Unnecessary blood tests

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Seasonal
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Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 9:58 am

I had my annual physical two days ago. I told the nurse drawing blood and the doctor more than once that I only wanted tests rated A or B by the US Preventive Services Task Force. I said this because I don't want unnecessary tests (not rated A or B) and research has shown them to be either useless or have potential harms outweighing potential benefits (stress, false positives, cost). Nurse wanted to do one test rated D (harms outweigh benefits) and I said no. Doctor asked if I wanted another, I said only if it's rated A or B. He said it was. In fact it's rated C. I've now found out they are doing a number of other tests not rated A or B, although the tests are not unusual or exotic.

Also, when I made the appointment I asked what labs they use. Person said Northwell (the office is affiliated with this large network) and Quest. Only Quest is in my network. I told the nurse who took blood to use Quest, she said she'd check how to do that. I don't yet know what lab they actually used.

I'm concerned about a doctor who either doesn't listen or isn't familiar with the USPSTF ratings (or can't be bothered to check).

I'm hoping I don't have an issue with large charges either for unwanted tests or charges for out of network lab work.

I suppose one strategy is to print out a list of A & B tests and hand it to the doctor and nurse.

Any thoughts or suggestions?

I explicitly do not want medical advice.

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climber2020
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Re: Unnecessary blood tests

Post by climber2020 » Wed Oct 30, 2019 10:09 am

Go to a different doctor.

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nisiprius
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Re: Unnecessary blood tests

Post by nisiprius » Wed Oct 30, 2019 10:22 am

Medicine isn't a precise science. I don't think you gain much by trying to micromanage professionals who work for you.

I assume that a blood draw in itself has the same microscopic risk whether they draw one tube or three and do one test or fifty, so this is mostly about billing and money.

Doctors, unfortunately, can't know what is and isn't covered. Even if two people both have Green Caduceus XPFlex, every company negotiates different "feature lists" and the employees of Acme may have different coverage under Green Caduceus XPFlex than employees of Peerless.

On the one hand, you've communicated to your doctor that you lean toward conservative management. That's useful for doctors because some patients want to be sure everything is being done and others would prefer never to have anything done.

On the other hand, the doctor probably is ordering stuff that most insurers will pay for, or he would have heard complaints about it. In other words, he probably is misinterpreting your request. You say "I only want necessary tests" and he probably heard "I don't want tests that I'll need to pay for out-of-pocket."

(Yes, I get it that the more unnecessary tests you have, the higher the chances they will find "something" that sends you down a path to unnecessary treatment.)

In your situation, I'd just shrug it off and see if your insurance covers the cost. If the situation is just outside your comfort zone even if you don't need to pay anything, then I think your main recourse is to try a different doctor, not try harder to micromanage the doctors you have. Unfortunately, most doctor seeing a new patient for the first time generally want a big pack of tests done, because when it's done at their own facility everything is comfortable and familiar and the records show up just the way they expect, so changing doctors can be a recipe for "unnecessary" tests initially.
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Re: Unnecessary blood tests

Post by HomeStretch » Wed Oct 30, 2019 10:39 am

I think you did all you could with your doctor. The insurance contract charge for many routine lab tests are very low. Hopefully any tests you deemed non-essential have a low out-of-pocket cost.

Your doctor is a medical expert, talk to your him/her next time about the C/D tests. Perhaps there is a valid reason for running them on you.

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Re: Unnecessary blood tests

Post by adamthesmythe » Wed Oct 30, 2019 10:46 am

As far as I know, the only blood test that warrants a detailed discussion your doctor is the PSA test.

What test were you trying to avoid?

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Seasonal
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Re: Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 10:59 am

nisiprius wrote:
Wed Oct 30, 2019 10:22 am
Medicine isn't a precise science. I don't think you gain much by trying to micromanage professionals who work for you.
Medicine may not be a precise science, but there is research on many topics. In particular, there's the USPSTF which examines research and rates various tests.

I don't want to go into medical issues, but there are more problems with unnecessary testing than blood draw risk and costs. If you're interested, there's a lot of information on the USPSTF web page and by googling the issue. https://www.uspreventiveservicestaskforce.org/

This is not a question of insurance coverage, which I would not expect a doctor to know, this is a subject of the major research rating organization of the US government. I'm concerned about a doctor who is either not familiar with current research or who purports to be familiar, is not and but pretends.

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Re: Unnecessary blood tests

Post by SevenBridgesRoad » Wed Oct 30, 2019 10:59 am

Seasonal wrote:
Wed Oct 30, 2019 9:58 am
I had my annual physical two days ago...t I only wanted tests rated A or B by the US Preventive Services Task Force. I said this because I don't want unnecessary tests (not rated A or B)...

...I suppose one strategy is to print out a list of A & B tests and hand it to the doctor and nurse...
Why then, if you are trying for only A and B level evidence, have an annual physical exam at all? USPSTF says:

"Comprehensive routine physical examinations are not recommended for the asymptomatic adult, although many patients and physicians continue to endorse the practice."

https://www.ncbi.nlm.nih.gov/books/NBK82767/ Go to Table 1, which is pretty interesting. Follow the reference link at the bottom for the quote above.

A lot of my colleagues scoff at the USPSTF altogether, but if you are going to be internally consistent, the annual physical is not evidence-based.
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Doom&Gloom
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Re: Unnecessary blood tests

Post by Doom&Gloom » Wed Oct 30, 2019 11:02 am

climber2020 wrote:
Wed Oct 30, 2019 10:09 am
Go to a different doctor.
+1

Easier to change doctors than it is to change your doctor.

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Seasonal
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Re: Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 11:02 am

HomeStretch wrote:
Wed Oct 30, 2019 10:39 am
I think you did all you could with your doctor. The insurance contract charge for many routine lab tests are very low. Hopefully any tests you deemed non-essential have a low out-of-pocket cost.

