At least once a month, I am contacted by a client who is concerned that the orthopedist, gastroenterologist, cardiologist [fill in name of specialty], did not send them to do a CT (cat scan), MRI, x-ray, or ultrasound [fill in specific test]. My clients feel that the doctor was ignoring their complaint, or not taking their complaint seriously.
I completely understand this situation. Many times, when I sit in the doctor’s office with a client (or my own child), I need to gently push, or reassert, a suggestion for a referral for an additional test. This can happen because, truthfully, ten minutes may not be enough time to assess a situation or make an accurate evaluation of what the patient is, or is not, saying.
Yet, as I try to explain, often, to my clients, is that there is a thought process behind sending, or not sending, a patient to do a diagnostic test. As I repeat, often, ‘there is a logic behind it.’
Recently, I was reading a review in JAMA medical journal and I came across an article that I thought summarized this logic perfectly. A diagnostic test should meet three levels of effectiveness, “accuracy, clinical utility, and patient benefit” to justify its use.
There is a lot to unpack in these three terms. Let’s take a closer look.
Accuracy: First off, what is known about this test? How many true positives usually occur with it, vs. how many false positives?
Case in point: Mammography is an x-ray of the breast tissue that is the current gold standard for early diagnosis of breast cancer. Although there has been an increase in false positives and overtreatment, the majority of the larger studies still find benefit for those women who underwent routine mammography screening as compared with those who have not.
Routine mammography is considered, therefore, as an acceptable risk, since breast cancer is common, more curable when it is not metastasized. The current medical consensus is that this percentage of false positives is a risk worth taking.
In contrast, however, is using an MRI to diagnose lower back pain. Dozens of studies have shown that this test actually creates very high levels of overtreatment and false positives, with little gain in the way of true positives (resolving the pain). Hence, the universal protocol for lower back pain management is not to send these patients to undergo an MRI.
Clinical utility: This means how applicable are the results of this diagnostic test going to be to actually treat the patient.
Case in point: A theoretical case here could be testing a patient for Alzheimer’s Disease biomarkers. Currently, if identified with specific gene mutations, a patient has a 75% chance of developing Alzheimer’s. However, currently, there is no cure for this disease, nor treatment that will significantly curtail symptoms or delay the inevitable plaque buildup in the brain. So, although the test may be accurate, currently it offers little clinical support to improve the patient’s health.
Patient benefit: This, perhaps, is the most difficult of all to assess. How does one define what is beneficial to the patient?
It could be that “Knowing the diagnosis could be therapeutic and benefit patients by allowing them to understand or make sense of their condition even when” (Kennedy, 2022) there is no treatment able to change it.
Yet for other patients, the knowledge could be “unsettling, anxiety-provoking, or depressing” and not give any true benefit to the patient if nothing really can be changed.
Here is where the real conversation between the doctor and patient must begin. Many times, we need to discuss our feelings/opinions/background with the doctor, because the details can be relevant.
Case in point: Years ago, my 7-year-old nephew was diagnosed with leukemia (Thank G-d, he’s a healthy computer engineer today).
Yet, this history colored my perception of illness for my children.
When my own son was pale and had a low-grade fever, I asked the doctor for a blood test. Overkill? Probably. Calmed my fears? Definitely.
This is a simple example of a relatively non-invasive test that had accuracy, (blood tests for leukemia are pretty accurate), clinical utility (definite treatment plan if identified) and patient benefit (calmed the mother down). In my sister’s case, it was her clear measured response to her son’s paleness and low-grade fevers that led to the diagnosis of that rare but possibly fatal disease.
In Israel, due to the structure of our medical system, physicians are not incentivized to refer patients to testing which encourages them to only prescribe when they truly feel it will be beneficial to the patient.
It could be that you read online that having an MRI to diagnose your abdominal pain may be helpful, but the gastro doctor would like to start with a more basic ultrasound and then a colonoscopy, before sending for an MRI. This does not mean s/he is being negligent or dismissive. This is the recommended progression for this type of testing.
The point is, having the discussion, and bringing up your concerns and reasons for wanting the test in the first place, is crucial. By having that dialogue, you may better understand the doctor’s assessment or demonstrate the patient benefit in a different way to your doctor. Either way, you benefit.
For more articles like this, please take a look at our website as well, www.healthadvize.com.