In part one of our review of medical tests you may not actually need, I shared the reasons why there seems to be a cycle of over-testing in this country, starting with the media’s overpowering influence (referring mostly to TV and internet) on people to push for expensive tests and costly drugs when it comes to their health. This in turn pressures doctors into ordering unnecessary exams in order to please patients who rate them on Yelp and other non-quality measuring surveys. Patients are really “customers” in our current healthcare system, just like any other business. This shoots healthcare costs through the roof.
At the heart of this issue we should be asking: should healthcare be a business? Is it ethical for it to be so? As things stand, the lines are blurred and our state of healthcare continues to suffer for it. It's a slippery slope. Should financial decisions be influencing the practice of medicine? How can it not—if it affects patient decisions, then how can it not affect your care? Should your doctor be distracted by financial factors and their desire to please the patient, or should they practice medicine using their expertise and training without external influences? I’ll leave these questions for us to ponder for now.
But let’s pick up where we left off. In our first segment on medical tests you don't actually need, we dissected the reasons we typically don’t need some commonly ordered tests (but may think we do)—including Vitamin D levels, shoulder/knee MRIs, hormone levels, and blood typing. Today, let’s review the next set of four.
5. Testosterone Level
For those of you who listen to my podcast or read my articles, you knew this one was coming, right? I’ve dedicated an entire podcast to this one. The “low T” rage has taken up a storm in the last decade or so, thanks to the fortune-hungry pharmaceutical companies that have largely driven this fad. Men in their 20s seek “Dr.Google” for a cure for their depression and fatigue, while middle-aged men yearn for more robust stamina or some fountain of youth. “Low T” seems to be the answer to it all.
First of all, similar to the Vitamin D controversy, experts don’t agree on what is considered a “normal” level. That makes it tough for doctors to determine the appropriate target levels when treating the patient. Next, symptoms like depression, fatigue, and low libido are all complex medical issues that are often multifactorial—meaning that they are influenced and caused by multiple factors. Low testosterone alone is unlikely to be the sole cause, if at all. Also, studies on testosterone are mixed and inconclusive. That’s right, currently we don’t have a lot of evidence to back up the efficacy of testosterone treatment. A placebo, however, is a powerful drug that's well-established in the scientific community. Now I’m not saying it’s all a placebo effect, by no means. We simply need more solid answers before jumping on this “low T” bandwagon.
Testosterone treatment is also not risk-free. According to research studies, it can cause infertility, worsen sleep apnea, potentially feed a hidden prostate cancer or enlarge a prostate, cause blood clots, or possibly even increase the risks of cardiovascular disease (heart attack and stroke).
As with everything, we must weigh pros/cons before making decisions for each patient when it comes to controversial tests like testosterone levels.
6. Routine EKGs
Speaking of heart disease, it's the number one killer of men and women in the U.S. There was a time when routine electrocardiograms (EKGs) were run during physical exams (and I believe the military still performs them if I am not mistaken) in order to help identify those with potential risks of cardiovascular disease. And by “routine,” I mean performed as a preventative test for asymptomatic people, not for those with chest pain, heart palpitations, or symptoms of potential cardiac issues. That’s a whole different ball game.
But not any longer. The U.S. Preventive Services Task Force (USPSTF), one of the primary expert groups that set guidelines for practicing doctors, concludes that based on current evidence the harm of routine EKGs on asymptomatic low risk patients outweighs the benefits, and therefore recommends against it. The USPSTF also states that there is currently not enough evidence to recommend it in asymptomatic but intermediate risk people.
Why would a simple EKG harm anyone, you might be thinking? The test itself is harmless—you simply lie on a table while electrodes that are placed on your chest take a reading of your cardiac activity printed on a piece of paper. However, it’s the “downstream” effects of the test that may lead to more harm than good (when compared to not having it performed in the first place). For instance, if there’s a “blip” on a routine EKG, it doesn’t mean you have heart disease or that this “blip” will ever pose any health consequences for you in the future. But now that it’s there, it’s not easy to ignore.
And an EKG is not typically diagnostic, it’s simply a tool used to determine if more studies may be needed. Therefore, a simple “blip” may lead to more invasive procedures, like an angiography which carry potentially serious risks such as bleeding, radiation exposure, and kidney damage. And not to mention any harm from the side effects of medications prescribed as a result of these “blips,” such as with statins or aspirin.
Meanwhile, if the EKG findings were never discovered in the first place, it may never have caused any health consequences. Conversely, just because an EKG is normal, it doesn’t mean heart disease doesn’t exist.
This is a prime example of how the harms and benefits of all tests in medicine should really be considered prior to execution.
7. Allergy Titers
Suffer from hay fever? Sneezing, itchy/watery eyes, runny nose, postnasal drip, or perhaps an annoying seasonal cough? Yes, many of us do. Or perhaps you're experiencing a mild rash on your arms that your doctor said may be allergic months ago?
Mild allergies are common. Many of us simply live with it, and may never require treatment. For others with more bothersome symptoms that actually interfere with quality of life, however, treatment may be worthwhile. Do you need allergy testing in order to get treatment? The truth is, no matter what environmental allergen is causing your symptoms, for most people the treatment is essentially the same—intranasal steroid for cough/postnasal drip and/or antihistamines for the itchy, watery eyes, runny nose, and sneezing. For less responsive symptoms to the standard treatment, other prescription pills are also available.
Blood allergy testing is not exactly high-yield. The blood titers measure the amount of antibodies, or proteins, that your immune system produces in response to a perceived “foreign invader.” And unless you’ve had enough exposure to that foreign invader within the recent past (how much exposure, we don’t really know), your levels can be normal even though you may indeed still be allergic to pollen, for example.
And if it does show elevated antibody levels to pollen, pollen may not be what’s actually causing you to sneeze all day long. The panel doesn’t test for every environmental allergen in the world—it can’t. So even though the panel often tests the most common allergens, your particular allergy may be triggered by something entirely different.
So what will you do with the final, often non-revealing results? Whether it reveals an allergy to pollen or grass, we are going to attack it using the same treatment in the end anyway.
Same goes for food allergy panels, by the way.
Allergy panels do have a potential role on occasion, however—yet mostly in those with more severe allergies, or in those potentially life-threatening cases of angioedema (lip swelling, throat swelling) or history of anaphylaxis. In these instances, the blood titers can make a huge difference in how we manage it—the avoidance of that one allergen will be paramount in preventing future life-threatening events, short of living in a bubble.
Cost of these “allergy panels”? Hundreds, possibly more.
What may be more useful than a non-diagnostic, potentially confusing blood test in those with mild/moderate allergies who require more investigation is perhaps skin testing performed by an allergist. But always ask yourself this question: “Will taking that extra step to see the allergist or obtain that extra testing actually change my outcome or the treatment I choose?”
8. Vaccine Titers
This is not an infrequent request from my patients. New employers often request “proof” of vaccines. And some adults no longer have proof of their childhood immunizations. But your employer wants proof that you’ve had that MMR or Varicella vaccine before they hire you and expose you to other employees.
The blood titers will test the antibodies to these infections, proof that your immune system can mount that response if exposed. But simply obtaining the vaccine, whether you’ve had it before or not, is more efficient (not to mention much, much less costly) than drawing your blood to test for these protein particles. And what often occurs is that the blood test will reveal non-immunity, and the patient will have to come back for that vaccine in the end anyway.
All after receiving a costly bill for hundreds of dollars (sometimes more) that insurance companies will often ultimately deny coverage of. They are not obligated to cover anything that is mandated for job-related activity and as I’ve mentioned, antibody testing is not cheap.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.
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