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An Egregious Example of Ordering Unnecessary Tests

flabbergasted

Last week I wrote about doctors who order unnecessary tests, and the excuses they give. Then I ran across an example that positively flabbered my gaster. A friend’s 21-year-old son went to a board-certified family physician for a routine physical. This young man is healthy, has no complaints, has no past history of any significant health problems and no family history of any disease. The patient just asked for a routine physical and did not request any tests; the doctor ordered labwork without saying what tests he was ordering, and the patient assumed that it was a routine part of the physical exam. The patient’s insurance paid only $13.09 and informed him that he was responsible for the remaining $3,682.98 (no, that’s not a typo). I have a copy of the Explanation of Benefits: the list of charges ranged from $7.54 to $392 but did not specify which charges were for which test. It listed some of the tests as experimental and not covered at all by the insurance policy, and one test was rejected because there was no prior authorization.

The tests were done by Health Diagnostic Laboratory, Inc., a company that offers an advanced comprehensive menu of biomarkers. Here’s a list of the tests they did on this young man:

  • Lipids: total cholesterol, LDL-C, HDL-C, Triglycerides, Non-HDL-C
  • Lipoprotein Particles and Apolipoproteins: Apo B, LDL-P, sdLDL-C, %sdLDL-C, Apo A-1, HDL-P, HDL2-C, Apo B: aApo A-1 Ratio, Lp(a) Mass, Lp(a)-P
  • Inflammation/Oxidation: Fibrinogen, hs-CRP, Lp-PLA, myeloperoxidase
  • Myocardial Structure/Stress/Function: Galectin-3, NT-proBNP
  • Platelets: AspirinWorks (urine) Ppg/mg of creatinine
  • Lipoprotein Genetics: CYP2C19*2*3, CYP2C19*17
  • Coagulation Genetics: Factor V Leiden, Prothrombin Mutation, MTHFR (C677T), MTHFR (A1298C)
  • Metabolic: 25-hydroxy-Vitamin D, Uric Acid, TSH, Homocysteine, Vitamin B12
  • Renal: Cystatin C, Estimated Glomerular Filtration Rate, Serum creatinine
  • Electrolytes: sodium, potassium, chloride, CO2, calcium
  • Liver: ALT/GPT, AST/GOT, ALP, Total bilirubin
  • Renal: Creatinine, BUN
  • Thyroid: TSH
  • Others: Albumin, Total protein, Ferritin
  • Omega-3 fatty acids: ALA, DPA, EPA, DHA
  • Omega-6 fatty acids: Omega-6 total, Arachidonic acid, Linoleic Acid
  • Other fatty acids: cis-monosaturated total, saturated total, trans total.

They did not report hemoglobin, hematocrit, blood glucose, or hemoglobin A1C, but they nevertheless commented:

  • Glucose and hemoglobin A1c are in the normal range and are consistent with normoglycemia
  • There may be some evidence of insulin resistance. There is evidence of adipose tissue insulin resistance.
  • There is evidence of hyperinsulinemia, suggesting beta cell strain. There is evidence of beta cell dysfunction. Elevated Proinsulin to C-peptide ratio has been associated with beta cell failure and beta cell dysfunction.

At the end of the lab report there is a long list of comments explaining the associations of various factors with various health consequences. Helpful information, like the fact that the patient’s genotype shows that he would be a normal metabolizer of the drug clopidogrel. Finally, the patient is encouraged to contact the lab to set up an appointment with a Clinical Health Consultant to discuss his exercise needs at no charge.

According to most published guidelines, a routine physical on a 21 year old male should include BP, weight, updating immunizations (and offering HPV vaccine), inquiring about risk factors, and counseling, as appropriate, about lifestyle issues like safe sex, smoking, alcohol, diet, exercise, etc. NO lab tests are recommended except for possibly checking lipids or HIV status, which most guidelines do not advise in the absence of risk factors.

I will not comment further, as I feel incapable of moderating my language.

Addendum: August 7, 2014

The young man in question called the doctor’s office to complain about the charges. They referred him to the billing department. The billing department said there was nothing they could do and he should call the lab that did the tests. He called Health Diagnostic Laboratory and they told him to just forward the check for $13.09 that his insurance company had sent to him. They told him he would not be billed for the rest of the charges. I don’t know how they can do business this way, but at least he doesn’t have to pay.

In response to a fraud alert issued by the Inspector General, Health Diagnostic Laboratory has recently dropped the “reimbursement for shipping and handling”  kickback to doctor’s offices.

This is all very reassuring, but my flabber remains gasted at the doctor ordering all those tests on a healthy young man.

Posted in: Diagnostic tests & procedures, Science and Medicine

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166 thoughts on “An Egregious Example of Ordering Unnecessary Tests

  1. PeteSYD says:

    “A friend’s 21 year old son went to a board-certified family physician for a routine physical. This young man is healthy, has no complaints, has no past history of any significant health problems and no family history of any disease…”

    From my Australian perspective, it is a total mystery as to why a robustly healthy 21yo man with no personal or family history of illness would even be seeking a “physical” from a Board Certified Physician!

    If a patient like that turned-up at my practice, with no complaints at all… Well, it would just seem like an entirely unnecessary visit, and an utter waste of our mutual time and his money. I contend that not only were the tests unnecessary, so was the office visit itself.

    1. Dick Funruckus says:

      A routine physical is often required for certain jobs, or school sports (being 21, he’d likely be at university), so the visit itself was quite correctly categorized as “routine”, not unnecessary.

    2. WilliamLawrenceUtridge says:

      I went to see a doctor when I was in my early 20s for a physical. Seemed like a good idea at the time, and he was quite patient considering I was an insufferable, arrogant prig. I was a vegetarian/borderline vegan, so there’s a bit of an excuse, but in retrospect it was a waste of everyone’s time and a bit of a contradiction since I showed up for a medical exam then spend the entire visit fighting with and dismissing the doctor’s opinion.

      Anyone else wish they could return to their youth and slap some sense into themselves?

      1. Windriven says:

        “Anyone else wish they could return to their youth and slap some sense into themselves?”

        Including defining my youth as ‘yesterday’.

      2. geekoid says:

        I’d be happy to slap you now, as a favor to your older self :)

        1. WilliamLawrenceUtridge says:

          Oh, no, now I’m perfect.

      3. Lytrigian says:

        You have NO idea.

      4. Thor says:

        Your question was probably rhetorical, but GODDAM YES. That sense wasn’t slapped into me then has had a long domino effect, and continues to haunt me almost daily. (Free will? I’ve been acting all this time with a deficiency of reason and comprehension not of my own doing.)
        Warning: not an invitation for a free will debate! lol

      5. mouse says:

        “Anyone else wish they could return to their youth and slap some sense into themselves?”

        Yeah, it would have been for dating too many arrogant, insufferable, prigs. (some of them vegetarians.)

        I’m sorry WLU, but it’s actually true. I should have had a lot more fun in my youth.

        I did have a very nice doctor in my twenties, though and I listened to her too.

        (Now who’s being an insufferable, arrogant prig? See aren’t you glad you got it over with.)

    3. Lytrigian says:

      First, whenever you see a doctor you usually want to see one that’s board-certified in the specialty he says he practices.

      Second, there are often benefits to getting a routine physical exam. Under my employer’s health plan, I get a contribution to a “healthcare fund” to cover part of my deductible and out-of-pocket expenses when I take certain “preventive health care” measures, such as walking a lot (and yes, they give me a pedometer) or getting an annual exam. So it actually saves me money to get one.

    4. Iorek says:

      My son has had a couple over the last few years for the Australian Army and the state police. For the former he went to our gp who bulk billed him-usually he doesn’t, but on this occasion he did; for the latter he had to go to a gp nominated by the recruiters and pay for the appointment himself (maybe $200ish).

      Both ran the rule over him, checked vision and hearing and ran what I think of as basic blood tests, which were bulk billed. For some reason the blood tests for the Army, a few months before the police application, had to be redone for the police, despite being entirely normal.

      Our gp has known him since he was a tot, and was happy to do it, the other one presumably does them all day long.

  2. Matt says:

    Wow. I’m a final year med student in Australia and I’ve never heard of half these investigations. And as for the others, there is no rationale for ordering any of these in an a symptomatic young person! Even the concept of a ‘routine physical’ is somewhat bizarre to me.

    1. Calli Arcale says:

      It’s a common practice in the US, though patients tend to find it a nuisance and oftetimes doctors do as well since it takes up a lot of their time for a disproportionately low recompense. I guess this doctor found a way to more than make up for the relatively low hourly compensation of the physical….

      I had to get a physical for my job, but the only part my employer really cared about was the drug screen. :-P Which, of course, leaves me wondering why they didn’t just order that. It’s a simple lab test, after all.

  3. Nigel says:

    Lordy, I take it 1st do no harm doesn’t include the wallet?

  4. Michael Finfer, MD says:

    Absolutely outrageous. In a healthy man of that age, there is very little in the way of laboratory testing that would be helpful. That guy needs a new doctor.

    You should anonymize the lab report and the EOB and offer it to a medical school to use as an example of what not to do.

  5. DavidCT says:

    Sounds like the physician was board certified in financial planning. Certainly it was not in anything related to patient care. I would also expect a financial interest in the lab. It is also possible that the physician is an employee and policy decisions are made someone with no ethical obligation to customers – I mean patients.

    This is an extreme example of inappropriate medical care but it does show a lack of transparency common in billing. If I were in this situation I would be inclined to seek legal advice to challenge the appropriateness of the test orders. I would want early on to be in a position to block any collection actions against me which could risk a judgement. Such a judgement would ruin my credit for at least 7 years. Doctors are not the only ones that have to think about legal consequences these days. Once the bill is paid or collection started it is too late to have any leverage.

  6. Mary Russell says:

    21 year old men do not need routine physicals. On occasion I have somebody come in at this age who needs on for pre-employment sort of thing, and think of it as a waste of time both for him and for me. Yes, you should offer them updates on their vaccines, but that can be done over the course of a non-preventive visit.

    1. Missmolly says:

      Mary Russell, have you read the Laurie R King books where you are Sherlock Holmes’s protégée? Please do- start with The Beekeeper’s Apprentice. Just reading your name has made me happy!

  7. Nick Theodorakis says:

    Usually when I hear about healthy people that young getting a physical exam, it’s because they are playing organized sports and it’s a requirement of whatever agency is in charge of that sports league to demand physicals from the participants.

    If a patient neither asked for nor consented to a test, is he obligated to pay it? It’s as if someone, for example, purchased a computer, and the salesman also charged him for the extended warranty even though he didn’t ask for one. I think he should challenge the bill, legally if necessary.

