Asking the right questions and deciding which diagnostic tests you want to take can help you reduce your medical costs.
Dr. Tom Ferguson authored numerous works on medical self-care.
PHOTO: RICHARD ALLEN
Despite its exalted rank in modern society, the practice of medicine is not, and never has been, immune to the whims of fashion. In 1860, for example, it was "stylish" to bleed patients who were suffering from a wide variety of ailments. Turn-of-the-century doctors (with the best of intentions of course) regularly applied leeches to their clients, and also ladled out doses of strychnine, mercury, arsenic, creosote, and hydrochloric acid. And, as late as 1945, many surgeons were still—with the blessing of medical fashion— removing tonsils, adenoids, appendixes, gall bladders, and uteri in attempts to cure arthritis.
Today, computerized machines stand in spotless laboratories, waiting to spew out numerical data at the touch of a button, and they hold much of the same magical lure for many modern physicians as the leech can and the bleeding basin did for their predecessors. Patients, too, may be fascinated by these marvels of medical science, but we mustn't be too dazzled to ask responsible questions when our doctors suggest that we subject ourselves to such powerful, hazardous, and sometimes extremely expensive technologies.
About a quarter of all medical costs incurred in this country stem from tests. In 1977, five billion laboratory tests were performed in the United States. That's an average of more than 20 per person! In 1981 alone, $21 billion (according to the most knowledgeable estimates) was spent on lab tests and X-rays, many of which were very likely unnecessary. That figure doesn't even include the diagnostic procedures performed by physicians!
Worse yet, the stunning amount of money being spent on tests is far from the only price exacted by push-button medicine: Radiation exposure, inaccurate diagnosis as the result of laboratory error or an incorrectly interpreted set of figures, and possible infection (or even death) can all—on occasion—be added to that cost!
Many people are surprised to learn that a doctor can't order any tests without his or her patient's consent. Most simply assume that lab exams are routine, required procedures, and therefore don't exercise their right to ask questions. Nonetheless, the decision to undergo, or refuse, medical tests is really up to you, and we suggest that you stand on your patient rights.
If your doctor wants you to have a cardiac catheterization, for instance, you'd be well advised to read up on the test in some detail and to prepare an extensive list of questions for him or her to answer, before you submit to such a drastic procedure. On the other hand, when dealing with relatively minor tests, you need only to assure yourself that they're necessary, safe, and inexpensive.
In general, however, you should get straight answers to five questions before you consent to any medical test:
And remember, a reply of "Because we do this test in these kinds of situations" or "Because this is part of our standard screening panel" should not be considered a satisfactory answer to the first question. As a matter of fact, the current trend is away from screening panels, which involve large numbers of unnecessary medical tests that may force your clinician and you to spend time and money running down meaningless abnormal values.
The fact is, since most lab tests are designed so that 95% of the healthy people who take them show normal results, the other 5% will show "abnormal" or "borderline" scores. Thus, if you have 12 separate blood tests done at the same time, you have a pretty darned good chance of showing an abnormal score, even when you're perfectly well! Of course, if you're retested, these false scores will probably fall back within normal limits, but—in the meantime —you'll have fretted needlessly, and will have been put to a lot of bother and expense besides!
Rather than evading your question concerning why you need a specific test, a conscientious physician might answer with something like this: "Since you're not feeling well and have been exposed to hepatitis, I'm concerned that you may have contracted the disease. The test will measure the blood levels of several enzymes produced by your liver, so I'll know whether or not there's been a significant change in the functions of that organ. If your test results are normal, I'll be pretty certain that you're free of hepatitis. If not, I'll suspect that you should follow a recommended treatment plan and take precautions so that you don't infect others."
If neither you nor your doctor would be advised to do anything differently by the outcome of a prescribed test—and all too often that's the case—what's the point in putting yourself through the ordeal in the first place? Of course, there are times when a test is undertaken for the doctor's benefit, rather than the patient's. Suppose, for example, that you're in the emergency room after getting a nasty knock on the head, but the medical consensus is that you haven't received any serious injuries. If the doctor then decides to order a skull X-ray for you, he or she may be requesting it simply to eliminate the risk of a future malpractice suit. Is it your responsibility to give the physician this protection? Who's paying for the X-ray (and being exposed to radiation), anyway? You have a right to refuse any test.