Your doctor is a medical expert, talk to your him/her next time about the C/D tests. Perhaps there is a valid reason for running them on you.
If there is a valid reason I would have hoped to hear them. I have no problem with a doctor who has a good reason for not following the guidelines.

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Re: Unnecessary blood tests

Post by Big Dog » Wed Oct 30, 2019 11:04 am

SevenBridgesRoad wrote:
Wed Oct 30, 2019 10:59 am
Seasonal wrote:
Wed Oct 30, 2019 9:58 am
I had my annual physical two days ago...t I only wanted tests rated A or B by the US Preventive Services Task Force. I said this because I don't want unnecessary tests (not rated A or B)...

...I suppose one strategy is to print out a list of A & B tests and hand it to the doctor and nurse...
Why then, if you are trying for only A and B level evidence, have an annual physical exam at all? .....
Bingo. In the large scheme of things, annual physicals are a (collective) waste. (Learned that long ago earning two Public Health degrees.)

btw: just out of curiosity, what C and D tests did they run?

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Seasonal
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Re: Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 11:09 am

SevenBridgesRoad wrote:
Wed Oct 30, 2019 10:59 am
Seasonal wrote:
Wed Oct 30, 2019 9:58 am
I had my annual physical two days ago...t I only wanted tests rated A or B by the US Preventive Services Task Force. I said this because I don't want unnecessary tests (not rated A or B)...

...I suppose one strategy is to print out a list of A & B tests and hand it to the doctor and nurse...
Why then, if you are trying for only A and B level evidence, have an annual physical exam at all? USPSTF says:

"Comprehensive routine physical examinations are not recommended for the asymptomatic adult, although many patients and physicians continue to endorse the practice."

https://www.ncbi.nlm.nih.gov/books/NBK82767/ Go to Table 1, which is pretty interesting. Follow the reference link at the bottom for the quote above.

A lot of my colleagues scoff at the USPSTF altogether, but if you are going to be internally consistent, the annual physical is not evidence-based.
The last time I had a physical (with a different doctor) I was borderline cholesterol level to get statins and that doctor recommended retesting. Said doctor is no longer available.

I'd have been happier with a doctor scoffing at USPSTF, with some rationale, then what I got.

Do you agree that a doctor should be familiar with USPSTF or, if not, say so when a patient mentions the issue?

I had thought the recommendation was against a "comprehensive" exam for an asymptomatic adult, but that an exam limited to A&B was recommended. I'll read the link.

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Re: Unnecessary blood tests

Post by UpperNwGuy » Wed Oct 30, 2019 11:13 am

Why do you use the services of this physician if you prefer a different approach to medical care?

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Re: Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 11:14 am

Big Dog wrote:
Wed Oct 30, 2019 11:04 am
SevenBridgesRoad wrote:
Wed Oct 30, 2019 10:59 am
Seasonal wrote:
Wed Oct 30, 2019 9:58 am
I had my annual physical two days ago...t I only wanted tests rated A or B by the US Preventive Services Task Force. I said this because I don't want unnecessary tests (not rated A or B)...

...I suppose one strategy is to print out a list of A & B tests and hand it to the doctor and nurse...
Why then, if you are trying for only A and B level evidence, have an annual physical exam at all? .....
Bingo. In the large scheme of things, annual physicals are a (collective) waste. (Learned that long ago earning two Public Health degrees.)

btw: just out of curiosity, what C and D tests did they run?
They are running or wanted to run PSA, thyroid, comprehensive metabolic panel, urinalysis, complete blood count and ECG. He did ask if I wanted a PSA, but no discussion of risks and benefits- I said only if it's A or B, it's C. I don't believe any of these are A or B, but might be wrong. I'm asymptomatic and did not raise any health issues.

As I mentioned, let's avoid a discussion of medical issues which are prohibited by the forum rules.

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Seasonal
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Re: Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 11:14 am

UpperNwGuy wrote:
Wed Oct 30, 2019 11:13 am
Why do you use the services of this physician if you prefer a different approach to medical care?
It's the first time I've seen him. How should I have investigated his approach?

Big Dog
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Re: Unnecessary blood tests

Post by Big Dog » Wed Oct 30, 2019 11:16 am

Personally, I'd want to know what the doc was looking for when running ALL lab tests. What do the C and D tests test for? Instead of telling the doc how to practice, ask why this test is being ordered?

fwiw: I used to go to one primary care doc that was all over the US Preventive list, but he was an MD-MPH, so was schooled in the finer points of cost-effective medicine. But again, in running a lab test, what does the doc suspect? And what will an abnormal test indicate?


In other words, instead of schooling your doc, let your doc educate you. (I did this once with my wife's onc, and he finally said, 'hmm, you are right'.)

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Re: Unnecessary blood tests

Post by jambadoc » Wed Oct 30, 2019 11:17 am

Moderators, if this message is deemed inappropriate, please delete it. I tried to be very careful with my wording to avoid political arguments or specific medical advice only making an actionable to this situation.

To be honest, I had not heard about these guidelines. I'm not in a primary or preventative specialty, but out of curiosity I looked through them. The vast majority of the A/B recommendation s seem to deal with pregnancy, gynecologic issues, newborns, or high-risk behavior. The only blood screening test that I could find on a healthy individual would be a screening blood glucose.

