The Complete Workup: Virtue or Waste?

Last year I saw an elderly man with mild peripheral neuropathy that had not been evaluated before. He was not a diabetic. I ran some basic tests and his vitamin B-12 level was extremely low. We started him on injections and monitored his response. He needed the injection every two weeks to stay in range. He said he felt better.

Recently, he saw a very respected neurologist for something unrelated. The in-depth report stated that the patient had undergone no testing for his peripheral neuropathy and the neurologist ordered a very extensive, undoubtedly expensive, set of bloodwork, part of which was eventually denied by the man’s health insurance. All of those tests were normal, starting with the first one on his list – an RPR test for syphilis.

This illustrates what I see as a fundamental issue in the practice of medicine, not often talked about: How far do you take the workup for mild, common symptoms?

In my 42 years in medicine I have never heard of a single case of syphilis (even before I stopped testing for it) in any patient I or a colleague saw, for example. But there it is, a recommendation passed down from the days of the Wassermann test (1906) and Portnoy’s RPR (1963). The incidence in Maine (1 million people) is reported to be about 50 cases per year. How likely is my octogenarian with mildly tingly toes one of them? Especially if we already know his B-12 was extremely low?

The syphilis test probably doesn’t cost much, but it is a fair illustration of consideration of probability. That is happening in some areas where the unreliability of testing is perhaps more accepted: Cardiac tests have different accuracy depending on pretest probability. Why have we forgotten that blood tests are also fraught with sensitivity and specificity problems that make them less useful in low probability clinical scenarios?

Maybe it’s the Swede in me, but my thinking is that healthcare spending cannot be limitless and needs to match the risk of the clinical situation.

When I trained, we didn’t compete about who could come up with the greatest number of esoteric differential diagnoses. There was more emphasis of what was common and what were the most dangerous and significant pitfalls in diagnosis.

We now have the insurance companies curtailing our workups, albeit often for profit reasons. Wouldn’t it have been better if we as diagnosticians practiced more stewardship and common sense in ordering tests?

0 Responses to “The Complete Workup: Virtue or Waste?”



  1. Leave a Comment

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s




Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

Tweets

Top 25 Doctor Blogs Award

Doctor Blogs

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Mailbox

contact @ acountrydoctorwrites.com
Bookmark and Share
© A Country Doctor Writes, LLC 2008-2021 Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.

%d bloggers like this: