Nobody likes receiving bad news, especially if it’s delivered by a doctor, and the fear of finding out leads many people to avoid seeking medical help. There’s no doubt that in many cases early detection of disease can lead to better outcomes. So, in the search for the holy grail of preventative healthcare, how do we simultaneously avoid providing too much medicine, and stop the spectre of overdiagnosis, scaring patients away from the doctor?
Overdiagnosis can be defined as “when the diagnosis is correct according to current standards of diagnosis but where the patient does not benefit from that diagnosis,” in other words, the patient is better off not knowing.
Pathology’s role in this debate is unique. Despite being the medical discipline performing diagnostic tests (and other tests), pathology labs are not responsible for ordering tests, and unless the circumstances are exceptional, pathology labs do not discuss results with patients directly.
If the pathology profession is simply responding to the needs of doctors (and their patients), is this really pathology’s problem?
A review of the evidence suggests that although there is over-testing in some areas, there is far more under-testing going on. Published in the Public Library of Science, (PLoS) 1 in 2013, The Landscape of Inappropriate Laboratory Testing: A 15-Year MetaAnalysis showed that on average, the rate of pathology overuse was 20.6% but pathology underuse was 44.8%.
In the study, underutilization of pathology refers to tests indicated but not ordered. This means where a doctor would have grounds to order a test – for example based on symptoms or family history – but chooses not to request the test for that patient.
The research suggested that earlier use of pathology testing during medical investigations could lead to better care.
Although we can clearly improve on overuse of pathology, we need to be very careful that we don’t view every negative or normal result as an over-test.
Normal results are powerful for patient peace of mind, and they help doctors in their differential diagnosis process – ruling out the first round of possibilities before other avenues are explored – including more expensive, time-consuming or invasive procedures.
Pathology is pivotal in preventative healthcare – for example, detecting a high glycated haemoglobin (HbA1c) result could trigger someone to make lifestyle changes that improve their health and help them stave off Type II diabetes.
This is where education and communication can be better utilised to create the balance we need.
When ordering tests, General Practitioners assess what is appropriate given a patient’s symptoms, medical history, age and other factors affecting disease risk. However, it’s important that patients understand this process – what the tests are, why they are being recommended and that testing is optional, patients can choose not to be tested or to delay testing if they wish.
In addition to the five questions that NPS MedicineWise recommends a patient ask their doctor before having any test or procedure, we could add one more: what will the results tell me?
In addition to knowing why a doctor is recommending the test, a patient should understand what the results might tell them. For example, will the result be delivered as a diagnostic positive/ negative? Will it show an increased risk to be managed for the future?
There are many different types of pathology test – some will detect a disease, some will show levels of chemicals such as hormones, proteins, antigens in the blood, some results will identify genes linked to disease. All of these results have different meanings and implications for treatment or other next steps. This information could inform a patient’s decision about whether to have the test and make receiving the results easier as they will know what to expect.
To support clinicians in their communication with patients, pathologists and medical scientists spend significant time in conversation with treating doctors, helping them make sense of pathology results and slotting them into the bigger medical puzzle.
As well as being part of the medical puzzle for individuals, pathology is an important public health tool.
The National Notifiable Diseases Surveillance System relies on pathology testing to confirm a number of diseases that have public health implications. This allows health authorities to track outbreaks of communicable diseases, food or water borne illnesses and to monitor epidemics and seasonal variations.
Without laboratory confirmation accurate tracking of these diseases would be impossible, leaving health authorities in the dark and potentially placing people in danger unnecessarily.
Discouraging doctors from doing ‘too much testing’ or giving reluctant patients further reason to avoid the doctor’s office could have consequences beyond the individual. On the flipside, promoting health literacy across the population enables people to make better decisions about their health and can improve patient-doctor interactions.
Some trusted sources of information that can help clinicians educate their patients about pathology include the Know Pathology Know Healthcare initiative, we partner with Lab Tests Online for in depth information about individual tests for consumers.
Patient education should be a shared responsibility across the health professions, as well as for patients themselves, but the power of the informed patient to create a healthier nation should not be underestimated.