From what is said on such websites it appears that people come armed with arguments why their will should prevail even against expert advice.

Picture by bo.peter

Why people will sack a plumber but won’t sue their doctor

Everyday somebody somewhere summons a plumber. The drain is blocked, the boiler isn’t working, there’s a leak under the sink. The problem is obvious the solution is technical and everyone knows when the job is done. If it’s not fixed asap the plumber is sacked.

That’s rarely what it’s like in medicine. Not everything is a blockage or a break. Not everything can be fixed by sitting quietly with a tool box and following the instructions in the manual.

Many of the commonest problems in healthcare don’t have an easy fix.

  1.  The pain of ‘tennis elbow’ can last for months despite treatment

Patients with tennis elbow can be reassured that most cases will improve in the long term when given information and ergonomic advice about their condition. Bassett et al.

2. Plantar warts don’t always respond to cryotherapy

Little evidence exists for the efficacy of cryotherapy and no consistent evidence for the efficacy of all the other treatments reviewed. Gibbs et al

3. Lung cancer is incurable in most cases

Lung cancer is the main cancer in the world today, whether considered in terms of numbers of cases (1.35 million) or deaths (1.18 million), because of the high case fatality (ratio of mortality to incidence, 0.87). Parkin et al. 

4. Anti hypertensives aren’t guaranteed to prevent stroke

Our analysis indicated that the absolute benefits of antihypertensive therapy depended on BP as well as the presence or absence of additional cardiovascular disease risk factors and the presence or absence of preexisting clinical cardiovascular disease or target organ damage. Ogden et al

5. Mild depression can be hard to treat

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. Fournier et al 

6. There is no cure for the common cold ( You don’t need a link for this)

These and most other problems in healthcare cannot be ‘fixed’. They can be diagnosed and they can be ‘managed’ but they can’t be fixed in the way that faulty plumbing can be fixed. Therefore that queue of people in the waiting room is saying something more than ‘I’m here to be fixed.’ Patients are saying:

  1. I am in pain
  2. I am anxious
  3. I am unhappy
  4. I am bored
  5. I am angry
  6. I am confused
  7. I am lonely
  8. I don’t like my job
  9. I can’t pay my bills
  10. I need tablets or surgery

The job of the doctor is to work out which and then to fix what can be fixed and help the patient to live with the rest until their perspective or their circumstances change.

  1. Most people won’t take their tablets as prescribed.

    Because non-compliance remains a major health care problem, high quality research studies are needed to assess these aspects and systematic reviews are required to investigate compliance-enhancing inteventions. Let us hope that the need will be met by 2031. Vermeire et al 

  2. Most people won’t benefit substantially from health promotion advice.

Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies. Williams et al

3. Most people get better in spite of treatment and not because of it.

Disease mongering can include turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeing risks as diseases, and framing prevalence estimates to maximise potential markets. Moynihan et al

But then most people will be deeply grateful to their family doctor because they don’t have to respond a certain way to be treated with respect and they don’t expect a ‘cure’ and won’t ask for their money back when things don’t work out. The doctor’s role is to be there, to encourage, to educate, to accept and to walk with their patient through all the challenges that life has to offer.

Picture by Vicki

Address the patient’s greatest fears ASAP

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I think my son has meningitis.

I glanced at the boy who was now walking across the room to look more closely at a poster on antenatal care.

I don’t think so was my first thought, followed by thank you for telling me exactly what you are worried about. It’s not always that easy. Often the ‘hidden agenda’ remains just that- hidden. The longer it remains unchallenged the greater its hold. Then it’s much less easily to address head on. Sometimes you get a sense of it from the smell of fear as it comes into the room. Occasionally it’s hidden in a request for curious tests:

Could you check my vitamin levels?

My favorite is those who come for ‘check ups’ and are seemingly asymptomatic. I recommend the paper by Sabina Hunziker and colleagues. They studied 66 cases of people who explicitly requested a ‘check up’. All consults were video recorded and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation (“open agendas”) and for clues to hidden patient agendas using the Roter interaction analysis system (RIAS).In RIAS, a cue denotes an element in patient-provider communications that is not explicitly expressed verbally. It includes vague indications of emotions such as anxiety or embarrassment that patients might find difficult to express openly and that prevent the patient from being completely forthcoming about his or her reasons for requesting a consultation. All 66 patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients.