Caveat emptor, and this is not meant as medical advice. To be fair, I don't think this approach is unreasonable. However, in our current society, as a physician, I would be very concerned about not doing any further testing than that. At the very least, I would be writing all over the chart that you are offered multiple further evaluations which you declined and appear to have capacity to make medical decisions. Screening tests do show problems often before they become clinically significant. Waiting for symptoms to occur can lead to bad outcomes. Physicians are essentially held at a 0% miss rate by what is considered "standard of care." Deviation from the standard of care put one at higher medical legal risk. While guidelines like this are trying to change the standard of care, I would argue that only a screening glucose is not currently the standard of care in medicine.

As a general statement, when guidelines are written, consider the person who is writing them and the agenda behind writing them. I am against unnecessary testing. However, if the purpose of the guidelines is to decrease testing to lower healthcare costs, that will also decrease the sensitivity meaning that things that would have otherwise been diagnosed earlier are no longer diagnosed. Bureaucrats have an army of number crunchers who define an acceptable risk/cost-benefit analysis. Unfortunately, if you or your family member is on the wrong side of that cost benefit analysis, you have no recourse.

Finally, I would find a doctor that you trust and discuss your concerns with them. They should likely be able to tell you why they are screening for something and why it would be of benefit to you. I would not take kindly to someone trying to define the exact tests I was going to order without a very good reason for it. A lot of the above most talked about finding a new doctor, but in this situation I might be tempted to find a new patient.

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Re: Unnecessary blood tests

Post by RickBoglehead » Wed Oct 30, 2019 11:19 am

Our prior insurance provider codes tests different than our current, which moved tests from the "preventative" category to the "diagnostic" category. Preventative is covered 100%, diagnostic is applied to the deductible.

When this first happened, we complained loudly, and ultimately got them to cover the tests ONCE. Now, each time we go for our physicals, we tell that that only one test is covered, so if it's not medically necessary we don't want the others. Both physicians have adjusted those other tests to every 2 or 3 years.
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Re: Unnecessary blood tests

Post by VictoriaF » Wed Oct 30, 2019 11:21 am

Seasonal wrote:
Wed Oct 30, 2019 10:59 am
If you're interested, there's a lot of information on the USPSTF web page and by googling the issue. https://www.uspreventiveservicestaskforce.org/

This is not a question of insurance coverage, which I would not expect a doctor to know, this is a subject of the major research rating organization of the US government. I'm concerned about a doctor who is either not familiar with current research or who purports to be familiar, is not and but pretends.
The first thing I noticed was that the USPSTF is .ORG, not .GOV. It does not discredit the USPSTF but means that it's less authoritative than, for example, the National Institutes of Health (NIH), https://www.nih.gov/.

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Re: Unnecessary blood tests

Post by adamthesmythe » Wed Oct 30, 2019 11:23 am

My MD always did a "panel" with a bunch of different tests, perhaps a dozen or so. The cost was pretty low, I suspect because it was a standard set, perhaps done by a single machine.

I suppose they could have deleted some of the results from the report, but I suspect it would have cost extra.

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Re: Unnecessary blood tests

Post by Good Listener » Wed Oct 30, 2019 11:31 am

As a former practicing internist and sub specialist, if a patient requested that for an annual physical that I should not obtain a CBC and metabolic profile, I would suggest that if there is no emergency at that visit, that he/she get another doctor and this visit is at no charge. The patient is telling me how to practice and likely will be a management issue should anything arise later. PSA is one thing to discuss, as others have said.

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Re: Unnecessary blood tests

Post by SevenBridgesRoad » Wed Oct 30, 2019 11:38 am

VictoriaF wrote:
Wed Oct 30, 2019 11:21 am

The first thing I noticed was that the USPSTF is .ORG, not .GOV. It does not discredit the USPSTF but means that it's less authoritative than, for example, the National Institutes of Health (NIH), https://www.nih.gov/.

Victoria
https://prevention.nih.gov/about-odp/pa ... aborations

NIH lists USPSTF as a partnership. I think NIH looks to the USPSTF to provide evidence reviews and evidence grading.
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Re: Unnecessary blood tests

Post by Broken Man 1999 » Wed Oct 30, 2019 11:48 am

Eh, I have always thought so long as my doctors weren't practicing technical engineering stuff, I wouldn't practice medicine stuff.

I kinda do the same thing with electricians, plumbers, A/C techs, roofers......

I'm all in with my doctors. If ever I am not all in with one, they will not be my doctor. I am curious by nature, so if facing something new, I will read up on it, and if there is something in particular I don't understand (at a very high level, certainly not into the nitty-gritty), I will ask my doctors. I ask not to question their diagnose, or treatment plan, just to satisfy my curiosity.

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Re: Unnecessary blood tests

Post by fru-gal » Wed Oct 30, 2019 12:01 pm

Seasonal wrote:
Wed Oct 30, 2019 11:14 am
They are running or wanted to run PSA, thyroid, comprehensive metabolic panel, urinalysis, complete blood count and ECG.
As an older person, I'm happy to have all these tests run (except the PSA since I'm female.) Three people in my cohort have had thyroid problems, for example. An EKG can catch silent problems.

If I were 20-30 I'd probably have a different opinion.

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Re: Unnecessary blood tests

Post by coffeeblack » Wed Oct 30, 2019 12:08 pm

Seasonal wrote:
Wed Oct 30, 2019 10:59 am
nisiprius wrote:
Wed Oct 30, 2019 10:22 am
Medicine isn't a precise science. I don't think you gain much by trying to micromanage professionals who work for you.
Medicine may not be a precise science, but there is research on many topics. In particular, there's the USPSTF which examines research and rates various tests.

