Perry Wilson, MD, is a Yale nephrologist who teaches ordinary people about methods. His Coursera course (free if you don’t want certification) explains how to read a medical journal. He encourages us to be cautious when reading statistics. He has a very good book, How Medicine Works and What To Do When It Doesn’t.
This week, Dr. Wilson’s blog post focuses on people who decide to order their own medical tests. Many companies now offer direct-to-consumer service so you can order your own tests for diabetes, cholesterol, vitamin deficiencies, and many other conditions. In July Quest Diagnostics initiated a direct-to-consumer test for Alzheimers.
Dr. Wilson speculates that people choose these tests because they’ve become more independent. They increasingly seek more control over their lives. He acknowledges he’s not a psychologist. He also notes that insurance companies make it harder for doctors to order tests, yet these are reasonably and transparently priced.
More likely, patients are tired of getting a runaround.
To get a test, you need an appointment with a primary care doctor, which could take weeks or months. You then go to a lab for the test. Why not just call when you get a positive test result?
I also suspect people simply trust doctors less.
Let’s face it. When a doctor recommends a test, she’s not drawing on her years of study. She’s probably not relying on journal articles and evidence. She’s applying guidelines, drawn up by some governing body influenced by Big Pharma or a special interest group. She probably doesn’t realize that bone density tests became standard as a result of the Merck Company’s intensive lobbying efforts – not as a result of scientific studies.
The doctor gets evaluated on her success in getting patients to follow the guidelines. They probably don’t want to dig too deeply for fear of cognitive dissonance.
So what’s the problem?
It’s not accuracy; Wilson’s article notes that these companies are regulated for accuracy and false advertising.
What could go wrong?
(1) The medical community seems to see patients as delicate wallflowers when it comes to getting medical news. I wrote about this in another article on Medium. Nobody seems concerned when patients get news of their bills.
(2) When patients get disturbing results on those tests, Wilson says, they turn to conventional medicine, incurring greater expenses.
The truth is, interpreting lab reports is rarely straightforward. One doctor told me he’s been trained to disregard certain lab findings listed as abnormal but with no reason to worry. Some doctors get so used to false alarms they miss a real warning.
If a patient reports elevated PSA levels, Wilson points out, they’ll need workups and further testing, which burdens the system. But unless the results are known to be flaky, it’s still up to the doctor to interpret the results and order more testing.
(3) Any form of testing will contain errors and subject patients to unnecessary pain and expense.
Take something as simple as blood pressure.
Nowadays doctors want to check everyone’s blood pressure on every office visit. Many results will be inaccurate. More than once, I’ve asked doctors how they can trust measurements taken after you’ve spent a long time in a crowded, noisy waiting room. They shrug.
A physician even made a YouTube video, suggesting that poor blood measurement “is killing our patients.” It’s costing a fortune in overprescribed meds, not to mention the impact on patients’ lives. The comments on this video suggest that improper measurement is extremely common.
Doctors also subject patients to pre-op tests after research shows the tests have no value; it’s not unusual for an ophthalmologist to demand “cardiac clearance” for a 7-minute operation with twilight anesthesia. It’s not unusual for doctors to order EKGs to screen healthy patients, even when the USPSTF finds no value in EKGs for healthy patients with no risk factors…and when there’s a false positive rate of 77-82%.
So why get upset when patients order their own blood tests?
I don’t think it’s a question of people seeking independence and control. I think it’s more about doctors and other professionals fearing a loss of control.
You can find thousands of books written by people who experienced serious illness. Inevitably they begin doing their own research and exploring options. Inevitably the medical system makes at least one serious mistake, ignores their early symptoms, or gives them false information.
As a patient, you have to be your own quality control manager, even if you like and trust your doctor. Choosing your own blood tests doesn’t seem like that big a deal, compared to what else is out there.