The discomforts and indignities resulting from such examinations as the barium enema and sigmoidoscopy (both of which involve having an instrument inserted into the rectum) may linger in a patient's mind long after the disease—be it real or only suspected—is forgotten. Moreover, as a result of the actual procedures involved, many medical tests expose you to hazards that include infection, allergic reactions to dyes, bruises from venipuncture, and radiation exposure. [EDITOR'S NOTE: For more on the dangers of radiation exposure, see X-Rays, Radiation, and You.] Furthermore, a death risk is inherent in certain tests: Cardiac catheterization, for example, seriously injures or kills a small percentage of those who undergo it.
At any rate, the only sure way to protect yourself is to assess the likely benefit of a procedure along with its attendant hazards.
The price of a test is also an important consideration (especially in this day and age), and some clinicians actually don't know what the tests they suggest will cost. Ask your doctor, or one of the office staff, to find this information for you before you make any decision, because you need to be able to calculate the cost-benefit ratio of what's being ordered for you.
For instance, if you planned to start an exercise program, you might want to go first to the doctor to get a checkup. He or she could then raise the possibility of your having a stress electrocardiogram and, at the same time, warn you that the information provided by it would be of marginal benefit. If the test were free or inexpensive, you might then opt to take it anyway. But if that exam would set you back to the tune of $150, you could justifiably decline spending the money on an examination of dubious value. On the other hand, simple testing for blood in the stool (which is an indication of possible cancer) costs only pennies and thus is well worthwhile.
Keep in mind, too, that even when you don't pay for a test out of your own pocket, you—and all of us—will have to pay for it indirectly, through insurance premiums, membership fees in prepaid health plans, and taxes.
Before submitting to any test, you should find out whether or not the information the doctor needs is already on record. There's usually no reason to duplicate data from a recent test you may have had at another clinic or lab.
In addition, you'll want to plan now to avoid repeating tests in the future, and you can do this by keeping your own records of the tests you've had, where they were done, and the results they produced.
There are a number of self-diagnostic tests available, many of which can be done at home. Instead of coming into the clinic every few weeks to have your blood pressure checked, for example, you can easily learn how to measure it yourself, and then phone your doctor if it rises above a certain level. Or, if you're a diabetic, you can teach yourself to do a blood-sugar test, rather than having it done at a clinic.
In any case, when you must have a test done by professionals, you can improve the accuracy of the results by finding out, in advance, how you can prepare for—and participate in—the procedure, and by learning the details so that you can help prevent mistakes (either your own or those of the person performing the test).
For example, if you're going to have a barium enema, you should know that you must go without eating for 12 hours prior to the test. Then, to prepare for it, you should also take an enema, laxative, and/or suppository. To undertake such a test without preparation would likely result in its cancellation, or in its having to be done over because of unsatisfactory results.
Many people—laypersons and health workers alike—overestimate the value of medical tests, mistakenly thinking that a satisfactory diagnosis can't be made without them. As a result, patients are sometimes disappointed or feel they're not getting their money's worth from a consultation when the doctor doesn't order a whole battery of examinations. Often, however, the test of time is the best one of all.
In short, medical tests aren't panaceas: They're useful only in specific situations. A frank, informed discussion between you and your physician can help you determine whether or not testing is indicated. If it isn't, you can refuse it. After all, it's your body and your pocketbook, isn't it?
Dr. David Sobel, M.P.H. is chief of Preventive Medicine at the Kaiser-Permanente Medical Center in San Jose, California. He is an associate editor of Medical Self-Care.
Dr. Tom Ferguson was the founder and editor of a quarterly journal titled Medical Self-Care, which ran from 1975 to 1989, as well as Medical Self-Care: Access to Health Tools (Summit Books, 1980).