When Tests Create More Questions Than Answers
Modern medicine has extraordinary diagnostic tools. Blood tests, scans and advanced imaging have transformed our ability to detect disease early and accurately. Used well, they are invaluable. Used without sufficient clinical context, they can sometimes do more harm than good.
In rheumatology, many patients arrive having already undergone extensive testing — sometimes self-requested, sometimes arranged before a full clinical assessment has taken place. While these investigations are often done with the best of intentions, they can unintentionally create confusion, anxiety and uncertainty.
As I often say to patients:
“Tests are tools to support a clinical assessment — they are not a substitute for it.”
Why We Investigate in the First Place
The purpose of investigations is to help answer a specific clinical question. A blood test or scan is most useful when it is requested to confirm or refute a diagnosis that has already been considered through careful history and examination.
Problems arise when investigations are used as a starting point rather than a follow-up step.
“Good medicine starts with listening and examining — not with ordering tests and seeing what comes back.”
What Are Incidental Findings?
An incidental finding is an abnormal result that is unrelated to the symptoms that prompted the test.
Common examples in rheumatology include:
a low-titre positive ANA in someone without autoimmune features
age-related or degenerative changes on MRI scans
mildly raised inflammatory markers without clinical inflammation
imaging reports describing changes that are common and non-pathological
These findings are extremely common — particularly as we age — and most do not represent disease.
Why Incidental Findings Can Cause Harm
While incidental findings are rarely dangerous in themselves, the downstream effects can be significant.
They can lead to:
understandable anxiety and loss of reassurance
repeated testing to “keep an eye on” an abnormality
unnecessary referrals or treatments
people feeling labelled with a diagnosis they do not truly have
As I explain in clinic:
“Not every abnormal result is abnormal for you — and not every abnormality needs a diagnosis.”
When Over-Investigation Becomes Harmful
I do sometimes see patients who come to harm — not through missed diagnoses, but through a gradual accumulation of unnecessary tests, referrals and treatments triggered by incidental findings.
“What begins as reassurance-seeking can, over time, turn into anxiety, loss of confidence in the body, and medical decisions that offer no real benefit.”
Once this process starts, it can be surprisingly difficult to stop.
Self-Requested Blood Tests and Scans
Increasingly, patients arrive having arranged their own blood tests or scans, often privately and without clinical guidance. This reflects understandable concern about symptoms, but it can create challenges.
Tests requested without a clinical framework:
may not relate to the underlying symptoms
often detect normal biological variation
rarely provide reassurance, even when normal
“I frequently see patients who are more worried after testing than before — not because something serious has been found, but because results have been taken out of context.”
This is particularly true for autoimmune blood tests and advanced imaging, which require careful interpretation.
You may find it helpful to read Blood Tests in Rheumatology: What Do CRP, ESR and Autoantibodies Really Mean?
Investigations Before a Full Clinical Assessment
A related issue is testing that occurs before a patient has had a thorough consultation.
In these situations, tests may be ordered:
to ‘cover all bases’
because access is easy
in response to understandable anxiety
However, without understanding the pattern of symptoms, examination findings and medical history, such testing risks being unfocused.
“Investigations are most powerful when they follow a careful assessment — not when they precede it.”
Why This Is Particularly Relevant in Private Practice
This issue is particularly relevant in private practice, where access to investigations is often quicker and broader. This can be a real advantage when tests are genuinely needed.
However, easier access also increases the likelihood of uncovering incidental or borderline findings that are unrelated to the original problem.
“One of my roles in private practice is not just arranging tests, but helping patients decide which tests will genuinely help — and which are more likely to confuse matters.”
Thoughtful restraint is therefore not about doing less; it is about doing what is most appropriate.
Normal Variation Is Not Disease
Human biology does not fit neatly into reference ranges. By definition, a proportion of healthy people will fall outside “normal” values on blood tests or scans.
This is especially true for:
autoimmune markers
inflammatory markers
imaging findings
Understanding this variation is a core part of specialist practice.
“Reference ranges describe populations — they do not define illness in individuals.”
Reassurance Without Dismissal
Recognising incidental findings does not mean dismissing symptoms. Pain, fatigue and functional limitation are real, even when investigations are reassuring.
This is particularly relevant in conditions such as:
fibromyalgia
hypermobility spectrum disorders
chronic fatigue syndromes
You may find it helpful to read Fibromyalgia: Making Sense of Widespread Pain and Fatigue and Joint Hypermobility: Symptoms, Diagnosis and Management.
The challenge — and the skill — lies in explaining results clearly while avoiding unnecessary medicalisation.
“Sometimes the most valuable outcome of an investigation is the confidence to say we don’t need to go further.”
A Balanced Approach
This is not an argument against investigation. Tests save lives and are essential in many situations. The aim is balance.
Good medicine involves:
careful clinical assessment
selective, targeted investigations
interpretation in context
clear explanation and reassurance
“More tests do not always mean better care — better judgement does.”
Final Thoughts
In an era of increasingly accessible testing, the role of the clinician is not simply to order investigations, but to guide patients through them — helping to distinguish what matters from what does not.
For many patients, clarity and explanation are as important as the results themselves.
Please note, these posts are for general information only and do not constitute medical advice. Dr Singh would encourage you to speak to your healthcare professional to be assessed and managed for your specific symptoms.