Would you rather?
- Jeanette Thomas
- Apr 15, 2024
- 7 min read
We’ve all played it as a hypothetical game, right? Would you rather touch a dead rat for five minutes, or lick your dog’s poop for a second? It’s rarely a choice between two good things, like chocolate cake or apple pie. The game is never an obvious choice, like dog poop vs chocolate cake.
Would you rather DIY your botox, or do it in a doctor’s office? Is your distrust of the medical system so great that you’d prefer to play roulette with your health—botox does stand for botulinum toxin—than see a licensed provider in a clinic and run the risk that your insurance won’t cover your procedure?
We believe that we are immune to buying snake oil, because we have the ability to test and measure so many things. We can check our DNA to see if asparagus makes our pee smell, or if we are super tasters of cilantro, rather than use our senses. (Full disclosure, I did participate in a DNA study, and I have neither trait. But I already knew that). We’d rather consume a supplement formulated just for us than take an over-the-counter multivitamin which is likely very similar in composition.
The same is true for most personalized panels of labs run on relatively healthy people in a spa or wellness setting. You paid for that out of pocket, didn’t you?
I’m not talking about a cholesterol screen or diabetes test, a screening test with clearly established benefits. And the medical establishment isn’t immune to looking for the latest and greatest lab or treatment for the fountain of youth.
Vitamin D was all the rage a few years ago—checking levels, using weekly mega doses (50,000 IU [international units], studied in dose up to 100,000 to 200,000 IU weekly). It’s still a popular lab and patient request. It turned out with further study that all most of us actually needed was to take a regular dose of a vitamin D supplement (400 IU daily). Measuring didn’t make it better. None of us had rickets from a severe vitamin D deficiency. And, because it is a fat stored vitamin, you can get too much.
https://ods.od.nih.gov/factsheets/VitaminD-Consumer/ which also has a link to a lengthy version for health care providers.
https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d/ If you don’t trust the NIH for some reason.
"It would be...nice...to know”:
In medical school, we had a pathology professor with a big, booming Irish voice and a belly to match. He was the kind of teacher who was a self-acknowledged equal opportunity asshole. We loved learning from him. He mocked one of my male classmates for knitting in class, and asked if he was "a Gladys". My classmate named Gladys said, “Hey! I’m a Gladys.” He apologized to her and continued to mock the guy knitting. This was the late 90's--it would never fly today.
He taught a lab medicine course to fourth year students, and many of us tried to make that classroom lecture fit into our schedule of clinical rotations. Yes, we went out of our way to sit in a lecture hall for an hour every day instead of being on the wards, seeing patients. Despite the insults, the constant need to be on your toes (or perhaps because of them), his messages stuck. We learned so much. I still hear his voice ringing in my head, complete with dramatic pauses:
With a wrong answer-- “NO!!! Have you even been listening?” after a pause-- “but brave attempt”.
“The more different specialties involved in the care of a patient, the more likely it is that none of them have a bloody clue what is wrong or how to fix it.”
And: “When someone says, 'it would be...nice...to know...' means that we have no idea what the fuck to do with the answer to this test. We are ordering it for no reason.”
Rarely does anyone—doctors or patients-- want to hear “it would be nice to know” means the test is bullshit. If we don’t have a plan for a test result, if it isn’t to rule something in or out, to change course or diagnose a disease, then we shouldn’t be ordering it.
There are so many things we can measure and quantify in the lab now. They aren’t all useful. THEY AREN’T ALL USEFUL. We are swayed by the temptation that knowledge is power, even when we haven’t got a bloody clue what to do with that knowledge. Never mind that the hormone levels being tested naturally vary throughout the day or the month, and the timing influences the test result, or that the level doesn’t necessarily predict disease or health. We treat the symptoms, the patient, not the lab.
TREAT THE PATIENT, NOT THE LAB.
Sorry to all caps yell today, but some things need a bit to sink in.
You shouldn’t pay hundreds, thousands of dollars just because your naturopath or fitness coach or chiropractor or dog walker recommends that you should have x panel done. There’s a reason that your insurance didn’t cover this panel. Do not ask your primary doctor or your gynecologist to measure something if we don’t have a plan for the answer, or because your insurance will cover it if it’s ordered by your primary.
