Medical Mistrust, Part 2: More Testing Isn't Always Better — What a Doctor Wants You to Know

Executive Summary

Core Premise

The article challenges the growing trend of "over-testing" in modern medicine. While patients often feel that extensive lab work provides a comprehensive safety net, the post argues that indiscriminate testing can lead to clinical confusion, unnecessary anxiety, and "over-diagnosis" without improving patient outcomes.

Key Insights

• The "False Positive" Trap: Every test carries a statistical margin of error. When a large battery of tests is ordered without a specific clinical indication, the likelihood of a false positive—or a clinically insignificant finding—increases significantly.

• The Cascade Effect: One abnormal (but irrelevant) result often leads to a "diagnostic cascade"—further invasive tests, specialist referrals, and even treatments for conditions that were never going to cause harm.

• Focus on Clinical Utility: The blog emphasizes that testing should be evidence-informed. A test is only valuable if its results will directly change the treatment plan or significantly clarify a diagnosis.

• Foundation First: The post advocates for prioritizing foundational health—such as nutrition, sleep, and metabolic balance—over searching for microscopic anomalies that may not require intervention.

Strategic Conclusion

More data does not always lead to more clarity. The goal of effective healthcare should be precision over volume, ensuring that every diagnostic tool used is purposeful, clinically relevant, and focused on the patient's long-term well-being rather than just "checking boxes."

Table of Contents

1. Why Doctors Order Tests (motivations behind physician testing decisions)

2. From “Sign Here” to Shared Decision Making (paternalistic to collaborative)

3. How Informed Consent Evolved (informed consent became shared‑decision making)

4. The Hidden Cost of Incidental Findings (incidentalomas and their risks)

5. When Patients Do Their Own Research (online information and patient expectations)

6. Who Pays for Medical Studies (funding drives researched and testing topics)

7. How Medicine‑Adjacent Businesses Create Niches (techniques for carving out niches)

8. The Harms of Routine Lab Panels (false positives, mental health, and care cascades)

9. The Bottom Line: Why Targeted Testing Matters (personalized testing is superior)

The Myth of More

Have you ever left a physician’s office with a list of orders and wondered if you truly need them?  Or, have you come across a website that offers a laundry list of lab tests to help you get a sneak peek into your health and wondered if they were a good idea?  This piece is a follow-up to my initial discussion about medical mistrust entitled “Cholesterol, Statins, and a Story of Medical Mistrust” where I evaluated how growing medical mistrust stems from rushed, fragmented care and the influence of biased or misleading voices while emphasizing that strong scientific evidence supports cholesterol management which may include statin use.  I ultimately hope we can rebuild trust through transparency and a clear understanding of the available data, as well as taking the time needed in clinical care.  In this piece, my hope is to address the nuances around ordering tests and procedures, wherein I discuss the habits and motivations around ordering tests from the physician’s and patient’s perspectives, how those perspectives may clash, and how to proceed when we have different agendas.

Why Do Doctors Order Tests?  It is More Complicated Than You Think

When considering what compels a physician to act in their clinical practice, it is important to acknowledge that some physicians are excessively driven to make money and may push the limits on what is medically necessary.  Periodically, there will be big news about healthcare fraud with settlements into the tens of millions of dollars.  A type of abuse that may not rise to the level of fraud is seen in the fee-for-service realm where a doctor may be more likely to make a medical decision that gets them extra money from that decision.  For instance, a cardiologist may be more likely to order a stress test or echocardiogram if they get paid for interpreting that test.  Fortunately, this type of behavior among doctors is uncommon.

Because of fraud and abuse in medicine, doctors go through extensive training and monitoring to ensure they order tests that are medically necessary and avoid performing unnecessary procedures.  Physicians are monitored through a process called utilization review and compelled to use tools that dictate appropriate use criteria to ensure we are not ordering an excessive number of tests.  There can be significant penalties for excessive utilization which can include putting the physician’s license to practice medicine in jeopardy.

From "Sign Here" to "Let's Decide Together": The Rise of Shared Decision Making

In addition to having pressure to avoid ordering too many tests, physicians are also taught to be mindful of the risks of our actions.  When we are considering ordering tests or procedures, part of our decision process mandates a balancing of the benefits versus the risks of the tests and procedures we are ordering.  Unfortunately, all procedures come with risks, whether the procedure is clipping a skin tag or removing a brain tumor.  While medicine has historically been paternalistic, with doctors making decisions with limited patient input, medicine has more recently adapted to ensure the patients are actively involved in benefit versus risk discussions in a process known as shared decision making (Hoque, 2024).  Patients may not have truly understood the benefits and risks, so shared decision making strives to ensure the patient and physician have realistic goals and expectations before proceeding with a new test or procedure.

