STD testing: how often is too often?

[Febrifuge]

Hi, I'm wondering about others' experiences with this, or just thoughts and reactions. It's one of those "customer service" vs "being a steward of limited resources" deals.

 

The question is: have you heard of, or seen, younger people coming in for STD checks "just because?" No symptoms, no particular concerns about exposure, no cheating partners... there appears to be a segment of our patient population who considers it "responsible" just to come in and get tested. I saw someone tonight who has a clean GC/chlamydia within the past 90 days, and wanted another one. She thought it was weird when I tried to suggest this isn't how it is normally done.

 

Some caveats: I realize there is a lot of variability in terms of provider style and institutional rules or priorities. It would be great if someone knows of a hard and fast rule I could refer to, but I doubt it exists. Still, I'd love to wrap my head around the concept, and getting a cross-section from other clinicans would be helpful. 

 

I also personally think that getting a clean slate of STD tests when starting up with a new sexual partner can be a great idea; if that's the situation I'm honestly not too concerned how often it happens. Likewise, when patients are otherwise monogamous people who just found out their relationship hasn't been all that monogamous, I tend not to question them about condom use etc.

 

But this kid tonight surprised me. Just doesn't care to use barrier methods. Chooses their partners carefully, takes responsibility for their health. Always uses birth control, so understands that one can be proactive about preventing babies... yet apparently doesn't see the disconnect, or doesn't see anything wrong with being reactive about STDs.

 

Over the past 12 months, this person has had approximately 6 to 10 negative tests. There was a positive one within a year prior to that. And partly because if the history, they realize that infections can be asymptomatic. So they just routinely ask for testing, for what I would consider no apparent reason.

 

I felt like I was taking crazy pills. I tried to broach the subject of condoms, and mentioned that the tests aren't actually free in the strict sense of the word, so there's an element of being appropriate with utilization... and that conversation did not go well. So I'm asking the group: what's up with this phenomenon?

 

[rev ronin]

Why do you even do free STD testing in the ED absent cause (e.g., as part of a rape kit/SANE exam)?  There's nothing under EMTALA that could possibly require it.  Medical business stupidity abounds.

 

Having said that, I would document V69.2 and let it go at that.

[akdEM]

Over the past 12 months, this person has had approximately 6 to 10 negative tests.

 

It sounds to me like a case of some mild OCD. I don't think you were dealing with a rational person. I've had similar conversations with more reasonable patients and it has gone well.

[RealityCheck]

I experienced this in a community health center primarily with state insured individuals who thought everything was free.

Looking back, they were mostly unemployed young women often with small children born at a young age and - way too much time on their hands.

They worry about every tiny itch, vaginal discharge, sneeze, etc.

I think it brings attention to the person and they might be lonely or lacking purpose and this gives them something to worry about or talk to their friends about.

It happened with strep throat too. EVERY sore throat was strep and "maybe the test isn't right" - instead of stop smoking, there are wildfires outside, you have allergies, etc.

 

I have been in ERs too and had to explain repeatedly that ERs are not for this purpose. I would repeat their phrases to them - "you haven't had sex in 4 weeks", "you haven't had a new partner in 6 months", "you don't suspect cheating", "you have no itching, no discharge, no pain, no fever". 

I would then recommend community clinics, Planned Parenthood and condoms, condoms, condoms, condoms and even give them a bag full of condoms.

 

Too much TV, too much time on their hands and poor education and understanding of basic human anatomy and functions. It is sad. 

I do not think we should waste resources when absolutely NOTHING says the testing needs to be done - repeatedly.

 

It is a sad state of our society that burdens an already taxed medical system and makes it harder and harder for us, as clinicians, to use resources without fear of retribution through complaints or litigation.

[Febrifuge]

It sounds to me like a case of some mild OCD. I don't think you were dealing with a rational person. I've had similar conversations with more reasonable patients and it has gone well.

 

Without getting too into it, yes, there is a mental health history for this person. I thought I was doing the "respect the patient by talking to them like a person, not a diagnosis" thing, but in retrospect it would have been easier to go with the "give the crazy person what they're asking for so we can be done now" strategy.

 

This is an after-hours UC, not an ER, by the by, so we have a little more of a customer-experience focus than many places.

[RealityCheck]

Always do right by the patient.

I do believe we have an obligation to educate our patients, though, to their responsibilities and a learning curve that they have to participate in.

 

There is a fine line between customer service and coddling.

 

And, even crazy people get hurt and sick.

 

Some days it does take "whatever gets them out of here" and other days you choose the battle and try to plant a seed of knowledge.

 

Keep plugging away, my friend.

[EMEDPA]

I think they really do have some risk factors that they just don't want to talk about or they think a partner has been unfaithful, etc....if someone wants the screening and is willing to pay for it at urgent care, just do it. In the ER I refer these folks to the health dept for free screening.

[Febrifuge]

Aaaaaand, it's positive.

 

Teaching point: I guess there are a lot of different ways for patients to answer our questions indirectly (or fail to answer our questions adequately), and if someone wants an STD test they have some kind of a reason. Even if they insist they have no concerns, sometimes there are concerns. And sometimes, there should be.

 

Live and learn. I still feel weird repeating something that was recently negative, but the fact they asked might be enough of a justification. That feels like lazy medicine... but it's my experience, now.

[EMEDPA]

Aaaaaand, it's positive.

 

Teaching point: I guess there are a lot of different ways for patients to answer our questions indirectly (or fail to answer our questions adequately), and if someone wants an STD test they have some kind of a reason. Even if they insist they have no concerns, sometimes there are concerns. And sometimes, there should be.

 

Live and learn. I still feel weird repeating something that was recently negative, but the fact they asked might be enough of a justification. That feels like lazy medicine... but it's my experience, now.

now doc, could you repeat that oxycodone script too? I know I got one yesterday, but you can't be too careful, it might get lost or something....:)

[winterallsummer]

I once had a patient come in requesting a UDS in our ED because they thought someone slipped them something.  Can't make this stuff up.

 

Patients coming in for asytmptomatic STI screen do not get tested, they get sent back to wherever they came from and a referral to the free clinic and/or the health department.