Pharmacist and 4th year medical student here. Medical tests are ordered based upon their statistical ability to alter your likelihood of a diagnosis. No test is perfect in either direction (negative result meaning you don’t have disease or positive result indicating you have disease). Tests cost money, take resources of the healthcare system, and have the potential to be wrong. When a test is wrong, it can result in financial, emotional, and physical harm to an individual.
Example: you’re an otherwise healthy 34 year old and you feel a little under the weather and are coughing. It’s only been going on a few days, mild fever, but you’re worried and you go to the doctor. Your doctor thinks this is most likely a viral infection, recommends Tylenol and ibuprofen and sends you home. You imply to the doctor you’ll sue if you don’t get antibiotics and a chest x-ray just to be safe. The doctor, rather than argue with you when they have a dozen other patients to see, just orders the stuff and moves on. The chest X ray doesn’t explain your cough, but there’s a small lesion of undetermined significance on the X-ray. Now you need a CT. The CT says “probably a self-limited granuloma from a fungal infection, can’t rule out cancer, correlate with biopsy”. Then you have to go get sedated, put a camera down your throat, and have a pulmonologist take a sample of your lung to see if you have cancer. Maybe you end up with a complication from the sedation or a pneumothorax. Meanwhile the antibiotics you took didn’t really improve your cough but now you have this uncomfortable itchy rash. Are you allergic to the amoxicillin? Or did you just develop the typical rash seen in people who have mononucleosis that also take amoxicillin? Will you get allergy testing for the amoxicillin? Just avoid amoxicillin, an awesome antibiotic, for the rest of your life?
We are restrictive in our prescribing of medications and tests not because we don’t care about you, not because we want to save the hospital or the insurance company money (in fact the hospital prefers we order more things because they make money on testing). We are restrictive because we want to maximize benefit while minimizing risk, and everything we do has risks and benefits.
Not to mention, the entire medical system does NOT want to prescribe antibiotics - especially cutting edge ones - unnecessarily, in the interest of dragging out the emergence of antibiotic-resistant strains as long as possible. Some pathogen (commonly, though not exclusively, staph) somewhere will eventually mutate into a resistant strain to some particular antibiotic. This is extremely problematic, because it means that the antibiotic becomes essentially ineffective at eradicating that mutation of the pathogen. If this occurs with a cutting edge antibiotic, and the pathogen happens to be a strain that’s resistant to many other antibiotics, you get what’s called a “superbug”; in the worst case, you’re all the way back to “get some rest, stay hydrated, and good luck”.
This is actually true. We have an over testing problem in the western world and it does cause some people harm, at least in the form of stress and anxiety caused by believing you have something that you don’t (due to false positives), or in some cases in the form of unnecessary operations and their associated medical risk.
And that’s without getting into the financial impacts, whether that be an impact on an individual or, in a civilised country, on the government.
That’s obviously not to say that nothing should be tested. Only that tests should be limited to cases with a heightened risk, be it someone showing symptoms (as OP obviously was, which is why this general problem of over testing is not applicable in this case) or being part of a demographic know to have heightened risk, as determined by experts and medical best practices.
Yeah, great question, I don’t understand it either, but marginalized groups like women or people of color can have a hell of a time getting medical professionals to take their concerns seriously. Maybe it’s just a hubris thing. “How dare this person question my judgment when I’m the doctor?”
I mean, there are tons of studies on racial and gender inequality in healthcare, but OK, go off.
For example, members of minority groups have longer wait times in the ER [7-9], are less likely to receive catheterization when identical expressions of chest pain are presented [10], and are less likely to be recommended for evaluation at a transplant center or be placed on a transplant waiting list when suffering from end-stage renal disease [11]. African Americans receive lower-quality pain treatment [12, 13], even when covered by the same medical insurance [14, 15] and seeking treatment at the same emergency department [16] as patients of other races. (https://journalofethics.ama-assn.org/article/education-identify-and-combat-racial-bias-pain-treatment/2015-03)
“I was told I knew too much, that I was working too hard, that I was stressed out, that I was anxious,” said Ilene Ruhoy, a 53-year-old neurologist from Seattle, who had head pain and pounding in her ears.
