Monday, June 25, 2007

Testing.... testing....

“Never,” admonishes the old, beak nosed, fossil of a medicine professor, resplendent in a pristine white coat at the foot of some hapless victim’s bed in mid Grand Round, “never, request a test to which you do not already know the result!”

We somewhat more shabby looking and infinitely more sleep deprived juniors huddle round the hapless punter’s bedside, gazing at our shoes and wishing that Dr Bloggs hadn’t blurted out the first test that came into his head when the Prof quizzed the assembled company as to what was to be done to our victim next. After the round we would all shamble off to the mess and commiserate with poor old Bloggs, whilst secretly congratulating ourselves that for this round at least we had evaded the basilisk’s gaze.

Then we would have a group chunter about the arrogance of old age and professed professorial omniscience. How could we be expected to diagnose and treat without the freedom to do tests. After all we had sweated and strained for years to train to this point, finally to be given the run of the toy-box that was the path lab, only for our elders and betters to now repeatedly nag at us not to use it.

I’ll warrant that there isn’t a houseman / intern trained in the past four decades for whom the above scenario doesn’t ring true. And yet as I sit here in what I take to be the mid-point of my career, I find myself more and more on the side of the fossils. Perhaps this ossification is just a part of the natural conservatism (very small c for this writer) of advancing age and experience, but it comes more form the increasing realization that the more tests you put otherwise healthy folk through, the more anomalous results you find, and the less you have a clue what to do with them.

As a case in point I offer the following. Our local path lab has recently “enhanced” its level of service by including for free in all liver function tests an assay of an enzyme called (in short hand) Gamma GT. This enzyme is well recognized as a marker for excessive alcohol intake, but sadly it is not at all specific as other forms of chemical challenge to the liver (including many prescription medications) will also provoke a rise in levels.

In these days of health promotion and disease prevention we have a lot of patients on med’s (especially statins) that require regular monitoring of their liver function. In the past six months, since the path lab’s generous “upgrade”, many of them have had their liver function tests reported as “abnormal” as a result of higher than expected Gamma GT levels. Doubtless a number of these patients will have taken our advice about a glass of red wine a day being good for the heart a little too literally, but the majority (we are a sober society here in Ambridge—Eddy and Lillian notably excepted perhaps…) will not. And now they have “abnormal” Gamma GT’s what are we to do with this unasked for knowledge.

We have invited a professor to comment.

An eminent professor from the centre of excellence.

I’ll leave you to guess what his reply was….

4 comments:

Shinga said...

Dr. J - are you obliged to mention these abnormal LFT levels in information that you might be asked to provide to insurers, employers etc.?

This is the perfect example of a test result that you would be loath to be put on a networked computer system to be hacked and misinterpreted by all and sundry.

Regards - Shinga

Doctor Jest said...

Shinga-- you are right on both counts. Insurers seem to have stopped specifically asking about alcohol and tobacco use recently, but still ask for all results of investigations.

As for central data holding and confidentiality, don't even go there. (It's a bit of a GP Hot Button issue I'm afaraid.)

Z said...

This reinforces my own rule...never go to the doctor unless you are pretty sure that what you have won't, eventually, get better on its own. And ignore all letters suggesting you make an appointment for a check-up.

Doctor Jest said...

z-- I have no problem with your rule re checkups. After all to quote John Stewart Mill "Over his mind and body the individual is sovereign."

The only thing I would say is that under the shiny new GP contract we are obliged to invite patients for check ups a lot more often now, and if they fail to respond to our initial invitation, in theory we are required to send another, and if need be a third, before assuming our service is not required.

And we are required to do this every year.

To avoid the junkmail this will subject you to it is well worth contacting the surgery and politely declining their kind offer. This especially applies if you have more than one of a list of defined ailments, each of which we have to send for separately which could significantly increase the ammount of "spam" the surgery may subject you to.