    1. George Locke says:

      I too wonder what legal options are available…

  8. Sean Duggan says:

    Absolutely ridiculous, and yet I’ve run into a similar situation a few times in the United States. Nothing quite so egregious, but I’ve been hit by the occasional $50-60 bill for tests I didn’t ask for. In each case, the doctor claims that the tests are standard and it’s a matter for the insurance companies, the insurance companies claim that the doctor had no authorization to order those tests and that non-payment will result in my account being sent to bill collection agencies, and of course, the bill collection agencies care for nothing other than the money. It’s gotten to the point where, at the beginning of every appointment, I ask the doctors to please state all tests they wish to run and whether they’re covered by insurance. Largely, this just results in very few tests being run as the doctors claim that they have no idea whether a given test will be covered, or how much of it will be covered, until they call the insurance companies. I’ve had some limited success with halting the examination to call the insurance company to inquire directly, but that of course takes time which I’m already losing from my company’s sick leave (or, when I’m on contract, out of pocket in terms of wages). Frustratingly, I’ve occasionally learned that the exact same test is covered under slightly different medical coding, but once it’s submitted, that code can’t be changed even if the test would have been covered under the other code.

    1. Windriven says:

      Yow! Where do these physicians come from? My internist and I discuss everything to death. Blood tests. Screening colonoscopies. The relative uselessness of PSAs (which I continue to get ’cause they don’t cost me a dime and … why not).

      The relationship between a patient and their PCP is arguably the most important relationship with a professional that most people will have. Doesn’t it make sense to spend the time and money to find one with whom one can build a successful relationship?

      1. Jane Cobb says:

        And there is another one that the US seems to thin essential while the rest of the world does not. Colonoscopy carries a significant risk of doing damage and they are only done if there is a known genetic susceptibility or risk factor, or there are symptoms which may indicate a problem.

    2. Nell on Wheels says:

      Quest Diagnostics gives you an estimate upfront of how much the ordered tests will cost. This should be standard practice.

      They also request a credit card to cover the costs in case your insurance won’t cover it, but I always refuse and it’s never been a problem–I guess you can’t blame them for trying, but I can see that some patients might not realize that they can refuse.

      Frustratingly, I’ve occasionally learned that the exact same test is covered under slightly different medical coding, but once it’s submitted, that code can’t be changed even if the test would have been covered under the other code.

      It hasn’t happened very often, but, I’ve never had a problem having a code changed. I just took the refusal to my doctor’s office and they took care of it with the insurance company. Mistakes happen.

  9. Marilyn Mann says:

    Hm… I suspected as much. Check out this article telling docs how they can increase their practice revenue with this testing.

    http://www.physicianspractice.com/blog/new-practice-revenue-sources-health-diagnostic-laboratories

    1. Harriet Hall says:

      Good Grief! It’s worse than I thought! It says the company pays the doctor’s office $20 for each test and they advise doing the tests to improve the doctor’s revenue stream! It also says they accept whatever the insurance pays, and the patient is not billed, which is obviously a lie. My friend got a check from the insurance company for $13.06 so he could pay for the lab bill himself. I’m sure the lab will not accept that as full payment!

      1. Nell on Wheels says:

        The patient billing page is no longer available on their site, but a cached version says:

        Worry-Free Billing

        Lab costs and bills are worry-free with HDL, Inc. For patients with PPO/POS/HMO insurance, if it turns out your insurance company does not cover a specific test, HDL, Inc. assumes all the risk. For patients with Medicare/Medicaid, the entire cost of services performed by HDL, Inc. is covered under current Medicare/Medicaid coverage.

        Will Patients Receive A Bill From HDL, Inc.?

        There are three instances in which a patient would receive a bill from HDL, Inc.:

        1> If HDL, Inc. learns that payment for services was sent directly to the patient and not forwarded to our billing department as requested above
        2> If the patient does not have Medical Insurance or opts for services at the Cash Price
        3> If HDL, Inc. has filed claims with the patient’s insurance company and the patient has NOT met the patient contribution requirements (e.g. deductibles, co-pays, etc.) for laboratory services

        For any billing or other payment questions, please contact our office at 1.877.4HDLABS and simply select ”Billing” when prompted.

        1. MacSmiley says:

          HDL, Inc.? Isn’t that the lab Thomas Dayspring has been posting YouTube videos for?

      2. Wayne says:

        That’s strange. I have had three blood tests through HDL now, none of which were 100% covered by insurance and none of which I received a bill from HDL for. All I ever get is a letter asking to have any insurance checks related to the tests that I receive sent to them. That said, I don’t recall ever seeing a pre-insurance charge of more than $600 or so, with about half that paid by my insurance.

        1. Long Time Lurker says:

          Hi Wayne,

          The labs typically don’t run services not ordered by the physician. Their order forms are often setup to select “panels” which are often selected by physician offices without verifying what constitutes said panel (often $4,000 in charges) or with no concern as the labs have told them then patient won’t be billed regardless.

          The testing can still be selected a la carte which may have been what your physician chose to do.

          This also allows them plausible deniability when the charges are questioned.

      3. Long Time Lurker says:

        I work as a fraud investigator in a fairly large health insurance company. We have providers sending to multiple labs for several panels offered by each. I have personally viewed over $20,000 in labs billed on a single patient with no disease diagnosis/history.

        Most physicians we contact state they are told by the lab reps they will never bill the patients, most also do not have this in writing. It often isn’t until we point out they just made an individual liable for the cost of a new car -should the lab ever change its billing policy – that they start to reconsider their approach.

        If you’d like more information, feel free to e-mail me and I’d be happy to help.

        1. WilliamLawrenceUtridge says:

          Science-based medicine does accept guest posts…

          http://www.sciencebasedmedicine.org/about-science-based-medicine/submission-guidelines/

      4. Michael Finfer, MD says:

        This sounds like a Stark violation to me. The appropriate authorities should be notified.

      5. Tazia K. Stagg says:

        Did you report this already? Along with the family doctor, the laboratory (and medical director Tara Dall) also need to be reported.

    2. Nell on Wheels says:

      I wonder if the patient has informed the doctor that he’s been charged for the tests? According to the article, “HDL functions as an out-of-network lab — they submit claims for the tests performed and they accept what the insurance company has paid; there are no additional bills to the patients for copays or to cover out of pocket payments. This is a huge benefit to patients who often avoid necessary lab tests due to high deductibles and/or copays.”

      If the doctor is operating under the impression that there’s no additional cost to the patient (despite the fact that the tests are totally unnecessary), perhaps he can get involved. He should take steps to correct the problem, Or, better yet, stop performing the tests. If he doesn’t, at the very least he should be reported to the insurance company. Also, social media can be a powerful tool.

    3. Marni says:

      Isn’t this illegal? It’s essentially a kickback to the physician.

  10. Daniel Falcon says:

    This particular case/example should be referred to the appropriate professional governing board for review and consideration of disciplinary action. This physicician is practicing ouside of well-accepted practice parameters. It is in the interest of the community and all physicians to do so.

  11. DW says:

    That is truly appalling.

  12. Dolph says:

    The real(!) scandal is rather that these test would cost $3682.98 in any civilized country…

    ~50% of it is basic stuff that every health insurance in europe does happily pay for at least once a year because it has a lot of preventional value and will SAVE money in the long run. For example:

    -total cholesterol, LDL-C, HDL-C, Triglycerides, Non-HDL-C
    -Cystatin C, Estimated Glomerular Filtration Rate, Serum creatinine
    -sodium, potassium, chloride, CO2, calcium
    -Uric Acid, TSH
    -ALT/GPT, AST/GOT, ALP, Total bilirubin
    -Creatinine, BUN
    -Albumin, Total protein, Ferritin

    To think that any western medical professional would call these tests “unnecessary” tells the rest of the world a whole lot about what is wrong with the US medical system.

    1. Harriet Hall says:

      ” it has a lot of preventional value and will SAVE money in the long run”

      There is zero evidence that any of those tests have preventional value or will save money in the long run. It is more likely that testing will worry the patient, lead to further unnecessary testing, and increase costs. The USPSTF exists solely to evaluate all the evidence and advise doctors and the public about what tests have preventional value, and they do not advise any of these tests for a healthy 21 year old.

      1. Windriven says:

        Dr. Hall, I have been getting annual blood tests for at least 30 years: CBC, lipids, liver enzymes, nothing esoteric. I’ve never had an alarming result but have watched my total cholesterol inch up from ~160 to ~190 and recently went on atorvastatin. I watch the liver enzymes because I drink alcohol moderately but daily.

        I don’t know if there is any real preventative value but I’ve never paid more than $100 for the whole shebang. I’ve always monitored BP regularly too. To me it seems like good common sense, like monitoring engine temperature and oil pressure or following routine preventive maintenance procedures on production equipment. If it was easier to come by a decent spirometer I’d probably track FVC as well.

        1. MadisonMD says:

          Windriven,
          Unless I’m mistaken, you are not a 21 year old without any medical conditions or significant family history of hereditary dyslipidemia. Dr. Hall is asserting, correctly, that these are not necessary for this patient. Some (not all of the tests) may be indicated for other clinical situations. e.g. 40 year old with hypertension, family history of heart disease. Or, say healthy 60 yo, in which screening and primary prevention of CAD might be indicated.

          Some of the tests cited by Harriet are experimental and are not indicated for any patient outside of a clinical study. You are not getting these, Windriven.

          1. Windriven says:

            Madison, I was not suggesting that the tests for the man in question were reasonable. But Harriet said, “It is more likely that testing will worry the patient, lead to further unnecessary testing, and increase costs.”

            I guess my point was that some procedures are barely hazardous (phlebotomy), pretty inexpensive (CBC, enzymes), and have low risk of inaccurate results. Whether they have demonstrable epidemiological value is debatable but they give me a sense of prudent monitoring of my general health.

            And you are correct, I certainly have never had several of the tests ordered for the 21 year old.

        2. Byron says:

          Why were you were put on a statin for a 190 total cholesterol? Are there other factors going on? I have read that as long as ldl remains low that up to 200 total is nothing to worry about.

          1. Windriven says:

            Byron, the latest AHA recommendations for a collection of factors put me at a risk appropriate for prophylactic statins despite being in good health. Actually, I had been on them when I lived in NOLA. My then physician had participated in the Bogalusa Heart Study and pretty much put everybody on statins.

            1. Andrés says:

              Windriven said:

              I’m here for a good time. A long time is optional.

              and:

              I’ve never had an alarming result but have watched my total cholesterol inch up from ~160 to ~190 and recently went on atorvastatin.

              I am not going to dispute the value of statins in secondary prevention for the elderly population here. But. You are aware than higher cholesterol once you are older is associated with lower mortality (a very clear hard point), aren’t you? Take a look by yourself at the Honolulu Heart Program paper and some of the correspondence (via Dr. Briffa). Moreover, it seems that PROSPER was the one statin trial focused on an elderly population (via Petro, correct me if I’m wrong), far from healthy though (from Table 1 there were 26.8% smokers, 61.9% hypertensives, 44.2% with history of vascular disease). It found a relative risk ratio for any-cause mortality (Table 2) of 0.97 (95%CI 0.83 to 1.14). It seems that not living longer is quite likely.

              I have already critiqued the consensus about medicalization of healthy individuals. Extrapolating drug outcomes from some population with a given computed risk value due to some unhealthy status to another one with the same computed risk value due to age is wishful thinking. Not finding any statistically significant mortality benefit should give pause to anyone not completely focused on population medicine. Anyone on statins (specially for primary prevention) should take a look at Statins: proven and associated harms. At a minimum they should supplement CoQ10 just in case.

