[Medicine-for-people]
Diagnostic Testing, Healthy Lifestyle Classes, Influenza
Douwe Rienstra
medical at olympus.net
Thu Feb 7 11:09:55 PST 2008
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Medicine for People!
February, 2008
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Contents
- Diagnostic Testing - a Brief Consumer's Guide
- Healthy Lifestyle Support Group
- Influenza Vaccine Discount
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=== Diagnostic Testing - a Brief Consumer's Guide ===
My patient, John, a 50-year-old diabetic, smiled gratefully when I
gave him the news. His blood test looked good. We'd just drawn
blood and run it through our shiny new government-certified analyzer.
"John," I said, "we just checked your hemoglobin A1c and it is
7.2. This isn't too bad. We like to see it under 7, but this is
pretty close and we should have no trouble achieving that goal."
He was happy and I was happy. With the recent purchase of this new
machine, we could measure hemoglobin A1c in our office at a fraction
of the Seattle laboratory's price. We were already performing a few
tests in our office. To increase our scope and our speed of
reporting, we purchased the new machine. We were optimistic about
the benefits.
Just to make sure, I double-checked John's Alc number (at no cost to
him) by sending his sample to our regular Seattle lab. When I
received the results, I had to call him back. His hemoglobin A1c
was actually 8.2. That's a big difference in what kind of medication
adjustment we needed to make. He was unhappy and I was
unhappy. After two more patients, two more inaccurate results, our
shiny new hemoglobin A1c system was on its way back to the
manufacturer, government approval notwithstanding.
Every year, Americans lavish billions of dollars on laboratory tests
and other diagnostic studies. Unfortunately, there is no medical
Consumer Reports to help you spend your money wisely. This month, we
try to fill that gap. We take a look at laboratory testing and
diagnostic imaging. Then we recommend a few labs we have found to be
reliable.
= Testers Must be Tested =
These days I resist the ads promising I can buy a miniature version
of a clinical laboratory system. There are just too many details
required to ensure the thing is putting out correct numbers
Laboratory machines require care and feeding. Technicians don't just
run your blood through it and collect the report. They also run test
samples for which the levels are known. They need to be sure the
machine returns the right answer. Sometimes it does not. Then the
technicians have to figure out why and correct the problem. It could
be a contaminated part, a chemical reagent that went bad, something
wrong with a pump, thermostat, heater, tube, timer, circuit board or
detector. Major labs also face continual testing by federal agencies,
which send mystery samples and require the lab to correctly identify
what they contain. The feds don't insist that all labs participate,
but serious labs accept the challenge.
= Cholesterol Roller-coaster =
Even with government testing, not all labs produce consistent
results. Have you had your cholesterol tested recently? If you were
not careful about choosing the laboratory, that cholesterol level
could have an error rate of plus or minus 15 percent. If your
cholesterol level came out as 200, it could actually be 230 or 170!
(see
http://findarticles.com/p/articles/mi_m0813/is_n4_v15/ai_6393690).
The ramifications are not insignificant. With a cholesterol reading
of 230, your physician might prescribe an expensive statin drug. Do
you really need it? You don't know if you can't trust the results.
= Nutritional Testing =
People are always interested in their nutritional status, so a few
years ago I set up a protocol using a comprehensive nutritional
analysis from a Medicare-certified laboratory in Texas. Their
technique would measure about twenty nutrients for $400, a sweet deal
considering sometimes it costs that much to measure one nutrient
using conventional methods.
I sent in the first sample. The report showed my patient low in
folic acid and carnitine. A month later, a sample from the same
patient, no change in supplements, came back low in coenzyme Q10,
potassium and riboflavin. What?!!? I called the lab. The director
explained that the values differed because they can change over
time. That sounded fishy to me, but even if the assay was correct,
it isn't worth $400 to know that your folic acid is low in January
when it will be normal again in March.
Although the dream of getting a complete accurate profile of
nutritional status seems impractical, it still makes sense, at times,
to test for a single nutrient. If you suffer from osteoporosis, it's
likely your vitamin D levels are low and I need to test for that and
supplement to bring them up. We use two different labs that do this
test, and they both do a pretty good job, say within 5 to 7 percent
of each other. Given that a low value is around 35 and a high value
over 60, that's adequate accuracy.
= Diagnostic Xrays =
Originally, all we had was X-ray, images from electromagnetic
radiation, so that area of medicine was given the name
"Radiology." Today, though, we have several kinds of images derived
from radiation, including CT (a three-dimensional X-ray) and
radionuclide scans (from radioactive materials injected into the
bloodstream) called SPECT and PET scans. We have images that require
no radiation, derived from ultrasound and strong magnetic fields (MRI).
Like laboratory tests, these tests have their limitations. I
remember a great muscular man, a meat-cutter who consulted me in
Milwaukee with severe fatigue. He looked like a football player, but
he could barely pick up his fork. He was very anemic and required
hospitalization and eventually a series of transfusions. A full
work-up including a CT scan found no cause for his severe anemia, and
the hematologist said, "It's just one of those things we won't figure
out. You'll just have to send him home and hope he needs no more
transfusions."
Having attended medical conferences at the Mayo Clinic, I was
impressed with their skill at solving tough problems. Against the
hematologist's recommendation, I transferred my weak-as-a-kitten
butcher to Mayo. They ran a different kind of imaging study and
discovered an enlarged spleen the CT scan had missed. The reason the
first scan had failed was that the spleen in this man was of equal
density with the surrounding tissue (as far as the scanning beam was
concerned), and so, like two clouds in the sky of similar shade of
grey, blended into the normal background.
= Beware of Supermarket Tests =
Recently, patients have been asking me about "Lifeline Screening"
tests. You can read full details at
http://www.rienstraclinic.com/newsletter/pre2002/2001Dec.html.
