Chapter 21. How to communicate need for further tests or referral for second opinion?

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

If you can’t measure it, you can’t manage it -Peter Drucker / If world thinks you are not good enough, you know it’s a lie but get a second opinion

                                                                                                            Nick Vujicic

Provisional diagnosis a must before ordering tests

Laboratory tests are specific to a disease and there are no “routine” tests. Thus, it is imperative that doctor thinks of provisional diagnosis based on analysis of detailed history and focused physical examination before considering specific laboratory tests to support bed-side diagnosis. It is likely that doctor may consider 2 or 3 probabilities and may like to exclude them all together at one time or by priority. Doctor should never consider all possibilities as there could be many. Of course, tests without any provisional diagnosis is irrational as test results have to be correlated with clinical diagnosis. No test result offers diagnosis and most laboratory reports end up with a statement “correlate clinically”. It is ironical that laboratory person reminds a doctor to depend on clinical judgment for correct interpretation.

Not all diseases need confirmation by tests

Disease that is clinically evident and easy to monitor progress does not need any confirmative tests. Acute tonsillitis is a classic example. However, when a disease is not evident clinically such as urinary tract infection or when progress of disease is difficult to monitor as in case of meningitis, specific tests such as urine culture and CSF respectively are a must before starting treatment. Also  due to increasing drug resistance in diseases such as malaria, tuberculosis and typhoid, they must be confirmed before starting treatment.

Counselling a patient before ordering tests

After arriving at a probable clinical diagnosis, it is ideal to explain the patient why you feel the need for confirmation. It is important to preempt likely test results and how they would guide you further in proper management. Test results often mention insignificant abnormalities noted in a given test that may not be relevant as such findings may be seen in normal persons. For example, abdominal USG often reports small lymphnodes that are of no consequence but for patients it is an abnormality. In such expected situations, it is ideal to inform patients ahead of test results their insignificant relevance. It allays fears and doubts rather than defending results after they are received. Patients don’t understand variation of test numbers nor its relevance. This commonly happens in CBC when patient is worried about numbers that don’t tally with norms mentioned on test reports. This is more so when tests are done in infants or neonates in whom normal numbers are different than those of older children or adults and most laboratories have

But when patient does not get well as expected –

printed norms for adults and age-related norms are not mentioned. So when you order tests, inform patients why they are asked for and what could it mean if results are positive or negative. Such a discussion prior to getting test results is important. Unfortunately, most doctors depend on test results for their opinion as they have no clinicaldiagnosis. Don’t forget test results are not reliable for final diagnosis without clinical correlation..

When first set of tests provide no clue

It is ideal to discuss interpretation of positive as well as negative test results and possible plan thereafter, right when you ask for first set of tests. It ensures that patient is not surprised and upset to know tests have not offered any clueto diagnosis.  If first set of tests fail to diagnose the disease, obvious plan after negative test results would be to order second set of tests or consider second opinion. At this stage, you must discuss pros and cons of both the alternatives. I feel at this point, first choice should be second opinion. This is because second opinion invariably would end up with asking for more tests. However, if you order second set of tests without second opinion and if they also fail to diagnose the disease, second opinion will be followed by another set of tests. Drawing blood repeatedly is hated by patients and so also ordering more tests periodically. This is because it conveys to patients that doctor has no clue and he is searching for diagnosis without any specific direction. Besides, expenses mount up and all this may lead to dissatisfaction and even argument or allegation. It is best avoidable with second opinion that you must suggest at right time.

Personal notes

I prefer to discuss every aspect of the disease with the parents to an extent that my medical assistants wonder whether I take a post-graduate teaching session with the parents. I also subtly inform them that outcome of treatment also depends on how patient is able to respond and follow it with what I would do in case of failure of treatment. If this is followed, parents don’t question the need for some more tests or second opinion because they are preempted. Over years I have become more aware that I am liable to make mistakes and parents should be subtly warned about such a possibility. Though as I become senior, parents disbelieve that I could be wrong. Well, it is a bonus to seniority but I never depend on it.

Take home message

Communication and counselling are key factors in treating a patient. Relevant information about the tests being ordered and need of carrying out these tests must be conveyed to patients and so also possibility of positive and negative test results. This is the way patients must be involved in disease management that in turn leads to faith and mutual trust between doctor and patient. Once this relation is established, I am sure patients would be ready to follow advice thereafter, be it additional tests or second opinion.

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