              1. Windriven says:

                I’ll certainly have a look.

              2. Windriven says:

                Andres, I don’t have time to read through this carefully as I’m trying to blow out of the office early for some of that ‘good time’ stuff. Dinner party tonight featuring chili, quesadillas, and copious quantities of beer.

                That said, at first glance the Schatz studied Japanese/American men. They are likely to follow a diet quite different from my own. Also, I am much younger than that cohort. Better looking too ;-) And the Shepherd looks at individuals at risk for CVD.

                My actual risk is pretty low and no family history beyond pacemakers in the 8th decade for most of them.

                I have thought about the CoQ10 but don’t know enough about it yet. My general recollection is that the science is weak.

                If I don’t blow an artery or some crap between now and Monday, I’ll give this all a closer look when I get back.

    2. MadisonMD says:

      To think that any western medical professional would call these tests “unnecessary” tells the rest of the world a whole lot about what is wrong with the US medical system.

      That’s an odd assertion because the best evidence is that the U.S. pays more than Europe for medical care with outcomes that are inferior. The main reason is that the healthcare dollars are deployed inefficiently on high-tech tests and interventions. Harriet’s example– ordering blood tests for a healthy 21 year old without specific indications to do so– is a prime example. I’d venture such poor medical practices are less common in Europe than the U.S..

  13. cshearson says:

    Regarding physicals for young adults, the family practice (in the US) that I go to will not see patients for sick visits unless they are “established” patients, which means, as far as I can tell, that you have to have previously been seen at the practice for at least one well visit (i.e., a physical). So when when my 21 year old came home after graduating from college, he had a perhaps otherwise unnecessary physical so that he would at least have somewhere to go, besides urgent care, should he get sick.

    1. Windriven says:

      “the family practice (in the US) that I go to will not see patients for sick visits unless they are “established” patients, which means, as far as I can tell, that you have to have previously been seen at the practice for at least one well visit (i.e., a physical).”

      Would you really want your first visit to a primary care physician be when you are extremely ill?

      1. cshearson says:

        No, I wouldn’t, which is why the kid got a physical.

        One of the other commentors wondered why a healthy 21 year old would even get a physical. I was simply providing one possible scenario.

    2. Vicki says:

      I moved across country last year. The doctor I am now seeing doesn’t do routine physicals, but was happy to schedule a new-patient visit. That wound up including some conversation about my medical history/current health, a Pap smear (after she asked how long it had been since the last one), and a prescription for a shingles vaccine (my request, since I am now old enough). She asked about a flu vaccine, but I’d gotten that at the pharmacy a month earlier.

      But the main thing was that when I had actual medical issues over the winter, I was able to call up and say “I’m a patient of Dr. M’s, and would like to make an appointment” and was seen quickly.

    3. CHotel says:

      About 2 years ago my family doctor left town and his replacement also mandated a recent physical for anyone wanting to have her as their physician. As a very healthy 22 year old who was a year away from graduating with a Pharmacy degree, I was dubious about the utility of such an exam, but needed a doctor so I went with it as well.

      Turns out I had developed a heart murmur at some point in the last 17 years or so (last physical before then was when I was around 5 according to my mother), and needed to get a TTE to ensure it was of a benign origin. So that was fun. The bloodwork was all totally useless though.

  14. Aaron H says:

    I had a physical at 30 that included most of those tests plus an ECG. Thought it was excessive. The doctor mentioned that it is standard for him on all new patients. The upside is that this was in Canada and there was no cost.

    1. Harriet Hall says:

      “The upside is that this was in Canada and there was no cost.”

      That’s one of the drawbacks of universal health care. It increases the temptation to do unnecessary tests. No cost to patient, but everyone pays for it through taxation.

      1. Kim says:

        Citation needed.

        1. Harriet Hall says:

          I don’t have a citation, but I have a knowledge of human psychology. I’d think the temptation would be self-evident. And it’s obvious that tests have to be paid for by someone even if the patient isn’t charged for them.

          1. Jeremy says:

            “It increases the temptation to do unnecessary tests”

            It might seem that way, but unnecessary tests just divert health dollars from where they’re needed (e.g.. Grandma needs a new hip again and now has to wait 18 months). And it comes from my taxpayer dollars, incidentally.

      2. Frederick says:

        When I read the 3600$ bill I was shock, But I guess you have a point. Although if it was covered by his insurance, that doctor will still have been Paid, so it is still temping for MD to do too much test. I guess that our free health care might make it more temping, but I think this is a minor flaws compare to the huge benefits of a universal health care. In the end Doctors get paid whatever it is by the patient, Insurance or government, So some doctors who are less “ethical” with the money problems might over test whatever pays him/her.

  15. Joel A. Harrison, PhD, MPH says:

    I agree with Daniel Falcon that the doctor should be reported to the Medical Board; but also to local law enforcement to investigate if he is getting kickbacks and/or charging extra for each test report he reads. I agree with Dolph that the charges for the tests, as with everything else in American medicine, are much higher that would be considered “reasonable;” but disagree that a number of them should be given regularly. There is a small, but real possibility of false positive. In fact, statistically if one gives 100 tests one can expect about 5 false positives. Even the most “healthy” peoples’ physiological measures vary. One time I went in for a physical, was rushing, walked up five flights of stairs, and the nurse immediately took my blood pressure. It was much higher than normal so I asked if she would take it again in a few minutes; but she wouldn’t, so I asked the doctor, he did, and it was much much lower. Some doctors might have just accepted the first measure and prescribed me some type of medication for high blood pressure, all types having risks of side-effects besides being uncalled for. False positives can lead to additional testing and as my example, even medical interventions, both costly and with risks. In addition, medical interventions may be aimed at “real” albeit “normal” variations that the risks and costs of the interventions are greater than any benefits.

    Three books deal worth readings are:

    Lynn Payer’s book “Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France,” Henry Holt, 1988 discusses how medicine isn’t just as science; but culturally defined where the U.S. ranks highest in aggressive treatments of just about everything, often resulting in adverse outcomes.

    There is an excellent book that discusses results of too much screening by Dr. H. Gilbert Welch, a nationally known expert on screenings at the Dartmouth Institute for Health Policy and Clinical Practice: “Overdiagnosed: Making People Sick in the Pursuit of Health.” Beacon Press, 2011. Anyone interested can follow with another book by Shannon Brownlee: “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.” Bloomsbury, 2007

    1. Dolph says:

      Sure there is variation, no doubt about that. But that is rather an argument IN FAVOUR of regular screening.
      How are you going to identify and treat let’s say for example familiar hypercholesterolemia if you don’t screen for it in YOUNG patients? Is a 21 year old men with LDL-C of let’s say 200 mg/dl “healthy” just because he didn’t have a heart atack yet and maybe won’t have one until he is 40? When exactly does the so called “science based” medical professional think it is the right time to screen for it? After the first heart attack or stroke? Post mortem? Come on, that’s even worse than just ridiculous.

      1. Harriet Hall says:

        Screening for familial hypercholesterolemia is a standard recommendation for every child with a family history or other high risk factors. There is also an argument for testing every young person once: a total cholesterol and/or LDL/HDL would be sufficient; there is no reason to do apolipoproteins or CRP or any of those other things. It would be far more productive to counsel everyone about how to reduce modifiable risk factors, regardless of their cholesterol levels.

    2. KayMarie says:

      I’m surprised the nurse wouldn’t retake the blood pressure, but the one time I was seriously high on intake I had just narrowly avoided being T-boned by someone running a red light so maybe my adrenaline rush was accepted as a reason. Or just normal variation in standard practice.

      I used some of the biofeedback I learned from my migraine treatment and the nurse seemed actually impressed by how much I lowered the blood pressure and heart rate in a couple of minutes.

  16. Stella B. says:

    Those are ridiculous tests. They shouldn’t be performed on anyone, much less a 21 year old. Those are sCAM lipids tests beloved by the alternative nutrition crowd. Sometimes, I’m sorry to say, even MDs get caught up in sCAM.

    The CDC does recommend an HIV test.

  17. Jon says:

    The comments make is seem like they thought he was a diabetic. Probably just some mixup or mistake. No way I’d pay that bill.

  18. @GeekPharm says:

    I’m 31 and starting my final year of pharmacy school. My school requires both a physical and a drug screen every year (but the drug screen, from a contracted provider, is the only lab test required by the school). This year I had a new GP and when I went to schedule an appointment for the physical (after I had already completed the drug test) my doctor’s office wanted me to come in a couple days early to give a blood sample for lab tests. I’m beginning to think that I lucked out in having to cancel that appointment and getting my physical done at a drop-in/ low-income clinic, otherwise who knows what charges I might have ended up with.

  19. Rob Cordes, DO says:

    Harriet, I can understand why you cut the post short.
    An extreme example of what NOT to do.
    I still see some 21 y/o as a pediatrician (US). If healthy I’d recommend routine PE, preventative counseling – diet, exercise, STI, seat belt, sunscreen, update immunizations double check on HPV immunization status, reminder on flu vaccine (LAIV usually available by mid August), discuss transition to adult care, possible lipid panel if not already done.
    If cost was not a problem it would be interesting if he scheduled a recheck with this doctor to review what each of those lab test results mean.

  20. Marilyn Mann says:

    There is an NHLBI-sponsored guideline that recommends universal lipid screening at age 9-11 to check for familial hypercholesterolemia and other extreme lipid disorders.

    http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_sum.pdf

    I believe it is reasonable for everyone to have at least one basic lipid profile in early adulthood to check for FH, a common lipid disorder for which treatment would be recommended even in the absence of any other risk factors. Early treatment with statins has been shown to reduce the risk of early heart disease in FH patients.

    However, that is not what was done here.

  21. pk says:

    I was once told that I could not have orthopedic surgery on my finger unless I had a chest x-ray to “look for pneumonia”. I asked the surgeon if he missed class on the day they taught how to use a stethoscope. He laughed; I had the surgery without the x-ray and somehow survived.

    1. MTDoc says:

      I had to laugh too. We all started out, at least in my day, learning clinical skills. Most specialists in those days also served a “rotating” internship where he/she continued to deal with a broad range of primary functions, such as a general history and physical. As times changed, surgeons became more specialized and felt more comfortable delegating the pre-op physical to another specialist. The liability crisis that started in the 1960s further encouraged this. And some years ago we had hospital rules mandating certain pre-op lab and X-ray. Guidelines soon become rules, especially in court.

      A personal observation. On my recent colonoscopy, I saw eight persons before I actually spoke with my GI man, in the exam room. The histology report noted three polyps, but no mention of degree of dysplasia. And my pre-op exam by a (very nice young PA) was charged to me with a specialist co-pay! I’m actually not complaining, as the service was great and medicare covered most of it. But there should be a simpler way.

      Oh, and orthopods don’t have any bones in the chest that they are particularly concerned with.(-:

  22. Art Malernee Dvm says:

    Even the concept of a ‘routine physical’ is somewhat bizarre to me.>>>>

    Even cat owners in the USA think their cat needs them.