I don't want to go into medical issues, but there are more problems with unnecessary testing than blood draw risk and costs. If you're interested, there's a lot of information on the USPSTF web page and by googling the issue. https://www.uspreventiveservicestaskforce.org/

This is not a question of insurance coverage, which I would not expect a doctor to know, this is a subject of the major research rating organization of the US government. I'm concerned about a doctor who is either not familiar with current research or who purports to be familiar, is not and but pretends.
Research is great and very important in medicine. Evidence based medicine is also great. We as doctor try very hard to follow that. Except that we also follow our experience and knowledge about medicine. First the USPSTF is not the only organization that has guidelines. And they are only guidelines. 2nd, I think you need to understand that it is actually you who is not the expert in medicine. Dr. google is not a substitute for your medical doctors years of training and expertise. That doesn't mean doctors never make mistakes it just means the odds of them making mistakes about medicine are far less than your odds of micromanaging your doctor and making less mistakes as a result of it. You said several times you are concerned about a doctor who is not familiar with current research or who pretends etc. You should know that medical research changes are rapid and it takes years to come to conclusions on treatments based on research. You should also know that much of the guidelines in medicine are expert consensus. That means the collective experience of many doctors plus what some current research guidelines suggests.

I doubt your doctor has the time to sit you down and explain all of that to you. And I don't think he should need to. I think if you don't trust a doctor you should find another one. Based on your behavior you most likely won't trust any doctor unless they do exactly as you say. That would not be good medicine. Part of a doctors job is to save the patient from themselves.

So I doubt your doctor is pretending about anything. He/she is has devoted their entire life to learning and practicing medicine.

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Re: Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 12:48 pm

coffeeblack wrote:
Wed Oct 30, 2019 12:08 pm
So I doubt your doctor is pretending about anything. He/she is has devoted their entire life to learning and practicing medicine .
That's fine. I would think it's reasonable for a doctor to respond to "I'd like to stick to USPSTF A&B recommendations" with either (1) yes, and then do so or (2) I don't agree with those recommendations. If he says he doesn't agree, then he can give as much or as little rationale as he thinks is appropriate.

I also think it's reasonable for a doctor to say that she's devoted her entire life to learning and practicing medicine and if you, the patient, don't trust me or want to question my recommendations, then you should seek another doctor.

I don't think it's reasonable for a doctor to agree to stick to the USPSTF recommendations and then not do so or to say that a test is an A or B when that test is not in fact an A or B.

I'm curious if you disagree with this.

I'm more than happy to have doctors save me from myself. I'd just like to know they're doing so. I have recently being dealing with a lot of doctors on behalf of relatives with very serious health issues. I almost always push them on their recommendations and they have all been happy to explain their positions, sometimes only very briefly. Some have changed in response to my questions. I almost always point out that I don't posses any medical knowledge beyond research and always get the response that it's good to ask questions to make sure I'm comfortable.

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Re: Unnecessary blood tests

Post by downshiftme » Wed Oct 30, 2019 12:59 pm

As an older person, I'm happy to have all these tests run (except the PSA since I'm female.) Three people in my cohort have had thyroid problems, for example. An EKG can catch silent problems.
I think this illustrates (again) that people have different viewpoints and approaches to life, even medical. While the original poster is trying to avoid unnecessary tests, I am always trying to work with my doctor to perform more blood tests. I may have to deal with the aftermath of a potential false positive, but I also welcome having additional data and the possible screening for problems that aren't yet presenting symptoms but could do so if no action is taken. Speaking only for myself, I'd rather have more data for many reasons, including the possible future in which a problem is discovered and we have baseline historic data that helps with understanding it.

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Re: Unnecessary blood tests

Post by coffeeblack » Wed Oct 30, 2019 1:04 pm

Seasonal wrote:
Wed Oct 30, 2019 12:48 pm
coffeeblack wrote:
Wed Oct 30, 2019 12:08 pm
So I doubt your doctor is pretending about anything. He/she is has devoted their entire life to learning and practicing medicine .
That's fine. I would think it's reasonable for a doctor to respond to "I'd like to stick to USPSTF A&B recommendations" with either (1) yes, and then do so or (2) I don't agree with those recommendations. If he says he doesn't agree, then he can give as much or as little rationale as he thinks is appropriate.

I also think it's reasonable for a doctor to say that she's devoted her entire life to learning and practicing medicine and if you, the patient, don't trust me or want to question my recommendations, then you should seek another doctor.

I don't think it's reasonable for a doctor to agree to stick to the USPSTF recommendations and then not do so or to say that a test is an A or B when that test is not in fact an A or B.

I'm curious if you disagree with this.

I'm more than happy to have doctors save me from myself. I'd just like to know they're doing so. I have recently being dealing with a lot of doctors on behalf of relatives with very serious health issues. I almost always push them on their recommendations and they have all been happy to explain their positions, sometimes only very briefly. Some have changed in response to my questions. I almost always point out that I don't posses any medical knowledge beyond research and always get the response that it's good to ask questions to make sure I'm comfortable.
Since the doctor is not here to defend him/herself, I won't comment. This is your side. We don't know the doctors side. What we do know is you like to micromanage so much that you had to get on bogleheads and run it by everyone else.

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Re: Unnecessary blood tests

Post by SevenBridgesRoad » Wed Oct 30, 2019 1:05 pm

Seasonal wrote:
Wed Oct 30, 2019 12:48 pm

...I'm curious if you disagree with this...
I don't think you are asking anything unreasonable. But you will need to find a doc who is a better fit for you.

Medical practice is very difficult and I’m not trying to be disrespectful of my colleagues. I know it is hard. It is almost impossible to keep up, especially these days. But too many of us rely too much on "in my experience..." My most brilliant attending when I was in training always challenged us by asking, "What is your evidence?" He would do this for almost any claim we would make. It made us aware that there is very little hard evidence for much of medical care. First do no harm got hammered into us daily.

I have to think that any physician who doesn’t want to listen to patients and their preferences, and their thoughts/concerns on what they’ve read and understand, is missing an opportunity to perhaps learn something. Dogma is maybe the greatest killer of all time.

