An Op Ed form Lewis S Blevins, Jr. M.D. – on the review of laboratory results….good medicine?
I couldn’t tell you the number of times each year I hear that question posed by patients who simply don’t want to come in for an office visit.
It is, of course, a legitimate question for a lot of different reasons. Frankly, symptoms and signs of endocrine disorders are nonspecific meaning that they may be related to a large number of unrelated diagnoses. For example, weakness and fatigue are common in most disease states. If the patient with hypopituitarism has these complaints, and the thyroid hormone levels are appropriately normal, then we know the patient is not hypothyroid. Laboratory results are the “proof” of where the hormones “stand” regardless of symptomatology. The issue as to what is “normal” for one person compared to the next is totally different story. The point is, patients sense that lab results are important and relied upon heavily by the treating physicians, and they regularly ask to have labs reviewed in lieu of visit to the office.
As an academic neuroendocrinologist, I see 40-60 patient’s with pituitary disorders each week. Guess how many laboratory results were faxed in each week. It may surprise you to know that I receive, by fax, almost as many lab results each week as the number of patient’s that I see! Add to that a scattering of MRI films sent for review on occasion. Each faxed result or MRI study requires me to access the patient’s chart, to evaluate the result in the context of the patient’s disease state, the current medications, prior similar results, etc. This is a lot of work! Work that my institution is not compensated for. “Free” medical care. However, that is not the case. For my time is valuable. Furthermore, I am required to document response to each laboratory results and either call the patient’s or send letters about their results. My office staff must prepare the documents for my review, ultimately scan them into the electronic medical record, stuff letters, etc. You get the picture. “Free” medical care costs us a lot of time and money! Keep this in mind when you wish the “favor” of the physician reviewing the lab so that you do not have to take time to go to the office to receive medical care.
Of course, we like to do favors for our patients, and, sometimes, our schedules might be full…. or yours my not permit you the time to travel. So, the best course of action may be to simply review the lab results. Especially, if patient’s live at a great distance. However, regular followup is important because the practice of medicine involves the interaction between human beings. A Doctor-Patient relationship is simply that…. It is not a relationship between a doctor and the patient’s laboratory results. We physician’s gain so much information by having you, the patient, in front of us. We can instantly, almost subconsciously, tell whether you are doing well, comprehend your disease state, our impressions, etc. So much more information can be conveyed in the setting of an office visit then it can by fax or on the telephone. Further, when patients are sitting in front of us, they’re usually our sole focus. Would you prefer to be in the examining room in front of your physician while he or she looks through your chart and reviews laboratory results? Or, would you rather be the 10th set of faxed labs of 40 for the week that the physician has to fit into his busy schedule edgewise to review and make decisions that directly affect your health and well-being? As for me, remember, doctors are patients, too, I would rather be sitting in front of my physician! Further, I prefer that my patients are sitting in front of me when I am wearing the white coat (I was going to say with my “doctor’s hat” on but we don’t wear hats!).
I was involved in a review of medical records as an expert witness in two legal cases recently. In both of those, physician inattentiveness to laboratory results that were sent to the offices in between visits led to egregious errors that resulted in an untimely deaths of the patients. As a result, I’ve decided to ask my patients to come in to review results, and to make the effort to actually receive medical care, in the office, when able, which will hopefully be most of the time, rather than to simply ask me to review their laboratory results to save them the trouble of coming to the office.
A couple of weeks ago, a lady wrote and asked what I thought about the recent results to determine whether her Cushing’s Disease had recurred. I reviewed her record and determined that I had been reviewing laboratory results for about 2-1/2 years and hadn’t seen her in that time. We had not gotten together because I was simply doing her the favor and she thought it was my preference to review her results rather than to see her. Rather than look at the results, I asked her to come in for a visit. She complained of fatigue and exercise intolerance as well as an unspecified weight gain. Her ACTH, cortisol, and urine free cortisol results were, however, normal. Her thyroid functions were normal. Her IGF one level was normal. I did, however, believe her symptoms. Having her in front of me prompted me to review her past laboratory results. I wouldn’t have done that had I simply reviewed her faxed results as I would’ve taken a cursory look at the results and seen they were normal and indicated so in a letter or an e-mail. This time, she was in the room with me, and I was determined to evaluate her symptoms thoroughly. I was, in essence, her audience as I was actively listening. This is one of the prime benefits of the face-to-face encounter with a physician. What did I notice? Well. Her IGF one level, though it was normal, was half of what it was 3 years prior and just after her transsphenoidal surgical procedure. We know that about 40% of patients who have had pituitary surgery have mild to moderate growth hormone deficiency despite otherwise normal pituitary functions. I suspect that she has growth hormone deficiency that manifested itself by a slow decline in her IGF one level that went undetected because we weren’t fully evaluating that possibility, instead being focused on whether her Cushing’s disease was still in remission based on review of periodic laboratory results, and didn’t have a face-to-face discussion about her symptoms, which are clearly related to growth hormone deficiency, because we simply didn’t sit together to review labs and solve her problems. Basically, her overall sense of well-being and health will improve markedly in the following couple of months as we initiate and titrate growth hormone replacement.
I will come down off of my “soapbox” now. I will, however, ask you to do yourself a favor and, when able, plan to see your doctors about important lab results and any concerns that you may have. There is no substitute for the opportunity of an actual visit, however brief that visit may be, to review results and scans, and to discuss symptoms and signs that are pertinent to your health.
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