Too much lab testing, or too little?

You’ve heard the scenario.  Or maybe you’ve lived it.

“…and they ran all these tests on me…”

Or some variation on that theme.  A reference to “all that lab testing”, a “whole bunch of lab tests”, or something similar.

What the general public generally doesn’t understand is that so many symptoms overlap.  A single symptom could be a manifestation of a whole cluster of health conditions.

For example, “fatigue” could be anything from low thyroid function (hypothyroidism) to adrenal fatigue to mitochondrial dysfunction to a nutrient deficiency to a chronic bacterial/viral/fungal/parasitic infection to venous insufficiency or other cardiovascular dysfunction to malabsorption syndromes to autoimmune disease to anemia to…

…well, you get the point.

As a doctor, I assume a certain (significant) amount of responsibility for getting people well.  After all, that’s my job, and if I don’t do everything I can to reach that goal, then what’s the point of coming to see me?  If I didn’t do my job, I’d be incompetent, and those who set foot in my office would continue to suffer.

Who wants that?

I don’t suspect that anyone would raise their hand and say, “Oooh!  Me!” (I’ll take the time to insert the visual of a sympathetic wry grin here, because I don’t want to come across as a sarcastic jerk, because that’s not where I’m going with this.)

Rather, I take the health and the trust of my patients very seriously, like I’m sure that the vast majority of doctors do, even if they don’t always get around to saying so.

Taking someone’s health and not failing their trust means that I use everything I have available at my disposal in order to get to the root(s) of their current concerns as efficiently–but also as thoroughly–as possible.  There are extra points for speed, but not at the sacrifice of accuracy.

The tools I have at my fingertips include:

Lots of questions, either asked and answered on intake forms or during consultations

Clues acquired during observation and a thorough physical exam

Lab tests, every one of which tests for only one thing, never telling the whole story, and thus, necessitating panels made of multiple tests

Diagnostic imaging, including plain film X-Ray, ultrasound, MRI, and the like

None of these investigative tools are perfect.  Some are more specific than others, and if we’re lucky, the diagnosis can be nailed down fairly quickly, after just a handful of procedures.

But I’ll repeat: very few of these procedures and lab markers are perfect.  The older ones–the ones that insurance companies tend to actually pay for–are indeed older, often inferior, less specific, and often, quite vague.

This is why I must often resort to either:

1 – Larger panels of these vague, non-specific markers, and/or

2 – Newer, more specific, specialty functional lab testing (which unfortunately, is tougher to get covered by insurance, save for a few lab companies who have the resources to negotiate)

What people need to understand is that for every test a doctor doesn’t order, they’re having to make a guess.

Some guesses are safer to make than others; those guesses are ones that I’m more comfortable making.  It’s in those situations that I’ll forgo the lab test and make an assumption or two.

(But even then, one must proceed with caution; you know what they say about the word “assume” and how it’s spelled and all that.)

Why is it so important to order enough testing?

Well, because if you have the fatigue symptom I used in the earlier example, and I make the assumption that it’s because your adrenal glands have fallen asleep (figure of speech), and I start giving you licorice root or something to get them going again, and I haven’t even tested your adrenal function yet, I’m taking a gamble.

And if you’re my patient with the fatigue, I’m gambling with you and your health.

If we get lucky and the root of your issue really is adrenal fatigue, then congratulations to us – we won.

But so often, that wouldn’t have been the case.

Thyroid dysfunction is much more common in my office than adrenal fatigue.  So is unrealized autoimmunity–the people walking around with autoantibodies to their bones, brain, intestines, nerves, heart, thyroid, tissues, you name it…without even realizing it.  They have no idea they have these problems because no other practitioner had bothered to look.

I can hear the (understandable) protests of many people now: “but they just ran all these tests!”

I know.  But let’s look at what they ordered.  What follows is a true story of a real patient.  I’ll use the terms “they” and “them” to maintain their full anonymity, including gender.

This person came in with a whole host of health concerns…and a whole battery of tests.  Tests that sounded extensive and impressive, but actually revealed little.

“Let’s look at your body’s functions,” I suggested, and began to briefly explain each.

“Oh, I’ve already had that done,” they said.  They passed me the stack of lab results, and I took a good look.

