|The magic of modern medicine is often diluted by its misery.
- Dr. Oscar London
Today, the practice of modern medicine is based to a large extent on laboratory tests. These tests form the scientific basis of present-day medical practice, and provide considerable and valuable information about what's wrong with the patient, thereby helping doctors to come to an accurate diagnosis. However, while it is true that lab tests can be very useful, they are often misused as well. With billions of medical tests being performed every year, modern physicians appear to be relying more on tests results rather than on their clinical skills to make a diagnosis. And testing means big bucks! Outpatient testing has tripled in the last 10 years; in fact, laboratory tests, X-rays and scans now account for over 25 per cent of hospital bills. Many doctors have also started practicing 'defensive medicine' in order to defend themselves in case they are sued by unhappy patients or their relatives. They often perform many unnecessary tests to protect themselves from possible charges of negligence. After all, few lawyers will find fault with a doctor who performed too many tests, but woe betide the doctor who fails to perform a test, if his patient falls victim to an unfavorable outcome! This is the main reason why many doctors go in for tests even when they are not required, and it is important for you to safeguard yourself against excessive testing, which can cause a number of problems. Not only is it a financial drain, but it can also lead to a domino effect of spiraling testing, if the initial results are abnormal! Consider the common example of an abnormality found in a "routine" ECG performed in the course of a routine health check-up for a man with no complaints. In order to determine the significance of this abnormality, the doctor may decide to 'order' further testing, including an exercise stress test and even an angiogram, both of which are expensive and painful. Most angiograms will reveal some degree of block in the coronary arteries for practically everyone, and the significance of such a block is difficult to determine for the individual patient. But, once they come to know that they have a 'block' in their artery, many men become 'cardiac cripples', who worry about every twinge of pain in the chest. As a result of the testing, many men will also have to undergo unnecessary open heart surgery to open the blocks - blocks with which they could have lived happily for the rest of their lives!
The unreliability of medical tests also poses a major problem in India today. The most obvious reason can be attributed to laboratories whose functioning is marked by factors such as poor quality control, unskilled manpower and obsolete equipment. There is little 'policing' or retesting, with the result that the needed standards are not maintained. After all, even a science graduate with a six-month diploma in laboratory technology can set up a medical lab, if he so desires. Most people tend to rush to the nearest laboratory to get their tests done, but such haste can be a big mistake. After all, if the laboratory is not reliable, how can you trust its report? You should try go to the best laboratory possible - your life can depend upon your test results!
A problem with all medical tests, no matter how well they are performed, is that they may give rise to false positives and false negatives. Let me clarify. False positives are test results which are abnormal ('positive'), even though the patient has no disease. A false positive result causes needless anxiety, and will often lead to a situation in which the patient will have to undergo even more tests to prove or disprove the previous results. Conversely, test results which are normal ('negative'), even though the patient does have the disease are called 'false negatives'. These results could also cause problems, because they may induce a false sense of security, thereby leading to a delayed or missed diagnosis. Most tests have a wide range of normality, and can only very rarely yield a simple 'yes' or 'no' answer as to whether a patient has a particular disease or not.
Remember that if your doctor performs enough tests on you, the mathematical certainty is that he will find something wrong with you. And if he finds something wrong with you, he'll usually end up treating you - whether you need treatment or not! However, such diagnostic labeling may be harmful to you, because the 'diagnosis' has now transformed you from a person into a 'patient', even though the abnormality may be a 'red herring' which has no significance to your medical problem ! Many cynics call these abnormalities 'incidentalomas' (for example, a small fibroid in the uterus detected on an ultrasound scan), and these often result in unnecessary surgery as well.
The real irony is that today many patients demand that the doctor 'order' the latest 'whole body scan' to confirm that they are 'healthy'! because they often have more faith in a computer-generated report than in a doctor's skills! Health check-up schemes which perform a 'comprehensive panel of tests' have also become very popular, but you need to remember that your body is much more complex than a car which needs an annual 'tune-up'! Tests need to be targeted for a particular problem, rather than subjecting all patients to a whole battery of tests, something which can be wasteful and expensive as well. After all, in medicine, 'one size' simply cannot fit everyone!
The upshot of it all is that you don't need to panic if the result of the test is abnormal. A simple common sense rule is that if the result is abnormal it needs to be rechecked, preferably from an independent laboratory! Competent laboratories will store blood samples for a few days, so that the old sample can also be retested if needed. If the repeat test also proves abnormal, then you need to ask your doctor to interpret the significance of this result.
Most people are overawed by impressive looking computer printouts, and medical tests are considered to be extremely reliable and objective. However, this is a popular misconception. Tests can be just as subjective as a symptom (which is what a patient complains of) or a sign (which is finding noted by the doctor on clinical examination) . In other words, merely conducting more tests does not ensure better medical care; after all, the value of a test to the patient depends not only on the skill in interpreting its result, but also on the clinical judgment exercised in ordering the test in the first place. When a test which is not needed is done, the result is often more misleading than helpful, and overused tests can lead to confusion, misdiagnosis and unnecessary treatment. You should begin feeling suspicious if tests are ordered before an adequate history has been taken or before a physical examination has been performed. Remember that more than 80 per cent of all diagnoses are made on the basis of a patient's history alone! A competent doctor will go in for tests selectively, their primary use being to confirm a diagnosis .
You should also make sure that your doctor examines your original scans and X-rays, and not just the reports, because his interpretation may be different from the radiologist's. If you have undergone a series of scans, they should be arranged in chronological order, so that the doctor can compare them easily.
All tests have their limitations, which patients need to understand. For example, when we carry out a semen analysis (sperm test) to check a man's fertility, the question to which we seek an answer is: are these sperm capable of 'working' or not, i.e., can they fertilize an egg? Unfortunately, present-day tests simply cannot answer that question! A semen analysis simply provides an accurate count of the total number of sperm and their ability to swim, but because there is such a wide range of normality, the result italicise cannot be used to predict a man's fertility. Similarly, a positive skin test for TB (the Mantoux test) simply means that the patient has been exposed to the tubercle bacillus in the past (as most of us in India have been!) Such a result does not mean that the patient is suffering from an active TB infection, an erroneous conclusion many patients (and their doctors) still jump to. Here's a checklist of questions you should ask your doctor when a test is recommended:
Other relevant questions are as follows:
In the final analysis, remember that medical tests can be very helpful in pinpointing your problem, but they need to be used wisely and well; after all, doctors do not treat abnormal test results, they treat patients !
Here is a checklist which highlights the important factors you need to consider before in for a medical test.
Medical Test checklist
Test name _____________________________________________
To confirm diagnosis?___________ Diagnosis _______________
To exclude diagnosis? ___________ Diagnosis ______________
Where will the test be done? Clinic? _________
Independent lab?________ Hospital? _________
Cost of test in: Clinic _______ Independent lab ________
Are there risks associated with the test (i.e., is the test invasive)?
If yes, what risks? _____________________________________
Are there less invasive tests that might give the same
If the test result is abnormal what will be done next? __________
If the rest result is normal what will be done? _______________
You should fill out this checklist for every medical test suggested.
The more invasive or expensive a test is, the more important this checklist becomes.
Saturday 19 March, 2016 05:05