Medical Tests

Sit down. Here’s some tissues. Here’s a cup of tea. Here’s a nurse. I’ve got some bad news for you. The NHS needs to get more expensive. Well, perhaps I should qualify that: clinical intervention within the NHS needs to get more expensive. You can probably more than make up the shortfall by cutting down on the ever-expanding cohort of managers whose numbers swell with every innovation so that it can be “properly monitored”, but that is another article. And you’re the customer, so I should explain why.

When you go to see your doctor, what is the first thing that happens? Stop and think for a moment… Do you immediately get a needle thrust into your arm for a blood test? Are your body cavities assaulted by a gloved hand? Do you even get a stethoscope on your chest? Hopefully not. Not straightaway, at least. The first thing that happens is that the doctor speaks to you. Even, in fact, if you are unconscious the first thing most medics are trained to do is to shake you by the shoulders and ask, “Are you alright?” It is an adage of medical education that, even with all the medical gadgetry at the disposal of the profession, 80% of the information that leads a doctor to make a diagnosis comes from the story you tell him. I believe this. Every week I see someone who has a pain in the chest, and they are worried that the pain is coming from their heart. Usually, just from their description of the pain, I can reassure them that some other cause is at the root of it. I may not be able to tell exactly what the source is so easily, of course, but the way your heart is wired into your nervous system produces a type of pain which is, well, just different to most other pains.

On many of these occasions this explanation is enough. Sometimes, however, a patient needs more than this. Most patients are aware of the electrocardiogram (ECG, or, for fans of American medical dramas, EKG); this is a reading of the electrical activity of your heart, and in its most basic form produces an A4 sheet with 12 slightly different wiggly lines on it. The various ways in which the lines wiggle can give your doctor very useful information about the condition of your heart. Interpreting ECG’s can seem rather like an art than a science. Students struggle with them, and they are taught the secrets of unlocking the information as a sorcerer’s apprentice might be taught to read the future in a crystal ball – that is, with great difficulty and through a fog of ignorance which is particularly keen not to clear. And in many cases, the similarity to crystal balls does not end there. Occasionally, when confronted with a patient with chest pain which is clearly not cardiac in origin, the initial explanation just doesn’t seem enough. Even though your doctor has known the pain is not arising from your heart from your second sentence, your worried eyes cast a glance at him just as your bottom lip curls into your teeth to be chewed. You’re wondering if it is impolite to ask, “Are you sure, Doctor?” when the doctor, ever keen to stay one intellectual step ahead of you (we are really a bunch of intellectual snobs who have to create a sense of superiority by translating your symptoms into Latin and pretending that’s a diagnosis) notices your disquiet and jumps in with, “But to be absolutely certain,” (for which read, “To show you I am never wrong”), “we’ll do an ECG”. Your face relaxes, and, as it does so, mine does too. I know I’ve won at this point, but the show is not over.

You see, now I can attach ten wires to your chest and limbs and, while we both watch, the wiggly lines draw themselves. It is like watching a seismograph in an earthquake. On older machines you could even see the little pen twitching away as your body’s activity was drawn magically into the paper. At this point, you are usually examining my face to see any signs of worry. I, on the other hand, am remaining strictly poker faced – the effect of the test relies on you thinking I am taking it seriously and, if I’m honest, I’m not sure how I would deal with an abnormality I wasn’t expecting; I can’t let you see that there might be one.

Then comes the examination: each of the twelve lines is examined thoroughly. The rate and rhythm of your heart are assessed. The morphology of the QRS complex is compared in the limb leads to the chest leads, and the corrected QT interval is calculated. This is where the sorcery is in medicine. Remember, I have known this ECG will be normal since long before I ever fired the machine up. But my experience wasn’t enough to reassure you, so this test must become the fortune teller. This test has to be seen to have the weight your reassurance deserves. And so I peer into it, as if waiting for the fog to clear, and gradually it does. I can see normality arising from the fog. I let a calm smile start to break out across my face and as you cross my palm with silver, I pronounce your heart healthy.