Despite having a medical degree, Ruhoy said she struggled to get doctors to order a brain scan. By the time she got it in 2015, a tennis ball-sized tumor was pushing her brain to one side.
[…]
Since the data has been collected from white majority countries, and I’d be very surprised to see the same trend in, say, China - I think it reflects basic tribalism more than anything.
Still a problem if you’re part of a minority group anywhere, but I genuinely think it’s a fundamental human characteristic.
The medication thing is because the trials are overwhelmingly run on white men aged 18-30. You can imagine the outrage if we’d been selectively testing on minorities, and women of childbearing age are avoided to protect any unborn children.
Complex topic, but these things don’t always come down to calculated racism. And yet there is that kernel of truth in it that people don’t want to confront, which is that humans have this basic level of racism “baked in” to the hardware. Tricky.
On top of that, I’m sure unhelpfully paternalistic and sexist attitudes do persist in medicine. Anecdotally, this can be particularly severe in Indian cultures - I couldn’t believe how differently a female friend was treated by the same doctor.
The research is out there with a quick search. As a white woman though, I definitely don’t need research to know it’s true. Especially with gynecological issues, pain levels, and psychiatry. We’re “hysterical,” and though they don’t use that word anymore, that judgement is alive and well.
Well I’m guessing that the healthcare will pay it. And at least in Switzerland, the healthcare can announce official that they won’t pay anymore for anything that one doctor decides/order. So if the doctor orders to many thing, that the healthcare has to cover, then he soonly will lose his job. So in this way the doctor will only order stuff that are really needed and maybe won’t make a test against cancer (but this happens not really often)
Else if the customer has to pay, then yes it would be stupid to not let the customer do the test.
There are some tests that can do harm to patients. In this case obviously a CT scan should have been ordered immediately, but not every pt with a cough needs a fat dose of radiation.
On that note, why would they decline tests in the first place? You’re the one paying.
Pharmacist and 4th year medical student here. Medical tests are ordered based upon their statistical ability to alter your likelihood of a diagnosis. No test is perfect in either direction (negative result meaning you don’t have disease or positive result indicating you have disease). Tests cost money, take resources of the healthcare system, and have the potential to be wrong. When a test is wrong, it can result in financial, emotional, and physical harm to an individual.
Example: you’re an otherwise healthy 34 year old and you feel a little under the weather and are coughing. It’s only been going on a few days, mild fever, but you’re worried and you go to the doctor. Your doctor thinks this is most likely a viral infection, recommends Tylenol and ibuprofen and sends you home. You imply to the doctor you’ll sue if you don’t get antibiotics and a chest x-ray just to be safe. The doctor, rather than argue with you when they have a dozen other patients to see, just orders the stuff and moves on. The chest X ray doesn’t explain your cough, but there’s a small lesion of undetermined significance on the X-ray. Now you need a CT. The CT says “probably a self-limited granuloma from a fungal infection, can’t rule out cancer, correlate with biopsy”. Then you have to go get sedated, put a camera down your throat, and have a pulmonologist take a sample of your lung to see if you have cancer. Maybe you end up with a complication from the sedation or a pneumothorax. Meanwhile the antibiotics you took didn’t really improve your cough but now you have this uncomfortable itchy rash. Are you allergic to the amoxicillin? Or did you just develop the typical rash seen in people who have mononucleosis that also take amoxicillin? Will you get allergy testing for the amoxicillin? Just avoid amoxicillin, an awesome antibiotic, for the rest of your life?
We are restrictive in our prescribing of medications and tests not because we don’t care about you, not because we want to save the hospital or the insurance company money (in fact the hospital prefers we order more things because they make money on testing). We are restrictive because we want to maximize benefit while minimizing risk, and everything we do has risks and benefits.
