let the testing begin

Tuesday, October 26, 2010

Once upon a time, not so long ago, the art and skill of medicine took years to develop. It was a wonderful compliment to be called a great clinician, a physician who would ask just the right question of the patient and be able to observe subtle findings on physical to arrive at the diagnosis. These skills took years to develop and the senior physician would mentor protégés to pass along those abilities. But times change, technology evolves and high tech has replaced high touch. Expectations change and patients often wonder how a diagnosis can be made without a test and doctors sometimes forget to explain the benefit and risk of the stuff that gets ordered.

Television plays a big role in developing perception. While dramas like House and Grey’s Anatomy push their story lines along by using the latest and greatest tests, forgetting that they take time to do, may have harmful side effects and results may not be 100% accurate. Sports add to the misconception that technology is king. It seems that an MRI is now a routine test for a sprain or strain. High priced athletes have become too expensive commodities to be trusted to the examining hands of a doctor or trainer but the results of the test rarely change the planned course of treatment. The test provides a soothing calm to the situation.

There are two problems with using technology to replace medical skill, presuming that money doesn’t matter. The first becomes a teaching point in medical school when the student is asked: “Why are you ordering this test? What will you do if the result is normal and what will you learn if the test is abnormal?” The second has to do with complications and side effects. Do the benefits of the test outweigh the risks?

From blood tests to imaging studies like CT, MRI and ultrasound to a variety of more invasive things that doctors can do to patients, the reason for the test needs to be firmly established. Picking the right test to be done at the right time requires that the doctor understands the patient’s situation usually by taking a good history and performing a solid physician examination. Technology comes at a cost and not necessarily financial. Pick the wrong test and the patient might enter the endless spiral of chasing an abnormal result. D-dimer is a blood test used to screen for blood clots. The chemical is released when a blood clot starts to dissolve. The test is not very specific but can be used to rule out the presence of a deep vein thrombosis in a patient who presents with a swollen leg. In patients with chest pain, a negative d-dimer makes the likelihood of a pulmonary embolus or blood clot to the lung very low. Unfortunately, d-dimer turns positive in a variety of other situations including recent injury or surgery, pregnancy and in cancer patients. As it turns out, these are the same patients who are at high risk for forming clots. A positive test often leads to a more invasive test looking for that clot. It would be better to decide clinically what should be done.

Those same clinical skills can be used to decide if a minor injury to the head requires a CT scan to look for bleeding. Radiation is the major worry, especially as patients accumulate a lifetime of medical radiation exposure. It is especially true in kids and another complication arises with them. If the baby or child won’t hold still and the CT is really needed, then anesthesia may be required for sedation and just one more potential technology risk is added.

The biggest risk of technology creep has to do with the loss of physician skill in talking to patients and examining them. Most of the time, the diagnosis can be made just listening to the patient. They will tell you what’s wrong if you take the time to listen. The physical exam helps confirm the diagnosis and also look for other potential problems that can mimic the same symptoms. Diagnostic tests may be needed but should be done only when appropriate and when they will make a difference in decision making.

If I order this CT, will the patient go to the operating room to have their appendix removed or will they go home? Would I operate anyway?
Will the chest X-ray change whether I will prescribe antibiotics?
Will the MRI make a difference in treating Brett Favre’s ankle?

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