    1. mouse says:

      I thought cats and dogs did need them. How else are you going to get the recommended vaccines and test for heart worms (for dogs)?

      1. KayMarie says:

        Generally that was what the doggies growing up did. Go once a year for boosters and heartworm check, have their teeth checked (and cleaned if needed) and kind of like the see your primary care doc (even if just a follow up and not a real physical) just get to know the animal a bit so when something changed (like a calm animal/person suddenly becomes scared and aggressive) you have some baseline to compare it to. As well as some relationship over time usually is helpful when things do eventually go sideways.

      2. Chris Hickie says:

        My new vet (as we moved) has signs prominently displayed in their office that every dog/cat they see, be it for medical purposes (sick or well) or boarding must be tested by them annually for heart worm. The sign does not say what the consequences are if one refuses–presumably it would be termination of the relationship.

    2. Frederick says:

      we do have 4 cats, One passed away last winter, Soy was 12 years old. He had Heart problems. All of them were vaccinated, but none had booster shots. we go to the vet only when they have symptoms.They are all crossbreed and ex stray cats. Couple of years ago, our Grand Eldest, Willie, Died at 18.5 years. They all go outside as they please, I don’t think the older ones really need annual Vet visit. we have 2 younger one now, ( 9 month, 2 years, 12 and 12) for those 2 we are going to be more discipline. we never gave booster shots to our olders one, but the young we will do more follow up.

      We that said, Cats and dog do have behaviour changes when they feel bad, but it is not like a human to who you can ask questions.

      I always wonder how is going the Vet medicine science. I wish there was a SBVM

      1. goodnightirene says:

        Try skepvet.com

        You will love it.

        1. Frederick says:

          Nice! Thank Irene!

    3. Angora Rabbit says:

      “Even cat owners in the USA think their cat needs them.”

      Dr. Malernee, I don’t know where you practice, but I am thankful you are not my vet because I would have to fire you. As caregivers we humans are responsible for making sure our animal companions are healthy, safe, and have their health needs met when illness happens. Animals cannot speak when they are ill, and this is where the veterinarian intercedes, to speak for them through diagnostics and practice. I’ve had over 700 rescue animals come through my home over the years, and I sure wish I could tell immediately when they are ill, as that would save a lot of money, heartache, and potential suffering. I need a veterinary professional to tell me that BUN is elevated and that there is a renal issue, or that there is left ventricular hypertrophy and needs medication, or that the apparent stiffness is real and not only the animal is twice as old as believed but also needs an antiinflammatory.

      Wellness checkups provide baseline information on an individual and serves a useful comparison for the situation when the animal falls ill. When the animal is ill, I don’t want to be guessing if that serum calcium level is normal or abnormally elevated, as an example. Do I repeat serology every year? Of course not. But I do bring everybun in for an annual evaluation, physical and oral, so that we can track any changes that are too subtle for me since I see them daily, instead of annually.

      A colleague does something similar with human children having a particular medical condition, and has documented how the annual checkup reveals subtle but meaningful changes in, for example, the child’s growth curves and pulmonary function. The same is true for our furry patients.

      It’s not an income generator. It’s because my veterinarian’s skills enables my pets to speak.

      1. brewandferment says:

        my mom’s cat wouldn’t come out from under her bed whenever anyone came to visit. I decided it would be too hard and too stressful on him to drag him out from under it by his paws–the one time that I’d actually caught him he crapped in my arms (might have been a coincidence but maybe not.)

        So after she died when he got used to my house and actually did really blossom into a more friendly lap kitty, as well as play with his cat siblings (but is still wary with the other family members) and I finally got him to the vet, it turned out that most of his teeth were rotted to the gum. A few had resorbed and the very few salvageable teeth had to come out or he’d have been back at the vet within a year or so because his gum disease was so bad.

        So why not a regular check up that would catch such things early before it got that bad? With this cat, maybe it wouldn’t have been caught in time but our other cats are easier to corral into the carrier and are more familiar with the routine.

  23. Hilary says:

    This article resonates with me as I have just started going through a similar situation. I am 29 years old and pregnant with my first child. I was advised by my ob/gyn that I should undergo genetic testing for trisomy 13, 18 and Down’s syndrome, as well as looking for Spina bifida and cystic fibrosis. I was told I was approaching greater risk for these diseases due to my age, and since my doctor is in network with my insurance company, I allowed the testing to be done. Turns out, they send my bloodwork to a lab that’s out of network, and my insurance company is refusing to pay ANY of the $2000 bill for these tests. Mind you, my EOB is not itemized so I’m not even really sure what each charge is for. I called the lab that did the testing and they also said “we don’t bill our patients”. This is so confusing as my insurance company doesn’t seem to be paying for it, and surely it won’t be free! Even when I ask now if tests will be covered, its a confusing and often pointless conversation as things don’t ever seem to be clear until tests have already been done and claims have already been made.

    1. Long Time Lurker says:

      Most labs that run on this model won’t bill you (or bilk a set, much lower amount.) They attempt to keep patient outrage at a minimum to avoid government and patient advocate service referrals.

  24. NotADoc says:

    Can’t say this one surprises me.

    A little more than a year ago I was referred to the rheumatology clinic at a nearby teaching hospital. I was sent for blood tests: if I remember, they took about 15 vials of blood. Total bill: $7000 (yes, seven friggin’ thousand dollars). After the insurance discount it was about $4500, and my 20% was $900.

    I had had some of these tests run previously through Tricore, and still had bills. Ol’ Tricore is really missing the boat: the esteemed university charges 4x to 8x more for the same tests. Same with the x-rays- they were about 5x more expensive than those done elsewhere.

    Of course this story has a punchline: the tests showed absolutely nothing. Nada. I happen to have a form of inflammatory arthritis, fairly easy to spot with a medical history and a good hard look at the patient, that usually doesn’t result in any funky blood work. seeing as this clown never even asked which drugs I was taking or which drugs I’m allergic to, no surprise that he missed it.

    Do I need to say, I have a new rheumatologist?

  25. Art Malernee Dvm says:

    I thought cats and dogs did need them. How else are you going to get the recommended vaccines and test for heart worms (for dogs)?>>>

    In the last few months the speciality group the American board of internal medicine informed doctors in new guides “don’t perform routine health checks for asymptomatic adults.”
    There is a good article now in the NYT written by an internist called “doctors bad habits ” as he tell everyone how hard it is to stop giving up annual exams. I can feel his pain. At least he does not have the AMA, like the AVMA, telling people it’s “as essential as food” . Most fully immunized dogs and cats do not need annual “boosters” although some local laws still require them. Many of the newer heartworm medications are approved for Heartworm positive dogs,so a test before Heartworm season every year so reactions to the medication will not occur is no longer a concern.
    Art Malernee Dvm

    1. mouse says:

      @Art Malernee DVM – Huh – interesting. To be honest I have no idea how often I take the pets to the vet. I basically take the dog when either the kennel or the vet says they need another vaccine. I don’t think each vaccine gets an annual booster, it seems to alternate between a few. Then there is the darn bordatella which doesn’t even last a year, but they have the tech do those. I did not know that about the newer heart worm, though.

      The cats are vet/car phobic. So I admit I only take them after I have received several reminders, because it upsets them so much.

      Really, between the kids and the animals I can’t keep track of who’s supposed to get what when. I thought that’s what I paid doctors and vets for. But it seems like there’s always someone who thinks I should be telling my doctor/vet to vaccinate more or less, likewise with testing, medicating, etc.

      1. Calli Arcale says:

        I take mine in annually, but they’ve started pushing for at least annual dental cleanings, and I have concerns about that. I mean, I get my teeth cleaned twice a year, and that’s good, but I don’t have to undergo general anesthesia to do it, and I worry if my dog gets enough out of a dental cleaning to justify the anesthesia risks — to say nothing of the expense, since her cleaning is obviously much more expensive than mine. Even though she has fewer teeth. ;-)

  26. Jann Bellamy says:

    I think a call to the doctor’s office is in order to see what his explanation is. Tell the doctor that you’ve had the lab results reviewed by another physician and she does not feel the tests were medically necessary, if that is ok with Dr. Hall. If he just made a mistake, or someone in his office did, he should pay for the tests. If he doesn’t have an explanation, or if he can’t explain why they were medically necessary, he should also pay. If the doctor has an explanation, then tell him he needs to argue with the insurer on the patient’s behalf and convince the insurer to pay because the tests are medically necessary. The patient should follow up the conversation with the doctor or his office with a written confirmation of his understanding of these conversations. He should also get a copy of his medical records, which he has a right to do.

    If circumstances dictate that the doctor should be held responsible, but he won’t pay, the patient should try to see a lawyer, but that will likely cost more than the test. If the patient is in school, the school may help him with legal assistance. Same for an employer, although unlikely. If there is a law school in the area, they may have a legal clinic. State bars often have lists of lawyers who will do an initial consultation for free or reduced costs, as do some local bar associations. Legal aid is an option if the patient qualifies.

    If he can’t get a lawyer, he should find out what his consumer rights are from the state consumer protection agency and file a complaint. I would consider turning the doctor in to the state medical board if the circumstances warrant, Once he finds out more about what happened. It might be worth a call to whatever agency regulates labs in his jurisdiction if he thinks the lab is doing something wrong. Also, let the lab know that he is investigating the circumstances of the tests being done and to hold off with the bill until he determines who is responsible. That may not work, but at least it puts them on notice. Consumers have certain rights if disputing a bill, and that’s why a lawyer or a consumer protection agency should be contacted to determine what these rights are. All of this varies from state to state.

  27. Alia says:

    Well, my routine physical for my job as a teacher does not include chest X-ray anymore (it used to, for fear of TB). Nowadays it includes just blood pressure, general questioning about habits and symptoms, and a visit to laryngologist. However, before going on certain medication I was advised to check liver enzymes and have an ECG done. Which I did, even though it was not covered by insurance. But then, I paid like $30 for the whole package.

  28. Nyet says:

    Wow! I am T1DM pt who manages chronic pain symptoms and I never get this kind of work up…

    These are some cursory thoughts (not in defense of this practice) on this test ordering behavior:

    1.) Is, or was, this physician, a colleague, or their practice named in a malpractice claim?
    2.)Physician has a previous test ordering behavior that may indicate they are oriented towards defensive medicine (fear of failure to diagnose .)
    3.)Physician has low threshold for uncertainty (fear of criticism?), or they sense that the parent (or patient) does and are responding to that with testing instead of communication and education.
    4.)Due to age and lifestyle of patient, Physician was making an assumption or inference (again side-stepping communication and delivery of correct, useful information for self care) that the individual was unlikely to pursue a full physical for quite some time- so the extensive tests were like a “no time like the present” or “strike while the iron is hot” kind of thinking.
    5.) This practice does not take insurance so the physicians tend to not prioritize considering insurance company guidelines when ordering labs or writing referals, as they do not have to deal with the conflict when it arises- the patient does.

    It seems like a lot of factors, not just financial, affect this choice of behavior which thus makes it challenging to suggest a lasting, effective answer, no?

