The Rise in Unconventional Test Requests: How Laboratories Are Responding

As interest in complementary and integrative medicine (CIM) testing gains traction, pathologists and laboratory professionals are fielding requests for tests they may not trust or feel comfortable interpreting. This can create a complex push-pull that leaves the potential for tension and unease. How should the laboratory respond when patient requests fall outside the test menu and established standards?    

The good news is that with an empathetic and respectful approach, pathologists and laboratory professionals can navigate these moments successfully, leaving patient-provider relationships intact and keeping the door open for tests that may evolve into the mainstream over time.   

Michael Astion, MD, PhD, Medical Director of Regional Laboratories at Seattle Children’s Hospital, and Jane Dickerson, PhD, Division Head for Laboratory Medicine at Seattle Children’s Hospital, co-founded a laboratory stewardship collaborative in 2013 called PLUGS (Patient-centered Laboratory Utilization Guidance Services).  PLUGS has 110 members, who are mainly laboratories in integrated health systems and commercial labs.  

One recurring topic within PLUGS is how to respond when belief-based testing requests conflict with evidence-based practice. Dr. Astion and Dr. Dickerson explain how these requests arise, why they can sometimes be difficult to navigate, and the approaches that have proven the most effective.  

How belief-based testing differs from evidence-based care  

CIM testing encompasses a broad range of approaches often associated with functional, integrative, complementary, or naturopathic medicine. Dr. Astion and Dr. Dickerson use the term “belief-based medicine” to describe these approaches which are based on belief and experience, but on lower levels of scientific evidence.   

In contrast, traditional doctors and laboratory practitioners — like Seattle Children’s and the members of PLUGS — practice using an approach that is mostly based on rigorous scientific evidence, and which is also based on experience.    

“Evidence-based medicine has a rubric where we analyze scientific papers, regarding how good those papers are, using various kinds of statistical criteria to determine if a test meets the scientific evidence for clinical validity and clinical utility,” Dr. Astion says.   

The appropriate response depends largely on the level of risk involved, Dr. Astion explains. Sometimes, the recommended intervention related to an abnormal CIM test result may be relatively harmless or even helpful — such as the CIM provider recommending more sleep, exercise, or a nontoxic cleansing group of food or beverages. In those situations, clinicians may simply affirm the patient’s concern while gently declining to order the test. They do not have to invest significant time in trying to convince the patient that their CIM provider need not order this test.  

But when the CIM request is tied to a potentially dangerous treatment — such as IV antibiotics, Interchelation therapy, or avoiding conventional cancer therapies — the patient’s care provider will need to have a more serious discussion with the patient that they should not consider these tests.   

Sometimes patients express a desire to bring in a CIM testing kit or obtain a blood draw so it can go to a CIM lab. In these cases, one effective approach is for laboratory professionals handling the request to use a pre-written script that ensures everyone in a lab or organization is answering questions in the same way. Here is an example of such a script, which is a composite for teaching purposes used by a PLUGS member laboratory:     

“Thanks for your inquiry. The test you are requesting is not on our test menu. Our Hospital Laboratory supports patient-centered, evidence-based care. Even though the test you are requesting may have analytical validity (it can measure what it says), it is often harder to understand the test’s clinical utility: will we do something different based on the results of the test? And, will that make you better? I am not sure if we can coordinate this request, and I will check with our laboratory stewardship team to learn more. This team reviews new labs/tests before they can be offered to our patients.”  

Of course, there are always exceptions. Dr. Astion says they’ll sometimes go ahead and send out a CIM test if it means they can keep a patient in their system and maintain goodwill and understanding. For example, if they want a chronic disease patient to continue getting a particular treatment, they may send out a low-risk complementary medicine test request to maintain the relationship.   

Responding to requests to interpret external test panels  

A different challenge arises when a patient arrives with results from a CIM test that has already been performed and asks an evidence-based provider to interpret it.   

“The guidance we offer in those situations is empowering them to say something like, ‘This is not a test I would have ordered, and it’s not something I feel comfortable reviewing,’” Dr. Dickerson says. “Then we offer tests that could be alternatives, if additional testing is needed. So instead of interpreting the test, we answer the question from a new lens and help them get to the right test.”   

In other words, the goal is not to debate or denigrate the outside panel or spend time interpreting it, but to redirect the patient to a more evidence-based diagnostic path that can answer their questions.  

If the patient believes they have a diagnosis that the provider is confident they do not have, Dr. Astion says the clinicians often respond clearly but respectfully.    

They say something like “We’ve done the type of testing that is on our menu of tests, and I’m confident you don’t have that.”   

No matter the specific scenario, the guidance is to be firm but kind, utilizing an approach similar to what a restaurant would use if a person asked for a menu item they don’t serve, Dr. Astion says. There is no reason to be mean and every reason to be respectful and let them know that they are free to go fulfill their request at a health care facility that has the test on its menu.  

Laboratory approaches to testing are evolving over time 

At the same time, Dr. Astion and Dr. Dickerson emphasize that laboratory medicine is not static. In some cases, tests that once seemed peripheral may move into the mainstream as evidence accumulates and disease patterns evolve.  

Lyme disease is one example where this may already be happening, Dr. Dickerson says.   

“It’s always been a real test, but it’s been a very tricky clinical diagnosis to make,” Dr. Dickerson says. “For example, the West coast historically has not had Lyme disease. In those regions, we may talk through that risk and have a very low volume of testing. But a variety of factors can alter these geographic patterns, since ticks are migrating. That’s an area I’m predicting we’ll see a change in how we approach that testing.”   

Of course, it’s vital to keep all of this in perspective, Dr. Astion notes.   

“Even though CIM testing is getting more popular, it’s really a small part of the industry,” Dr. Astion says. “So, you’ve got to keep it in perspective. It’s no more than 2 percent of the industry. The majority of laboratory testing in the United States — and this has been the case for some time — is on chronically ill people having periodic tests to monitor their diseases”   

The challenge isn’t in the volume of requests, but in responding in a way that upholds evidence-based standards while remaining respectful and concerned. The overall goal is to maintain a positive patient-provider relationship.