When I was a medical student in the early 1980s, I did a rotation in neurology. The neurologist I worked with ordered a head CT on every single patient. When I had the temerity to ask, diplomatically, why he ordered so many scans, the neurologist replied: "You have to stick their heads in the machine."
The neurologist explained that he ordered lots of head scans to make sure he "wasn’t crazy." I understood this reply to mean that he ordered all those scans to make sure that he wasn’t missing some dire diagnosis that only a CT would detect. For him, the CT served as a clinical safety net.
Dr. Larry Greenbaum
The topic of how many tests to order was a recurrent theme throughout my training. As a resident, I met a hematologist who made fun of other doctors for ordering what he dubbed "the hematology six-pack" for the initial evaluation of an anemic patient. He espoused the quaint point of view that a doctor should personally review the peripheral smear and then order a refined set of tests. He expected us to use a microscope and then to start thinking! How retro is that?
During my fellowship I recall a rheumatologist that ordered an ANA, a rheumatoid factor, an ESR, and a CRP on every patient. I asked politely about his broad "shotgun approach" and he told me bluntly, "If I don’t order these tests, someone else will order them, and if they are abnormal, I’ll look foolish!" According to this line of reasoning, you never look foolish for ordering unnecessary or irrelevant tests. Unfortunately, patients usually don’t know what tests are necessary, and they often feel that a doctor who doesn’t order lots of tests is either incompetent or uncaring.
Another professor remarked, "The lab is your scope." Since rheumatologists don’t usually do a lot of fancy or lucrative procedures, our claim to fame as a specialty is our ability to appropriately order and interpret lab tests for rheumatic diseases.
Lately, I have been ordering a lot of tests for tuberculosis screening. Treatment guidelines for patients on biologic medications recommend annual TB screening. I always screen patients for TB before initiating treatment with biologics, but I resisted implementing annual surveillance screening because I thought it was wasteful. A few years ago, I felt compelled to join the bandwagon, lest I start to look foolish or substandard in my care. So, I too started ordering annual TB tests for my patients on biologic medications.
I was explaining this concept to one of my patients with rheumatoid arthritis and dementia. I spent more time speaking to his family and less time speaking directly to him since his dementia had slowly progressed to the point that he couldn’t participate much in the discussion, but he unexpectedly piped up and told me that TB was an abbreviation for "tired butt." I frequently feel the same way when I leave the office late in the afternoon, but I kept that sentiment to myself.
The main choices for TB screening in my office are a blood test or a PPD skin test. The blood test is more expensive than the PPD, but it offers a big convenience factor. If the patient has a PPD, he/she needs to return to the office in 48-72 hours for the nurse to look at the skin test, but if the patient has the blood test, there is no need to come back to the office.
Sometimes my patients with financial problems ask me not to order unnecessary tests. With expensive health care bills, and a bad economy, every dollar counts. In those circumstances when I feel like my back is to the wall, I dust off that much-ignored clinical skill and take a history: Have you had any unexplained fever or weight loss, cough, or bloody sputum? Have you been exposed to anyone with TB? Have you been in jail or in a homeless shelter? On a few occasions, I used negative answers to those questions in lieu of TB testing for patients who couldn’t afford the blood test or a return visit to the office that a PPD would entail. I wouldn’t recommend doing this all the time, but the few times that I have done this for my financially stressed patients, they really appreciated the courtesy of having one fewer test and a smaller bill.
I can’t help but wonder what useful information our profession might collect if our lab requisitions had check boxes for indications such as "I’m afraid of being embarrassed" or "I’m afraid of being sued," or "The patient made me order this even though I didn’t think it was necessary!" Sometimes in the office, I daydream about creating a set of labs and procedures called the unhappy patient profile.