Rather than simply peppering medical learners with questions about the pathophysiology or management of a particular condition, although that does have a place in certain situations, I will often make use of “teaching cases” as a means of simply starting a dialogue. In my opinion, the aspects of patient care that surround the diagnosis and treatment are often equally valuable. Also I really like to see how students and residents think through the complexities of individual patient biopsychosocial particulars, and how they handle unexpected findings that don’t fit an expected narrative.
How our gears turn when approaching patient care is extremely important. There is often more than one way to discover the cause of a patient’s complaints, but some ways are simply more effective than others in that they reduce health care expenditure and, more importantly, patient exposure to diagnostic and treatment misadventures that may result in harm. A solid foundation in critical thinking and scientific skepticism optimizes this process.
Good communication is paramount at every step. Medical professionals must become skilled in retrieving information from patients and caregivers, not to mention from the recesses of our own minds and/or UpToDate®, but also to be able to help them process complex information about their health and understand the risks and benefits of various treatment approaches. Sounds simple, right?
Often we need to guide patients and caregivers as they make difficult medical decisions, and without inappropriately compromising their respective autonomy or authority. The days of paternalism in medicine are over, not that we are completely beyond reproach in this regard. But we have improved significantly in recent years. In fact, discussion of the ethics surrounding medical decision making occurs frequently on my rounds.
Most recently, the case I presented to the team involved drug testing on an adolescent patient.
“I want to know if Timmy is on drugs!”
I described the following encounter to the team:
An anxious appearing woman has brought her 15-year-old son into the emergency department (or urgent care or PCP office) seeking a drug test. The patient, Timmy, has become less interactive with the family over the past few months, quit his soccer team, and sometimes his clothes smell funny. He spends more time alone in his room than in the past and his mother feels like he has become less interested in school, noting that he used to be an honor student but now he is barely passing his classes.
Timmy’s mother also expresses concern regarding a new group of friends, which she does not approve of because they are older and she has heard rumors of possible drug and alcohol use. Timmy, who appears uninterested in the conversation, denies drug use. During a thorough history and physical exam, performed while his mother waits in the hallway, Timmy again denies drug use. He states that he does not want to be tested.
So we have a reasonably concerned parent requesting drug testing of a minor for whom they have the legal authority to make medical decisions, and a neurologically intact patient who does not want testing to be performed. Now what? Should testing be done against the patient’s wishes? If not, how do we explain our refusal to perform drug testing to the mother in a way that will help her understand the decision?
SBM presents You Make the Call!
In this case, although not necessarily easy to execute considering the understandable anxiety on the part of Timmy’s mother, the right answer is to refuse to perform drug testing against the will of a competent adolescent patient who has decisional capacity. Of course, decisional capacity in a minor depends on the patient and the situation, but most experts would agree that in this setting the risk of forced testing outweighs potential benefit. In 2014, the American Academy of Pediatrics released their updated recommendations on drug testing in children and adolescents, which warned that involuntary testing is extremely problematic for numerous reasons, and they didn’t beat around the bush:
Drug testing of a competent adolescent without his or her consent is, at best, impractical and without his or her knowledge is unethical and illegal.
In other words, you would have to either restrain the patient in order to obtain a catheter specimen or deceive them in such a way that they would provide a urine sample believing that it was for a different reason.
It is important to recognize that caregivers often do pick up on changes in mental and physical health, and become aware of high risk behaviors, long before they are brought to the attention of medical or law enforcement professionals. These concerns should be well-documented and taken seriously. In some cases, a recommendation for drug testing may be an appropriate component of an evaluation, particularly when a patient of any age has an altered mental status and might be acutely intoxicated. In that case, a young patient would not have decision-making capacity and test results would inform emergent medical management.