Normal and abnormal results have to be taken in context, and one point above or below the standardized normal may not mean a problem exists. We don’t all fall on a bell shaped curve. A “normal” kidney test in a pregnant woman can be very abnormal in the context of preeclampsia.
Do not skip the tests recommended by your doctor, like your cholesterol or thyroid levels, in favor of a customized hormone panel or vitamin levels.
A four or ten page printout with “personalized recommendations” doesn’t guarantee health or improved quality of life. Seven tubes of blood drawn does not mean that you are getting A+ care.
The customized and compounded substances based upon these tests aren’t necessarily better than those approved by the FDA—in fact, they are sometimes dangerous because they aren’t regulated in any way. Many of these pass through the body via the kidneys without being absorbed-- “you are making really expensive urine”. (I cannot take credit for that wording, but it is an apt description).
I am all for a benign placebo. If getting these tests inspire you to take the walk, change your diet, lift the weights, then it may be worth the out of pocket costs to you.
We all know that accountability and paying for something inspires us to stick with it, to do better. Tracking what we eat and how we move works for better health because we see it and realize that sometimes our habits are...suboptimal:
The day I snacked instead of having an actual meal, I consumed 3000 calories. I really did walk only 1200 steps at my mom's house on a blustery winter day, too cold for my dog to want to go out. One glass of wine turned into half a bottle. No wonder I feel crappy.
Your insurance or company likely does have a wellness program that offers similar inspiration, screening labs, accountability, but it's free, and therefore we're inclined to believe less worth our time.
The exceptions: if you are participating in a study for something, by all means get the 7 tubes of blood drawn as part of the study. If you have a rare condition, or it runs in your family, if you have a cancer or concern, and your doctor recommends the tests, then you should get them. If you are hospitalized and nobody can figure out what the fuck is ailing you, sometimes the shotgun approach yields an answer.
But usually the answer is in the history and physical, not the lab.
If you do have a well-studied test that was abnormal and nobody knows why, it makes sense to ask. And maybe ask again.
Case in point: screening for birth defects.
We didn’t always have great prenatal ultrasound—early ultrasound was pretty shitty and blurry. In the 1960’s, an association between an elevated maternal blood level of alpha-fetoprotein (AFP, we love acronyms) with fetal spinal defects (spina bifida, neural tube defects, or NTD) was reported, investigated, and AFP levels were found to be an appropriate screen for these defects. By looking for AFP in mom’s blood, we could estimate if she had an increased risk of a baby with spina bifida. Eventually we realized we could decrease this risk with folic acid supplement
(and guess what? an across the board supplement, not based upon personal blood levels of folic acid. Moms with a higher risk, based upon their history, get more folic acid).
Flash forward a decade to the 1970’s. A woman had a very low level of AFP, undetectable. Nobody knew what to do with that result. According to my pathology professor, she asked everyone why. She delivered a baby with trisomy 18, (AKA Edwards syndrome, rarer than Down Syndrome, these babies almost never live beyond a few days). She asked again why, why, could this be related to my abnormal AFP test? Doctors, med students, nurses, the janitor. Finally, someone looked into it. This index case was a “fortuitous finding”, which led researchers to look back on study patients for other defects associated with a low AFP. Which in turn led to other combination tests to look for abnormalities before babies were born. *
Many of my patients would think that the only reasons to do such screening tests were to terminate a pregnancy if a baby was known to have birth defects. These tests can prepare families for babies that may need surgery, before or after delivery, may need to deliver in a specialty center, may only have a few hours or days to live.
Case reports lead to case studies, lead to reviews of larger groups, and ultimately, the gold standard of testing, the randomized controlled trial. (when appropriate). But they don’t generally come from an 11 page report of labs that were ordered to personalize your care.
Data, people. Ask why, with a specific question. Not (in booming Irish accent) “it would be...nice... to know.”
And for God’s sake, don’t do Botox injections at home.
* Merkatz, IR, et al. “An association between low maternal serum alpha-fetoprotein and fetal chromosomal abnormalities” https://pubmed.ncbi.nlm.nih.gov/6201071/#:~:text=Am%20J%20Obstet,84)90530%2D1
Thank you! Such good info!