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Invited Commentary |

Diagnostic Testing and the Illusory Reassurance of Normal Results Comment on “Reassurance After Diagnostic Testing With a Low Pretest Probability of Serious Disease”

Kurt Kroenke, MD
JAMA Intern Med. 2013;173(6):416-417. doi:10.1001/jamainternmed.2013.11.
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Diagnostic testing is enticing to patients and clinicians. It appears more objective and less pedestrian than a simple clinical interview and physical examination. Medical certainty is seldom solidified until all the tests results are in. Patients anxiously await the telephone call or letter announcing “your tests are all normal.” Indeed, the grander the technology, the more alluring. However, the testing imperative can become addictive. As noted in a 1991 cautionary essay:

Like many of our treatments, however, diagnostic testing is not without its adverse effects. Increased health care costs are the most obvious: wide geographic variations in the use of expensive tests persist more than 30 years after such inexplicable variation was first exposed.2 Still more insidious consequences lurk. One is the problem of false-positive results. The prevalence of detecting a serious condition may be as low as 0.5% to 3.0% when diagnostic tests are ordered in patients with a low probability of disease,3 meaning that a diagnostic test with a 90% sensitivity and 90% specificity would yield 4 to 19 false-positive results for every true-positive result in patients for whom the test is ordered simply to rule out a disease for which the clinical suspicion is already low. This disproportionately high false-positive rate may then cascade into additional and sometimes invasive procedures, not to mention considerable patient anxiety that may persist months after a negative finding of a workup cancels out the initial test results. One might consider this PTSD (posttest stress disorder) an iatrogenic variant of the traditional PTSD (posttraumatic stress disorder).

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