Back to the boy with ‘meningitis’. He had a fever and aches and pains. However according to Dr. Google, who mum consulted just before rushing to the surgery, if the child had ‘cold hands’ one of the possibilities is that the child has meningitis.

I examined the child thoroughly and found that he had a mild pyrexia and signs of an upper respiratory tract infection. He was awake, alert and clearly interested in his surroundings. He was persuaded to smile and had no signs of septicemia. As this is a common fear in anxious parents I am prepared with standard advice that might be helpful and outline the way meningitis presents. Something I have encountered in practice.

There are many other fears that are presented in an urgent consult. In 99.99% of cases, they are unfounded. However the opportunity to allay the patient’s fears is also an opportunity to forge a bond that may be of enormous assistance when those fears prove to be well-founded. It may be worth considering how you will respond to patient fears of the many monsters that appear in the dead of night; cancer, heart attack, Kawasaki’s disease and meningitis in particular. Bearing in mind these monsters do occasionally present in the most atypical fashion.

Picture by Pimthida

 

Healthcare is not akin to internet shopping

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It’s encouraging when the patient asks you for your card after consulting about their warts. It suggests you have earned their trust and the next time they present you can expect to hear about something more worrying.

With regard to primary care there are those who believe there is money to be made by providing access to any doctor, anytime over the internet. However, the first commercial failure of this approach has just come to light. HealthSpot was featured in the New York Times, the BBC news and the HuffPost tech. According to posts on the internet:

HealthSpot Inc. told its largest pharmacy chain customer, Rite Aid Corp., that it would “cease operations” as of Dec. 31, and its telemedicine stations have shut down in Rite Aid pharmacies in northeast Ohio and the Dayton area.

And this after announcements in Mar 2015 that Internet provider Cox Communications was pouring money into HealthSpot, a telemedicine kiosk provider. At the time the Internet provider was reported to suggest that this could be:

As important to health care as ATMs have been to banking.

There was an expectation that doctors would virtually diagnose ailments such as allergies, bronchitis, the flu, earaches and ear infections, fevers, rashes, and sinus infections.

The model was nicely illustrated in this video.

But something appears to have gone drastically wrong and according to journalists attempts to reach the HealthSpot CEO have been unsuccessful. Commentators have been speculating that what may have contributed to the demise. An interesting comment was reported by Neil Versel

Jason Gorevic, CEO of telemedicine company Teladoc, expressed his belief that there are three critical elements to success in this industry segment: the technology platform, clinical capabilities and consumer engagement. “Consumer engagement is hard to do,”

And that may be the crucial point- the patient experience was not baked into the design of this innovation. The limitations of telemedicine in the context of primary care may be far greater than is being acknowledged by people who have very little insight into the business of doctoring.

Three years ago our research concluded:

Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools. Jiwa et al.

A minor illness provides an opportunity for the doctor to bank social capital, something that both will rely on when the symptoms presented at a future consultation suggest a life-threatening pathology.

Photo by C.C. Chapman

Are doctors OK with being fallible?

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Every doctor’s nightmare

  • Patient presents to doctor looking reasonably well one day.
  • Doctor fails to make the correct diagnosis of some dreadful disease.
  • Bad outcome the following day.

It starts in medical school. Student’s, especially those who are used to giving the right answer, may feel unworthy if they didn’t ask the right question, didn’t examine under the drapes or didn’t order the right test. How mentors handle receiving the ‘wrong’ answer will make a huge impact on whether the student will cope with mistakes in future.

In reality patients rarely present as described in textbooks. Biology is not a mathematical science. People may not be good witnesses to their own illness. There are four presentations that are troublesome in relation to people with significant pathology:

In these circumstances misdiagnoses are possible and, in theory, could result in legal action. Bad outcomes however are rare. So could a doctor survive a lifetime in clinical practice worrying about their fallibility?

How doctors handle a case of someone in each of these four scenarios will depend on the context. Their response might vary depending on:

  • What they know about this person before they presented
  • Who was expressing concern
  • What they say that doesn’t fit with what appears to be wrong
  • How the patient describes what’s happening to them and not just what they say

But more than that it depends on how they practice:

  • Are they able to review the patient soon afterwards?
  • Is there anyone else who can corroborate the patient’s story?
  • If they take shortcuts on the way to making a diagnosis (too little time listening, no examination or too many distractions) .

The consequences of the bad outcome will also vary. They are most likely if the patient or their family don’t believe the doctor cares.