“Checking adrenal function” amounted to a single blood cortisol reading.  At least they noted the time the sample was taken, which prevented the test from becoming utterly useless.

But what about the free fraction of cortisol, the form in which cortisol actually exerts effect on the cells of the body?

Not ordered.

What about the other three readings that other labs offer in a preset panel in order to provide a readout of the daily rhythm?

Not performed.

What about the other adrenal hormone, DHEA, which is so important to compare cortisol levels against in order to get the whole story?

Not done.

Let’s move onto the next test this person came in with…

“Checking thyroid function” meant checking TSH only, without regard to any of the other hormones, and none of the hormones that are actually made in the thyroid gland itself.

T4, the main thyroid-made hormone?  T3, the bioactive form of thyroid hormone?  Reverse T3, the “dead” form of thyroid hormone that provides a red flag that something might be amiss in the body?  T3 uptake?  Others?

Nothing else had been done.

What could I glean from that test?

Nothing.

Ok, moving on to the gluten sensitivity/Celiac panel.

Negative.

Not really, but that’s what the page said.

I say “not really” because the standard marker they ordered is an immune system protein that starts declining in our 20s and 30s, giving rise instead to a different, related reaction protein that the test panel doesn’t include.  And this person was older than that.

What information could I use from that test?  Did it rule anything out or answer any questions?

Nope.

This person was in their late 30s to late 40s.  How accurate was that panel?  Should they avoid gluten or not?  Do they have Celiac Disease or not?  How serious should they be about eliminating gluten from their diet?  Would they ever be able to eat gluten again?

We’ll never know.  I have a test that could have answered all those questions, but because it wasn’t covered by insurance, the person declined it.

The last lab result in the stack was a stool test, to screen for infections in the GI tract.

Also negative.

Except that it was a culture-based test, as opposed to DNA analysis (in which the equipment screens for the non-human DNA of microbes).  And stool cultures can only test 3 bacteria.  Only 3 species–Lactobacillus, Bifidobacter, and E Coli–will grow in culture.  And they’re hardly ever the bad guys you’re running the stool analysis to screen for.

Yet another test that sounded similar to those which I order…

…but come up extremely short.

Everything had come back “negative” and “normal”, but was it really?  Could I trust it?

Nope.

So, even when it sounds like a bunch of tests have been run, the usefulness might be limited.  Very limited.

I often feel like a schill for the lab companies, because practically every patient will eventually need plenty of testing.

But if I actually had stock in or got kickbacks from these lab companies (which would be highly illegal and unethical, by the way), I might have updated my 16-year-old pickup truck by now, yes?

But although these folks understandably feel pretty alone (they’re chronically ill, after all), what they don’t yet know is that they’re not.

I’ve seen issues like theirs before.  (In fact, that’s my specialty, so my practice is exclusively made up of those people.)  And what they also may not realize is that, since I’ve been doing this for a few weeks now (wink, grin), I already know what evaluations we’re going to need to do.

This ain’t my first rodeo.

So did the patient’s previous practitioner order too much testing, or too little?

Well, the answer is, they ordered the wrong or incomplete versions of each.  They missed the point of all four, and ran cheaper, shoddier variations of all of them.

They ran too many of the wrong tests and too few of the right ones.

Why did I tell her we needed to check these areas and functions again, using my lab test selections?

Because if I had kept mum about mine and continued to feel our way in the dark, and it came to light later that I had something better up my sleeve, not only would this person have continued to suffer (and remember what I said in the very beginning about what’s the point of going to a doctor if they’re not going to be able to help you?), but they also would have demanded to know why I didn’t speak up about the superior versions of testing.

And they would be 100% correct.

And I would have no excuse.

This does put doctors in an interesting catch-22 predicament:

If we order the testing we know people need, we’re accused of committing overkill.

But if we neglect to run a test, and it turns out that it would have been useful after all, then we’re accused of incompetence and malpractice.

So when faced with the dilemma of giving the illusion of “overkill”, versus committing negligence and malpractice…

… I think I’ll choose “overkill” and let everyone criticize me for being too thorough.

I’ll go the distance.

And I guess everyone else will have to either deal with it or visit a practitioner who’s comfortable with the mediocrity/incompetence option.

🙂

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