What’s the cost of peace of mind?

Everything has a cost, including every aspect of the health care system, even if you don’t directly “pay” for it such as in our system. Some things have a dollar figure, some things are priceless. But what is the cost of having peace of mind? Is there a value that can be placed on such a request?

Very often, patients come in requesting specific testing just to “find out” if they have a particular condition or diagnosis. This puts me in a difficult position: I have a duty to my patients, but I have an authority and responsibility to society, ie: the system. On one hand, I do want to ease any discomfort presented in front of me, and that includes mental anguish. However, on the other hand, sometimes these requests are frivolous and are not a necessary expenditure to the system. And if we are in a situation where we’re trying to reduce costs in order to prevent privatization, we have to start drawing the line somewhere.

There are 3 requests in particular that I often get asked, and they are presented below, in no particular order.

Can I get tested for Celiac disease

With the rise in gluten-free awareness and more product availability, there has been a substantial increase in the number of individuals (and families) exploring a gluten-free diet. New studies are coming out showing the benefits of such a dietary change, though it’s still controversial as to whether the gluten-free component is the winner, or if it’s the reduced number of carbohydrates that’s indirectly making people feel better. Nevertheless, many patients who have previously had a diagnosis of irritable bowel syndrome (IBS) or gastrointestinal symptoms, have started their own gluten-free diets and have reported improvement of their symptoms. That is when they then come in to request testing for Celiac disease.

My answer is always the same, especially when there is no family history of Celiac. “How will the result change how you eat?” Even if they get the test, and it comes back negative (meaning no evidence of Celiac disease), all who have broached this subject unanimously tell me that they’ll continue to stay on a gluten-free diet. To which I reply, why bother doing the test if you are going to continue the treatment anyway? Some people “just want to know”. Others agree with this logic, and then retract the request. In Ontario, this has been more successful, since the test for Celiac, a tissue transglutaminase (TTG) assay is an out-of-pocket expense, meaning the Ontario Health Insurance Plan (OHIP) does not pay for it. Once people are fronted with the bill to get a test, the number of second thoughts has a drastic increase.

I want to get tested for allergies

This is probably the most popular request I get. Once upon a time, when allergy testing first became available, its purpose was to find the unknown cause for someone’s first anaphylactic reaction when the culprit could not be identified. If someone was stung by a bee and their face swelled up, we had a fairly reasonable idea that this person was allergic to bees. But if someone at a restaurant ate something and had a major swollen tongue, and we could not accurately figure out what it was in the meal that caused the reaction, that’s when an allergy test was prime.

Not many people had these attacks from an unknown cause. At least not enough to make a living out of it. So allergy doctors opened up their specialty to essentially anyone, in order to make more money. Now people could go and have a panel of potential allergens put on their skin, and have a prick test performed to see if there was a reaction, which would denote an allergy. The problem is, pretty much everyone will have some sort of atopic (allergic) reaction to specific things such as pollens, moulds, and dusts.

Add that with our commercial industry pumping out so many hypoallergenic and anti-bacterial products, our bodies just aren’t building the same immunity nowadays that they did generations ago. Seasonal allergies appear to be on the rise, as do food allergies. This might be a societal change, or, it might be we’re testing for it more. Whenever someone sneezes now, it appears they want to be tested. I am now seeing people who have had a rough go during the spring and summer months, and are requesting testing for allergies. They have tried over the counter anti-histamines. They have tried nasal sprays. They just can’t bare the outdoors during these times. So I ask them: “How will the results change your day to day living?” This question is often returned with a blank stare. The only sure cure for allergies is to avoid the allergen. That would mean living in a bubble, or staying indoors with the windows sealed; obviously, this is not a practical option.

Since people are already doing symptomatic treatment, or avoiding a particular food that they feel is causing them ill, just like the Celiac example, there is no relevant need to perform a test when the treatment is already being executed. Still, people “just want to know.” Unfortunately, this also expands to their children. Same thing applies in that they are preventing their son or daughter from being exposed to whatever they think is causing them symptoms, yet they still want their child to be tested. Please trust me when I say that this test is not the most pleasant for anyone under the age of 6. It’s probably not that pleasant for anyone under the age of 12. Despite these warnings, parents are still insistent, even though they have already begun doing what they would be told if the test came back positive, and will continue to do the same even if the test is negative.

I need antibiotics

This example is a bit of a tangent, but along the same lines of having peace of mind. Viruses account for the vast majority of colds, especially this time of the year. In the past, the medical culture had been just to give antibiotics. Over time, with or without the help of these antibiotics, people got better. People became accustomed to receiving antibiotics when they had a cold. As time has gone by, we have noticed a sharp rise in the number of bacteria that are resistant to the usual antibiotics we would prescribe. These are the so-called “super bugs”. We now realize that over-prescribing of antibiotics has lead to this widespread resistance.

Nevertheless, people still present to clinics and Emergency Departments with cold symptoms, requesting, and expecting to receive antibiotics. I would estimate that over 85% of the time, if not higher, they have a viral illness, meaning antibiotics would give them nothing except the risk of diarrhea (which is a common side effect of many antibiotics).

Despite my attempts to educate them, and never mind the fact that I was the one that trained to wear the white coat, they insist that I am wrong, and they need antibiotics, because that’s how it used to happen and they would get better. I’ll admit, doctors are not 100% correct 100% of the time. I especially do not preach to be the gospel on all things medicine. But we are trained not only through schooling and textbooks, but also through experience, and as the days, weeks and years collect under our belt, the on the job training enlightens us even further. I have become more and more aware of what is a viral versus bacterial infection, even when the hallmarks of a particular bacterial infection aren’t flashing in front of me. Call it gestalt, but doctors often possess it. Confirmation comes later once a swab or culture sample has been tested by the Microbiology lab; but that is an after-the-fact piece of knowledge that helps us for future presentations and diagnoses.

Yet people still want antibiotics just to “ease their mind” that they’re getting something. This practice cannot and should not continue, or else we further risk increasing the amount of antibiotic-resistance, which will come back to haunt us when we start losing the battle against those pesky microorganisms, and set us back 70 years.

That is not to say that new infections can come in on someone already fighting something else. If the body’s immune system is being occupied by fighting a virus, a bacterial infection could easily venture its way in and take advantage of the temporary freedom. So if your symptoms change or worsen, that could indicate just that, and medical attention should be sought. But also remember that viral illness, such as flu-like colds, can often linger for up to 2 to 4 weeks unfortunately.

Every medicine has a side effect. Every treatment has a side effect. Sometimes it is that very side effect that we want when we offer the treatment (ie: Viagra). But don’t forget that some of the effects of a treatment may not always be immediately evident, and may not always directly affect just the individual. Antibiotic-resistance and frivolous spending on unnecessary tests are prime examples of effects that venture beyond instant detection. So next time you go to your doctor with the sole intention of your visit to request a specific test, first ask yourself: how will the result of the test change your management? If your answer is “it won’t”, take the time to have a second look at if you truly do need that test at all. Sometimes your doctor will agree, but sometimes they won’t. Now you know why.

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