For those interested, the subject of translating research into standard of care is fascinating (at least to me). The time lag appears to be 17 years.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241518/
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Re: Unnecessary blood tests

Post by dm200 » Wed Oct 30, 2019 1:34 pm

First, I fully agree that (in my non-medical opinion) many tests (blood and other) are either unnecessary or, on balance, harmful.

In my case, with my Medicare plan - blood tests are no charge to me - so there is no personal financial impact.

I actually do note to my PCP when the test(s) she might order have already been done recently by another specialist physician.

In my case, as well, because of specific (to me) reasons and conditions diagnosed, I need to have several blood tests done - that are generally not recommended for everyone. It seems to me, though, that just about any Physician should be able to "justify" all blood tests ordered.

Opinions change back and forth about certain tests - one I have encountered is PSA! First, for me, a few years ago: "No, PSA is a weak test." Then, I was told I "needed" the test for a while. Then, I was told I didn't need it. Now, last year (2018), I was told that it is now recommended. :oops: :oops: :confused :confused

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Re: Unnecessary blood tests

Post by fposte » Wed Oct 30, 2019 1:41 pm

SevenBridgesRoad wrote:
Wed Oct 30, 2019 11:38 am
VictoriaF wrote:
Wed Oct 30, 2019 11:21 am

The first thing I noticed was that the USPSTF is .ORG, not .GOV. It does not discredit the USPSTF but means that it's less authoritative than, for example, the National Institutes of Health (NIH), https://www.nih.gov/.

Victoria
https://prevention.nih.gov/about-odp/pa ... aborations

NIH lists USPSTF as a partnership. I think NIH looks to the USPSTF to provide evidence reviews and evidence grading.
And USPSTF is funded and staffed by the HHS. I don't think it's any less governmental than the NIH; they just went a different way with the domain hierarchy.

coffeeblack
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Re: Unnecessary blood tests

Post by coffeeblack » Wed Oct 30, 2019 2:55 pm

SevenBridgesRoad wrote:
Wed Oct 30, 2019 1:05 pm
Seasonal wrote:
Wed Oct 30, 2019 12:48 pm

...I'm curious if you disagree with this...
I don't think you are asking anything unreasonable. But you will need to find a doc who is a better fit for you.

Medical practice is very difficult and I’m not trying to be disrespectful of my colleagues. I know it is hard. It is almost impossible to keep up, especially these days. But too many of us rely too much on "in my experience..." My most brilliant attending when I was in training always challenged us by asking, "What is your evidence?" He would do this for almost any claim we would make. It made us aware that there is very little hard evidence for much of medical care. First do no harm got hammered into us daily.

I have to think that any physician who doesn’t want to listen to patients and their preferences, and their thoughts/concerns on what they’ve read and understand, is missing an opportunity to perhaps learn something. Dogma is maybe the greatest killer of all time.

For those interested, the subject of translating research into standard of care is fascinating (at least to me). The time lag appears to be 17 years.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241518/
Good points.

So the thing to remember is if it takes 17 years for something to become standard of care, and during that time new research may negate some of that standard of care, it would be even more important to use "in my experience".

The brilliant attending was right to make you think about your decision making process. But evidence isn't always up to date evidence. I'm not even sure if there really is such a thing.

You have to go with what you know today and use experience as your best guide.

rich126
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Re: Unnecessary blood tests

Post by rich126 » Wed Oct 30, 2019 3:05 pm

I had a problem where i had to go to a urology center several times and every time I went they wanted a urine sample. Seemed a bit strange to me, especially since my issue could only be tracked via a blood sample which they didn't do at that facility. One time I was there (it was one of those large places with a number of doctors, maybe 5 or more) an older guy came in, signed in and then when asked for a urine sample went on a loud rant about how it is unnecessary and how the facility is only using it to charge medicare/insurance money.

After I thought about it, I kind of think he was correct.

Fortunately I didn't have to return and the doctor I was seeing actually left that practice and moved a bit further north in the city. Sometimes you do have to speak up regarding items. I usually don't say too much but since I'm treated by a cardiologist and get year echos and some other tests, I make sure that my annual physical doesn't duplicate those tests.

(Personally I dread those testing labs since I've had some horrible poor people drawing my blood, everywhere else I haven't had an issue.)

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patrick013
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Re: Unnecessary blood tests

Post by patrick013 » Wed Oct 30, 2019 3:20 pm

Someone told me once that a blood test can reveal 84 things.

Now they want 85 things because some bus drivers feel relaxed using CBD.

I give up. :)
age in bonds, buy-and-hold, 10 year business cycle

Kennedy
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Re: Unnecessary blood tests

Post by Kennedy » Wed Oct 30, 2019 3:33 pm

rich126 wrote:
Wed Oct 30, 2019 3:05 pm
I had a problem where i had to go to a urology center several times and every time I went they wanted a urine sample. Seemed a bit strange to me, especially since my issue could only be tracked via a blood sample which they didn't do at that facility. One time I was there (it was one of those large places with a number of doctors, maybe 5 or more) an older guy came in, signed in and then when asked for a urine sample went on a loud rant about how it is unnecessary and how the facility is only using it to charge medicare/insurance money.

After I thought about it, I kind of think he was correct.

Fortunately I didn't have to return and the doctor I was seeing actually left that practice and moved a bit further north in the city. Sometimes you do have to speak up regarding items. I usually don't say too much but since I'm treated by a cardiologist and get year echos and some other tests, I make sure that my annual physical doesn't duplicate those tests.

(Personally I dread those testing labs since I've had some horrible poor people drawing my blood, everywhere else I haven't had an issue.)
I have had that same experience with a urologist. No matter what you go in for, you are always asked for a urine sample after you check in.

