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Re: Re Fwd: First Do No Harm (fwd)From: Arthurfree@aol.comSun Dec 8 18:46:17 1996
In a message dated 96-12-08 11:07:29 EST, you write:
> Roberta, In your first two paragraphs you've displayed a more thorough understanding of medical testing than most of my residents and many practicing physicians. It is crucial that pre-test counseling for many of these types of examinations be just as thorough (if not more so) than informed consent for a procedure. AFP screening is a great example. If you would not wish to proceed with confirmatory testing (the amnio) there is (almost) no benefit to the test (and significant emotional risk, as you found). There is significant, but very minimal, benefit to any antenatal diagnosis "found" by triple screen in a patient who would not want to terminate the pregnancy based on the results. And again, the personal emotional issues are incredible. If you've never cared for a mother with a known trisomy, anencephaly or the like through five months of prenancy it is not an experience to be recommended for the provider or the patient. The same principle can be applied to everything from a CT to a lead level (damn if I'm not preaching to the choir again). I'll often spend way too much time explaining to the patient "If this test is negative it means something, but if it's positive, we're essentially where we started because of your pretest probability" or vice versa. The old saw "If you don't take the temperature you won't find a fever" has a whole new context for me, having watched several patients grind through a workup of "positive findings" (put at significant physical risk as well as the emotional trauma) when they had no history suggesting the illness in question. My favorite was a 26 yo medical student who was a subject of a treadmill for colleague's practice, and had a self limited run of Vtach. A few thousand dollars (and a cardiac cath!) later, was pronounced healthy. Roberta, thanks for your eloquence (it seems like personal experience always speaks loudest). Don't be bashful! Arthur Freeland Warrensburg Missouri
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