Do You Test with Guidelines or Instinct?

Practicing medicine hasn’t been the same since the internet came along. Sure, there are plenty of benefits to having the internet as a tool to your aid. For doctors, it can be used to access journals online instead of having to rely on hard copies, we can also utilize and share EHRs with other healthcare providers, and even take advantage of online CME activities to stay up to date with all that’s new in the world of medicine. There are also perks for patients, such as allowing them to read more on their condition in order to better understand and communicate with doctors via email and telemedicine without having to visit their office.

Unfortunately, the internet is a two-edged sword. It has plenty of benefits but it also has a downside. Now every patient comes to you having already formulated their own diagnosis and might just be coming to you for a “second opinion” or to ask you to treat them without having to go through a diagnostic process, because they already did that at home. Another flaw is that the internet can be a scary place when it comes to medicine. You look up your headache and it tells you it could be a brain tumor. Patients will come to you because they’re worried, probably because of something they read on the internet, and want you to order tests so they can make sure they’re okay. So as a doctor, what should you do? Should you comply with the patient’s wishes? Or do you say no and risk upsetting them?

First of all, you need to make sure your patient isn’t a hypochondriac. If you’re working in a hospital, then you might see the same patient several times a month. Each time, he or she will present with a new complaint and ask for it to be investigated. So you need to be able to identify a hypochondriac in order to deal with him or her in the best possible way. You can try to reassure them all you want but until they have a test that says they’re okay, they’ll just keep going through doctors. So order the test they’re asking for (which will probably turn out negative) and establish a trusting relationship with them. Don’t refer them to a psychiatrist. Become their doctor and they’ll come to you whenever they start worrying about having a disease or illness. Through time, you’ll earn their trust and maybe they’ll start to take your word for it rather than need a test each time. Don’t overdiagnose hypochondriasis though. People might actually be sick and you need to use your clinical sense to be able to tell the difference. Also, don’t dismiss a hypochondriac’s complaint as an exaggeration. They’re people too and they’ll probably actually get sick sometimes.

Now, when it comes to a patient asking you for a test, there’s a lot at stake for you as a doctor. For starters, patients might leave you and go to another physician if you’re not giving them what they’re asking for. If they want a test and you’re not giving it to them, they might think you’re not as concerned about their health and wellbeing as much as they expect you to. This could lead to the breakdown of your doctor-patient relationship and they might stop trusting you. No doctor wants to lose their patients, but at the same time doctors want to stick to the guidelines and do what’s right. Another problem with refusing to order a diagnostic test for a patient is that they might give you a negative review. Reviews are tricky because most people who have a pleasant experience somewhere don’t really take the time to give that place a positive review. On the other hand, any negative experience is enough of a motive to make sure you let other people know you had a terrible time.

When you have an amazing Uber ride, you don’t always rush to give a 5 star rating, you might postpone it until the next time you open the app, but a terrible ride is one that you’ll immediately give a one or two star rating to. The same applies to everything and medicine is no exception. You might have 10 patients who love coming to your office and only 4 of them will take the time to give you a positive review. However, if 3 patients have a bad experience, then at least 2 of them will give you a negative review. Of course the threat of being sued is another concern.

Then there’s the issue of your image. A lot of people picture doctors to be brilliant people who know what to do and what to say. Doctors shouldn’t take orders or they’ll consider it a sign of weakness and being a bad doctor. At the same time, people are becoming increasingly demanding of doctors and want to get the things they ask for. So doctors have to find a way to balance the equation. Keep their image as a strong character who is sure of what he or she is doing and at the same time not say “no” to patient requests all the time.

It’s not easy to find a way to balance all these things and the stakes are clearly high. You have your doctor-patient relationship, your image, and ratings to worry about. The first thing to do is find out why a patient wants a certain test. If a woman comes in worried she might have breast cancer and asks for BRCA gene testing even though she doesn’t fit the criteria in the guidelines, ask her why she wants to be tested. If a patient with knee pain asks for an MRI, find out the reason behind the request. By knowing the reasoning behind their request, you might be able to dispel their fears and reassure them. The next thing to do is to tell them “I’m going to tell you why you don’t need to be tested, if you still want the test when I’m done talking, then I’ll give it to you.” You’d be surprised at how many people will take your word for it and change their mind after you make your case. You’ve also shown strength of character, wisdom, and that you’re concerned about their health. If they still prefer to be tested then you’ve done all you can and you should just order it for them. If you don’t, then they’ll keep visiting other doctors until they get what they want anyway. Just keep their health in mind and if a test will expose patients to any kind of threat such as radiation you should warn them against it and explain the hazards of the test. Make sure they’re well-informed of the risks.

The important thing is to earn the trust of your patients from the first time you meet. This will make every following meeting and encounter easier to handle. By earning their trust you’ll also get to know them better, so you’ll understand their fears and be able to find better ways to reach them.

It’s not easy battling diseases as well as the internet. It’s great that patients can use it to understand more about their bodies, but at the same time it can cause unnecessary and unwarranted fears of serious diseases that a patient most likely doesn’t have. There’s a reason we have guidelines that tell us if and when to order a particular test. Unfortunately there’s little doctors can do to get in the way of that. You can’t blame someone for wanting to make sure they’re okay and it’s not their fault that someone posted something terrible on the internet that made them worry. The best thing to do is to manage the situation and try to please all parties involved.