I assume this is to save time on the back end. After all, many patients are there for symptoms that necessitate a urinalysis. It's a lot more efficient for the doctor to have the urine sample result (if run in the office) in her hand while she is talking to the patient rather than to talk to the patient, order the urinalysis, wait for the result and then go back in to talk with the patient.

Therefore, the front desk will often have a standing order to get a urinalysis for everyone.

It's similar to an urgent care I use. If I go in for a sore throat, triage will swab my throat for strep so the result is ready when the doctor enters the room. The same is true if I go in for a twisted ankle. The staff will take an xray so it will be done before the doctor sees me. It's all for efficiency, which I appreciate.

In your case, if you don't want (or think you need) the urinalysis, tell the front desk staff that you want to see the doctor first. They will most likely be happy to oblige.

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Re: Unnecessary blood tests

Post by Grasshopper » Wed Oct 30, 2019 3:38 pm

Concerning unnecessary urine tests at the urologist, I checked my last MSN from my last visit and my doctor actually looked at my urine specimen with a microscope, did a test strip and was paid $3.52. All to make sure that an infection wasn't the cause of my condition. If there was a ripoff I think my doctor was the victim.

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Re: Unnecessary blood tests

Post by Teague » Wed Oct 30, 2019 3:39 pm

Medicine may not be a precise science, but there is research on many topics. In particular, there's the USPSTF which examines research and rates various tests.
Yes, but they do so on a broad population basis. Let's not give them too much credit. They try, but humans are anything but homogeneous. The best choice for you may not be the best choice for the population as a whole.

Also be aware that the USPSTF does not necessarily include experts in the fields they study. For example, when they came out with their rather anti-PSA recommendation some years ago, there were no urologists on the USPSTF. Urologists were up in arms at their recommendation, as they have to deal with the patients with intractable bone met. pain.
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treadingwater
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Re: Unnecessary blood tests

Post by treadingwater » Wed Oct 30, 2019 4:08 pm

I have seen large differences in costs at different facilities. It is worth getting a cpt code and calling around to find lowest price ( I have a high deductable and saved $1100 on an ultrasound)

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StormShadow
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Re: Unnecessary blood tests

Post by StormShadow » Wed Oct 30, 2019 4:09 pm

Seasonal wrote:
Wed Oct 30, 2019 9:58 am
I'm concerned about a doctor who either doesn't listen or isn't familiar with the USPSTF ratings (or can't be bothered to check).

I'm hoping I don't have an issue with large charges either for unwanted tests or charges for out of network lab work.

I suppose one strategy is to print out a list of A & B tests and hand it to the doctor and nurse.

Any thoughts or suggestions?

I explicitly do not want medical advice.
I've never heard of the USPSTF ratings. If it means that much to you, I'd have a conversation with the doctor about why they recommend a test be checked.

Personally, I have near complete trust in the recommendations of my healthcare providers. In the (rare) event I question something, I simply ask why and/or seek out a second opinion. I try not to make a big deal about it, and I've not known a physician to take offense to it.

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6miths
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Re: Unnecessary blood tests

Post by 6miths » Wed Oct 30, 2019 4:29 pm

Teague wrote:
Wed Oct 30, 2019 3:39 pm
Medicine may not be a precise science, but there is research on many topics. In particular, there's the USPSTF which examines research and rates various tests.
Yes, but they do so on a broad population basis. Let's not give them too much credit. They try, but humans are anything but homogeneous. The best choice for you may not be the best choice for the population as a whole.

Also be aware that the USPSTF does not necessarily include experts in the fields they study. For example, when they came out with their rather anti-PSA recommendation some years ago, there were no urologists on the USPSTF. Urologists were up in arms at their recommendation, as they have to deal with the patients with intractable bone met. pain.
There are several good reasons not to have 'experts' on the panel evaluating the evidence, it is much better to have experts on evaluating evidence on the panel. Clinician experts are much more likely to have serious bias in one direction or another compared to evidence experts. For clinician experts the direction of bias is more likely going to be favorable to their pocketbook. Upton Sinclair and all that. I agree with the sentiment that one would be very anxious about an MD who was not knowledgeable about the USPSTF and its recommendations or receptive to a patient who is interested in them. It seems that Medicine in the US is big business and as often as not, business considerations trump patient and individual considerations.
'It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so!' Mark Twain

Teague
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Re: Unnecessary blood tests

Post by Teague » Wed Oct 30, 2019 4:42 pm

6miths wrote:
Wed Oct 30, 2019 4:29 pm
Teague wrote:
Wed Oct 30, 2019 3:39 pm
Medicine may not be a precise science, but there is research on many topics. In particular, there's the USPSTF which examines research and rates various tests.
Yes, but they do so on a broad population basis. Let's not give them too much credit. They try, but humans are anything but homogeneous. The best choice for you may not be the best choice for the population as a whole.

