Running Late - Annals of Internal Medicine: Fresh Look Blog


Wednesday, February 28, 2018

Running Late

Sometimes I feel like I work at a burger joint instead of a primary care clinic. Patients come in requesting blood tests or medications as if they’re following a gastronomic craving, “Yeah, and toss one of those vitamin checks in there, doc,” as if BMPs might come with a side of fries.

Part of this is because my patients don’t pay for their blood tests, so their results are every bit as academic to them as they are to me. I spend a not insignificant amount of time explaining why certain tests are or are not indicated, and I see this as an important part of my job as a primary care physician. In most cases, I’m proud to say, patients seem to understand why they don’t need their thyroid/liver/kidney/etc. numbers checked every few months “just to see.”

However, sometimes the tests are ordered by others, and I am left figuring out what to do with the results. I work in a clinic with “standard order sets” that nonclinical staff are approved to enter. These sets were created to decrease the administrative burden on clinicians of ordering previsit laboratory test. However, like any algorithm, it is only as effective as it is current, so the one we have still includes a “screening” 25-(OH)D level.

Therefore, at least once a week, I receive an alert about a patient’s vitamin D level. As that patient’s primary care doctor, I am expected to notify my patient of those results. In a field notorious for a high paperwork burden, it is tempting to do just that: I could copy and paste all the patient’s lab results into a letter and click “send,” as if I am relaying an itemized dinner receipt. There is even a template in most electronic medical records to assist with this process. However, most patients expect (and, I would argue, deserve) not just result notification but interpretation. And this becomes increasingly difficult when clinicians can’t even agree on the next best steps.

After receiving a number of these alerts (and desperately attempting to understand and modify how the “order set” algorithm was set for my new clinic), I was glad to find I was not the only clinician wondering whether screening of my asymptomatic patients’ vitamin D was warranted, or whether treatment of “low” readings was necessary. Annals of Internal Medicine addressed the issue in a Beyond the Guidelines discussion, which reminds readers that “the issues of how to measure vitamin D, the optimal serum level for good health, and whether to screen for deficiency (and, if so, in which populations) or whether to recommend that all at-risk patients take a daily vitamin D supplement remain controversial" (1).

The discourse is robust, with both sides arguing their case with evidence. I was most drawn to the reminder against screening asymptomatic adults based on the lack of fulfillment of Wilson’s criteria for screening: Any test whose acceptability based on these criteria is debatable should be ordered only when it is based on clinical judgment from a clinician’s thorough patient evaluation.

So my next task is to take the vitamin D “off the menu” of standard order sets and practice my politest, “I’m sorry. We no longer serve that here.”

  1. Libman H, Malabanan AO, Strewler GJ, Reynolds EE. Should we screen for vitamin D deficiency?: Grand rounds discussion from Beth Israel Deaconess Medical Center. Ann Intern Med. 2016;165:800-7. [PMID: 27919096] doi:10.7326/M16-1993


  1. Surprisingly, oceans away, in another continent, in a 'low-resource (developing!) country'; I feel your angst! Everything comes at a price and the internet is no exception. In India, most of such requests probably stem from the education that the widely, cheaply available mobile internet is offering to patients and family members. Your stoicism and patience are appreciated.

    1. The world is definitely at our fingertips these days—literally all over the world! Thanks for reading and for sticking to patient care despite some of these new challengers of 21st century care. Our patients deserve people like you!

  2. While I comprehend the sentiment that many tests are unnecessary and believe in science and evidence, the tone sounds dismissive of patients' true need to be involved and control their actual care. Moreover, the large amount of money being invested by so many in so-called "alternative care" via supplements and other providers suggests that indeed patients are willing to shoulder the burden of such a cost as a vitamin D test. Moreover, Vitamin D, if one examines the basic and clinical research, may hold a key to preventing autoimmune disease and some cancers. We have only begun to understand vitamin D's hormonal actions. It is far more important than just for bones. Let's not dismiss patients so freely based on guidelines which are likely to change (as they have for the decades I have been in practice).

  3. Having been a primary care doctor in a past life, I share your feelings on many levels. In my current life as a hospitalist, I completely agree with your idea to "take it off the menu," which would likely be effective in reducing its rate of being ordered. I agree also with the previous responder, in that guidelines come, guidelines go, and the evidence often seems more like a balance board than solid step stool that we would like. But you have to draw the line someplace as to what is considered appropriate and inappropriate for general screening in your population / practice. This is a great opportunity for a High Value Care (HVC) project, with perhaps QI methodology to institute cycles of improvement. Your next project?

  4. While the guidelines and the evidence informing the guidelines could change in the future, it is unequivocal that current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults at this time. I wholeheartedly agree with Dr. Candler that such tests should be ordered only when it is based on clinical judgment from a clinician’s thorough patient evaluation and that this service should no longer be "automatically" offered in any burger stand.

  5. Unfortunately, we have had psychiatrists, NPs and others DOCUMENT that the PCP should address risk of developing pancreatic cancer and a host of other idiotic and unproven associated conditions just because THEY ordered the Vitamin D level ... that creates unnecessary liability concerns for PCPs ... How often should we "screen" for pancreatic cancer and other conditions?


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