For $149, you can go online and obtain a “basic wellness” panel of labs. You can see for yourself if you have anemia or diabetes. For another $300, you can sign up for a “premium” package to check out how your liver and thyroid are doing. All of this can be done without even a phone call to your doctor’s office. So should you do it? (For the instant answer, jump to the end. For true understanding, read on.) One snowy, wintry afternoon, an attractive if not slightly frazzled young woman sat in my exam room and said, “My husband says I should come in and get my blood tests done.” I asked, “OK, what labs would you and he like done?” She looked at me blankly and answered, “Oh, I don’t know exactly. Whatever is normally recommended.” “Do you have any medical concerns or health problems?” I inquired. “No.” “Do you have any symptoms such as difficulty breathing, chest pains, dizziness…” I asked, listing out another twenty or so possibilities. “No, I feel good. I’m tired, that’s all, but I have three young children.” Further questioning revealed she had no notable health problems in her family, did not take any medications, ate a “normal” diet without any restrictions, did not smoke or drink alcohol, and had difficulty finding time to exercise now with the little ones running around. Her physical exam was only remarkable for pale colored skin, which perhaps suited her naturally straight blond hair and light blue eyes. She appeared to be a normal, tired young mother who wanted routine labs done just to make sure everything was OK. The first idea of using some type of analysis beyond the physical exam to assess a person’s health was back in the Middle Ages when doctors evaluated urine by casting it onto a surface (which incidentally led to the urine flask becoming the symbol of medicine during these times). It was not until the late 19th century that blood counts could be performed. Fast forward to the post World War II era when influential physician-led organizations in the United States encouraged the annual preventative exam, which over time, included laboratory evaluations of blood, urine, and stool. These evaluations became the routine labs. (Side note: Routine blood tests most commonly included a complete blood cell count, electrolyte levels, a kidney function test, and cholesterol and glucose levels. Sometimes they included liver function tests, a vitamin D level, and a thyroid test.) Initially, these tests were performed by the doctor, but as the laboratory technician profession developed, doctors contracted with laboratories to complete this work. It is interesting to note that even now, you cannot actually get blood work done without a doctor. When you purchase a blood panel through an online company, that company has contracted physicians to write the lab order. Recognized laboratories in the U.S. cannot perform clinical lab work for patients without a doctor’s order, which, as you can imagine, is a controversial topic between physician and laboratory special interest groups. Over the past decades, a society was therefore created that associated routine labs with optimal health. As the force of so-called data-driven medicine took hold, practitioners became curious as to whether all these annual tests actually improved health. It turns out, they didn’t. That is, to be precise, the United States Preventive Services Task Force (USPSTF, an independent organization that develops medical guidelines which are subsequently deemed standard of care for health care today) states there is insufficient evidence for the benefit of screening asymptomatic, non-pregnant individuals for such medical problems as anemia, thyroid disorders, kidney problems, blood in the stool and urine infections, to name a few. Notable exceptions are screens for diabetes, high cholesterol, and possibly for men, prostate cancer, which are still advised and performed regularly today. Many insurance companies subsequently dropped their financial coverage of these routine labs to minimize their costs. It is now considered ‘bad medicine’ for a healthcare provider to order additional lab tests for the healthy adult beyond those few recommended screening studies. Health organizations also discourage this practice through methods such as provider report cards. Those score providers on how often they order unnecessary labs and computer ordering systems that give multiple warning boxes providers must click through to place such orders. So if science and money reject doing routine labs, why do some doctors still do it? Sometimes it is easier and faster to click those buttons than explain all of the above, and many providers, despite perhaps our reputation, really do want their patients to be happy. There are also, of course, those practitioners who still believe in the value of these labs. Many have their, “But you know, I had a patient once who we found out to have …” stories. Indeed, here is another. Let’s go back to the fair-haired young mother. I explained to her that there is no such thing today as routine labs beyond the recommended screening studies. Additional labs are ordered only when needed to evaluate a concerning symptom or medical problem. I suggested we evaluate her fatigue and reviewed what labs I would order. I also warned that her insurance might only pay for the screening studies. She agreed. The next day, I discovered she had a hematocrit of 30, which is quite low and meant she was anemic. After another visit, more lab work, and a confirmatory endoscopy study (camera into the stomach), she was diagnosed with Celiac’s disease. So were these labs worth it in the end? Of course. However, it still does not support the use of routine labs. In time, she would have developed more profound symptoms from her Celiac disease and sought medical attention. “But isn’t earlier better?” I hear you ask. Yes and no. Early diagnosis is valuable, but it can come at high health and financial cost. Lab tests don’t always reveal an ultimate truth, and seemingly abnormal results can lead patients and doctors down a fruitless road filled with expensive tests, more doctor visits, increased risk of medical mistakes, and treatment side effects. Some of you, like some of my patients, hear all of this and conclude that’s all very well and good, but I still want my labs. If you are willing to pay for them, go ahead and order them for yourself. It’s your body, and you’re curious. I understand. Your insurance may cover the expense, but don’t count on it. Remember, insurance is community financial support, so what you get for “free” someone else is actually paying for. Buyer’s caution: Again, many labs are of limited value without additional information, such as a specific symptom, physical exam finding, or family history. Abnormal autoimmune lab findings or elevated tumor markers do not automatically mean you have an autoimmune condition or cancer. If you are going to undertake ordering and evaluating your own labs, something that historically a physician with years of education and training would do, make sure you are well informed. That means reading a lot and only from trusted sources.* If you do receive abnormal lab results, always discuss them with a doctor. It’s your body, and you are in control, so be smart. Jill A. Monteiro is an internal medicine physician. Source