Also be aware that the USPSTF does not necessarily include experts in the fields they study. For example, when they came out with their rather anti-PSA recommendation some years ago, there were no urologists on the USPSTF. Urologists were up in arms at their recommendation, as they have to deal with the patients with intractable bone met. pain.
There are several good reasons not to have 'experts' on the panel evaluating the evidence, it is much better to have experts on evaluating evidence on the panel. Clinician experts are much more likely to have serious bias in one direction or another compared to evidence experts. For clinician experts the direction of bias is more likely going to be favorable to their pocketbook. Upton Sinclair and all that. I agree with the sentiment that one would be very anxious about an MD who was not knowledgeable about the USPSTF and its recommendations or receptive to a patient who is interested in them. It seems that Medicine in the US is big business and as often as not, business considerations trump patient and individual considerations.
Well, that's the idea, and the ideal, to have dispassionate objective analysis, but it doesn't always work out that way. For example, a urologist on that initial panel could have pointed out that the two studies upon which USPSTF based their initial PSA testing recommendation had serious flaws. This is one reason the USPSTF later changed their recommendation on that subject. The task force simply didn't know what they didn't know. And we are still left with the problem that a population-wide recommendation is a crude tool for individual care.
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6miths
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Re: Unnecessary blood tests

Post by 6miths » Wed Oct 30, 2019 4:58 pm

Teague wrote:
Wed Oct 30, 2019 4:42 pm
6miths wrote:
Wed Oct 30, 2019 4:29 pm
Teague wrote:
Wed Oct 30, 2019 3:39 pm
Medicine may not be a precise science, but there is research on many topics. In particular, there's the USPSTF which examines research and rates various tests.
Yes, but they do so on a broad population basis. Let's not give them too much credit. They try, but humans are anything but homogeneous. The best choice for you may not be the best choice for the population as a whole.

Also be aware that the USPSTF does not necessarily include experts in the fields they study. For example, when they came out with their rather anti-PSA recommendation some years ago, there were no urologists on the USPSTF. Urologists were up in arms at their recommendation, as they have to deal with the patients with intractable bone met. pain.
There are several good reasons not to have 'experts' on the panel evaluating the evidence, it is much better to have experts on evaluating evidence on the panel. Clinician experts are much more likely to have serious bias in one direction or another compared to evidence experts. For clinician experts the direction of bias is more likely going to be favorable to their pocketbook. Upton Sinclair and all that. I agree with the sentiment that one would be very anxious about an MD who was not knowledgeable about the USPSTF and its recommendations or receptive to a patient who is interested in them. It seems that Medicine in the US is big business and as often as not, business considerations trump patient and individual considerations.
Well, that's the idea, and the ideal, to have dispassionate objective analysis, but it doesn't always work out that way. For example, a urologist on that initial panel could have pointed out that the two studies upon which USPSTF based their initial PSA testing recommendation had serious flaws. This is one reason the USPSTF later changed their recommendation on that subject. The task force simply didn't know what they didn't know. And we are still left with the problem that a population-wide recommendation is a crude tool for individual care.
Yes a urologist could have point out studies that they felt were relevant and important, and almost certainly many did, and there would then be analysis as to what studies should be included in a systematic review to reach a conclusion. Until quite recently, and in most cases still, most 'expert' bodies are still composed of 'clinical experts'. To suggest that the USPSTF (or their British, European or Canadian equivalents) were in some way ill informed is not really credible. Urologist (and some patients) may have been upset about the initial recommendation but people who know things about evidence and the power of lobby groups (and some patients) were certainly upset about the change in the recommendation given that many felt that there was no substantive change in the evidence available. Many tests that are done have absolutely nothing to do with practicing good medicine. Patients are unwise not to be skeptical and try to keep themselves as informed as possible.
'It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so!' Mark Twain

sergio
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Re: Unnecessary blood tests

Post by sergio » Wed Oct 30, 2019 5:00 pm

Good Listener wrote:
Wed Oct 30, 2019 11:31 am
As a former practicing internist and sub specialist, if a patient requested that for an annual physical that I should not obtain a CBC and metabolic profile, I would suggest that if there is no emergency at that visit, that he/she get another doctor and this visit is at no charge. The patient is telling me how to practice and likely will be a management issue should anything arise later. PSA is one thing to discuss, as others have said.
On a somewhat related question - if a patient asks the doctor to do extra tests beyond what is suggested, would that be offensive to physicians? Like if someone says "Hey Doc since I'm already here, any chance you could throw in a few more tests that you think are useful? I'll pay even if insurance doesn't cover them..." Is this out of line for a patient?

J295
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Re: Unnecessary blood tests

Post by J295 » Wed Oct 30, 2019 5:21 pm

Change doctors.

chessknt
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Re: Unnecessary blood tests

Post by chessknt » Wed Oct 30, 2019 5:33 pm

sergio wrote:
Wed Oct 30, 2019 5:00 pm
Good Listener wrote:
Wed Oct 30, 2019 11:31 am
As a former practicing internist and sub specialist, if a patient requested that for an annual physical that I should not obtain a CBC and metabolic profile, I would suggest that if there is no emergency at that visit, that he/she get another doctor and this visit is at no charge. The patient is telling me how to practice and likely will be a management issue should anything arise later. PSA is one thing to discuss, as others have said.
On a somewhat related question - if a patient asks the doctor to do extra tests beyond what is suggested, would that be offensive to physicians? Like if someone says "Hey Doc since I'm already here, any chance you could throw in a few more tests that you think are useful? I'll pay even if insurance doesn't cover them..." Is this out of line for a patient?
No that is far more common. Pcps have 10-25 minutes to spend in the room including the exam. Having to explain to the misinformed op about the difference between evidence level and recommendation strength, the population based nature of usptf, the relative paucity of quality evidence in medicine, and the difference between guidelines and recommendations is an enormous waste of time since it contributes nothing to their medical care in the event they actually have an issue that is concerning.

It would be like if I went to a lawyer for a lease agreement review, paid a flat fee, and wanted him/her to explain the complexities of specific case laws on the definition of a domicile and the different legal operators in each sentence and rewrite the entire agreement to make sure it confirmed with my layman understanding of the law (or explain to me why I was wrong).

