In my last rant I promised you the “Four Questions” every healthcare practitioner (and patient) should ask before any diagnostic test is contemplated. This holds true whether for a simple blood test, an MRI or an invasive operative procedure. These questions are not brain teasing conundrums; they are good old cheap, common sense:
How will this test make a difference in the overall picture of the patient’s medical issues? To expound a bit, a great example if this occurs daily in our outpatient resident practice where we want the Internal Medicine Resident’s to take a step back and see how this test fits in the overall prognostic picture for the patient. Eg: should we get a mammogram in a 70 year end stage heart failure patient who is on dialysis? Probably not as the patient’s underlying illnesses will more likely cause her death than breast cancer, which tends to be a less aggressive disease in older women than it is in younger women. She will likely die WITH breast cancer, rather than FROM it. Additionally, be sure you document the conversation in the medical record and engage the patient’s family, significant others and the person with the power of attorney for health care decisions (if applicable). It is important that everyone be in the loop to prevent conflicts surrounding the decision-making rationale.
What are the unintended consequences of getting the test? A great example of this is the current prostate cancer screening controversy where the USPSTF recently weighed in (place link) not recommending PSA test for screening purposes in low risk patients. The rationale is that most men with prostate cancer die WITH their prostate cancer rather than FROM it. Since prostate cancer is typically a disease of older men with other medical problems, it is usually one of those diseases, or a more aggressive malignancy that will cause his death. The other concern about prostate cancer screening is the false positive rate that leads to other tests, biopsies and interventions for something that may never affected the patient. Of course, no one has a crystal ball and patients sometimes request prostate cancer screening because they know someone whose prostate cancer was life threatening. Another example is getting a contrast CT for an unindicated condition such as nonpainful GI bleeding. All of us wince when the 90 year 100 lb. female with a creatinine of 1.0 gets a CT of the abdomen for this indication and develops acute on chronic renal failure from contrast-induced tubular damage to the kidney.
Is there a more cost effective, less risky way to get the answer to the question? Here’s where a great history and physical can assist. Remember that, despite the explosion of medical technology, most questions can be answered with an excellent history and physical! Another example in a patient with low risk for pulmonary embolism based on clinical prediction scoring: don’t get the expensive, contrast and radiation laden CT angiogram, get the D-dimer instead.
Is the patient willing to act on the results of the test? A great example of this is the workup of a solitary pulmonary nodule. Rather than embarking down the garden path of biopsies to rule out malignancy (if that workup is indicated by current guidelines), ask the patient first whether they are willing to act on the results of the test. Now this can be a tricky area as you may have a chicken and egg phenomenon… the path followed may be predicated on the results of the test! If the patient tells you that they don’t want to know because they wouldn’t pursue treatment, make sure they understand the risks that they take with an undiagnosed medical condition such as a malignancy, infection, etc. Most importantly, document the conversation and revisit the issue with the patient and make sure to engage their family, caretakers and/or whoever is the designated power of attorney for health care decision making.
Hopefully the Four Questions diatribe caused you to reflect not just on the questions but the importance of communication with your patients, their family members and other key people and decision-makers in their lives. Stayed tuned for more in the next installment…It’s Not Rocket Science, It’s Great Communication That Will Take You Far In Life and In Medicine!