I was recently in Arizona for a meeting and being there made me think of an email that I had received the day before I flew out. Apparently, the Arizona House of Representatives recently passed legislation (HB 2645) allowing direct lab test ordering by patients without a physician’s request or written authorization. This bill would still need to be signed into law to go into effect but I was still surprised to read about this bill.
Interested parties worked together to have the original bill amended with the stipulation that the laboratory would have the authority to decide which tests (or none) that patients may order. In some states, such a law I believe already exists (but don’t quote me on that…I tried finding confirming this but was not successful). But this begs the question, who takes responsibility for the test results? Currently, the Arizona bill states that test results would go to the person who provided the sample if a physician did not order the test. It would be their responsibility to consult with a physician for test result interpretation and required care and no physician would be liable for not acting on the test results if s/he did not order them.
So what is your opinion on patients self-ordering lab tests for themselves? Would this lead to patients second guessing their physicians if they want a lab test based on information that they personally gathered but that their physician disagrees with? Or would this make it easier for both the patient and physician in cases of routine testing? Are there implications that we have not thought of?
As an AP/CP resident, I’m not quite sure where I fall on this issue. Sure, having been “raised” in a training environment where vestiges of a previously patriarchal ethos and bias remain, it is difficult to imagine patients, and not physicians, choosing what tests to order. After all, hopefully, four years of medical school and multiple years of residency and eventual fellowship, should help inform these decisions more than internet searches and anecdotal stories can. But I have always been a patient advocate first. And I am always willing to take a step back to think about questions from the patient’s point of view and try to set aside my own biases, if doing so will improve patient care and safety.
But as with every human being, I’m cognizant that I do have biases. And as a resident who has had to navigate what we know as CP call, I understand that physicians, too, often have difficulty knowing what tests to order and what they should be looking for in a “good test” to provide them with the appropriate answers that they and their patients seek. I’m sure we’ve all dealt getting pages where we had to shut down what I like to refer to as “shotgun” ordering – multiple tests that are ordered hoping to find an answer in those cases where there is no differential or a very exhaustive one. Especially since without a targeted differential, test results may be difficult to interpret. Additionally, I’ve often seen other issues such as duplicate orders when a panel along with specific additional tests that are (unknowingly) included in the panel are ordered or the wrong test(s) ordered altogether. So it does pay to have another set of informed eyes look over test orders.
As a pathology resident, and even one with extensive lab and research experience prior to medical school, I can admit that I learn more and more each time I’m on a CP rotation about how to gauge the analytic and clinical validity of specific lab tests. Just because a test exists, doesn’t always mean that we should use it or always order it for every patient. This is the role I feel that we fill for referring physicians and patients. We develop and make sure tests are conducted properly, safely, and efficaciously. We also serve as a resource with knowledge on which tests, specimen sources and other analytic parameters, and patient populations are appropriate. We can also identify and troubleshoot when false positives or negatives are suspected as well as provide an interpretation of the test results within the context of clinical patient history that we can access through the EMR. But that is within the confines of the walls of the medical culture and environment, which I admit is not perfect and has areas that we can still work on to improve.
But when it comes to patients ordering tests outside the purview of direct medical care, I’m not sure what my stance is. In this country, patient autonomy is king. As physicians, we don’t always have to agree with our patient’s decisions, but we do need to respect them. We cannot arbitrarily subjugate patients to the dictatorship of a patriarchal perspective (at least not in this modern day), even within a patient care setting. So, at least in my mind, a grey zone exists in the context of a patient who is willing to pay or who can get his/her insurance to pay (although that is entirely another issue) for a specific test not ordered by their physician. But I do worry that this could set up complications for evidence-based patient care. There are multiple levels of implications that I’m sure we have not even thought of – not only for the physician who has to decide what to do when their patient brings in results from a test that they personally ordered without physician authorization but also for the patient to not feel as if they are falling through the cracks of our healthcare system if physicians decide to not act on these test results. I can imagine that there are medicolegal issues that are significant as well but I humbly admit that these are definitely beyond my expertise to comment on at this time. However, I do know that I believe that patients have a right to access their test results directly and not have to go through their provider if they choose not to.
I wrote this post not to necessarily push readers to one viewpoint or another but more so to provoke thought. So, how do you think this bill will affect healthcare in Arizona or set a precedent for other states to follow and what is your stance? I can honestly say, I’m still thinking it over…
This post is an edited version of one that appeared on 2/27/15.
-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.
Lablogatory 
I am recalling my Mother-in-Law who was sure she had every disease she ever read about. She was forever going to her doc, requesting MRI’s for a torn rotator cuff, CAT scans for brain tumors, she was once convinced she had liver cancer and wanted a biopsy. Someone like her with limited knowledge (what she read in Good Housekeeping or Prevention) could go crazy with this. The limiting factor would be will insurance companies pay for patient ordered testing?
As a former Med Tech, I don’t see why a layman with the access of the internet cannot order their own laboratory test. I don’t believe they are second guessing their own physician and if so, then their physician relationship is already at odds. Most physicians are already overwhelmed with their cases that the contact time for an annual checkup is usually only an hour. I don’t think that an individual will go crazy ordering elaborate test. A lot depends on their insurance as mentioned above. If someone is willing to pay then it should be allowed and within their own rights
The bill is pushed by Theranos, http://www.azcentral.com/story/news/arizona/politics/2015/02/27/high-tech-pushes-consumer-friendly-lab-testing/24150229/
Are you saying this is a good thing or a bad thing? Or neither, just letting it be known that someone with a stake in the outcome is pushing the legislation along?