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ram
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Re: Unnecessary blood tests

Post by ram » Wed Oct 30, 2019 5:46 pm

If I was practicing in sub saharan Africa I would have no problem restricting to only the tests approved by USPSTF.
Most doctors in US will order more tests than prescribed by USPSTF.
Many patients in US will have no problem suing a the doctor if the doctor misses a diagnosis which would have required a test beyond what is required by USPSTF.
A few years ago task force advised that mammograms are most cost effective at age >50. The US population did not like this recommendation. This has resulted in a relatively ambiguous recommendation in this regard.
https://www.uspreventiveservicestaskfor ... screening1

In an ideal world the doctor would discuss the benefits and disadvantages of each test. The average physician does not have time to do this. There is usually enough time to discuss if a patient has questions about one or 2 tests. Physicians who have more patients than they need will prefer to avoid a patient who wants to micromanage each visit.
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Seasonal
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Re: Unnecessary blood tests

Post by Seasonal » Wed Oct 30, 2019 6:12 pm

chessknt wrote:
Wed Oct 30, 2019 5:33 pm
It would be like if I went to a lawyer for a lease agreement review, paid a flat fee, and wanted him/her to explain the complexities of specific case laws on the definition of a domicile and the different legal operators in each sentence and rewrite the entire agreement to make sure it confirmed with my layman understanding of the law (or explain to me why I was wrong).
A better analogy would be going to a lawyer, asking the lawyer to include some provision in a lease, having the lawyer agree, then finding the the delivered lease did not include the agreed provision.

I'd expect the lawyer in your scenario to tell the client that the request is unreasonable given the flat fee. Expecting a full explanation would be unreasonable, as would not delivering the requested and agreed provision.

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SevenBridgesRoad
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Re: Unnecessary blood tests

Post by SevenBridgesRoad » Wed Oct 30, 2019 6:19 pm

Re blood tests, I'll give a very current (today) example of the problem faced of translating knowledge into daily practice. And it doesn't involve USPSTF.

Today's e-edition of JAMA includes the results of a clinical trial evaluating a condition known as subclinical hypothyroidism. The results of the randomized trial showed no benefit in the treatment group over the placebo group. This is a diagnosis based substantially on a lab test. The accompanying editorial in JAMA (written by an endocrinologist at U Penn) says, "This study provides information that should change clinical practice."

Translational research says info may take 17 years to change clinical practice. Why? Many factors.

About 5,000 medical articles are published each day. It’s very difficult to keep up even in one's field. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191655/

Even if a doc read JAMA today, the results fly in the face of "in my experience" for physicians in practice. Many doctors will say, that's not what my years of experience have shown me. "In my experience" of course contains all the elements of bias we often discuss here in our financial/behavioral economic world.

And, many patients come to us wanting this test. They want a clinical reason for their fatigue and know someone who got better.

The endocrinologist editorialist notes that the normal limits for the thyroid test should be changed in older folks. How long does it take to change the abnormal line in a common lab test? I don't have that data, but I'll bet it takes a very long time.

What can it hurt you might say? Well, besides labeling someone with a disease they don't have and prescribing a medicine that doesn't benefit them (placebo gave the same results), the author points out almost half a billion dollars a year (2017 data) are spent by Medicare on this test. 122 million Medicare prescriptions were written for thyroid medication in 2017.

Moving from "in my experience" to practicing by knowledge (when we have the evidence available) is a big deal.

The OP is on solid ground. But the challenges facing physicians are real and translating new knowledge into practice has many barriers.
Retired 2018 age 61 | "Not using an alarm is one of the great glories of my life." Robert Greene

Teague
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Re: Unnecessary blood tests

Post by Teague » Wed Oct 30, 2019 6:32 pm

6miths wrote:
Wed Oct 30, 2019 4:58 pm
To suggest that the USPSTF (or their British, European or Canadian equivalents) were in some way ill informed is not really credible.

There was tremendous cross-contamination between the control and experimental groups in the main study the USPSTF evaluated, enough to render the results nearly meaningless. Many in the urological community understood this.

Urologist (and some patients) may have been upset about the initial recommendation but people who know things about evidence and the power of lobby groups (and some patients) were certainly upset about the change in the recommendation given that many felt that there was no substantive change in the evidence available.

No doubt special interest medical groups exist. That does not imply that they are nefarious or solely self-interested in their intent.

Many tests that are done have absolutely nothing to do with practicing good medicine. Patients are unwise not to be skeptical and try to keep themselves as informed as possible.

Agreed
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chessknt
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Re: Unnecessary blood tests

Post by chessknt » Wed Oct 30, 2019 6:37 pm

Seasonal wrote:
Wed Oct 30, 2019 6:12 pm
chessknt wrote:
Wed Oct 30, 2019 5:33 pm
It would be like if I went to a lawyer for a lease agreement review, paid a flat fee, and wanted him/her to explain the complexities of specific case laws on the definition of a domicile and the different legal operators in each sentence and rewrite the entire agreement to make sure it confirmed with my layman understanding of the law (or explain to me why I was wrong).
A better analogy would be going to a lawyer, asking the lawyer to include some provision in a lease, having the lawyer agree, then finding the the delivered lease did not include the agreed provision.

I'd expect the lawyer in your scenario to tell the client that the request is unreasonable given the flat fee. Expecting a full explanation would be unreasonable, as would not delivering the requested and agreed provision.
Was your visit an annual physical or a specific visit to discuss how the usptf grading system works and applies to tests that may be ordered for you? The doctor is paid a flat fee and having to explain why a c recommendation is not a contraindication to a test or how the recommendation doesn't apply in your case is eating in to somebody else's visit time for free assuming anything else happened during the visit.

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AAA
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Re: Unnecessary blood tests

Post by AAA » Wed Oct 30, 2019 7:16 pm

Without comment/recommendation/endorsement, I offer the following as a potentially interesting read relevant to this discussion:

Barbara Ehrenreich: Why I’m Giving Up on Preventive Care:
https://www.yesmagazine.org/happiness/b ... e-20180529

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