A provocative commentary published this week on the physician-oriented website KevinMD.com gently takes doctors to task for often failing to ask an all-important question before ordering a medical test for a patient:
“What am I going to do with the answer?”
In other words, doctors too frequently order a test that will not change the course or outcome of the patient’s illness, despite what the test’s results turn out to be.
“There is a great deal of pressure on doctors not only to overturn every stone, but to dig five feet into the earth, no matter how unlikely a revelation or how probable a complicating scar,” writes Dr. James Salwitz, a New Jersey oncologist with considerable research and clinical expertise in end-of-life care.
But the “What am I going to do with the answer?” question is one that patients often fail to ask as well.
And, as this commentary makes clear, it’s particularly important for people with an advanced disease — and/or their loved ones — to ask that question.
“I often see patients with advanced disease who are continuing to get x-rays and labs, even though their medical condition is beyond remediation,” writes Salwitz. “Instead of focusing on comfort at this moment right now, intrusive testing is the theme. Families, patients, get distracted from pain control and simple encouragement, while they run along with a medical team which is trying to treat by test, instead of achieving comfort as the primary goal.”
“This vicious cycle of testing distracts from humane goals and can bring real harm,” he adds.
Salwitz provides several examples of that harm, including these:
I saw a consult with sudden kidney failure. The patient’s kidneys stopped working after a cardiac catheterization; the intravenous dye was too much for his system. The cath was done because he was short-of-breath. This was more likely because his left lung was being destroyed by cancer. That he could not breathe because he had a chest full of malignancy was ignored, in favor of an improbable diagnosis, unstable heart disease. More important, no one had asked, before they invaded his heart and wiped out his kidneys, “are we going to fix the coronary arteries of a patient with advanced lung cancer?”
The family and primary doc of a patient of mine canceled hospice, even though the patient’s brain was massively invaded by a horrible and aggressive tumor. She was taken off hospice so that an MRI of the brain could be performed and a laundry list of blood tests performed. The tests were done, to the discomfort of this frail patient, so that they could “better understand what was happening.” What was happening? She was dying, [albeit] slowly, from brain cancer. The patient went back on hospice.
Only if it improves life
Salwitz ends his commentary with some advice to doctors about ordering (or not ordering) tests, which is also good advice for patients and their families:
Have a clear understanding of how a particular test is going to change the plan. Do not go hunting in the dark and do not be fooled that unnecessary tests bring reassurance. They bring confusion. A test only has value if it improves life. Occationally we need to remind ourselves that is the purpose of the practice of medicine, anyway.