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My Doctor Says I Need a Test
Is it really necessary?
At your last visit your doctor ordered a certain test, and you’re wondering why. Maybe you wanted to have a test done, only to have your doctor say it wasn’t needed. How do doctors make decisions about tests? Is there a way to understand which symptoms need tests and which do not?
Answering these questions is the goal of Choosing Wisely, an international organization started in the United States in 2012. Choosing Wisely is meant to help doctors and patients choose better tests, rather than more tests. Since it was founded, many countries have adopted the organization’s principles. This includes 25 medical specialties across Canada. Medical costs have been successfully reduced, without reducing the quality of medical care. In fact, quality has probably improved.
Choosing Wisely is not the only organization seeking to limit unnecessary testing. The Canadian Task Force on Preventive Health Care also wants to clarify recommendations for the best tests at the best time. As a result of the work of these two organizations, you may notice fewer:
- routine tests offered by your family doctor or nurse practitioner,
- screening tests like Pap smears,
- tests required before low-risk elective surgery.
Deciding if tests are needed
Why do we need Choosing Wisely? Don’t doctors always do their best to choose the right tests? Of course they do, but making the decision is complicated. Doctors are taught to take a history by asking questions, and to do a physical examination. This helps create a short list of possible diagnoses. The history alone provides enough information to make a diagnosis in 70 per cent of cases. To rule items on the short list in or out, the doctor may order tests.
In the last 25 years, technology and the availability of tests have transformed medical practice. Testing has taken on a larger role in the process of making a diagnosis. For many reasons, we may rely less on the doctor’s expertise and more on test results. In addition, it could seem like more testing means that nothing will be missed, or that the process is more thorough. However, tests themselves are not perfect. Results can be inaccurate or misleading.
Looking for early warning signs of a condition before symptoms appear is called screening. Using screening has added even more tests for healthy people. In some cases, there is no clear sign that having this information before symptoms appear will actually make any difference.
Current testing recommendations are changing.
- Mammograms, which once began at age 40, are now recommended for women over 50 every two to three years. This test is not recommended for average-risk women between the ages of 40 to 49.
- Pap tests were once recommended yearly. The current recommendation is to do this test only every third year if the first few tests are normal and to not begin it until age 21. Some organizations in Canada and abroad do not recommend Pap tests until age 25 to 30.
- Bone density tests for women were once done every two years starting at menopause. Now, the recommendation is to begin testing low risk women at age 65.
- For average-risk people, cholesterol testing is now recommended every three to five years after age 50 for women and at age 40 for men, instead of more often.
- Chest X-rays and breathing tests are no longer recommended for smokers who do not report breathing problems.
- For men, routine PSA screening to detect prostate disease is not recommended.
There are always exceptions. If you have risk factors, the above guidelines may not apply to you. Mention concerns about screening to your doctor, and tests may be tailored to meet your needs.
Choosing Wisely also encourages you to ask questions about your own tests. For instance, if you are not sure why a test, treatment, or procedure is necessary, it is perfectly reasonable to ask the doctor about it. Other reasonable questions are whether the test is likely to be harmful, if there are other options, and what happens if you do nothing (called watchful waiting).
Similarly, Choosing Wisely recommends testing do’s and don’ts for various symptoms and emergency conditions. For instance, back pain is common. Often even severe back pain resolves on its own in about six weeks. Choosing Wisely recommends against investigating with X-ray, CT, or MRI for new back pain if red flag (worrisome) symptoms are absent. Your doctor will ask questions about possible worrisome symptoms. If they are present, appropriate tests should be ordered right away. If not, taking pictures is less likely to be helpful. Why? Back X-rays can show common wear and tear changes that most people have anyway, even if they do not have pain. Seeing these pictures can trigger over-treating symptoms that might resolve on their own or with minimal treatment like home exercises or physiotherapy.
Another recommendation is aimed at people who have diabetes controlled by diet. These people should not do daily finger-prick blood glucose tests. For many people with diabetes, this is good news. It turns out that all that testing and worry about blood glucose does not change long-term health in people who do not need insulin.
Treatment
Choosing Wisely also guides doctors and patients on appropriate choices for treatment. It continues the campaign against using antibiotics unnecessarily. For instance, most coughs and colds do not need antibiotics. Older people who have bacteria in the urine but no symptoms do not require them either.
To see the complete list of Choosing Wisely Canada recommendations, go to:
choosingwiselycanada.org
The bottom line?
More testing is not better. Sometimes, the best investigation is no investigation, and the best treatment is time.
FAMILY HEALTH is written with the assistance of |
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FAMILY HEALTH is written with the assistance of |
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