Informed Consent Evolved to Shared Decision Making

Informed consent was an initial structure used to document that a patient had been told of the risks of medical decisions and that the patient agreed with proceeding, though the amount of discussion between doctor and patient may have been limited and the process seen as more of an administrative or legal hurdle.  As an important improvement over informed consent, we have moved to a model of shared decision making, whereby a patient is actively involved in medical decision making instead of simply listening to someone say there are risks while internally they hoped the procedure would fix what ails them or the test would give them the truth about what is going on in their body (Dennison Himmelfarb, 2023).

An example of how shared decision making is applied in real life is called the SHARE approach:

• S – Seek the patient’s participation

• H – Help the patient explore and compare treatment options

• A – Assess the patient’s values and preferences

• R – Reach a decision with the patient

• E – Evaluate the patient’s decision

The Hidden Cost of "Finding Something": What Incidental Results Really Mean

While potentially harmful direct outcomes may be clear, such as a surgery being complicated by an infection, the indirect outcomes may be less clear.  For instance, ordering an imaging study such as a CT scan for kidney stones will give excellent information about kidney stones, but may also identify an abnormal mass in an adrenal gland.  This will then lead to further tests, possibly even including surgical biopsies, and those surgical procedures will carry real risks of serious harm including bleeding, infection, and death that may affect 2-3% of people.  With 75% of those abnormal adrenal gland masses being completely benign and another 20% being of limited clinical importance, close to 95% of the masses seen in the adrenal gland are of limited clinical significance (Kebebew, 2021).  Consequently, there may be a similar number of people helped by pursuing an incidental finding as may be severely harmed.  This is one of the main reasons why whole-body scans are discouraged, as finding the incidental finding, or “incidentaloma”, may hurt as many people as are helped.

In addition to considering the financial aspects of a test or procedure, as well as the risks of complications, we also consider whether or not ordering the test or procedure will change the person’s eventual outcome.  In the end, the patient may simply see value in the outcome of the test or procedure, even if they do not understand how the results can help them move forward.  An important part of a physician’s medical education is ensuring the physician does not order tests or procedures if they will not affect the patient’s outcome or modify the existing plans.  Hopefully the patient has a healthy relationship with their physician and they trust their physician’s opinion.  Increasingly, patients may come to the physician’s office with their mind already made up from doing their own research.

When Patients Do Their Own Research: The Good, the Risky, and the Misleading

As I referenced in the Part One of my musings about medical mistrust, for a variety of reasons patients are being forced to, or choose to, do their own research online and this may take them to both vigorous academic sites as well as other sites.  In going to these non-academic sites, patients are increasingly being exposed to ideas that run counter to mainstream medicine, though they are presented in such a way as to capture the patient's attention.  The patient may be drawn in by phrases such as “The Hidden Truth” or “The Real Story”, captivating the patient’s attention by tapping into a desire for secret knowledge and an understanding of conspiracies.  Or, patients may see social media posts based on fear, encouraging doing more testing to catch diseases early, before they become real issues.  The “hooks” in social media are designed to draw people in and motivate behavior that may primarily be for the benefit the social media poster but is presented in a way to suggest the patient is advocating for their own health.

Given the numerous delays and hurdles of communication in healthcare, it is understandable that people turn to the internet and social media to fill in knowledge gaps and get much-needed help.  The drive to be proactive and take control over one’s life can be compelling but may lead to inappropriately biased decision-making.  People may have an illusion of control but then are insensitive to feedback and may be more risk-prone (Fenton-O’Creevy, 2010).  People looking for compelling ways to improve their own health are at risk of falling into a trap of confirmation bias, finding evidence to suggest added testing will help them, though they may not appreciate the potential downsides (Bojke, 2021).  A final drive for patients may be one where a patient starts with a conclusion that they want to be exhaustive, performing deep dives into the root causes of their health concerns, ensuring they’ve not left out any key tests or perhaps they don’t believe earlier results, so they are trapped into a form of motivational reasoning bias where they will have a difficult time accepting alternatives that deviate from their initial path (Svenson, 2022).