Four things might help:

  1. If the description of the symptoms doesn’t fit with what the doctor can confirm on physical examination, the doctor should think again before dismissing it as benign.
  2. Doctors must have excellent communication skills to practice medicine even if their patients are going to be a sleep most of the time they have contact with them.
  3. Doctors should anticipate being wrong at some point in their career and have a strategy for how to handle that scenario.
  4. Clinicians must be aware of the circumstances in which they are more likely to get it wrong and have contingencies in place.

The other lesson that is seldom taught is the harm that is done because of an injudicious use of tests in search of the needle in the haystack. But that’s another story.

Picture by mob mob

What do you want from your doctor?

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Finding a good doctor is like finding a good lover: there are lots of anecdotes but no data Richard Smith

Our family has moved to an new city and we are looking for a family doctor. What would you look for if you knew a little about evidence based medicine? Would you want your doctor to have read the latest medical journals and could quote research evidence for every decision they make? New premises? New furniture? Free wifi? Short waiting times? A coffee machine? Text messaging? Internet booking? A PhD?

How do you choose a new dentist? A new hairdresser? Do you just walk in to the nearest premises and hope for the best? Do you ask your neighbours for a recommendation? Do you google the names you see in the phone book? The chances are you spend more time choosing a restaurant then you do choosing your doctor. And yet there is far more at stake other than a good meal or a hair cut.

For us in selecting a doctor nothing matters as much as the doctor’s interest in our family. Our new doctor may not have read this week’s medical journal but he or she will be curious about our family because they will want to understand the context of any symptoms . That isn’t simply limited to our medical history, allergies or genetic predisposition. It also means the fact that we have moved interstate, we have new jobs, renting for the first time in years and experiencing a number of other life events. They will take into account any support we might be receiving from friends or family and our satisfaction or otherwise with our decision to relocate.

If you feel the same way then you might agree that doctors, especially family physicians aka general practitioners, provide a relationship and not just a service. This is what we seek when we consult a doctor:

Their willingness to make eye contact, to listen actively, to pick up verbal and non-verbal cues, to be respectful  and unwavering in the opinion that our perspective on our bodies and its functioning is what matters the most. To our new doctor we will be free to make choices. They will see their role as adviser and advocate rather than enforcer of what’s best for us as determined by somebody else. The best doctors understand that they may not have all the information on which we make decisions but faithfully realise that we also want what they want i.e. what’s in our best interests.

I love this quote from Anatole Broyard:

What do I want in a doctor? I would say that I want one who is a close reader of illness and a good critic of medicine…I see no reason or need for my doctor to love me, nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time, I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.

We will choose our next doctor based on how we feel not what we think. Is that a good thing? It’s not logical, but it’s the only basis on which humans make the most important decisions in life.

Picture by frances1972

What factors trigger an urgent and appropriate medical consultation?

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There are circumstances in which it is critical for a patient to consult a doctor sooner rather than later. Imagine someone with symptoms of a stroke or a myocardial infarction ( heart attack), or with a breast lump.

In these circumstances timely intervention may be life saving. These circumstances are often the subject of public health campaigns and perhaps one of the most popular attempts to improve health care outcomes or reduce costs. Predictably such attempts are not universally successful. That may be because the issues are rarely considered from the patients’ perspective, because a solution is imposed from what seems to help ‘some people’, possibly those who might have consulted a doctor anyway.

Our help seeking behaviours are subject to the same three factors that Fogg speaks of in his behaviour model. Motivation is contingent on the person’s understanding of his or her risk to adverse outcomes. Ability is the person’s perception of access to treatment that may be life saving and finally, and crucially, triggers are factors that compel the person to make the effort to consult a doctor when they have the most to gain.

Therefore there are four possible scenarios:

High motivation and high ability to access health care.

This is ideal. In these circumstances a ‘signal’ trigger will suffice. Think ‘red traffic light’ .  Therefore someone who is bleeding or  experiences crushing central chest pain or develops sudden onset weakness on one side of their body, will quickly act to do what is necessary. Alternatively they might do the needful, as in the picture, when they are prompted by a relative or friend. Unfortunately it cannot be assumed, as it often is, that everyone is in this boat.

A health promotion campaign might be considered successful if five percent of the target audience make long–term changes in overt health behaviour. Rogers and Storey

There are three other less ‘easily’ remedied situations.

High motivation but poor access.

