When I was in pre-med (back in the Pleistocene Era, to many of you), I worked as a lab technician in a small hospital. All those blood and urine tests you’ve had whose results are now fully automated were once processed slowly and painstakingly by hand (mine among them). The so-called metabolic profile of about 20 tests that today takes a few seconds to complete would have occupied me for nearly a full workday.
Because of high labor and time costs, doctors back then ordered tests very carefully. In fact, to emphasize the labor involved, during my years in medical school doctors had to learn how to process blood tests, perform blood counts (manually, with a hand counter), and interpret blood smear slides and Pap tests. Today doctors are taught the chemistry behind these tests, but since it’s all automated they don’t learn the mechanics.
The concept of “labs” was relatively new back then. Physicians ordered tests primarily to confirm a diagnosis they’d already made by listening to their patient’s medical history and performing a physical exam. For a doctor to order reams of tests to see what might emerge as abnormal was considered the sign of a lazy clinician.
Over the past several years, the medical profession has been taking itself to task for allowing lab tests (and x-rays and CT and MRI scans) do their thinking for them, and they’re quite uncomfortable with what they’re finding.
Far (far!) too many tests are being done on patients, often with little return.
• First, as you might imagine, tests of any stripe are extremely expensive. Most of the results you see on a typical lab report are unnecessary, but the doctor can’t not order them because they’re part of a bundled package. I can’t say to the lab, “I want only four tests out of that package of 20,” because they deliberately price the four I want to exceed the price of the 20 in the bundle. And because we don’t have comprehensive shared electronic medical records in the US, the duplication of tests is simply astonishing.
• Second, all this ordering of tests may not be that good for you, the patient. We’re only now beginning to appreciate the high radiation exposure from CT scans. Women have undergone unnecessary breast biopsies–and men unnecessary prostate biopsies–for the most minimal of lab abnormalities. And, sadly, when an abnormal result (often on an unordered test) pops up, doctors feel compelled to order even more tests to follow up on it, or refer you to a specialist for another bevy of tests. By the time you hear, “Well, it turned out to be nothing,” you’re a nervous wreck.
In medical school we were endlessly warned “Treat your patient, not her lab test,” but too many doctors seem to have forgotten this, starting patients on a lifetime of meds to lower a slightly high cholesterol reading that could easily be handled by diet changes or labeling patients with serious illnesses based on a blood tests that have high percentages of false-positive test results. During the decades that a nearby university center “didn’t believe in fibromyalgia,” I saw dozens of women diagnosed (wrongly) with lupus and started on potentially dangerous medications because doctors treated their lab test, not them.
• Third (and this is not an original thought), I believe that having access to literally thousands of tests–and having a third party (health insurance) pick up the tab–makes doctors intellectually lazy. When new patients arrive at WholeHealth Chicago with enormous stacks of medical records, it’s obvious that doctors ordered many multiples of the same tests, with costs spiraling to thousands of dollars. As I read through piles of test reports, almost all of them completely and repeatedly normal, I have to wonder: Were all these tests ordered because the doctor didn’t have anything better to do with his or her mind?
If you’re thinking doctors do this for the money, you’d be wrong. The dollars for these tests go to hospitals and the lab testing facilities. Does a physician order all these tests fearing a malpractice suit? Yes, according to surveys that’s behind some of it. But ultimately, all this test ordering came about because it’s what the conventional health care system limited itself to. Chiropractors, naturopaths, acupuncturists, and homeopaths don’t order endless tests and yet they manage to make an astonishing number of people well without bankrupting them.
The answer, of course, is balance. Once your doctor has ordered the few tests needed to rule out some serious condition that might be causing your symptoms, or ordered some simple tests to screen you for diabetes or cholesterol problems, rather than ordering more tests, he or she should consider listening to you more carefully and perhaps suggesting you see an alternative practitioner for relief of your symptoms.
Don’t ever be afraid to question your physician when the only suggestion is “Well, let’s get a few more test results and see.”
David Edelberg, MD