Ford’s government recently proposed a series of cuts to what is covered by OHIP in the provincial budget. As justification for him depriving the population of Ontario of adequate healthcare, in particular those who happen to be poor, on social assistance including disability, or underage, were the claims that a significant portion of tests are unnecessary. He went on to claim that less than 4% of family doctors are responsible for ordering over 40% said tests, in a demonstration of how statistics and a lack of understanding can be used to obfuscate the truth.
Let’s start with the latter claim. While it may seem strange that such a small percentage of family doctors may be responsible for so many tests, it’s less surprising to those of us who deal with chronic illnesses.
Not All Family Doctors
As my own experiences with Crohn’s Disease have taught me, not all family doctors are equal. Many of them may be fine for the average person who will mostly likely only struggle with routine illnesses, but are unprepared for how to deal with more complicated or rarer disorders. This can be expressed in a variety of ways ranging from a direct referral to another family doctor with more experience (rarer reaction), or a complete dismissal of the symptoms or running nothing more than a blood test, then not looking further.
It’s not unusual for many family doctors to decide to leave all the tests related to these conditions to specialists or to not even know what tests to run when faced with them. Not only is this true of family doctors, but also of doctors in the ER. This can create very real problems for the patient themselves, however, since specialists are often significantly overbooked and unable to respond to emergency situations or manage some of the more mundane aspects of chronic illnesses. One of the purposes of a family doctor is exactly to act as a sort of shepherd of a patients different conditions, being the one person who gets to see the complete profile of the patient and so make possible connections to where there may be interactions between disorders, between treatments, and also to know when certain new symptoms may not be the result of an existing condition but may suggest the development of a separate pathology.
With me that looked like doctors who would decide that my crohn’s was to blame, and that it wasn’t swine flue, 2 months later it turned out, woops, they were wrong. When it became obvious that the doctors handling my file had no clue how to treat or respond to crohn’s disease nor the many ways my various conditions might interact, I started looking for a new doctor. Eventually, I was directed to a family doctor who had a bit more experience managing difficult case patients and who wasn’t afraid to both admit when she didn’t know something and also to learn something new when it became necessary.
Doctors like this are rare, and when they’re found, the community of people who live with these conditions will often spread the word. This is especially true when the condition is something rarer that may require a certain amount of expertise.
Additionally, since family doctors often treat entire families, and many conditions are genetic in nature, it’s not surprising that these doctors may find themselves with a greater number of patients who require frequent testing.
As a result, a small percentage of doctors appears to be ordering more tests simply because their patient-load requires it more than that of other doctors. If only a few family doctors will even take us on as patients, it’s not much of a surprise that those same doctors are then responsible for more tests.
What About Unnecessary Tests
The term “unnecessary tests” is incredibly misleading all on its own. With the exception of examples like performing a pregnancy test on someone without a uterus or ovaries, many tests may seem unnecessary simply because they didn’t show a specific pathology or lead to a conclusive diagnosis. These tests however still have significant value.
The example given by the government for example, is the rise in performing MRIs on the knees of middle-ages individuals when this pain often reverses itself after a few weeks or months. What isn’t discussed however, is the fact that MRI imaging is used specifically to check for the possibility of structural changes, to rule out underlying or contributing conditions and damage, and so on.
I can give you an example from my own medical history of how “a lack of pain” does not indicate that a test is unnecessary. In my first year of university, I experienced a weekend of significant lower back pain for which I was referred for a CT scan. For all that the pain disappeared after only a few days, the scan which took place a few months later showed that there was significant inflammation in my SI joint which ultimately led to my diagnosis of Psoriatic Arthritis. Had the test not been performed because my pain disappeared after only a few days, the underlying pathology would not have been discovered.
Given that my pain eventually returned and actually became much more serious, not having had the test at that time would have meant that I and my doctors would have been starting from scratch. Given the difficulty I had getting taken seriously even then, without the diagnosis that I had as a direct result of that CT, it is not outside the realm of possibility that the damage to my joints would have been much more extensive by the time I received a diagnosis and I would have likely required surgery to replace the joint at 19 years of age.
Medical Screening and Disease Management
Another example of tests that may appear unnecessary but aren’t, is the imaging done for Crohn’s patients when they come in with a flare. X-rays, CTs, and MRIs are often performed when this happens specifically to rule out the possibility of a blockage, a fistula, an abscess, or a bowel perforation: all known and possible complications of a Crohn’s flare.