Some IVD FDA approved tests have an FDA labeling restriction, physician prescription only. generally, you wouldn’t think that state law would override federal law in that case. (On the other hand, medical marijuana is freely available in a number of states, even though that does violate federal law). The Arizona bill states, ALL tests are available on patient demand. For the legislative text, see here – http://brucedocumentblog.blogspot.com/2015/03/arizona-hb2645-direct-access-testing.html For my blog on Theranos publicity, see here – http://www.discoveriesinhealthpolicy.com/2014/12/theranos-some-recent-journalism.html
I have been not been feeling right for a few years. Neither one of my doctors (GP or OBGYN) has been too interested in helping me figure out what is going on. Long story short, I went to a pharmacist who is a hormone specialist. I did a complete hormone work up through her (saliva and blood spot tests, through ZRT lab). My results came back that I am borderline thyroiditis. I have been on hypothyroid therapy for 15 years. Over the last few years, I have been asking for more in depth thyroid tests (free T3, reverse T3). My doc has never agreed to do the tests. The pharmacist had me request additional labs be added to my upcoming cholesterol liver function bloodwork – free T3, reverse T3, T4, Vit D, Ferratin. My doc said no! What? I asked him a second time and am waiting in the answer. Shouldn’t a person be entitled to getting information about their own health? Other concerns showed up in my lab work – adrenal fatique, low cortisol, low progesterone, low DHEA. We are handling the other problems with changes in diet, exercise, and strategies for healing adrenal exhaustion. Just curious what your thoughts are regarding my docs refusal, and what the consensus is along these lines in med school. He is early 40s and he has always had a bit of a tendency to not really listen to me. Which is obvious, given the state of my labs. Most of the time I don’t even mention those kinds of things to him because I don’t think he will take me seriously.
Hi Sarah, I’m sorry to hear about your experience. This is just my personal opinion and not official medical advice…and I’m a pathology resident and not a primary care physician but if you feel that your doctor doesn’t take the time to listen to you or to explain why s/he doesn’t think certain testing is necessary in a way that you understand, then it might be time to find a new doctor who will at least do those things. There might be a legitimate reason according to standard medical guidelines why they may think such testing is unnecessary and physicians are trained in medical school to convey these reasons to their patients. There is variability among labs in terms of the methods they use for testing and how fastidious they are about quality control and assurance. And so even if you did get test results elsewhere, most doctors would at least want to order their own labs if they thought they were necessary because they may not trust the results you bring in. And according to at least this law that is under consideration in AZ, doctors are not beholden to treat you on any results you may bring in if they didn’t order the tests so that could be another issue. So getting the tests done won’t necessarily help. Seems to me that the first order of business would be to find a doctor who will at least listen and explain about the indications for these tests and why they may choose not to order them or to get a referral to an endocrinologist if that’s required by your health plan to see one.
I do hope that you feel better soon.
I did fire this doctor and have found a new one that believes in shared decision making between the client and patient:)
Of course you should be able to order the test. It is information, not treatment. Is someone who has no history of hypertension going beyond the pale if they buy a blood pressure cuff and checking the readings every week? Most people would say no. My health will never be more important to any doctor, than it is to me. And I have heard of to many times a doctor does not take a patients request seriously, because what does the patient know, they didn’t go to med school. Once someone finds a doctor that does take them seriously and order the labs they want, they are behind the gun. I am a nurse, and have heard many patients and family members voice this complaint. The patient still can not order treatment, and the doctor can ignore the lab results, but people should have the right to know the state of their own body.
I believe that patients have a right to their own healthcare information. I believe that patients taking charge of their healthcare information could be very beneficial. Also, as Elizabeth Holmes stated, by the time patients reach the physician the disease process has been ongoing long enough to show symptoms. I also believe that all the scare of, “What will they do with the information?!”, is really not warranted. Most, if not all, patients would go directly to their physician if they had questions about a test result(s). No one has more of a vested interest in your health as you do. With that being said, I believe that there will be less ‘falling through the cracks’, if you will. No matter what, professional treatment will be in the hands of a physician.
I believe patients should be able to order laboratory tests, however, we all can imagine the can of worms this will open. This law may allow patients to order diagnostic tests, but interpretation is often difficult. Will patients then decide the proper course of treatment? Primary care clinicians will be obligated to follow-up on incidental abnormal results, resulting in potentially more harm than good for the patient. Or patients may continue to seek care from alternative medicine clinicians.
The question is: Will the health insurance pay for it, if the tests aren’t ordered by the physician?
My concern would be who do I call if there is a critical value, and would the testing laboratory be called to explain what the values mean.
I have had numerous lab tests run myself. I take any concerns I have to my doctor. My insurance doesn’t pay for the labs I have ordered myself.
We used to get so many phone calls when the High Schools in the area did blood typing in class. My daughter says her blood type is O, and my wife and I are A how can this be???? Sometimes a little information can be a dangerous thing. Many of these people were very angry or upset when they called.