Wednesday, February 25, 2015

Too many tests - The Tyranny of the Infertility Workup



The chakravyuha of tests

As a conservative infertility specialist, I try to do as few tests as possible. My focus is not on identifying problems, but rather on implementing solutions. Often, we are far better at using technology to bypass problems rather than wasting time in trying to identify the problem - after all, we are not a research clinic . Our focus is on giving our patients a baby !

Unfortunately, trying to make a diagnosis is the approach the majority of other doctors follow. After all, the first question every patient asks is not “What will you do to give me a baby?” but rather “What’s wrong with me? How can I have a baby in my own bedroom?” In a nutshell, patients ask the wrong questions to which doctors end up providing the wrong answers.

When patients come with the results of a large panel of so-called "routine" tests ordered by other doctors, this creates a lot of problems for me. Often these test results are abnormal, not because they have any clinical significance , but because there are lots of false positives in medicine. After all, every test has its own limitations. However, once we get an abnormal result, it tends to distract us because we are then forced to conduct further tests in order to evaluate the clinical significance of the abnormal result. We sometimes need to refer patients to other specialists and consultants , so they can dig in deeper into the "problem". For example, we often see patients who’ve gone through theTB-PCR tests for their endometrium, which come back as positive. They are then promptly referred to an infectious disease specialist for anti-TB treatment, which wastes one year of their time. It also exposes them to potentially toxic anti-TB drugs , without improving their fertility at all, because this test result is something that has no relevance at all to their infertility. However, once there is one abnormal result, it leads to a downward spiral of further testing , and this just ends up wasting the patient’s time and money.

You are ignoring  my abnormal test results Oh, then you’re a bad doctor!

Doctors have to be very careful when they see an abnormal test result. They can’t afford to ignore it, and are forced to practice defensive medicine in order to show the patient that they are doing everything possible, and are on top of the medical game. When you try to tell a patient that the abnormal test result is of no significance, the patient has very little confidence in your advice. She feels the very fact that the earlier doctor ordered the tests means the tests must be important, and that by refusing to do anything about it, you are not a good doctor. The patient’s worry is that you are not treating the underlying root cause for the infertility, and this will then reduce the prospects of a successful IVF. Doctors also need to protect their own interests, so they are happy to continue with the upward spiral of unnecessary tests. Even worse, this creates an entire group of patients who are absolutely fine, but who start getting worried because they have abnormal test results. This only serves to distract both the patient and the doctor from treating the infertility, and diverts their energies to dealing with something which is unimportant and irrelevant –a clinical red herring. Unfortunately,once the test has been ordered, most of the damage has already been done. It's a mathematical certainty that the more tests you do, the greater is the certainty of finding some problem, which may be of no clinical importance whatsoever. 

However, once the lab reports this "problem," or an ultrasound picks up an "abnormality,"it’s often highlighted, marked in bold, and printed out in red. All the energy then starts getting focused on "treating" this so-called problem. Doctors love to think of themselves as being the Sherlock Holmes of the medical world, who will do whatever needs to be done to fix the problem which the test results show, even though this may be of no clinical importance to the patient .

Be selective, be smart

More testing doesn’t mean better medical care. In fact, I believethat a doctor who orders too many tests is not a good doctorat all. A smart doctor uses tests very selectively in order to confirm what his clinical impression is, rather than going on a hunting expedition looking for problems , just because he is completely clueless and doesn’t know what to do next. Even worse, some of these newer tests can be very exotic and expensive, and doctors take a lot of perverse pride in ordering these tests. Patients naively believe that the fancier the test ordered by the doctor, or the more expensive it is, the greater is the skill of the doctor! After all, the very fact that he ordered an MRI scan, a test which no other doctor did, means that he must be far more up to date compared to his competitors !

The only way patients can protect themselves is by refusing to do the tests. The one question you must ask the doctor is: How will doing these tests change my treatment options? And if it won’t, then please, for heaven’s sake, don’t do the test !

Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !




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