Often times, the tests may come back negative, and yet despite this, the test is not actually unnecessary. For every time that a test comes back clean, there are many times when they don’t and the patient requires emergency intervention to prevent death. The reason these tests are performed even when they ultimately don’t show anything, is because it is the only way to check for known complications of this disease, other than cutting the patient open and digging around.
Similarly, routine screenings allow doctors to track the progress of a disease and adjust their treatments accordingly.
Even when my symptoms improved quite a bit externally, many of my tests showed continued inflammation and ulceration, which made it clear to my doctors that they needed to adjust the treatment accordingly.
The only way to know these tests are unnecessary, is by doing them, which actually makes them necessary. We can’t know if these tests will show anything until they are done, otherwise, we wouldn’t need them. These tests are only unnecessary if you don’t care if the person receiving them lives or dies, or whether their disease improves or remains active.
Further to the point about not knowing if a test is unnecessary until after you’ve done it, is the fact that some tests are part of an overall diagnostic protocol. They are done in order to rule out the possibility that something else which may present with similar symptoms, isn’t actually part of the problem.
For example, for a long time, one couldn’t be diagnosed with fibromyalgia until after lupus was ruled out as a possibility. This is because many of the symptoms of fibro overlap with those of lupus but the treatment for the two is very different.
Even when the ordering doctor is pretty certain that the condition they are ruling out isn’t the problem, the tests are often still necessary. That’s because doctors are not clairvoyant, they can’t just predict the future. The test may come back negative 99% of the time, but the end result for that 1% of the time it doesn’t could have huge repercussions on treatment.
Additionally, sometimes certain illnesses or conditions have abnormal presentations, which means even if the doctor is certain the issue is one thing, it could still turn out to be something completely different. Testing provides an insight into what is actually happening inside someone’s body and can provide information that is vital to achieving the right diagnosis.
Sometimes, the test being done is in the hopes of sparing the patient a more invasive or painful test. Since invasive and painful tests often have more significant risks associated with them, this serves a medical purpose as well as an empathetic one.
What about the Increase in Testing?
Using an increase in something as proof that the disease doesn’t exist or that the test is unnecessary is a fallacy frequently used by opponents of medicine. The reason it’s a fallacy is because it fails to take developments in science, diagnostics, awareness, and history into account.
Let’s go back to Ford’s own example of more frequent MRIs for knee pain in middle-aged individual.
There are multiple reasons why the number of MRI’s being performed have gone up, none of which indicate that they are unnecessary.
The number of tests being done, may be a reflection of demographics themselves. The number of middle-aged and older people is on the rise which means the number of tests related to concerns affecting this age group will also rise as well. More people needing tests will by definition increase the number of tests.
Additionally, the increase in testing can be a reflection of improvements in medical science. As doctors gain better understanding of the human body and its ailments, this will be reflected in how they respond to various conditions.
In the case of knee pain, we now know that it can be caused by things such as arthritis, bone degeneration, injuries, and so on. Additionally, knee pain can actually be the result of issues in other joints like the hip, the spine, which causes the patient to change how they walk and so putting pressure on ligaments and muscles not meant to take that sort of strain. In order to know conclusively the cause, imaging is required.
Doctors are more aware now of conditions like osteoporosis, and conditions affecting ligaments, muscles, bone and so on. This awareness in turn means that there is more to rule out regarding the ultimate causes of the pain in the knee.
They do these tests because it’s the only way to really know what is going on and to prevent more severe damage in the long run. Preventative care, which is what many of these tests are a part of, ultimately saves the province a LOT of money since treating arthritis is a lot cheaper than replacing a joint.
Pain doesn’t just materialize for no reason. It is a response to something going on. Knowing what that something else is requires investigation which is exactly what tests are.
Medical imaging, procedures, and tests all serve a purpose, and even a lack of answers provides clues that doctors can use to determine the cause of what is happening. When people with no knowledge of medicine or diagnostics try to dictate what tests or treatments are necessary, the result is often catastrophic.
The proposals put forth by the Ford government are not about saving money, but about cutting what healthcare is accessible to those who lack the funds necessary to pay for privatized care. He is attempting to force us into a two-tiered system where only those who can afford to pay for tests get to have them. That won’t save money, but will in fact harm public health and ultimately cost Ontarians more both is the cost of healthcare on a provincial basis since prevention is less expensive than treatment or emergency response, but also on an individual basis as in addition to insurance for dental and eye care, we will now require medical procedure and testing insurance. This isn’t about saving money but about maximizing profits, and we need only look at our neighbor’s South of the border to see what the end result is.
This plan won’t save money, but it will cost lives.