  29. Nell on Wheels says:

    First and foremost, let me say that health care shouldn’t be this hard. I acknowledge that if we had single-payer, we wouldn’t have these problems. That said, we are stuck for now with what we’ve got, so here are things every patient/consumer should know:

    1. Learn how to use your insurance company’s website. You’d be surprised how much information is available able there.

    2. Know, understand, and track your deductible, copayments, coinsurance and out-of-pocket maximums. Under the ACA, the 2014 out-of-pocket limits are $6,350 for individuals and $12,700 for families, but can be lower depending on the level of your plan. Higher premiums usually mean a lower out-of pocket maximum. Many people who shopped for the lowest premium are finding out that they’re on the hook for a large deductible and out-of-pocket obligation. I find that a lot of times people who claim that something “wasn’t covered” are talking about things that were covered but subject to their deductible and/or other out-of-pocket obligations.

    3. Be aware and beware of out-of-network services and providers. Coverage can vary from a percentage of the cost to your having to pay 100% (after satisfying #2 above).

    4. Know what preventive services are available without cost—as long as they’re performed in-network.

    Preventive Services Covered Under the Affordable Care Act
    Also, Affordable Care Act Implementation FAQs
    If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, [certain] preventive services must be covered without your having to pay a copayment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider.

    5. Know what’s not covered. Elective surgery for example.

    6. Shop around. Tests ordered by your doctor are rarely an emergency, nor do they necessarily have to be performed by the lab your doctor sends you do. Most insurance companies these days have a price comparison tool on their website to help you find the lowest cost option for tests and procedure. You can save up to 50% or more by having tests performed at a freestanding laboratory instead of a hospital.

    While it’s not recommended that you spread your prescriptions around, sometimes it can pay to shop at Walmart, Target or price clubs that offer low costs for generics or club member prices instead of your insurer’s “participating” pharmacies. There are a number of websites that allow you to compare prices. I found a widely available generic for $12 at Target that would have cost me $84 at my insurance company’s “approved” pharmacy, RiteAid, even with my insurance discount.

    7. Ask what a test, medication, or procedure will cost. While your doctor might not know, asking will make them aware that cost is an issue for you. Any lab or pharmacy should be able to give you an estimate and, as noted above, your insurance company probably has an online cost comparison tool.

    8. When in doubt, get prior verification or authorization from your insurance company. Most insurers require prior authorization for at least some tests and procedures—especially if they’re expensive. Sometimes, the provider does that, but sometimes you’re required to get it from your insurer. Failure to do so could leave you responsible for the whole bill.

    9. Question, question, question. Don’t be afraid to ask what a test or medication is for or whether it’s necessary. If a claim is denied, ask why and let your doctor know. Sometimes they can submit it under a different code or provide justification to the insurance company.

    10. Review your EOBs and never pay a bill if you aren’t sure what it’s for. You are entitled to and should receive an itemized accounting. If it’s not offered or provided, demand it. Report any questionable items to your insurance company.

    1. G.D. says:

      A really brilliant illustration of the Kafkaesque horror that is the American health care system. I’ll probably copy it and send it to my friends in Europe for a laugh and a scare.

      1. Harriet Hall says:

        The American health system has many flaws, but I don’t think “Kafkaesque horror” is an appropriate description. Keep in mind that I wrote about this precisely because it is a glaring exception to standard practice.

        1. G.D. says:

          The comment was intended for Nell on Wheels’s list of advice – well meant, to be sure, yet still (unintentionally) magnificently illustrating precisely why the system is a horror: the resources, knowledge and insight it requires of a non-expert to be sick in the US – even if you have an otherwise good healthcare plan. Any kind of serious condition is almost inevitably going to turn into a bureucratic and – yes – Kafkaesque nightmare unless you have prepared really, really well beforehand.

          Just the fact that ordinary people, if encountering any kind of medical issue, have to *check* whether particular hospitals or doctors are “in network” before seeking them out ought to be counted as a violation of basic human rights. And I truly mean that. (And that, of course, is just the tiniest beginning of the bureaucratic labyrinth you, as a patient, will have to face if anything really serious ever happens). And *of course* people are going to be exploited in the manner described in the original post when the system is set up like this – you cannot seriously expect ordinary people (with no medical expert or background in insurance management) to be able deal with these kind of situations in any kind of informed manner, and a system set up to expect it should exist only as some kind of deranged joke.

          1. DW says:

            I completely agree, a deranged joke.

            “If anything really serious ever happens”? For the vast majority of us, something really serious is going to happen, some day. We all want to think we’ll go in our sleep, but most of us won’t.

            So yeah, I think Kafkaesque is about right. It’s seriously traumatizing to deal with the health care system in general. Viz. the “psychosomatic” thread, if you weren’t stressed and twitching when you went in, you will be by the time you get out, if it’s more than a minor bug or cold.

        2. Nell on Wheels says:

          Unfortunately, based on my own experience and quite a few of the comments here, the original story isn’t a “glaring exception” but an all too common occurrence. And G.D, while my list was intended to be helpful, it was also intended to “magnificently illustrating precisely why the system is a horror: the resources, knowledge and insight it requires of a non-expert to be sick in the US – even if you have an otherwise good healthcare plan.”

          As I said, it shouldn’t be this hard. Nonetheless, I have been navigating the insurance/healthcare system for myself and friends and family for more than 10 years now, saving at least my friends and family thousands of dollars and immeasurable aggravation in the process. Sometimes I’ve just had to explain how the system works (deductibles, co-pays, out-of-pocket, out-of-network, etc.) and other times I have gone to battle questioning bills that made no sense, several time leading to the charges being waived altogether because even the doctors and billing departments couldn’t figure them out.

          I, too, have friends in Europe who have been at times horrified and mystified by this system that so many in this country think is “the best in the world.”

  30. MTDoc says:

    In my private practice days, the test I most often wished I had was a baseline EKG. When the 40 year old presents with chest pain, and has a non-diagnostic, but atypical EKG it can be very helpful. I also used to get baseline chest X-rays on smokers, as well as basic pulmonary function tests (PA/LAT chest $20, PFT $5), even on 20 year olds. Sometimes this had more effect on their future smoking than my lectures. And over a period of years, the gradual decline in VC and FEV1 can be very convincing.

    1. Windriven says:

      “the gradual decline in VC and FEV1 can be very convincing.”

      Got me to quit. No spirometry involved. I was working on a project at a hospital and the elevators were out so I walked up three flights of stairs. When I got to the top I could barely breathe (the erosion of pulmonary function sneaks up on smokers). Decided then and there that I wasn’t going to be doing that anymore.

      1. MTDoc says:

        Most long term smokers have lost 50% of their pulmonary function before they really become aware of it. Which is why influenza is so deadly. Walking up three floors is a pulmonary function test of sorts. Glad you connected the dots! ☺

        1. Windriven says:

          “Glad you connected the dots!”

          Me too. I really knew better. I actually knew better when I started – even though the link between cigarettes and lung cancer was not well established in the public mind when I started.

          I’ve always had authority issues and cigarettes were verbotten for 14 year olds. Had they been compulsory I’d have never touched one.

  31. Lytrigian says:

    By a strange coincidence, Language Log covered uses of “flabber” just yesterday. http://languagelog.ldc.upenn.edu/nll/?p=13329

  32. Fahren says:

    I can understand the outrage at the price charged for these tests, but suppose that the charge had been a more modest $200. Would that make a difference in judging whether or not the tests were appropriate? I purchase a battery of nearly fifty blood and urine tests for myself each year at a cost of about $125 and most of those tests are the same as those cited in this post.

  33. Fahren says:

    I can understand the outrage at the price charged for these tests, but suppose that the charge had been a more reasonable $200. Would that make a difference in judging whether or not the tests were appropriate? I purchase a battery of nearly fifty blood and urine tests for myself each year at a cost of about $125 and most of those tests are the same as those cited in this post.

    Why not test for everything if the cost is not too high? If every 21-year-old got the same battery of tests, there would probably be a very small number them who had genuinely serious problems that would benefit from early diagnosis and treatment.

    Suppose that number is one per 10,000 21-year-olds. Isn’t it worth testing 10,000 to find the one who would benefit? I suspect that the number of children who need to be vaccinated against certain diseases for one child to be spared a life-ruining case of such a disease is probably in that same one-in-ten thousand range. And the cost of vaccines is in the $200 range.

    So what’s the difference? Why be outraged at running a large number of tests when only a tiny fraction of the testees will benefit, but then argue that it’s irresponsible not to vaccinate against dozens of diseases where the cost-benefit situation is similar?

    1. Harriet Hall says:

      What’s the difference? Vaccinations do more good than harm; indiscriminate testing does more harm than good. When the prevalence of disease in a population is low, the number of false positive results exceeds the number of true positives (sometimes by orders of magnitude), leading to misdiagnosis, inappropriate treatment, unnecessary invasive tests, more expense, worry, etc. We are concerned with the benefits vs. harms to health, not just the monetary costs. The “why not test everything” argument doesn’t hold up to scrutiny.

      1. Fahren says:

        Is the statement that “indiscriminate testing does more harm than good” a science-based judgment? Do scientists have any special competence to weigh the value of a life saved compared to the negative effects of false positives? I’d think that evaluating the risks and benefits of indiscriminate testing is a personal value judgment that should be made by the patient, not the doctor.

        1. Harriet Hall says:

          Scientists don’t have any special competence to weigh the value of a life saved, and they don’t usually even try. But they can show whether a screening test results in a larger or smaller disease-specific and/or overall death rate. PSA screening tests do not affect all-cause mortality. http://www.nejm.org/doi/full/10.1056/NEJMoa1113135 And science can study the rate of complications like incontinence and impotence and give the patient the information he needs to make a personal value judgment.

          1. Tim Bartik says:

            Your general point on over-screening is good, but your specific example is problematic.

            The studies of PSA screening lack sufficient sample size to have adequate power to detect plausible and “large” effects of PSA screening on all-cause mortality.

            1. MadisonMD says:

              Harriet’s cite had sample size with N=182,160. Are you saying the all-cause mortality ‘goalpost’ is just unrealistic, especially when you demand a large effect? Is it your view that prostate-cancer specific mortality the appropriate endpoint and NNS=1055 on this endpoint is sufficient to recommend routine PSA screening?

            2. MadisonMD says:

              I found your comment below that answers my question.

              1. Tim Bartik says:

                If you want more statistical evidence on this issue, see my comment at the website prostatecancerinfolink a few years ago, at http://prostatecancerinfolink.net/2012/03/15/updated-data-from-erspc-trial-still-shows-no-impact-on-all-cause-mortality/

                In addition, look at the writings of Ruth Etzioni, a biostatistician at the University of Washington, who has done a number of simulation studies using the European estimates, and tweaking various parameters of what cut-off PSA level to use for recommending biopsies, and how frequently to screen. Her analysis suggests that we can reduce NNT to reduce one death by quite a bit with less frequent screening intervals and somewhat higher thresholds for ordering biopsies.

