Saturday, February 17, 2018

Is your IVF doctor ordering too many tests ?

Most patients are understandably wary about signing up for any surgical treatment options which a doctor offers,  because they understand that these treatments can be expensive and can have side effects. This is why they take a long time before providing consent for any invasive treatment. Unfortunately, they don't utilize the same skepticism when the doctor advises a panel of tests.
It is this unwillingness to question the need for tests which causes so many problems today. The fact of the matter is that too many doctors these days order too many tests. A lot of these tests are unnecessary, because they don't provide any useful information - they don't really change your treatment options, which is why they are pointless.
However, there is a lot of pressure on the doctor to do lots of tests, and this comes from many sources.
Ironically, patients will put often put pressure on the doctor, because they crave a diagnosis - they want to know what is wrong ! They are worried that if the doctor cannot put a label on their disease, they will not be able to treat it. This is why they're not happy when the doctor says, " All the test results are fine," , because they think this means the doctor is incompetent - after all, if he has not even been able to make the correct diagnosis, how can he be trusted to provide the right treatment ?
Doctors are also quite happy to play with the newest diagnostic toys, and when they attend a conference where a speaker waxes eloquent about the latest tests, they want to try it on their patients as well . After all, they want to remain on the cutting edge of medicine. The problem is that this results in their patients bleeding, because the conference talking about a new test is often out to promote it - either because he's the inventor, or because he has been " sponsored" to say good things about the test by the medical company which sells it. He talks at length about  how cool it is , and how it's helped him to find out the reasons for infertility in many couples, which other doctors have missed.
Doctors are still quite happy to use their patients as guinea pigs, because they want to try out new stuff ! They also believe - "What's the big deal about doing a test? Why don't I just go ahead and order it. It'll hopefully provide us with more information , and we may be able to use this in order to treat the patient's problem."  This is just wishful thinking - after all, the eye only sees what the mind knows.
And yes, doctors will often get cuts and kickbacks from the lab, and this incentivises them to order lots of tests, which is why so many of them subject their patients to "diagnostic panels" routinely - whether they actually need them or not. However, not all this over-testing is necessarily done with a bad intention.
The big problem is not the financial harm which this causes to the patient. The much bigger danger is that a lot of these brand new tests haven't been proven to be useful in clinical practice. Because they are new , we don't understand what their limitations are. They've not been subjected to controlled clinical trials to document they are beneficial in real life. However, the problem is that the moment you do tests , you're bound to find patients who have abnormal results. After all, that's what the purpose of doing a test is - to pick up abnormalities, so that's the easy bit. However, managing patients who have abnormal test results is exceedingly hard, because we don't have enough clinical data to do so intelligently !
Not only do these abnormal results cause a lot of anxiety in the patient, the doctor's knee-jerk reflex kicks in, and he wants to treat the so-called abnormality. This means his focus is now on treating the abnormal test result, rather than the patient. The moment he does this, he goes down the slippery slope of over-treatment. These tests are plagued with the problems of false positives - abnormal test results , which are completely unimportant and irrelevant. However , once a doctor gets an abnormal result, he triumphantly pronounces, "Ah, this is your problem. We found it!" The patient is also very impressed that he has such a clever doctor who's helped her to pinpoint what the problem is, and she's quite happy to take the treatment suggested, without realizing that this doesn't really increase the chance of her getting pregnant at all, because the test shouldn't have been done in the first place.
Unless patients learn to ask their doctor this simple question - How will the results of this test change my treatment options? - this problem is going to get even worse over time , especially with all the new DNA based genetic tests which are being introduced left, right and center - expensive tests which are looking for a patient to experiment on !
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