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One physician’s story: An Egregious Example of Ordering Unnecessary Tests

Harriet Hall writes on the Science-Based Medicine website about a 21-year old man seeing a board-certified family physician for a routine physical.  Excerpt:

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. …

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.

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.

At last check, well more than 100 comments were left on the website in response to the article.

I frequently write about the poor public dialogue about screening, overdiagnosis and overtreatment.  This example brings home the point about why that’s important.

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