Wednesday, August 26, 2015

When IVF Doctors Test a Patient’s Patience by Ordering Too Many Tests !

One of the things IVF doctors most commonly do is order tests. The uncharitable explanation for why they do so many tests is simple- financial reasons. It’s an open secret that the diagnostic laboratories and scan centers often give doctors a kickback (commission) on each test. This means the more tests they do, the more money they make. However, there are a number of doctors who don’t get kickbacks; but they still end up ordering a lot of tests. Why is this the case?

One of the reasons is a very common psychological fallacy most of us are fooled by. We often believe that the more the data we have, the more accurate our diagnosis will be. Doctors confuse more information with more accuracy. From a logical viewpoint, this seems to make sense. This is why when doctors encounter patients with a complex problem, they order more tests to get more information. They hope that the test results will give them more insight into the right diagnosis.

Increasing Confidence Levels

However, psychologists have shown that more information does not always improve accuracy . In reality, more data has the pernicious side effect of increasing the confidence levels of the doctor in his diagnosis. This is not a problem which is unique to doctors - it actually applies to experts in all fields, including financial advisors. Because lots of doctors are not aware of this common cognitive bias, they over-order tests when they are stumped; they hope it will improve the accuracy of their diagnosis, without realizing that they are not doing much good!

Catering to Patient’s Expectations

One more reason why doctors order excessive tests is because this is what patients demand and expect ! Most patients are no longer satisfied by a clinical examination (even though this is far more valuable than any number of tests !). Current day patients have more peace of mind if they have those scans and computer printouts in their hands.

They rely on technology to back up the diagnosis that the  doctor has presented them. Many patients are extreme in this context and will also feel that their doctor isn’t being efficient , thorough and careful, if he doesn’t order tests. This is exactly why there are times when doctors order tests – to keep their patients happy.

Excessive Tests can be Harmful

This is ironic, because only a very confident and competent doctor will actually refuse to order tests. A dirty little secret is that many of these tests can actually be harmful, as they lead to a lot of unnecessary overtreatment. More is not always better!  However, patients are not sophisticated enough to question the doctor. The key question they need to learn to ask when the doctor orders a test is simple – “How will this change my treatment ?”

Because they do not do so, the explosion of new technology means there is also an exponential rise in the number of tests that doctors can order. Also, when doctors attend conferences, they want to learn “what’s hot and what’s new”. They are seduced by attractively produced presentations, which tom-tom the accuracy and efficiency of the newest tests. No one bothers to highlight their limitations, because these keynote speakers are usually sponsored by the company that is selling the tests.

About ERA

Let’s look critically at the newest test that is being marketed for IVF patients today. This is called the endometrial receptivity assay (ERA). It uses genetic markers as an endometrial function test (to test if the endometrium will allow an embryo to implant). This is a very new, sophisticated test that is very expensive and to date, is offered by only one company.

Since failed embryo implantation is such a distressing problems, IVF specialists are very happy to order this test for patients who have failed IVF cycles. However, because doctors understand precious little about genetics, they end up fooling themselves - and their patients. Thanks to a lot of slick marketing, with tons of genetic jargon that doctors don’t understand, it’s not surprising that doctors are taken for a ride !

New Tests Translates to Unreliable Tests

Because doctors want to be “one-up” on other doctors, they are happy to order the “latest tests” – which are often much more expensive, because they are new. This newness  also means they are much more unreliable, because we don’t have enough clinical experience with them!

Ironically, patients don’t seem to mind paying for all these unnecessary tests. In fact, most of them are quite happy when the test results come back as normal, because they naively believe that these means they are fine! They don’t seem to consider the money spent on the test as a waste! Actually, the purpose of tests when used judiciously is to confirm or rule out a clinical diagnosis, based on the doctor’s clinical examination.

It cannot be a hunting expedition, where the doctor uses a “spray and pray” approach to try to find an abnormality, which may be of no clinical importance. The reality is that more knowledge can reduce the accuracy of prediction of uncertain outcomes, and simultaneously increase the doctor’s confidence in their incorrect  predictions.

As the Nobel laureate Daniel Kahneman pointed out, "Overconfident professionals sincerely believe they have expertise, act as experts and look like experts. You will have to struggle to remind yourself that they may be in the grip of an illusion."

Doctors need to learn from his wise words - “Be honest with yourselves! Admit what you don’t know!”

The bottom line is that before ordering a test,  doctors need to ask themselves- “How will this change the patient’s treatment options ?” Let’s not lose sight of this in our enthusiasm for ordering  tests ! (And if the doctor does not ask this question, the patient needs to learn to do so !)

Want to maximize your chances of IVF success? Need more information? Please send me your medical details by filling in the form at so that I can guide you !

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