Pressed to test: How should GPs respond?

My naturopath says I have adrenal fatigue and that I need my cortisol checked. He could send me but that would cost me money. I’m also thinking of taking bioidentical hormones, so I’d like this list of tests done since I am going to the lab anyway.”

“My chiropractor says I should get X-rays of my back before she treats me just in case there is a problem. She could send me for X-rays but I would have to pay. She also wants me to bring the X-rays to her for interpretation.”

“My massage therapist says I should get a cervical MRI because he has been treating my sore neck for a few months without much success.”

“My barista at Starbucks thinks I should get a PET scan as I can’t tolerate my three shots of espresso like I used to.”

I often have trouble knowing what to do when these requests come my way. Many of the patients asking for these tests are reasonable, likable people whom I have taken care of for years. They don’t really understand the different training that naturopaths, chiropractors, massage therapists, and physicians receive. Some of them have an incomplete understanding of science and certainly don’t waste time thinking about evidence-based medicine. All they know is that they have a problem for which they have seen a licensed health care practioner who is recommending further tests. They have been told that these tests will be covered by their medical plan if ordered by a physician.

Should I launch into a discussion of adrenal fatigue or bioidentical hormone replacement and the lack of scientific evidence backing up this diagnosis or treatment? Is a discourse on the appropriateness of diagnostic imaging in the presence of benign musculoskeletal neck or back pain in order? These patients are genuinely worried about their health and potential serious pathology in part due to the advice given to them by their allied health care practioner. 

Often the only thing that will allay their fears is obtaining the requested tests, but this adds an unnecessary cost to the already financially burdened health care system. I am pretty sure that the Medical Services Plan would like physicians to give a blanket “no” to all such requests. The College of Physicians and Surgeons would probably advise, “First, do no harm.”

There definitely is an art to medicine and subsequently there are many different ways to handle these situations—one is not necessarily better or more correct than another. The reality is that these requests aren’t going to go away and each of us has to search our conscience and practise patterns to deal with them. I’m not sure a blanket “yes” is appropriate, nor is an outright “no.” Personally, I try to weigh the appropriateness of the test against the potential harm or benefit, while explaining my concerns or misgivings to the patient. 

I am curious how many of you would order the cortisol or hormone levels? Would some of you grudgingly request lumbar radiographs or a cervical MRI? 

I’m pretty sure all of you, like me, would fill out the PET scan requisition because someone who creates such delicious coffee can’t be wrong.
—DRR

David R. Richardson, MD. Pressed to test: How should GPs respond?. BCMJ, Vol. 55, No. 7, September, 2013, Page(s) 312 - Editorials.



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