      2. Fahren says:

        Is the statement that “indiscriminate testing does more harm than good” a science-based judgment? Do scientists have any special competence to weigh the value of a life saved compared to the negative effects of false positives? I’d think that evaluating the risks and benefits of indiscriminate testing is a personal value judgment that should be made by the patient, not the doctor.

        Suppose that there ARE orders of magnitude more false positives than true positives for some medical tests. As long as the number of lives lost to the consequences of false positives is a smaller number than the lives saved by the indiscriminate testing, isn’t it worth a few hundred people experiencing “misdiagnosis, inappropriate treatment, unnecessary invasive tests, more expense, worry, etc?” for every one life saved? Aren’t those a small price to pay to save someone’s life, especially a young person with many years to live?

        And on a related note, aren’t the numbers-needed-to-treat for some drugs orders of magnitude higher than the number of lives saved. For example, the link below suggests that 167 people need to take statins for one person’s life to be saved. That’s more than two orders of magnitude. Do you think such a disparity is an example of “indiscriminate treatment” that does more harm than good?

        http://www.aafp.org/afp/2010/1001/p741.html

        1. MadisonMD says:

          There are many suppositions in your statements. What you are proposing is screening. Here’s an example of what can go wrong:
          Patient goes to mall to get CT scan for “screening.” (Mall CT scans were popular in metro NYC a few years back.) CT identifies lung module. A biopsy is performed and is complicated by pneumothorax. The man is admitted to the hospital and a chest tube is placed by the surgical resident. It hurts like hell. Two days later he gets pneumonia. He ends up getting home a month later after rehab. Choose your ending:
          1. Biopsy is benign.
          2. Biopsy is malignant but despite much treatment, the lung cancer kills the patient anyway.
          3. Biopsy is diagnostic and needs to be repeated.

          Before the CT scan is done in the first place, don’t you want to know there is a reasonable chance of #4:
          4. Lung cancer is caught early and cured.
          Well wait, even then the mall CT wasn’t worth it if the cancer would have caused a cough, then led to treatment and cure without the mall CT.

          For a good discussion of the conditions are required for a useful screening test see here.. Most tests don’t pass muster. Your point of saving one life is somewhat compelling but most tests you can imagine would not save any lives if used for screening. The best screening tests available today typically require 100-1000 people to be screened to save one life. So anything inferior needs to have less than 0.001 rate of complication including any work up complications for false positives.

        2. Harriet Hall says:

          “As long as the number of lives lost to the consequences of false positives is a smaller number than the lives saved by the indiscriminate testing, isn’t it worth a few hundred people experiencing “misdiagnosis, inappropriate treatment, unnecessary invasive tests, more expense, worry, etc?” for every one life saved? ”

          I think you wrote this before you saw my last comment. The point is that the lives lost are NOT always fewer than the lives saved. And the patient is the one who should make a personal value judgment about whether the possible adverse consequences would be worth it.

          1. Harriet Hall says:

            “aren’t the numbers-needed-to-treat for some drugs orders of magnitude higher than the number of lives saved.”

            Sure, but so what? Not a good analogy for screening tests. And it seems to contradict the other point you were trying to make. For drugs, we weigh the NNT against the number needed to harm (NNH). Harms are different for different drugs. We wouldn’t use a drug that killed more patients than it saved.

            Consider vaccines: thousands may need to be treated to save one life, but if the vaccines don’t kill anyone and rarely cause adverse effects, most people would consider it a good deal. And indiscriminately treating everyone protects everyone in the population, including those with medical contraindications to the vaccine.

            What if a drug saved 5 lives for every 1000 patients treated, shortened the life of 1 in a 1000 and caused annoying but not serious side effects in another 100 per thousand? I wouldn’t use the drug indiscriminately for everyone; I’d give the patient the numbers and let him decide?

            Since a PSA test doesn’t improve all-cause mortality and has known adverse consequences, don’t you think the patient should be consulted rather than indiscriminately testing everyone when you know it will result in false diagnoses and unnecessary surgeries?

            1. Tim Bartik says:

              We don’t actually “know” that PSA testing has no effect on all-cause mortality, as the sample size in the available studies results in inadequate power to detect medically and economically meaningful effects relative to the potential harms of unnecessary treatment of prostate cancer.

              PSA screening is actually a case where the research literature is quite mixed. If one believes the US study of PSA screening, screening has no benefits in saving lives, and only harms. If one believes the European study, then screening does reduce prostate cancer deaths by an amount that could plausibly be seen as “large” by many men relative to the potential harms. As you note, the European study does not find a statistically significant reduction in all-cause mortality, but this is meaningless given the expected size of the reduction in prostate cancer deaths relative to the overall mortality rate and the size of the sample. You would need a screening study that had treatment and control groups in the millions to detect the expected decrease in all-cause mortality.

        3. Andrey Pavlov says:

          s the statement that “indiscriminate testing does more harm than good” a science-based judgment?

          Why yes it is. And it requires thinking about more than just mortality. There is morbidity involved as well.

          I’d think that evaluating the risks and benefits of indiscriminate testing is a personal value judgment that should be made by the patient, not the doctor.

          You are almost correct here. But missing an important point. On an individual basis there may be a pressing need for an otherwise unwarranted test. For example if the person is undergoing serious mental anguish and would very much like a specific test to be more certain they don’t have something in particular that is worrying them very much. But that must also be balanced with the idea that the person may never stop and continue asking for test after test after test. It is also our responsibility to accurately frame and manage our patients’ expectations. Just like a bar tender should cut off a person who has had too much, so must a physician when it becomes clear that the test seeking behaviour is pathological.

          But that has no bearing on the first question you asked – indiscriminate testing on a population level will have a net negative effect.

          isn’t it worth a few hundred people experiencing “misdiagnosis, inappropriate treatment, unnecessary invasive tests, more expense, worry, etc?” for every one life saved?

          And now you are doing exactly what you say we shouldn’t – making a judgment call for other people and assuming what their posteriori feelings on the matter would be.

          What about the patient who gets a PSA, has a value of 3.8 and is extremely anxious. 6 months later demands another one. This time it is 4.1. Does that mean anything? Scientifically no. To the patient they now are over some magical threshold and have had a value go up. Now they want the biopsy. It comes back negative. But now they have chronic pelvic pain, some urinary incontinence, and difficulty with erections.

          You are making the assumption that every person in that situation would wipe their brow and be happy that at least they knew they didn’t have prostate cancer.

          But you are neglecting the ones that the biopsy missed and get the cancer anyways, just after a couple of years of the above side effects (which, if you are a male, should know are not minor side effects, particularly if the person is younger like in his 50′s).

          And the one who reads up on PSA’s over the couple of years after and finds out that his tests were technically scientifically unnecessary and now has these side effects vastly diminishing his quality of life.

          And the one who comes back positive. Now he has to have a radical prostatectomy with even more side effects. And his cancer may well have been one that was indolent and never harmed him. In fact, if you are diagnosed with prostate cancer older than 65 you are more likely to die with the prostate cancer than from it.

          You are making the assumption for all these people that they will happily accept their lot because that means someone else, somewhere out there, was lucky enough to have his life saved from the indiscriminate testing.

          Aren’t those a small price to pay to save someone’s life, especially a young person with many years to live?

          It isn’t always so small Fahren. That young person may now always have chronic side effects. Or always be worried about the possible outcomes and manifestations of a disease (s)he doesn’t have.

  34. swbarnes2 says:

    Is there really no virtue to having a base line for some of these, taken every, say, 5 years? So when someone does come in with symptoms, the doctor knows what’s normal for that patient?

    1. Harriet Hall says:

      No, there’s no evidence that it has any value. Just because a patient’s hemoglobin has always been 16 doesn’t mean that a new reading of 14 is abnormal or that the patient needs a workup for anemia. Keep in mind that lab results vary over time, that there is a margin of error for results, and that laboratory errors occur.

    2. Calli Arcale says:

      I think part of the trouble is that we forget what these tests really are for. Would it be nice to have a baseline? Sure! Would it be nice to know if you have early-stage cancer? Absolutely! But that’s not *really* what theses tests tell. Just as the Galileo spacecraft didn’t really sample Europa’s ocean to reveal saltwater, a cancer screening test doesn’t really tell you if you have cancer. Galileo detected shifts in magnetic flux around the spacecraft with its magnetometer as it encountered Europa; this data was analyzed and the most consistent explanation is that there is a subsurface saltwater ocean generating Europa’s magnetic field. But it doesn’t tell us what kind of salt, how pure it is, whether there’s other stuff in there, how deep the icy crust is, or even how fluid that water is — it could be a thick slush rather than what we all picture when we think of an ocean. Yet the public perception is “Galileo discovered an ocean under Europa’s ice”. So people want to send a cryobot submersible, but we really don’t know enough to design it appropriately for the conditions or even to know if it’s remotely practical.

      Same with screening tests. A prostate cancer screening test doesn’t tell you if you have prostate cancer. It measures your level of PSA, which correlates to your risk of having prostate cancer. This isn’t really enough information to know if you’ve got cancer, so now if it’s positive. you’re going to want more testing. The next step is a biopsy, and that’s not going to be especially pleasant. I know when my grandfather needed a biopsy there, he thoroughly despised the entire experience. It was negative, BTW. Should he have had the screen? I don’t know. I’m not a doctor. I’m not going to venture an opinion on that. But the outcome of a test isn’t necessarily benign, no matter how trivial the test itself may seem. Sure, if there was a simple blood test for prostate cancer, every man would want to do it. But there really isn’t; there is a simple blood test, but what it tells you is more nuanced than that.

      1. Andrey Pavlov says:

        An excellent analogy Calli! Now, let’s go swimming in Europa!

        1. WilliamLawrenceUtridge says:

          Bring a wetsuit, I hear it gets chilly at all times of the year :)

    3. MadisonMD says:

      Yes, Calli. I think this is one of the biases of human thought. We want to believe that we get absolute results from tests. When in fact (as any biostatistician will tell you), that is not at all what you get.

      Physicians are not immune from this. Clinical trials are the ‘tests’ that are used to determine whether something works or not. Physicians (I am not immune) tend to view the results as absolute, which is wrong.

      Recently some studies were reported leading to much hand-wringing in the oncology community (again). Basically Drug X showed benefit on surrogate endpoint. However, later it was found out to not be helpful in the larger clinical trial of ultimate endpoint. Now everyone is questioning whether that surrogate endpoint is valid at all. IMO, we have to recall (a) the first study had alpha=0.05 so there is a chance it might be false positive; (b) the second study had a beta=0.2 so there is a pretty decent chance it is a false negative; (c) the surrogate never had 100% correspondence in the first place– more like 50%. We knew about these limitations right from the start, so why is lack of concordance surprising?

      Whether clinical trials or test results, we have to make the best possible conclusions with the evidence at hand. However, we have to keep in mind, we may be drawing an incorrect conclusion. It is much safer when there is concordant evidence supporting a conclusion.

      Back to the topic of testing on patients. A test result that matches a patient’s symptom or physical exam finding is much more convincing than an abnormal result when you run 100 tests. It is Bayes in action. Such concordance is inherently absent in screening.