For these people ‘red lights’ will do nothing but cause frustration. What is needed is well publicised improved access to skilled care providers. For many people in specific areas of many countries access to health care is poor and it is reflected in inequity of outcomes for what is, anywhere else in the country, a preventable cause of morbidity and premature mortality. There is real scope to innovate here, perhaps the most promising avenue is online  or telephone access to care providers or innovations that better integrate care providers at the point of presenting symptoms especially within primary care.

Low motivation and easy access.

On the face of it this might be easily fixed simply by ‘educating’ people. However the empirical evidence is that such campaigns have limited ( as opposed to ‘no’)  effectiveness. Often the causes of low motivation are  many and varied. What speaks to one community or individual may not resonate with others and the scope for frustration or patchy results are very high. If this were not the case our jails would not have quite so many inhabitants. Law breaking like poor health is a complex issue and no solution including the death penalty will promote the most desirable behaviour. People don’t always respond to dire warnings. One strategy is to make the alternative action ( i.e. non consulting) less desirable than consulting. However such solutions fly in the face of patient autonomy.

 Low motivation and poor access.

Bad news. These individuals are unlikely to respond to anything. Changing attitudes is unlikely to follow ‘educational’ campaigns unless and until the issue of access to health care is sorted out. There are many individuals who have poor access to health care. The reasons for this are far too diverse for any strategy to be universally successful. If there were a simple way to do both then any of the triggers in the other of these four quadrants  might suffice. Fortunately only a minority of people are in this category but there are enough here to ensure that the idea of universally good outcomes for everybody is a utopian dream. Innovation, however well meaning, is set to fail some individuals most of the time.

Picture by amy_kearns

Can healthcare providers be more supportive?

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Most people who get cancer survive. The treatment now available means they are likely to die, years later, of some cause other than cancer. That’s great news. Unfortunately in many cases the intervening years may be punctuated by symptoms or problems that are related to the treatment. So cancer like many other human ailments is a ‘chronic’ illness rather a problem that is ‘cured’. For cancer it is likely that one group of doctors will offer treatment (specialists) but another group of practitioners (generalists) will be called on if there are problems later. The experience of many people in these circumstances is that a lot more could be done to help after treatment. Our team recently conducted a series of studies to explore what happens, from the practitioners’ perspective, given that one might want to develop interventions to assist them do a better job. In one study we focused on prostate cancer, you can read the paper and watch a video of how men might present to their doctors here. As we deployed simulations, no patients were harmed in this study. I present the results with reference to a map offered in an earlier blog. The analysis below pertains to how doctors respond.

Motivation

A: Rewards for action

For the most part men in these circumstances are unlikely to present with symptoms that are only ever a feature of recurrence or treatment side effects. It was accepted in our research that many of the problems presented (sexual dysfunction,anxiety and depression) were common in general and therefore subject to the same remuneration as other primary care visits. There were some scenarios that were considered outside the generalist scope of practice including radiation proctitis. However in these circumstances it was also accepted that such patients needed generalist investigations before specialist referral. It was interesting that rural practitioners were more attuned to expert opinion.  We speculated that they have greater involvement in supporting men in these circumstances compared to colleagues with much easier access to major hospitals.

T: Timeliness

We did not explore the time taken by such consultations. However this is likely to be similar to many other such problems that are presenting outwith the context of a cancer diagnosis.

R: Risk

Some scenarios, for example one in which a man presented with a raised level of ‘tumour marker’, proved very problematic for some respondents who immediately, and unnecessarily, referred for specialist advice. The doctor’s fear of missing a recurrence rendered it more challenging for the person living with the diagnosis to receive the strong reassurance that was indicated.

Ability

C: Cost

Referral for treatment of problems related to treatment or recurrence may be problematic in these circumstances. For example we could not assume that every practitioner had easy access to a radiation oncologist. This may have resulted in a financial burden on the patient or to referral for less than ideal treatment.

E:Effort

Some consultations required referral to, or discussion with,specialists or the organisation of tests and subsequent follow up with results. Some patients required referral to a very specific service- this was sometimes omitted. Although it is possible this was due to lack of knowledge it is also likely that such services were not available to those practitioners. In the case of practitioners from rural areas this was almost certainly the case.

Trigger

P: Recognising the patient

In a significant proportion of cases doctors missed the diagnosis. Unfortunately not every practitioner offered the best treatment options.  Others focused only on the cancer as a cause of the symptoms. The intervention we offered improved diagnosis but not management of cases.