So what does that tell us? Well, several things, actually. Firstly that I actually do value your concerns and I’m willing to do things that maybe aren’t strictly necessary in a hard-nosed clinical sense to answer them. Secondly, and perhaps less wholesomely, I recognise that making my job look difficult makes you value me and my colleagues more. If you knew with the same level of confidence as me, that pointing to the pain with your finger (rather than using the flat of your hand) means it is not your heart, you would never have needed to come to see me in the first place. The mystique surrounding diagnosis has, since the very earliest days of medicine, been an important part of the diagnostic process. You need to believe I am very knowledgeable to trust me. I can increase that sense by making the knowledge look harder to grasp than it actually is. But by doing that, I have disempowered you from taking responsibility for your healthcare in areas where it is actually quite simple, and increased your subconscious reliance on the investigation process, while decreasing your opinion of my ability to work without tests being done.

So how does that mean it’s going to cost more? Well, for many years there has been great pride within the profession about what we call “clinical skills” – the ability to work effectively using as few tools as possible beyond the history of the problem and examining you. It’s quite right that we should improve these skills. There are times, particularly in General Practice, when access to investigations is very limited. Being able to continue to practise medicine in these situations has the same sense of satisfaction as Ray Mears gets by living in the jungle with as few tools as possible, and can be just as useful. The problem is that the sense of collective pride in clinical judgement has led to a situation in which it is considered very poor form to order a test and have the result come back as normal. The difficulty is amplified by the resource issue in the NHS; the rising pressure on radiology departments, for example (although the problem is not limited to radiology departments) has meant that there are increasingly strict guidelines forbidding such-and-such a test unless a particular set of circumstances exist. But I think we have gone a bit far.

Someone I know has recently developed a problem with their eye. One of the muscles that control the eye movements has stopped working. She sees double when looking in a particular direction, which is annoying. What is worrying is that she, being medical, knows that a sudden change in the function of one her nerves may mean she has a malignant tumour. The probability is low. Very low, in fact. But, let’s face it, when malignancy is a possibility the probability doesn’t have to be that high before you want reassurance, does it? So she did a bit of research and, based on her prior knowledge and Google, she thought that the likelihood was that she had had it for ages, but never noticed. “It’s an acquired Brown’s syndrome,” she told me. “When are you being scanned?” I asked.

Well, the answer that she had got from the ophthalmologists was that she had an acquired Brown’s syndrome and there is a very low probability of malignancy and there’s no need to scan unless you’re worried. Please, just humour me and read that last sentence again. Then compare it to what she already knew before she went in. Spot the difference? No, neither could I.

The bit which felt very uncomfortable was the “if you’re worried”. Now surely there is either malignancy there or not. It cannot be the case that malignancy is there if she’s worried and not if she’s not. And what about the other diagnoses it could be that are rare, but need intervention. It seemed to me, as I heard the story, that this was a case of relying on clinical skills too much and avoiding investigation in case the result was normal, and demerits were added to the clinician’s mental score for themselves. But then I thought, “What is the difference between this scan being done ‘if you’re worried’ and my ECG being done for the patient who is not reassured by my knowledge?” Well, the difference is this: the ECG was being done after the diagnosis of “Nothing serious”. The MRI was being declined while there was still a small possibility of serious disease. (In fact it was not being declined, but had been presented in a way that made the patient feel she was fussing over nothing if she asked for it – I’m not sure which is worse).

As clinicians, we need to be very careful about ordering tests. They are expensive. They are invasive. They are usually not without risk. They increase patients’ reliance on investigation, and decrease their trust in the doctor’s own skills. But, despite all this, sometimes they are necessary even though they’re not. Necessary for reassurance; necessary when the doctor-patient relationship needs a bit of illusion to make it work well; necessary, even, because the test would be expected by a lawyer if the notes were ever examined in court. It is fine to do tests in these circumstances, but they don’t need doing every time. On the other hand, there are some tests which seem unnecessary because the probability of finding something sinister is low. But these tests are always necessary; the illusion here is that it is alright to leave a few people to get advanced disease to save the many from… well, from what? In the case of MRI, not even from a small dose of radiation. The only thing being saved is the humiliation generated by received medical wisdom that a test which comes back normal is a wasted test. It is another example of the ways in which medicine is infused with institutional arrogance, and there is much more to write on that subject…