Test Responsibly

I got a heads up the other day that our organization had been dissed by a CNN reporter who was frustrated by her inability to get tested for Zika. You can read her original piece and the follow-up here. Short version is that she was upset that it was difficult for her to get tested after returning from a vacation to Costa Rica where she encountered “a good amount of mosquitoes” and later developed a mild febrile illness.

I won’t defend that she was made to feel like she was getting the run around, and it seems like – at the very least – we could have done a better job of communicating with her. But what she seems to dismiss, even though it goes to the core of her encounters with all of the medical providers she contacted, is whether she should have been tested at all.

Sorry, but “I have insurance and was willing to pay” and “I just wanted to know for sure” fall well short of appropriate indications for ANY medical test. Responsible testing involves engaging a patient in a discussion about the clinical circumstances, the reliability of testing, and the likelihood of the results having an impact on management. Isn’t that why medical testing requires a physician’s order?

I am not saying that patient preference has no role in testing. I have had plenty of conversations with patients over the years, for example, about the utility of measuring lipid subfractions or performing coronary artery calcium scoring to refine individual cardiovascular risk assessments. No two of those conversations were ever the same, because they were influenced by lots of patient-specific circumstances:  their tolerance for uncertainty, their sense of self as “well” or “sick” and their willingness to undertake an intervention such as lifestyle modifications or medications, to name just a few. But I grounded every one of those conversations with the questions like “what are we going to do with the information” and “how would doing this test change how you feel or act”? Ordering tests because patients are “insured and curious” is irresponsible.

Those considerations seem to have been completely absent in the case at hand. Ms. Kosik concluded her article by saying that it is a “bitter irony” that she never got tested for Zika, and may have instead exposed herself to other pathogens waiting in ERs to get tested. To me, the irony is that she didn’t recognize that she was complaining about not getting a test she had no reason to get.

What do you think?

4 thoughts on “Test Responsibly

  1. Nicely said…tom donoghue

    Thomas Donoghue

    Executive Director

    Medical Educational & Scientific Foundation

    865 Merrick Avenue

    Westbury, NY 11590

    (516) 488-6100 ext. 350

    (516) 672-3625 (cell)

    1. Your indications for testing are reasonable and based on appropriate criteria
      for medical testing. Nevertheless, for this patient and others like her, the driving
      motivation for testing may be based on an emotional need, probably rooted in Health Anxiety. Her need for reassurance is medically inappropriate, but critical to her sense of comfort and safety. How physicians should respond to patients with health anxiety is complex, but at least if it is recognized for what it is, it can be addressed directly.

      1. Thanks for your comment. I agree that the patient’s “curiosity” may be a reflection of anxiety, which warrants attention. Ideally, it could provide an opportunity for the physician to more directly address health concerns. There was a very nice piece in the NEJM this week about the challenges of doing so. See “The doctor’s new dilemma”–

  2. It might be a good thing for a reporter to see what really happens in an ER. Personally, I think that going to the ER for lab work shows a severe case of acute ‘fuzzy thinking’, and it was probably the reason she had to sit and wait with other ‘fuzzy thinkers’. Couldn’t she have tried an “Urgent Care”? I find Urgent Care acceptable for things like a sty inside the eyelid, acute sinus, and all sorts of other things. Lab work- not so much.

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