Smoking Gun? Or Red Herring?

                As a family practice physician, I feel that giving patients access to their records via online patient portals has been a mixed blessing. On the one hand I’ve always been a big fan of folks having their records (see my post “Keep It Together (Your Records, I Mean!)”). On the other, understanding what those reports and results mean is an entirely different animal. People try to do it themselves, and God bless them for it, because I think they should be actively engaged in their health. But those records are just put out there with essentially no context and that can lead to a lot of misunderstandings.

                I’m not criticizing that lack of context, mind you. It takes a fair amount of time to explain what everything means and the typical workflow in a primary care clinic just won’t allow that outside of an actual visit. It’s just the nature of the beast. But getting into your doctor’s office so they can take that time and do that explaining, means time off work, transportation, babysitting, copays, and (to channel my inner Yul Brenner), ‘etcetera, etcetera, etcetera’. So people turn to Doctor Google and, quite often, end up more confused than when they started.

                Add to that the fact that every lab has their own range of ‘normal values’ for any given result, and every radiologist seems to have their own favorite stock phrases they like to use when describing xrays and CT scans, and you have a recipe for absolute mayhem.

                There’s not enough room in a blog post to help people figure all these things out. That’s literally why we spend four years in medical school followed up with anywhere from three to five years in residency. But what I can do, is go over some of the reasons why things are ordered. Maybe this will help folks understand why a result out of range is not necessarily a smoking gun (though it can be!).

                First things first: why are some tests ordered, and others aren’t? Or, even more baffling, why are they ordered in some cases of a particular condition and not in others? The rationale is, a test is only ordered if the result is going to change the management. If you’re trying to distinguish a sprain that will get an ace wrap from a fracture that will get a cast, you need that xray. But if that sore throat has been going on for a week and it’s only getting worse, and there’s goop draining out of the tonsils, you’re going to start antibiotics and worry about getting  a culture later, if at all. This gatekeeping is done because any test has a certain margin of error and you may get something that looks off when it isn't. Not only that but, if you order something unnecessary and it comes back abnormal, you have to take time, resources and attention to do something with that – which may not be appropriate, and may even send you barking up the wrong tree.

                Another problem with interpreting results is that quite often one abnormal result only means something if there’s another result that is also abnormal… or maybe if a certain other is normal. There’s a lot of interrelation between results. Then factor in anatomic variations, the reality that different people can react in completely opposite ways to the same treatments, etcetera, etcetera, etcetera... and you see why context is always important. As doctors we are taught to ‘treat the patient, not the numbers’. This means that the whole is more than just the sum of the parts. Getting the complete story is essential (which conversely means if the doctors aren’t trying to get that story they’re not doing their job).

                There is a reason it’s called the art of medicine. It’s not a math problem (which is ironic, considering my background) (and never mind the Internal Medicine guys that have a formula for everything). So don’t be confused, if it confuses you! We have to work pretty hard to figure it out sometimes, too.