Whatever the hook may be, some medical and medicine-adjacent sites may have honest intentions and are simply trying to grow a business.  With 20% of new businesses failing after their first year, the owners struggle to gain attention and demonstrate that they can provide value for their customers.  When sprawling health systems can spend more on advertising in a month than the small business will make in years, the small business often struggles and works to find a niche for their practice.  For examples of medical advertising spending, look up your local nonprofit health system using IRS 990 forms, part IX, and you will be able to see the non-profit expenditures for advertising and promotion.  Be aware large systems will have multiple Employer Identification Numbers.  Given the real chances of businesses failing and lacking the advertising budgets of large systems, new business owners have to be creative on how they can carve out their space in a crowded market.

For those doctors practicing more traditional medicine, they may create their niche with longer appointments, having no appointment slots under one hour.  This is quite different than the push in big health systems of 15-20 minute appointments.  Some systems even mandate double-booking, which is where a physician is required to put two patients in the same 15-minute slot, which then forces the physician to shorten the visit even further.  Those in Direct Care, such as Evexeya Health, also provide features including transparent pricing, easy access to the physicians, and removal of the burdens of insurance as a way to create a niche without deviating from evidence-based medicine.  Using the direct care model, physicians have more time and can provide a personalized approach to fully understand the patient’s concerns and address the underlying drivers of their health.

Who Pays for Medical Studies — and Why That Shapes What Gets Tested

In an ideal world, we would be able to apply the scientific method of finding a problem, proposing a solution, testing the solution, and evaluating the results to all aspects of life. Unfortunately, in medicine this process is expensive and takes many years to accomplish. While studies in the 20th century may have only used 50 or 500 test subjects, it is now common to see medical trials with 25,000 to 250,000 subjects to ensure broad applicability of the results across gender and race.

There are occasional trials of supplements, such as the Women’s Health Study testing whether vitamin E decreases the risks of cardiovascular disease and cancer (Lee, 2005). Funding for the study appears to be mainly from federal organizations, though industry supplied the vitamin E and aspirin. A similar trial investigated vitamin D for similar outcome goals (Manson, 2019). Nonetheless, many other supplements will not have the benefit of being tested in tens of thousands of subjects, so we are left making decisions on the merits of supplements with limited information, a situation further muddied by the lack of federal safety oversight of supplements.

With these studies requiring so many subjects, it’s unsurprising funding comes from multiple sources including the federal government and industry. For example, medical testing was largely paid for by industry (67%) and only a portion by the federal government (22%) (Schulthess, 2022). The involvement of industry is not seen as a donation but is an investment into the lucrative market focused on finding the next big-ticket medicine. Consequently, industry is unlikely to invest in trials that will not lead to a new breakthrough medicine. This is why you are less likely to see large scale trials of older, generic medicines or, importantly, supplements. The limited evidence-based medicine around supplements does not inherently indicate supplements are not useful. It may only mean no one was willing to fund a large enough study to test the hypothesis that a given supplement could be effective at treating a certain condition. The lack of evidence-based medicine supporting a given supplement is also why people can promote those supplements – there may not be evidence to suggest supplements are ineffective.

How Medicine-Adjacent Businesses Create Niches

To help understand how others create a niche that may deviate from more traditional medicine, it is important to understand some of the weaknesses of medicine in the large health systems.  As I touched on in Part One of the Medical Mistrust series, large health systems appear to be configured in a way that seems to add costs primarily for the benefit of the systems.  One example is how primary care is structured in a way that compels referrals to specialists instead of allowing the primary care doctors adequate time to address issues themselves.  The primary care physicians are certainly capable of handling many more ailments than they are allowed due to limited time.  There may also be some truth to how industry is able to influence the practice of medicine in how they subsidize research into expensive medicines, devices, or procedures, potentially avoiding subsidizing research around generic medicines or preventive care.  Consequently, there are certainly issues to address with care delivery in large systems, though there are many benefits to large systems such as efficiencies of scale and support for specialists.

A potentially concerning trend is how some medicine-adjacent clinics or businesses focus on the weaknesses of the big systems and use those to indicate how the entire practice of traditional medicine is flawed and that the medicine-adjacent clinic or business is the one that can provide what is actually needed.  This approach may be referred to as a “wedge” strategy, wherein someone identifies a real problem area and then proposes they are the only one capable of providing a real solution.