K: Knowledge of options

It was not clear from our data if doctors were aware of the treatment options for all scenarios in these circumstances.

Summary

There is  scope to ensure that people are more supported after a diagnosis and treatment of a potentially life threatening condition. They often present with problems that are not unique to those with the condition. Doctors may have to spend more time with them in these circumstances and also need to be more proactive in assessing their needs. In many cases reassurance is all that may be required by a knowledgeable practitioner. In other cases access to the most appropriate treatment will determine the degree to which practitioners can be responsive to needs. Motivation is high, ability could be improved and a trigger that identifies the patient and their options may help to ensure that practitioners fulfill their obligation to support people in these circumstances.

Picture by Andrew Currie.

Innovating without inventing something new

9562611683_cd9584baca_zI’m a pathologist, which means that I run the lab, and I’m continually shocked by all the unnecessary lab work that comes my way. Doctors have to find something wrong with you, because preventative measures aren’t sexy. They know that you’re more likely to appreciate them if they tell you something’s wrong, than if they tell you to stop drinking 40 oz sodas. Humans of New York

This week a report was released that documents changes in Australian GPs’ ordering of X-rays and scans in the decade 2002- 2012. The report includes an evaluation of the quality of GP test ordering against available guidelines. The team compared two periods: Apr 2002- March 2005 inclusive (Period 1) and April 2009 to March 2012 inclusive (Period 2). Three factors were found to be relevant:

  • The number of encounters between doctors and patients
  • The number of problems managed at encounters
  • The rate of ordering tests in the management of problems encountered

It was not surprising that people are attending doctors more often and that they are presenting more problems than before. However the rate of imaging tests ordered significantly increased from 8.7 per 100 encounters in Period 1, to 10.2 per 100 in Period 2. Extrapolation of this result suggests an average 8.45 million imaging tests ordered by GPs per year in Period 1 and 12.23 million per year in Period 2, an increase of 44.7%, equating to approximately 3.78 million more orders per year over the 3 years in Period 2 than in the years of Period 1. With respect to the guidelines current ordering behaviour for new back problems, shoulder sprains/strains, knee problems, and knee sprains/strains, has room for improvement, according to the researchers.  The results were not entirely unexpected. There has long been a concern about unnecessary test ordering. In a paper published in 2008 unnecessary laboratory tests may be defined as those that have a ‘vanishingly small’ chance of:

  • revealing any unexpected pathological process.
  • contributing to the diagnosis of the cause of a patient’s presenting symptoms.
  • assisting in the monitoring of the progress of a known pathological process.
  • helping to assess the management of a known disease process.

An interesting insight is offered:

The millions of dollars spent on unnecessary tests are, in [doctors’] minds, balanced against the tens of millions involved in adverse court judgments.

In this context I recently asked colleagues what test they would perform on me if I presented as ‘tired all the time’, adding that I had no physical signs, was not depressed and was not taking anything (prescribed or otherwise) that would account for my fatigue. The answer was unanimous-‘Thyroid function test’. This was based on published advice on the approach to such patients:

However, even though laboratory evaluations rarely play a crucial role, they should be used to exclude underlying organic illness.

So, I asked my colleagues how they would interpret the findings if my results were found to be just over the limit of normal. What, in their view was the probability that I have hypothyroidism? ‘High’ came the answer. ‘We would put you on thyroxine.’ The published data suggests that the positive predictive value of tests on people in this context is  less than 12%. Which means it is highly unlikely that I have anything physical wrong with me, much less that I need to take thyroxine. At a time when there is an increasing demand for GP services, it is going to be helpful for colleagues to be aware of the positive predictive value of the tests they order and to share that information with patients before recommending tests. The article listing laboratory tests to screen for a host of highly unlikely conditions assumes that the doctor has spoken to and examined the patient and that the indications for the tests are based on specific clinical findings.  In most cases the patient who has a life limiting pathology does not look or feel well. However every patient needs to know what the test results mean- they are often meaningless and place the patient in harms way. The approach in the Dutch paper to postpone tests for 4 weeks resulted in benefit to people with unexplained fatigue who may otherwise have been harmed by further investigation of equivocal test results. The study is testimony to what  can be achieved by practitioners sharing information with patients while harnessing the power of observation, applying a little bit of science and dispensing a tincture of common sense.

Picture by Send me adrift.