The Numbers Fetish (9/24/12)
Are You More Than Your Lab Test Numbers?
I’ve heard the story many times: a patient comes into a doctor’s office for a “checkup”. He or she is handed glowing lab reports, told they’re in the peak of health – walks out and drops dead.
So our lives are more than the sum of our lab numbers. But in the “empowered” world of “evidence based medicine” quantitation is king.
Doctors are now more intimate than ever with their electronic medical records. Some spend an extra two to three hours each day inputting data before the machines and the quality assurance offers let them go home.
What happens to all that stuff that doesn’t show up in numbers or checked symptoms on the electronic chart?
Congratulations – you’ve become what Abraham Vergese calls the “iPatient.”
It’s an increasingly universal experience.
A Personal Moment
Some time ago I was regularly writhing with pelvic pain. I went to see my internist. Waking up in the middle of the night because your private parts are burning does concentrate the mind.
It was also time for the the “yearly checkup.” He went through an exam of my chest, felt my prostate at my request, told me that everything “sounded good.”
Then he left. I cleaned up and waited to talk to him in his office. He was pleased. He liked how low my cholesterol was, my blood pressure, my weight, and other test results. I was in “great shape.”
I asked about my pelvic pain. He waved his hand. “Well, that.” I was referred to the urologist. I was let go with the message I was in “terrific” shape.
I certainly did not feel that way. I felt worse when I looked over the NIH guidelines for what my urologist felt I had. Going through those numbers put me at very high likelihood of becoming permanently disabled – and soon.
Perhaps my internist was trying to make me feel better – and let me know there was a way out of the problem. Another interpretation was that he was stumped about what I had.
But there was a solution. I ended up diagnosing myself, talking with other doctors around the country, and setting up different treatments with a physical therapist. She had lived through similar experiences. I had to change a lot of my daily activities, but it all worked.
If I had followed standard medical advice chances are very good I would not be working right now.
But my numbers were “great.”
The Numbers Fetish
We can illustrate what happens to a slavish interest in lab numbers by looking at the problem of prostate cancer.
For years the PSA was the sine qua non of urological practice. What did urologists do every day? They checked PSAs. If they increased above a set limit, men got prostate biopsies. Often they got several.
Those biopsies hurt, and occasionally caused permanent problems.
But if prostate cancer was “found” the choices were surgery or radiation. And many of those treated felt “saved” from death.
Different voices were slowly raised. Pathologists knew well that prostate cancer was found in “normal, healthy” twenty somethings – sometimes kids. If you biopsied elderly men virtually all of them showed some evidence of prostate cancer. But that prostate tumor would rarely kill them.
It took decades for proper clinical trials to get done. Finally the realization hit that for every man treated for prostate cancer, 30-100 were treated unnecessarily.
Many of those treated become impotent. Some lost parts of their bowel. Others could not control urine flow.
Yes, lives were saved. Prostate cancer kills a lot of men. But many other lives were ruined.
When the National Institute of Medicine looked at the data, they recommended against most PSA screening. The inventor of the test said screening was an engregious misuse of what he had created.
The PSA is extremely helpful in following prostate cancer patients.
Today PSAs remain an item of great contention. But the knee jerk response of the last several decades – surgery or radiation if tumor is found on biopsy – unnecessarily treated millions and millions of people.
What Is Lost
Lab tests can tell you a great deal. Yet they give you just the slimmest snapshot of the life of a human being – and their overall state of health.
What get missed? Many things: Psychology. The social life and engagements of people. What they care about in life. The feeling of human connection that is critical to the doctor-patient relationship. You also can lose a big part of medical care – the doctor as drug. A large part of the placebo response comes from feeling the person treating me is concerned and wants to do their best to make me well.
Information processing is what the body does. Greater use of many different forms of information – and understanding what they actually mean – will and must transform the future of health care.
But that should not be let people and physicians become bamboozled by numbers. For most of what goes on in the body there are no lab tests. For love, spirit, hope and caring are hard to quantitate. They may often matter as much as the pixels flaring up from the doctor’s computer tablet.
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