Why Use Medical Testing?

I’ve written before about Dr. Milhaud — one of the professors in my French medical school. I really liked him.

He was practical and he was enough of a friend to come visit me when I returned to the USA for my general and orthopedic surgical residency staff at the Jewish Hospital of Cincinnati, Ohio.

Nobody else on my faculty at Amiens even thought of doing that.

He was the first person who lectured to us in the third year of medical school — the first of the clinical years, where we stopped memorizing things as if they were the phone book and regurgitating them back on live exams.  Third year was when we started seeing real patients.

The first thing he did was write, in Latin on the board, “Primum non nocere,” which means first do no harm.

It was within a lecture or two of that when he spoke of the supremacy of clinical medicine as opposed to paraclinical, or laboratory tests.  He said most of us would end up being country doctors, probably not having lab tests available.  Very few facilities — a fluoroscope, maybe.  And we had to remember that this was socialized medicine. We were using the resources of “la nation,” and we would have to use them wisely.

So whenever we ordered a test, we had to ask one question only.  We had to ask how it would change what we did with the patient.  How would the test change the diagnosis, the progression of things, to care for the patient?

I was in a doctor’s lounge in the Midwest years later when I told this story, and a woman doctor said aloud “anyone can tell you studied your medicine in another country.”  She went on to tell how American doctors usually order tests in order to avoid malpractice suits.  They call it “CYA Testing” for “Cover Your ….”  Well, you know what I mean.

I still believe I am correct.  If the first question the doctor asks is not how this will help or change the patient or the diagnosis, then it has to be the first question the patient asks.

This is your first consideration, and it should be your doctor’s — put aside the regular cost and the risk and all of that.  What difference will the projected test make in your diagnosis and care?

Get percentage estimates of how likely you are to have a diagnosis they are looking for.  Are there other ways to tell it, perhaps simply by waiting?

This is an open-ended question, and I would suggest prolonging any resulting silence until something is said.

Ask what happens if the test is positive.

Ask what the outcome is if the test comes out badly.

My major concern here is cardiac testing, something about which the world has been notoriously cavalier, in my opinion.

People, tell me once in a while that I am a candidate for a cardiac stress test.  This basically means putting me on a treadmill, and seeing how hard and how fast I can run until I get troubles of cardiac conduction.  They say it rarely happens, but I could get a heart attack and die while taking this test.  Since I have never had chest pain or any kind of heart symptoms, I have always told people I do not want this test.

There are more specific indications for cardiac catheterization, which has its own morbidity.

I am not saying that nobody should take these tests.

I am saying that the clinical advantages and risks should be spelled out for each patient, who needs to make this decision for himself/herself.

What are the material costs?  How much does the test cost either your insurance, or you in cash.

This is the absolute minimum.  Numbers, statistics, whatever it takes to know before you sign.

If you walk out, you are likely to find a doctor who believes differently.

Folks do not often agree.  Most of this is not exact science, but opinion, based on the doctor’s experience.