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Miscellaneous thoughts and ramblings
Tuesday, September 06, 2005
Test Me For Everything
A common misperception among patients is that laboratory testing of their blood tells me absolutely everything about their health. They think that if their blood is drawn then all diseases will be either diagnosed or ruled out, because their blood will be tested for everything, like with a Star Trek tricorder, or a level 4 diagnostic. If later I tell them that their cholesterol is normal they assume this also means that I've ruled out pancreatic cancer, or a brain tumor, or being flattened by a truck tomorrow. This is a typical discussion.

Me: Mrs. Jones, the blood tests that I ordered last week showed some inflammation in your liver. Have previous doctors said anything about this?

Mrs. Jones: No, and my gynecologist just checked my blood a month ago. He said he was checking my hormones.

Me: Do you know if liver tests were in the tests he ordered?

Mrs. Jones: Oh, I'm sure he checked everything.

Me: Oh, I'm sure he didn't.

Mrs. Jones: You mean he didn't do all the tests? Does he think I'm in an HMO or something?

Me: No. I just mean that there are hundreds of different available blood tests and the vast majority have nothing to do with your specific issues. No one gets every test, and if anyone did, most of the tests wouldn't give any useful information.

Mrs. Jones: But he said everything was OK.

Me: He meant everything he checked was OK.

Mrs. Jones: So my liver might not have been OK? Should he have checked my liver?

Me: I'm not saying that, I'm just curious if he did, just because that will give me a clue about how long this has been going on.

Mrs. Jones: So what did he test for?

Me: I don't know. I'll call his office and ask him to fax me those results. Meanwhile I'd like to do some more blood tests to check what might be wrong with your liver and make sure that you don't have viral hepatitis.

Mrs. Jones: OK, but this time please test me for everything.

My previous reflections on doctoring:

Vitamins = Crap (Mostly)
You Should Know Better Than That
I Really Appreciated This Visit
If I could be a doctor...
If I could be an astronaut...
Gawsh, You’re Awful Purdy!
Going Around
What Is It?
The Secret To Longevity
Thank You, Doctor
Senior Sadness
Reminds me of a joke:

What did the Zen Buddhist say to the hot dog vendor?

"Make me one with everything."
There is a disconnect between Docs and patients. I am not suggesting that you are part of this, but all too often we feel like we are getting shafted and here is why.

We go to see you about our health. It is a topic that you are highly educated about but that education is not necessarily shared by your patients.

As health is such a serious issue there is a small feeling of worry that about things that could be wrong with us (patient) and often we do not know what questions to ask.

I guess what I am saying is that what may seem normal and routine for doctors is not always shared by the patient, so we spend a lot time trying to read the look of the doctor to make sure that things are ok.

If patients knew a little bit more about what was going on it would probably reduce some of the anxiety.
Jack has a good point. A lot depends on (a) the patient's capacity to ask pertinent questions; and (b) the doctor's capacity to answer intelligibly.

During the four years that I pastored a church, I sometimes found myself in the position of mediating between doctors and patients. The patient would express their fears to me, and I would make sure the doctor was asked the right questions; then I would check to make sure the patient understood the answers, which they often hadn't.

It's a problematic dynamic for both parties.
To stick up for my dear husband, sometimes the problem is that the Doc answers the questions but the patient doesn't "get" the answer. You see in the previous interaction that Dr. Bean actually takes the time to explain that no patient needs "all the tests" and that this information would not even be useful. The patient then goes on to ask for "all the tests" again. This happens to Dr. Bean all the time. I hear the phone calls.
Ralphie: pa DUM pum.

Jack and Q: You’re both right. I’m making light of a potentially very serious issue. Since I’m a primary care doctor and don’t do surgeries or procedures, 75% of what I do is teach. There’s frequently a huge chasm between me and the patient not just in terms of information but also in terms of expectations and anxiety. Sometimes I can educate that chasm closed, sometimes not. Just this morning I saw a successful financial analyst whose boss was just diagnosed with a brain tumor. Obviously, that’s a scary thing to watch, and he’d like to do whatever can be done to make sure that he stays healthy. So I talked to him about what diseases we can screen for but I was also honest that there’re a lot of diseases that we can’t screen for. Brain cancer is almost always lethal. Catching it earlier hasn’t been proven to change that. It’s sobering, but there are a lot of diseases that I could have right now that could kill me within a year and diagnosing them now or in 6 months wouldn’t make a bit of difference. Despite the incredible strides we’ve made in preventing strokes and heart attacks, in 2005 we still have to live with risk, and the scary truth is that there is no such thing as a “clean bill of health”.

ball-and-chain: You’ve always got my back, honey. Thanks. It’s a weird cultural thing being married to a doctor. You don’t have the technical training but you get all the cultural stuff that the rest of the world doesn’t get. Like that you can’t be tested for everything.
sometimes the problem is that the Doc answers the questions but the patient doesn't "get" the answer.

That's what I meant, when I talked about checking whether the patient understood the answers. Sometimes it's the doctor's fault for not explaining clearly, but sometimes the patient is overwrought or just not that bright.

I should also mention that I was speaking in the abstract, not about Dr. Bean specifically. Dr. Bean's communication as reported in the post is crystal clear. I assume Jack would say the same.
We seem to be on the same page.
That reminds me of a typical interaction with a patient:

I see a new patient who comes in to establish care. I take a full history including his past medical history, family, etc. Ask a bazillion (give or take) review of system questions, and examine him fully from head to toe.

As he's leaving, he asks me if we can schedule a physical.
Psychotoddler: OMG! That happens to me all the time. It really makes me think that the patients are speaking a different language than me. “A physical? Sure. Let’s schedule that. Just for my edification, what would happen on that day that didn’t happen today? Do I need to wear my ‘welcome to your physical’ rainbow wig?”
Oooh...I'd like to see that!

I used to work at an 'Olde Tyme' clinic. Not really. It was a clinic established about 50 years ago that used to cater to white collar workers at the local industries. They had 'executive physicals' which nowadays no insurance company would pay for, but they were perks the company provided.

In addition to the head to toe exam, they also got a free treadmill stress test, colonoscopy, 'all' the lab tests, Chest Xray, and i think a manicure. Then we would provide them with a typed summary that they could take to south america i guess. Probably a lot of that was useless (maybe not the manicure) but that's what they considered a 'physical.'

All this 'talking' and 'examining' doesn't count for much in that mindset.
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