Not to mention, the entire medical system does NOT want to prescribe antibiotics - especially cutting edge ones - unnecessarily, in the interest of dragging out the emergence of antibiotic-resistant strains as long as possible. Some pathogen (commonly, though not exclusively, staph) somewhere will eventually mutate into a resistant strain to some particular antibiotic. This is extremely problematic, because it means that the antibiotic becomes essentially ineffective at eradicating that mutation of the pathogen. If this occurs with a cutting edge antibiotic, and the pathogen happens to be a strain that’s resistant to many other antibiotics, you get what’s called a “superbug”; in the worst case, you’re all the way back to “get some rest, stay hydrated, and good luck”.
Because tests have harm. The average persone doesn’t understand what the sensitivity and specificity of a test means.
This is actually true. We have an over testing problem in the western world and it does cause some people harm, at least in the form of stress and anxiety caused by believing you have something that you don’t (due to false positives), or in some cases in the form of unnecessary operations and their associated medical risk.
And that’s without getting into the financial impacts, whether that be an impact on an individual or, in a civilised country, on the government.
That’s obviously not to say that nothing should be tested. Only that tests should be limited to cases with a heightened risk, be it someone showing symptoms (as OP obviously was, which is why this general problem of over testing is not applicable in this case) or being part of a demographic know to have heightened risk, as determined by experts and medical best practices.
Agreed
Yeah, great question, I don’t understand it either, but marginalized groups like women or people of color can have a hell of a time getting medical professionals to take their concerns seriously. Maybe it’s just a hubris thing. “How dare this person question my judgment when I’m the doctor?”
LMAO, bro, you can’t be serious.
Too right! It’s only white men who get the full benefit of modern medical capacity. Everyone else is fucked.
s/ in case it’s needed.
I mean, there are tons of studies on racial and gender inequality in healthcare, but OK, go off.
Can take this too far, though.
Since the data has been collected from white majority countries, and I’d be very surprised to see the same trend in, say, China - I think it reflects basic tribalism more than anything.
Still a problem if you’re part of a minority group anywhere, but I genuinely think it’s a fundamental human characteristic.
The medication thing is because the trials are overwhelmingly run on white men aged 18-30. You can imagine the outrage if we’d been selectively testing on minorities, and women of childbearing age are avoided to protect any unborn children.
Complex topic, but these things don’t always come down to calculated racism. And yet there is that kernel of truth in it that people don’t want to confront, which is that humans have this basic level of racism “baked in” to the hardware. Tricky.
On top of that, I’m sure unhelpfully paternalistic and sexist attitudes do persist in medicine. Anecdotally, this can be particularly severe in Indian cultures - I couldn’t believe how differently a female friend was treated by the same doctor.
https://www.hopkinsmedicine.org/news/articles/physicians-more-likely-to-doubt-black-patients
https://www.today.com/health/implicit-bias-medicine-how-it-hurts-black-women-t187866
The research is out there with a quick search. As a white woman though, I definitely don’t need research to know it’s true. Especially with gynecological issues, pain levels, and psychiatry. We’re “hysterical,” and though they don’t use that word anymore, that judgement is alive and well.
Well I’m guessing that the healthcare will pay it. And at least in Switzerland, the healthcare can announce official that they won’t pay anymore for anything that one doctor decides/order. So if the doctor orders to many thing, that the healthcare has to cover, then he soonly will lose his job. So in this way the doctor will only order stuff that are really needed and maybe won’t make a test against cancer (but this happens not really often)
Else if the customer has to pay, then yes it would be stupid to not let the customer do the test.
Possibly Kaiser, or similar, where they’re the ones paying themselves which is somehow legal?
There are some tests that can do harm to patients. In this case obviously a CT scan should have been ordered immediately, but not every pt with a cough needs a fat dose of radiation.