Interestingly, like Direct Care practices, some of these variant practices will focus on a more personalized touch, often providing a solution to one of the biggest weaknesses of “Big Medicine” – the time to sit with a person who will listen to the patient, not focus on the clock, and become a trusted resource.  Alternatively, the medicine-adjacent provider may be online-only, so the trusting relationship is more challenging to establish and may rely on the angle of providing a “real truth” solution.  One example is where a medicine-adjacent practice provides a service where a person can get numerous lab tests drawn under a label of proactive care to test for early signs of disease and get “deep dive” or “root cause” access to their health information with inadequate guidance on how to apply the results and with inadequate attention to the anxiety caused by seeing abnormal results.  Or perhaps they will attack the big pharmaceutical business and focus on a more “natural” approach, preying on the fear many feel about prescription medicines and encouraging the fallacy that supplements are inherently safe and effective alternatives.

Routine Lab Panels:  Are You Getting Your Money’s Worth?

Some medicine-adjacent businesses are built around an idea that by getting “all” of your labs tested once or twice a year for $200-$400 in cash, you are being proactive and will catch things those in traditional medicine will miss because they aren’t testing broadly and/or often enough.  These services are often able to tap into flexible spending account (FSA) or health savings account (HSA) money, which may be seen as forgotten money by some.  Unfortunately, unguided screening such as these labs can be wasteful and even harmful.

Harm? From a Lab?

The Figure above shows an example of generic lab test results in a normal distribution, where each column represents the number of people that have a value, such as a blood potassium level, and are “normal” with respect to that test.  Laboratory reference ranges are typically set at what is called a 95% confidence interval, depicted by the orange bars above.  As you can see, the blue “tails” of low and high values have very few people (i.e., 2.5% of graph area are in each tail), while the most common values are right in the middle.  It is important to recognize that the people with values in the blue tails are still normal and healthy, yet we typically use a 95% confidence interval to improve the chances that we can properly identify an uncommon value that may need further attention.  Why does this matter?  We can label someone as having an “abnormal” value when it falls outside of the 95% confidence interval even though it may be completely normal for that individual, an issue sometimes referred to as a “false positive” finding.  An example of why “false positives” can have harms was shown in a cancer screening study of nearly 70,000 people over three years, evaluating for prostate, lung, colorectal, and ovarian cancer (Croswell, 2009).  In that randomized controlled trial, subjects got up to fourteen tests to address all the various cancers.  At the end of the study, men were found to have had at least one false positive test 60% of the time and women 49% of the time.  These false positive tests led to invasive testing 29% of the time in men and 22% of the time in women.  If patients get hundreds of labs drawn once or twice a year, there is substantial risk of false positive results.

Mental Health

A fundamental risk of these screenings that may be minimized is the stress, anxiety, and overall mental health trauma people feel when they get an abnormal result.  A common example in my field of cardiology relates to how a patient may order a coronary calcium scoring or coronary calcium CT scan without a doctor’s prescription.  The patient pays cash for a study and then gets a report shortly thereafter.  The problem is that the reports may say someone is in the 75^th percentile based on their calcium score and the patient may not know how to interpret those data.  We can see similar issues when patients get basic bloodwork back, such as liver enzymes that are “high” at 80 U/L, but they do not know how to interpret that number.  People ordering these screening tests need to be aware of the weeks or months it will likely take to get in to a physician to review the data and develop a personalized plan based on those data.  Having to sit and wait for weeks or months to get closure around abnormal results can escalate stress and anxiety.  I have reviewed multiple reports from different companies providing this type of lab screening service and have been disappointed by the limited comments linked to the abnormal results, as they are brief and require personalized follow-up.  I have also been disappointed in reviewing these reports as they may use non-standard cut-off values for normal versus abnormal, potentially causing more stress for the patient due to confusion around the results.  To try to get more insight, people are forced to search the internet on their own, possibly engaging artificial intelligence, as they wait to get professional input on the test. There is promise in the use of artificial intelligence to aid medical decision as 1 in 4 answers by artificial intelligence were “excellent,” a concerning result was that 1 in 25 answers were “incompetent” and risked patient harm (Chen, 2026).  People should have a plan for how the results will be handled before ordering the tests and not rely on the marketing of the firm performing the tests.

Care Cascades – For the Business or the Patient?

A care cascade is a series of clinical events that follow an initial testing event (Ganguli, 2019).  A recent article evaluated over 300,000 tests including chest x-rays, electrocardiograms, and pap-smears and their related care cascades for adverse clinical outcomes.  The hypothesis of the work was that when healthy individuals were administered fairly inexpensive tests at annual appointments, they were more likely to get subsequent care (Bouck, 2020).  This work demonstrated a substantial increase in specialist consultations and expensive procedures, which benefits the business aspect of healthcare.  Those screened were 2.7x more likely to be referred to a pulmonologist and 3.5x more likely to be referred to a cardiologist.  Unfortunately, there was a significant increase in the risk of lung injury and death from procedures related to screening chest x-rays.  Death rates did not change with the other two tests, though the trial was short.