  35. Daniel Falcon says:

    Wow! What a flurry of outrage generated. The young man (or interested proxy) would do well to follow exactly the advice of Jann Bellamy in the comments. Please keep us updated in a post, if there are any new developments, Dr. Hall.

  36. Dan says:

    On the subject of overtesting, JAMA had a recent commentary on the physical exam that I found very interesting. In medical school we hear a lot about thinking before ordering tests, but I’ve often wondered how useful it is to do exams on asymptomatic patients (beyond the learning opportunity for students). It’s an article I’m definitely going to keep in mind for after I finish medical school.

    Reference: Rothberg MB. The $50,000 Physical. JAMA, 2014 Jun 4;311(21):2175-6. doi: 10.1001/jama.2014.3415.

    http://jama.jamanetwork.com/article.aspx?articleid=1877214

  37. Jesús R. says:

    It astounds me that a lab will perform tests without the permission of the one who is supposed to pay for them. In my view, the lab should know who orders the tests (who will pay for them) and make sure this person has indeed agreed on the exact amount he will pay for them.

  38. Chris Hickie says:

    Did the physician do this so s/he could upcode the visit (i.e. bill not just for a well visit but for a “sick” visit (as justified by all the labs ordered)? I’ve seen this and it bothers me greatly–the doctor may get an extra $50-100 on a well check, but the patient gets taken to the cleaners for all the labs.

  39. Jay says:

    adding my $0.02
    I used to work at a lab company. (I am not a physician or a medical technologist)

    I can see ordering the following as part of a physical, even with no history of problems (and these aren’t expensive tests by any means)

    lipids
    metabolic (some of these are pricey like the Vitamin D)
    renal
    electrolytes
    liver
    thyroid (maybe)

    I can’t believe no CBC with differential…(I know it’s anecdotal but the number of cases of people having an abnormal CBC result leading to further testing and discovery of leukemia/lymphoma)

    All of those lipoprotein tests, myocardial tests would be sent to a reference laboratory ($$$$) are not part of a standard of care or covered by insurance UNLESS you had a diagnosis or some kind, previous abnormal result, etc

    asking “is it necessary?” but also “what is the list of tests?” and “where are these sent? will the same lab perform them?” can help steer the conversation. If it isn’t a hospital lab nearby or one of the big players (Quest, Labcorp) can be a red flag. Ask if it’s a “Send out test” vs a test the lab runs on site.

    another is reflex testing…ask about it. a $40-50 urinalysis that finds something abnormal and has a UA culture can jump to $350-400 easily

    One last word of advise/comment, ask about the billing. Will it be billed to insurance? sometimes offices set up an arrangement with a lab where the lab bills the doctor for a test (at cost) and then the doctor submits the claim to insurance and pockets the difference. (called “client billing” or “doctor billing”). GPs do this for 2 reasons: 1) to make some $$$ and 2) if a patient doesnt have insurance, the office knows what the price of a test will be

    1. Harriet Hall says:

      “I can see ordering the following as part of a physical, even with no history of problems”

      I disagree, and so does the USPSTF and most professional groups that have issued recommendations. Your anecdote about leukemia illustrates the reason why: patients with leukemia will very soon develop symptoms that will trigger a blood test and a diagnosis, and there is no evidence that earlier diagnosis by doing routine tests on asymptomatic people improves outcomes. And since the progression of some leukemias can be very rapid, you would have to do a blood test every week or so to keep it ruled it out. And for every patient with a diagnosis of leukemia from a routine CBC, there will be many, many more people without leukemia who undergo further unnecessary testing. I had a CBC as part of a workup for a medical condition, not as a screening test, and it incidentally showed that I was anemic. I had a complete workup for anemia including a bone marrow biopsy; all was normal. My hemoglobin was only slightly below the “normal” range and the last test showed it back within the normal range. Another example is liver function tests: I can’t count the times I found an elevated alkaline phosphatase on a patient, did further testing without finding any reason for the elevation, and watched it return to normal on further tests.

      You didn’t mention blood sugar. There is an argument for detecting diabetes before it becomes symptomatic, but there have been two instances in my immediate family where an elevated fasting blood sugar was detected but turned out to be a false positive.

      Doing the routine tests you list intuitively sounds like a good idea, but it is not. Except for a lipid screen, and that should not be done as part of a routine every year in people with no risk factors.

  40. Phil Koop says:

    Off-topic, yet I can’t resist.

    There are unnecessary tests, and then there are imaginary conditions. Over at vox.com, they are saying that 19th century doctors warned that women were peculiarly susceptible to a hazard called “bicycle face”. Of course, bicycle face is not a thing; I thought it amusing that it took the “Phrenological Journal” to set the record straight.

  41. jpmc says:

    I didn’t read all the comments, but from what I read it is obvious that most do not really know how things work as far as costs and billing.

    1. Harriet Hall says:

      “it is obvious that most do not really know how things work as far as costs and billing.”

      It’s not helpful to say that without explaining what people got wrong and how things really work. Please enlighten us.

  42. Joel A. Harrison, PhD, MPH says:

    Estimations of false positive and false negatives change based on the prevalence of a condition (the prior probabilities). The risk of false positives for several blood tests in an overweight male over 60 would be small; but the same tests given to a normal weight 20 year old would be high. So, except for examples as familial hypercholesteremia, etc., testing “healthy” young people with batteries of lab tests would increase greatly the risks for false positives and false positives have consequences: 1. additional tests with further risks of false positives and, of course, some tests like biopsies incur their own risks, and 2. unnecessary treatments with both risk of side-effects and possibly economic consequences, e.g. affecting employment opportunities.

    I mentioned book by Lynn Payer “Medicine and Culture.” Someone thought cultural differences in approach to medicine would be minimal. Starting in late 1800s American doctors adopted radical mastectomies for breast cancer (see Pulitzer prize winning book: “The Emperor of All Maladies: A Biography of Cancer”). The French not only often used lumpectomies; but published survival data; but American doctors didn’t believe it, after all, it was the French. Now we know that radical mastectomies didn’t prolong life; but caused pain, disfigurement, and a host of other problems, e.g. removing a lot of lymph nodes reduced bodies ability to fight infections. American doctors were almost competing in how much of woman’s body they could remove whereas the French attitude was do the minimum necessary to complement the bodies ability to heal itself and the least disfigurement. Another example, a standard American textbook said if a woman was past childbearing age and had fibrosis of uterus, just remove the useless organ. The French approach to the body was to do as little as possible so they had a subspecialty that performed myomectomies, that is removing the fibrosis and sparing the uterus. We now know that the uterus manufacturers hormones, supports the pelvic structures, and its removal affects sexual enjoyment.

    Dr Robert Brooks at the Rand Corporation began a series of studies over 30 years ago where they went to medical records and using a strict set of criteria evaluated various therapies. They found that ca 15% of coronary bypass operations could not be justified by any criteria and another 30% were iffy. Dr Jack Wennberg at Dartmouth developed what is called small area variation studies where he found that two small cities, same size, same demographics, etc. in one just about all kids had tonsils removed by teen years whereas other only 30%. Another study found hysterectomies much higher in one community than another. In neither case could they find any medical justification, just one communities medical culture differed from others. And it wasn’t just money because the one community performing the high end on one type of operation may have been at the low end on another.

    The point of Payer’s book is that cultural aspects frame to some extent the scientific questions we ask and how we interpret them. Of course, in U.S. money also plays a role.

    American medicine does a lot of screening. In some cases it is beneficial; but not only can it lead to unnecessary tests and interventions; but can skew data. Imagine you have a condition that when discovered has prognosis of five years with best medicine. You develop a screening that detects before becomes symptomatic and now find on average patient living six years. Was the screening beneficial? Not if it detected one year prior to it would have been discovered anyway. In epidemiology this is called “lead time bias.” In fact, the screening may have been harmful. Obviously discovering a life-threatening condition would affect someone psychologically and beginning therapies that are unpleasant a year earlier. If it actually prolonged life, great; but, in many cases it doesn’t.

  43. Fahren says:

    I think that a false-positive test result is quite an under-appreciated human experience. A serious false positive can be one of the most transformative and exhilarating human experiences available in life.

    I had a powerful false positive a few years ago, a cancer scare, and it was quite a profound experience for a month or so. It was certainly on a par with any powerful artistic or religious experience I’ve ever had and I don’t regret it in the least. Like somebody says, the prospect of an immanent hanging concentrates the mind wonderfully, and I certainly looked at my life and life itself in new and useful ways on account of my false positive.

    Aren’t some kinds of art actually intended to create false positives for the audience to experience? When you walk out of a theater where you just watched a Greek tragedy, aren’t you kind of thankful that you weren’t an actual participant in the tragedy? Isn’t part of the value of the play the fact that it allows you to vicariously experience the awful consequences of being doomed, but then lets you walk out of the theater exhilarated to be alive, thrilled that you didn’t suffer the fate of the victims on the stage?

    If I were a doctor, I think I’d deliver a deliberate false-positive diagnosis every few years to each of my patients just to remind them how lucky they are to be alive.

    1. Harriet Hall says:

      “I think I’d deliver a deliberate false-positive diagnosis”

      So you would lie to all your patients just so some of them might have their mind concentrated? I’ve heard a lot of bad experiences from false positive diagnoses; you are the only person I have ever heard suggest that it was beneficial for you, much less advisable to offer to everyone else.

    2. MadisonMD says:

      If I were a doctor, I think I’d deliver a deliberate false-positive diagnosis every few years to each of my patients just to remind them how lucky they are to be alive.

      Yeah, that’s perhaps one reason why you aren’t a doctor. Now why don’t you just flip a coin to determine whether you have diabetes.

    3. KayMarie says:

      And such an approach is a crap shoot. For every person who saw a life changing diagnosis (real or false) as an opportunity to “live like they were dying” there is at least one person that will respond with depression, anxiety and those are not always benign reactions to stressful situations.

      Is there some ratio of suicides to skydiving trips taken sooner rather than later that is acceptable to you?

      How do you tell the widow that you just told the guy he had ALS just to see if he’d perk up and get some things on his bucket list done.

    4. WilliamLawrenceUtridge says:

      Dude, didn’t you see Fight Club? Such an approach leads to the downfall of civilization.

      But seriously – that’s a terrible idea. In your case it ended up being positive, over the long-term. What if someone got this “great” news and committed suicide because they watched their mom die a long, horrible death due to cancer?

      If you were a doctor and did this, you wouldn’t be a doctor for long, and with good reason. You’d be a monster on par with the Charles Cullen, playing God with patients and toying with their emotions for basically your own self-aggrandizement.

      Man, you did not think this through.

    5. R Miller says:

      “If I were a doctor, I think I’d deliver a deliberate false-positive diagnosis every few years to each of my patients just to remind them how lucky they are to be alive.”

      Do not ever become a doctor. You’re essentially wishing for the capacity to use your patients for your own personal psychological experimentation without their consent. It’s astounding you do not comprehend the problem with this.

