When You Are Ordered to Write Orders

Not infrequently, when I am ordering tests for patients, they request that I “throw in” some other test. Well, if I’m doing a comprehensive metabolic panel and lipids and an Hba1c for a diabetic, I don’t mind adding a CBC even if that wasn’t part of my plan. It’s justifiable, and I can use that information. 

But what about a blood type? I don’t need to know it. I don’t have a diagnosis to justify it. I understand that the patient wants to know. I also understand that he or she doesn’t want to get their blood drawn twice. Even worse is when they ask for tests like a PSA because they don’t have an appointment with their primary and it hasn’t been checked in a year. Who’s going to get the letter from the lab saying they don’t have the appropriate diagnosis code? Me, that’s who! Who’s going to be responsible for that test if it comes back abnormal? Me, that’s who!

And then there’s the patient who wants me to order some esoteric test because they read on the internet (*shudder*) that it can explain their symptoms. I had a patient demand that I order a leptin level and a reverse T3. What for? How is that going to change the fact that you need to diet and exercise to lose weight and that you need levothyroxine for your hypothyroidism?

And possibly worst of all is the patient that calls and says her rheumatologist/dermatologist/allergist want s me to do some test (or even worse a “full hormonal panel”). They’re all licensed physicians. They can order whatever test they think is necessary (now I may regret saying that, but that’s a whole other post). But if I thought that test was necessary, wouldn’t I have already ordered it? And if I’m missing something, then I need justification as to why another test need be done.

The most recent example is a patient who called and left a message saying her rheumatologist wanted a “full hormonal panel.” I called her back and said ‘I need to talk to your rheumatologist, because I don’t know what a “full hormonal panel” is.’ She said that he (the rheumatologist) wants her thyroid worked up further because it may explain her pain. The woman has a non-toxic multinodular goiter. Her TSH is normal. There’s no other test to do. And I’ll gladly explain that if he calls, but he has yet to do so. This is the same patient who wants her thyroid removed (even though there is no medical indication at present) and her surgeon wanted me to check a PTH even though her calcium is normal. Now, can’t he do that? Can’t the rheum doc check whatever test it is he thinks is missing?

I can’t be alone here. It’s one thing to refer a patient for evaluation of a disorder, and quite another to tell you how to do it. I could understand if someone is being referred for a procedure. I mean, of course I send patients to cardiologists for stress tests, and I doubt they balk at that. But I don’t tell them to check them Chagas disease.

So what do you do when patients or their other doctors dictate what tests to do?

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