Ultrasound of the carotid arteries produces accurate results only in
the hands of highly qualified technicians using the very best
equipment. Anyone offering that test in your church or the
supermarket parking lot is much less likely to provide accurate
information. For a balanced coverage, see this Washington Post
article:
http://www.washingtonpost.com/wp-dyn/content/article/2005/07/18/AR2005071801175.html.
= Testing the Heart to Death =
Years ago, while I was giving a young man a routine physical, I
discovered an unusual heart murmur. The man felt fine, and all other
physical findings were normal, but just to be sure we did an
electrocardiogram. An electrocardiogram, or EKG, measures electrical
activity of the heart. That looked basically normal, but showed
unusual wave form. So we did an echocardiogram, in which sound waves
are bounced in and out of the heart. Sure enough, nothing was wrong
with his valves, but the test was not entirely normal either, so I
discussed this with a colleague and then sent him to a
cardiologist. The cardiologist agreed his heart was probably normal
but, just to be sure, performed a stress test. The stress test was
pretty much normal, but not quite, so the cardiologist performed a
cardiac catheterization. In this procedure the doctor inserts a tube
into an artery or vein in the leg and pushes it up into the chambers
of the heart. That test was unequivocally normal.
While most heart tests can be expensive, they carry little risk. Not
so cardiac catheterization. It can be fatal; I've seen it
happen. This is an extreme example of over-testing, but every doctor
has experienced similar situations. Sometimes your doctor will not be
too thrilled about a particular test. If she doesn't order a certain
test, it is not because she doesn't care about you. If the insurance
company bulks at paying for a test, that does not necessarily mean
they are cheapskates. The test may be unnecessary or not worth the risk.
The major diagnostic tool is the human mind, properly
applied. Diagnostic tests support, but do not replace, this oldest
of medical devices. Most importantly, you need to understand what
the test involves and decide if a particular medical test will
benefit you. Group Health Cooperative provides good, solid
descriptions of diagnostic tests at
http://www.ghc.org/kbase/browse/index.jhtml?cat=medicalTests.
= Our Consumer Best Buys =
Continuing our Consumer Reports analogy, there are good buys out
there. Our favorite lab is Labcorp, located in Seattle. Their
quality is tops and their large volume allows them to offer a good
price. If you have your cholesterol checked through our Labcorp
service here at the clinic, you know your numbers don't vary that
much from test to test unless you've begun or discontinued
medication. That's because Labcorp far exceeds required
standards. Many labs do not. Other laboratories we've found
trust-worthy include Meridian Valley Clinical Laboratory and Genova
Diagnostics. Not that all others are slip-shod, but these are the
ones we think are reliable.
We all want to forestall illness and decay, and wisely chosen
laboratory tests can help. That is why we offer "Direct Access"
testing. Many people use this service to track their own cholesterol
or general health panel. For more information on Direct Access
Testing see (http://www.rienstraclinic.com/services/lab_testing.html).
= More Medical Consumer Resources =
Medicine for People! has long been interested in helping you sort out
the useful from the worthless and the good deals from the bad
ones. Here are links to previous topics.
= Diagnostic tests =
"Lifeline
Screening" http://www.rienstraclinic.com/newsletter/pre2002/2001Dec.html
Cancer
Screening
http://www.rienstraclinic.com/health_info/cancer/cancer_screening.html
Colon Cancer Screening
http://www.rienstraclinic.com/newsletter/2005/2005July.html
Colon Cancer
Screening http://www.rienstraclinic.com/newsletter/2007/2007October.html
Mammography http://www.rienstraclinic.com/newsletter/2005/2005Apr.html
= Nutritional Supplements =
Mexican Yam "Hormone Substitute"
http://www.rienstraclinic.com/health_info/hormones/yam_scam.html
Multi-level Multiple Vitamins
http://www.rienstraclinic.com/newsletter/2002/2002Nov.html
Coral Calcium http://www.rienstraclinic.com/newsletter/2003/2003May.html
Supplement Quality http://www.rienstraclinic.com/newsletter/2007/2007April.html
= Vaccines =
Shingles Vaccine http://www.rienstraclinic.com/newsletter/2006/2006Dec.html
= Procedures =
Lasik http://www.rienstraclinic.com/newsletter/2005/2005Feb.html
= Physicians =
Physician
Evaluations http://www.rienstraclinic.com/newsletter/2005/2005Sep2.html
How to Talk to Your
Doctor http://www.rienstraclinic.com/newsletter/2007/2007November.html
= Alternative Medical Treatments =
Ear Candles http://www.rienstraclinic.com/newsletter/2002/2002Oct.html
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== Healthy Lifestyle Support Group ==
"Creating Your Healthy Lifestyle", an 8 week educational support
group starting March 6, will help you make lasting changes to improve
your health. First, this class will help you understand the choices
you currently make. Next, you will learn simple and effective
techniques to develop healthy habits and create the life you most want.
Group facilitator Christine Nock, MA, LMHC addresses specific issues
such as weight, stress, activity, self-care, and other behaviors that
impact your health.
Find out more by calling 360-821-1407 or visiting
http://www.rienstraclinic.com/services/classes.html . The class runs
from 4:30 to 6:30 pm Thursdays, and is limited to six
people. Register now for this life changing group.
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== Influenza ==
According to the Centers for Disease Control at
http://www.cdc.gov/flu/weekly/ , influenza activity is
increasing. Here in Port Townsend we are seeing more frequent and
more severe influenza-like illness. We have a few doses of vaccine
remaining, which are available at a mid-season discounted price of
$18. Please call 385 5658.
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Medicine for People! is written by Douwe Rienstra MD, edited by
Carolyn Latteier, and published at Port Townsend, Washington.
Copyright February, 2008.
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