How to communicate need for further tests or referral for second opinion: Dr. YK Amdekar
M3 India Newsdesk Aug 19, 2019
Dr. YK Amdekar writes that communication and counselling are key factors in treating a patient. Relevant information about the tests being ordered and need of carrying out these tests must be conveyed to patients and so also possibility of positive and negative test results.
This is the way patients must be involved in disease management that in turn leads to faith and mutual trust between doctor and patient. Once this relationship is established, patients would be ready to follow advice thereafter, be it further tests or second opinion.
Provisional diagnosis a must before ordering tests
Laboratory tests are specific to a disease and there are no 'routine' tests. Thus, it is imperative that a doctor thinks of provisional diagnosis based on analysis of detailed history and focused physical examination before considering specific laboratory tests to support bed-side diagnosis. It is likely that doctor may consider 2 or 3 probabilities and may like to exclude them all together or by priority.
A doctor should never consider all possibilities as there could be many. Of course, tests without any provisional diagnosis is irrational as test results have to be correlated with clinical diagnosis. No test result offers diagnosis and most laboratory reports end up with a statement 'correlate clinically'. It is ironical that the laboratory person reminds a doctor to depend on clinical profile of a disease.
Not all diseases need confirmation by tests
Disease that is clinically evident and easy to monitor progress does not need any confirmative tests. Acute tonsillitis is a classic example. However when a disease is not evident clinically such as urinary tract infection or when progress of disease is difficult to monitor as in case of meningitis, specific tests such as urine culture and CSF respectively are a must before starting treatment. Also increasing drug resistance in diseases such as malaria, tuberculosis and typhoid must be confirmed before starting treatment.
Counselling a patient before ordering tests
After arriving at probable clinical diagnosis, it is ideal to explain the patient why you feel the need for confirmation. It is important to preempt likely test results and how they would guide you further in proper management. Test results often mention insignificant abnormalities noted in a given test that may not be relevant as such findings may be seen in normal persons. For example, abdominal USG often reports small lymphnodes that are of no consequence but for patients it is an abnormality. In such expected situations, it is ideal to inform patients ahead of test results their insignificant relevance. It allays fears and doubts rather than defending results after they are reported. Patients don’t understand variation of test numbers nor its relevance. This commonly happens in CBC when patient is worried about numbers that don’t tally with norms mentioned on test reports. This is more so when tests are done in infants or neonates in whom normal numbers are different than those of older children or adults and most laboratories have printed norms for adults and not age related norms. So when you order tests, inform patients why they are asked for and what could it mean if results are positive or negative. Such a discussion prior to getting test results is important. Unfortunately most doctors depend on test results for their opinion as they have no clinical diagnosis. Don’t forget test results are not reliable for final diagnosis without clinical correlation.
When first set of tests provide no clue
It is ideal to discuss interpretation of positive as well as negative test results and possible plan thereafter, right when you ask for first set of tests. It ensures that patient is not surprised and upset to know tests have not offered any clue to diagnosis. If first set of tests fail to diagnose the disease, obvious plan after negative test results would be to order second set of tests or consider second opinion. At this stage, you must discuss pros and cons of both the alternatives. I feel at this point, first choice should be second opinion. This is because second opinion invariably would end up with next set of tests. However if you order second set of tests without second opinion and if they also fail to diagnose the disease, second opinion will be followed by another set of tests. Drawing blood repeatedly is hated by patients and so also ordering more tests periodically. This is because it conveys to patients that doctor has no clue and he is searching for diagnosis without any specific direction. Besides expenses mount up and all this may lead to dissatisfaction and even argument or allegation. It is best avoidable with second opinion that you must suggest at right time.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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