It's not that I dislike patients researching their symptoms or their concerns on-line. Actually, the patient with the "petit papier" of questions is my favorite kind of patient. They are usually well-informed and have questions I enjoy answering. Often it is educational for me because I have to do a little research to be sure my response is accurate. The far end of this pendulum swing is the individual demanding unnecessary tests or drugs. I'll address the medication problem in another blog, today I want to concentrate on tests.
Yesterday I began to write this entry and low and behold the New York Times has an opinion piece by H. Gilbert Welch on this topic appearing in today's issue. I strongly believe prevention is important and put myself forward as a physician interested in keeping my patients well. But prevention is different from finding problems early. Prevention has to do with avoiding lifestyle behaviors that promote illness--bad choices with sexual relations, drinking to excess, smoking, an unbalanced diet, no exercise, etc. Prevention is NOT obtaining every laboratory test known to medicine, getting a "total body scan" or having surgery to remove a body part that is low risk for cancer.
Recently one of my patients, a 32-year-old, asked for a vaginal ultrasound because she "wants to know her body better down there". What? She suggested that I use the "NPC Guidelines" for ordering the exam. The what? When I Googled that organization the closest I could come up with was the National Phlebotomy Certification. When she was told that insurance would not pay for an ultrasound without symptoms (and that I did not recommend such a thing) she decided that she had some discomfort "down there". I am caught between not wanting to deny a patient a test only to find out later she had something horrible that keeps me talking to attorneys and being annoyed that the insurance company will be paying for an unnecessary test. If she was willing to pay cash for it I would happily order it. But no, no one wants to do that. Our society somehow doesn't put value on piece of mind, unless someone else is paying for it.
The worst-case scenario is the patient who insists on getting a CA125 blood test. You know, the "ovarian cancer test" that makes the email rounds once or twice a year. I've drawn this test on numerous individuals at their request, one time it was elevated. In this particular case she received multiple vaginal ultrasounds over two years, multiple pelvic exams, got an opinion from a gynecologist and an oncologist and ultimately when she stopped smoking for one month (she subsequently resumed cigarettes) the CA125 dropped into the normal range. WAIT--she smokes? Her number one cancer risk is what--maybe LUNG CANCER??? Would it not make more sense to STOP SMOKING????? By the way, the CA125 blood test's purpose is to watch for recurrence of ovarian cancer in individuals who already have the disease but are in remission. It is not a screening test. It's not meant to be a screening test. When you try to make a test into something it is not, people end up with unnecessary tests, sometimes very uncomfortable tests and lots and lots and lots of worrying.
Lifestyle changes -- YES. Shotgun approach to finding early disease -- NO!
Well written and am convinced prophetic.
ReplyDelete