Sometimes the results from a drug test, positive or negative, can be helpful. If caregiver-requested drug testing is deemed reasonable in a non-emergent situation, it is imperative that all parties receive proper informed consent and that the patient be treated with the same consideration of confidentiality as an adult. The AAP recommends specifically that caregivers be informed of “the limited scope of information available from testing as well as the need to reach a consensus on an action plan for both positive and negative results.”
Confidentiality is incredibly important when caring for the adolescent patient. This is a population prone to numerous high risk behaviors and worrying that information shared with their pediatrician or family doctor might be handed over to an outside party without permission might lead to avoidance of the medical system and a critical delay in care. If they don’t want to share the results of drug testing, we don’t do it. In fact, in many states adolescents are legally allowed to consent for their own drug treatment without parental notification.
It is equally important to understand that proper medical care of an adolescent who may be abusing drugs or at risk of it does not end with their refusal to provide a specimen for testing or to share results with caregivers. A mental health referral may still be very helpful, particularly considering the overlap of symptoms of depression and psychosis with drug use. It is also not uncommon for adolescents to self-medicate with psychoactive substances when dealing with the symptoms of mental health problems.
No test is perfect
Drug testing, and I am referring to urine testing because that is by far the most commonly used modality, is limited by the possibility of both false positive and false negative results. Cross-reactivity with other substances, such as with some common antibiotics, can occur. And no drug test can distinguish proper use of certain medications from abuse. ADHD medications, for example, can trigger an amphetamine screen. And even a true positive result says nothing about the extent of the patient’s drug use.
False negative results also occur for a variety of reasons, such as when a patient provides urine from a clean friend or adulterates the specimen with tap water or some other masking agent. And even a negative test on a legitimate specimen doesn’t necessarily rule out drug use because timing of the last use is a key factor in the sensitivity of the test. Also, not all drugs are included in standard screening tests, such as numerous newer designer drugs. And not even all drugs in a particular class are metabolized in such a way as to be detected by the screen. This is why clinical concern is the ultimate indication for referral.
The AAP points out the many challenges in specimen collection in their clinical report. Protocols for obtaining urine properly, particularly in the event that results may be used by law enforcement, are onerous, and most offices don’t follow any of them. These include direct supervision, leaving coats/bags outside the bathroom, removing access to running water or other possible adulterants, tinted toilet water, and measurement of the specimen temperature within four minutes of collection. Many offices just put someone outside the bathroom door to listen for the sink.
Conclusion: Appropriate care doesn’t always require testing and testing doesn’t always result in appropriate care
If there is a good reason to suspect drug use or abuse, a negative test doesn’t rule it out. Again, it is always okay to refer a patient for counseling when clinically indicated. Paternalistic forced testing that violates a patient’s autonomy and confidentiality, even if resulting in a positive result for the suspected drug, may not even be of benefit considering the low likelihood of treatment success when a patient is unwilling to participate. And a great way to ensure an unwilling teenager is to treat them like a child.
Explaining why drug testing won’t be carried out is the true challenge in this scenario. Caregivers should be told of the ethical standard and why it is important to uphold it. It is important to explain the risk of harming the relationship between the patient and the medical community, but also how coerced or deceptive drug testing may severely impair family relationships. If drug use is actually occurring, this can make it more difficult to achieve a successful outcome down the road. This is also an opportunity to counsel the patient on the potential benefit of having an open dialogue with his or her family.
Final thoughts
Ethical dilemmas such as this are common in medicine, and healthcare professionals are required to continually refresh our knowledge through CME courses. There are even medical ethicists who focus on these issues and can be consulted for assistance with the most challenging cases. I have to wonder, if given the opportunity how would the “chiropractic primary care provider” respond to Timmy’s mother? I was unable to find anything regarding this topic online other than websites discussing how to boost profits by offering drug testing:
In short, while you can have a positive impact on your practice’s revenue through drug specimen collection itself, the true benefit in providing this service is the opportunity it provides you to educate the employer about chiropractic and “sell” the other services your clinic provides.
Classy.
On the other end of the spectrum, here is some great info from the AAP on adolescent drug testing.