    6. MadisonMD says:

      This stuff happens every day. I just took a phone call from a patient who had what is likely a false positive finding… but I can’t be sure yet. She will need another scan in a few months to help us determine this, and will be on pins and needles until then. She tells me she strongly requested the scan of another physician who reluctantly ordered it (at a very well known academic center, mind you) . Now that physician isn’t returning her call so it falls within my purview.

      Not a good experience for her and very unlikely to improve he health. Also, part of why the U.S. medical system spends the most healthcare $ without the best overall health outcome.

    7. mouse says:

      “If I were a doctor, I think I’d deliver a deliberate false-positive diagnosis every few years to each of my patients just to remind them how lucky they are to be alive.”

      Cool – Would you do it to me? – Because I’ve got some home renovations coming up and I could use some malpractice cash!

  44. Tex says:

    The doctors have to order the tests in order to keep their malpractice rates down, or else they will be sued by the people who weren’t smart enough to be doctors, the lawyers.

  45. Marilyn and Harriet, HDL labs is imho the finest cardiovascular biomarker testing company in the world. Like MANY Clinical Lipidologists, i use them every day to help diagnose and guide therapy for my cardiometabolic risk patients. EVERY day i identify TREATABLE residual risk in patients told by their MD’s doing standard testing “you’re fine”, and am able to implement morbidity and mortality reducing strategies based on the advanced testing. every day ! The ability to reassure patients that they will not receive ills for state of theart testing is huge. The ‘draw fee’ enables me to pay for a phlebotomist, and is no different than what i’ve seen Quest and Labcorp do in other offices. the real question here is Does a healthy 21 year old need such a comprehensive workup , and i would agree not.

    Gregory S Pokrywka MD FACP FNLA NCMP

    Prevention of Cardiovascular Disease and Women’s Menopausal Health

    Assistant Professor of General Internal Medicine
    Johns Hopkins University School of Medicine
    Diplomate American Board Clinical Lipidology and Fellow, National Lipid Assn.
    Certified Menopause Practitioner: North American Menopause Society
    Director: Baltimore Lipid Center. Board Member, South East Lipid Assn.

    1. WilliamLawrenceUtridge says:

      Dr. Pokrywka is on the commercial Interest speakers bureau for Astra Zeneca, Daichii Sankyo International, Genentech, Health Diagnostics Labs, Kowa Pharmaceuticals America, Inc., Lilly USA, LLC, and LipoScience.

      Heh, sometimes the pharma shill gambit just feels so good. I see why quacks like it so much.

      Anyway, I see 63 separate tests there, none of which really seem necessary for a 21 year old. I’m not sure where the blame lies, but enthusiasm for the ability to measure everything in the absence of symptoms seems misplaced.

      1. WilliamLawrenceUtridge says:

        Wow, you sure recommend a lot of companies on your website. And support low carb diets.

      2. MadisonMD says:

        Looks like Dr Greg also sells Ultrameal 360 and metagenics supplements. Perhaps he’d like to share the clinical evidence for these. I’m guessing Dr Greg accepts a lower level of evidence than most regulars at SBM would be comfortable with. That’s easiest to do with diagnostics and supplements where FDA oversight is low to nil. Also easier in private practice where pesky colleagues don’t ask about your clinical practice.

  46. seh says:

    I want to reiterate that the U.S. CDC does recommend universal opt-out HIV screening for all adults. The yield in a “routine physical” would of course be low, but higher than a lot of the tests on that list. And we know exactly what to do about a positive result, which is not the case for many of the tests.

    1. Windriven says:

      Anyone who is sexually active and who does not watch his or her HIV status is at minimum a fool and quite likely a danger to others.

  47. Newcoaster says:

    Wow. I’ve being doing ER and general Family Practise for 20 years, and never ordered OR HEARD OF half those tests.

    As nearly every other MD has mentioned already, healthy young men don’t need physicals (assuming ANYone does) and certainly not a panel of irrelevant and obscure tests. There is something fishy about this story, and I’m guessing the physician in question has an interest in the lab. Flabber my gaster indeed.

    I’ve inherited a group of patients from a retired colleague who only show up once a year for their “annual labs”. I look on the chart and see year after year of normal cholesterols, liver panels, renal panels, diabetes, etc etc. No sign the men have had prostate exams, or the women are getting mammograms, mind you. I try and tell them that is old school style of practice and I won’t be doing that, and they get offended, and feel they aren’t getting good health care.

  48. clodia83 says:

    I actually had a similar experience with my pre-natal labs. I freaked out after receiving a payment summary from my insurance company explaining that they had paid only $50-ish to Sunset Laboratories, and that I would be responsible for about three grand in additional charges. I brought the notice to my OB, in a blind panic. He reassured me that Sunset Labs had indicated that I was fully covered for their services. I never received a bill. It seemed to me later, upon reviewing the charges, that the lab simply gave me every possible test (at almost no cost to them, really), and then through all the billing codes at my insurance to see what would stick. They ate the rest. And why not, from the labs perspective? They only stand to gain, even if it stresses out the patient.

  49. Many (if not most) people are very low in vitamin D (unless you are out in the sun a lot, like a field laborer or life guard), so that one is a good one to check. You didn’t give the height/weight of the 21 year old– depending on his build, it might be a good idea to get his lipids once every 5 years if he hasn’t had them done before. All the others seem unnecessary, but wondering if he drinks a lot or has any sexual risk factors? Liver function tests might be useful as would HIV test (recommend universal opt-out screening). However, this being said, a good primary care provider should be able to discuss with the client what tests are recommended and why BEFORE ordering them. Also, what were his results– were they *all* normal?

  50. Heather Annis says:

    Winddriven, I have personally known 2 people who suffered permanent and irreversable memory loss after starting statins and there is also well documented proof of other horrible and very common side effects. I am a physician and I NEVER suggest that a health person start dangerous medications that can be handled with diet and exercise. The benefit should outweigh the risk which it certainly does not if you are otherwise healthy.

    1. weing says:

      “I have personally known 2 people who suffered permanent and irreversable memory loss after starting statins and there is also well documented proof of other horrible and very common side effects.”
      Has this been documented and reported? Otherwise it sounds like an urban legend. We know there are side effects. What do you consider very common? Again, documentation please.

    2. MadisonMD says:

      @HA. How do you determine there was memory loss? How do you know what caused it? Really that is a very strong assertion to make based on 2 anecdotes. Do you understand why it is difficult to determine causality? Were you taught the Hill criteria in med school?

      Nevertheless I agree that diet and exercise are preferred especially in primary prevention when NNT is high.

    3. Windriven says:

      @Heather Annis

      There are no problems with my diet or my exercise. I consume a moderate Mediterranean diet and exercise daily.

      I went on statins because I score high enough on the new AHA guidelines.

      - Are you suggesting without having seen me that you know better than my internist and the recommendations of expert cardiologists by way of the cholesterol guidelines?

      - Echoing Madison, how did you establish the causal relationship between statins and memory loss in these two individuals. How was the change in memory assessed. How were other potential causes investigated and rejected?

    4. Andrés says:

      Medical literature doesn’t seem homogeneous. We have both positive effects on intervention trials (for example this not randomized one lasting 3 months, this systematic review and meta-analysis evaluating both short and long term effects) and negative ones out of clinical practice (for example this review commenting upon 60 case reports). I think that while evidence doesn’t get clearer the prudent thing to do is to filter focusing on those not short term either clinical cases or intervention trials evaluating discontinuation/rechallenge of statins. There are several clinical cases commented on the previous review. There is some others rechallenged in this survey on a population participating in a previous statin effect study. There is at least this prospective withdrawal and rechallenge pilot study. The Statin Cognitive Safety Task Force doesn’t recommend a baseline assessment of cognition before initiating a statin drug. I don’t know why one should abide to them though. I would much prefer having that information over not having it.

    5. WilliamLawrenceUtridge says:

      Winddriven, I have personally known 2 people who suffered permanent and irreversable memory loss after starting statins and there is also well documented proof of other horrible and very common side effects. I am a physician and I NEVER suggest that a health person start dangerous medications that can be handled with diet and exercise.

      So…you are relying on personal anecdotes to over-rule the information found in the drug information provided by doctors, pharmacists and the FDA? That’s and…interesting approach.

      Also, some people’s cholesterol can’t be controlled through diet and exercise. One would hope that in the case of someone whose cholesterol can’t be controlled through diet and exercise, or someone unwilling to undertake such lifestyle changes, you would provide a prescription for statins.

  51. ernie says:

    Christ on a cracker!!

    i’m 68 and I don’t get this kind of workup,,,,,

  52. Preston Garrison says:

    For that kind of money, they could have sequenced his genome. Likely more useful than what was done.

  53. jimmy says:

    Lipidology in an otherwise NORMAL healthy 21 yo male….silly rabbit, tricks are for kids….oh by the way – what’s your VISA card number again?
    Follow the money….always follow the money

  54. Self Skeptic says:

    Here’s a fun explanation of one reason too many tests get ordered. It’s at KevinMD, by Susan Hecker, MD.
    http://www.kevinmd.com/blog/2014/07/dear-patient-5-minute-appointment-awaiting.html

    “snip

    However, if you would like to talk to me about the fact that you have lost 30 pounds these last three months, have a past history of cancer and you’re not sure if you want chemotherapy again, this should take only 10 minutes because your concern is just “weight loss.” I am not allowed to make special accommodations for your concerns; if I do, I am giving away care and contributing to the current health care crisis. I am also not to consider the fact that you traveled 60 minutes, took unpaid time off from your job, or spent half your day arranging for childcare to see me.

    Because of these schedule enhancements, I will likely rush through our time together and gloss over details. I will need to spend my time multitasking with the computer as I can only prove the quality of my care by checking boxes. Do not worry; studies have shown that physicians can’t multitask any better than anyone else and I will likely miss important details. In order to make up for that fact, I will order a bunch of unnecessary tests so I don’t miss anything.

    Yes, I could probably figure out you don’t need half of them if we spent more time together, but I am told just talking to patients is poorly compensated care and I need to be mindful of this. I will rush out of the door onto my next patient who has been waiting over 30 minutes to see me to do the same to them.

    snip”

  55. Harriet Hall says:

    I have added a followup to the article:

    Addendum: August 7, 2014

    The young man in question called the doctor’s office to complain about the charges. They referred him to the billing department. The billing department said there was nothing they could do and he should call the lab that did the tests. He called Health Diagnostic Laboratory and they told him to just forward the check for $13.09 that his insurance company had sent to him. They told him he would not be billed for the rest of the charges. I don’t know how they can do business this way, but at least he doesn’t have to pay.

    In response to a fraud alert issued by the Inspector General, Health Diagnostic Laboratory has recently dropped the “reimbursement for shipping and handling” kickback to doctor’s offices.

    This is all very reassuring, but my flabber remains gasted at the doctor ordering all those tests on a healthy young man.

    1. Nell on Wheels says:

      “…they told him to just forward the check for $13.09 that his insurance company had sent to him. They told him he would not be billed for the rest of the charges. I don’t know how they can do business this way, but at least he doesn’t have to pay.”

      Good point, but that would be in line with their stated policy stated above: “…if it turns out your insurance company does not cover a specific test, HDL, Inc. assumes all the risk.”

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