Concluding Thoughts

The bottom line is that the clinical benefit of routine screening has not been demonstrated, including when people pay cash for their annual panel of testing including electrocardiogram and blood work (Krogsboll, 2019).  These screenings may identify new diagnoses and lead to further steps in the treatment cascade, though the screenings could not be demonstrated to have an impact on actual illness burdens or mortality.  Admittedly, some may use the screenings as their only healthcare, as they may not be able to afford insurance and/or regular physician visits, so they feel the screenings are better than nothing, which is unfortunate.  Targeted, appropriate testing should be the goal, not overly broad and unguided testing.  The challenges with the unguided periodic tests are the harm of the incidentaloma and the anxiety caused by waiting to address the results.

In the end, it is understandable that the patient may be left wanting more information and struggling to find reliable sources of medical information without being taken advantage of.  It is vital for people to be proactive about their health and be their own best advocates.  Yes, there are problems with large health systems that need attention and better patient advocacy such as limited physician access and rising healthcare costs.  Unfortunately, some businesses position themselves to manipulate those looking for more information and monetize their time and attention.  Am I suggesting that all proactive screening tests are bad?  No, but it is important to have a clear understanding of the risks and benefits of going through those tests.  When going through testing, you should work with a physician who knows about you, your preferences, and your health history and can help guide you through the process of testing, interpreting the results, and forming a cohesive action plan based on the results.  By utilizing a Direct Care model, patients will be able to review their healthcare decisions and not feel dismissed or rushed, so they can decide if/when screening testing would add value.  My hope in writing this is that, as I touched on in my earlier piece on medical mistrust “Cholesterol, Statins, and a Story of Medical Mistrust”, we can return to a place where people will again trust their physicians while we collaborate on the patient’s healthcare.  We need to return to a time where healthcare is based on discussions between the patient and their physician to the exclusion of other voices that want to be involved in the decision-making process.

References

• Bojke, L., et. al. Developing a Reference Protocol for Structured Expert Elicitation in Health-Care Decision-Making: a Mixed-Methods Study. Health Technol Assess. 2021;25(37):1-124.

• Bouck, Z., et. al. Association of Low-Value Testing with Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA Intern Med. 2020;180(7):973-983.

• Chen, P., et. al. Multidisciplinary Blinded Randomized Expert Evaluation of Large Language Models for Clinical Diagnosis and Management. Commun Med. 2026; in press.

• Croswell, J.M., et. al. Cumulative Incidence of False-Positive Results in Repeated, Multimodal Cancer Screening. Ann Fam Med 2009;7(3):212-222.

• Dennison Himmelfarb, C.R., et. al. Shared Decision-Making and Cardiovascular Health: A Scientific Statement from the American Heart Association. Circulation. 2023;148(11):912-931.

• Fenton-O'Creevy, M., et. al. Trading on Illusions: Unrealistic Perceptions of Control and Trading Performance.  J. of Occupational and Organizational Psychology. 2003;76:53-68.

• Gangluli, I., et. al. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Network Open. 2019;2(10):e1913325.

• Hoque, F. Shared Decision-Making in Patient Care: Advantages, Barriers and Potential Solutions. Brown Hospital Medicine. 2024;3(4):13-15.

• Kebebew, E. Adrenal Incidentaloma. N Engl J Med. 2021;384(16):1542-1551.

• Krogsboll, L.T., et. al. General Health Checks in Adults for Reducing Morbidity and Mortality from Disease. Cochrane Database of Systematic Reviews. 2019;1(CD009009):1-110.

• Lee, I-M., et. al. Vitamin E in the Primary Prevention of Cardiovascular Disease and Cancer. JAMA. 2005;294(1):56-65.

• Manson, J.E., et. al. Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease. N Engl J Med. 2019;380(1):33-44.

• Schulthess, D., et. al. The Relative Contributions of NIH and Private Sector Funding to the Approval of New Biopharmaceuticals. Therapeutic Innovation & Regulatory Science. 2023;57(1):160-169.

• Svenson, O., et. al. Cognitive Bias and Attitude Distortion of a Priority Decision. 2022;23:379-391.

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 This post is for educational purposes only and does not constitute medical advice. Please consult a qualified healthcare provider for personalized guidance.

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