From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: The Coburn Attempt to let HIV spread unchecked.
Date: 12 Apr 1997
Newsgroups: misc.health.aids

In <5ino6c$ee07@ha2.rdc1.sfba.home.com> davet1@home.com (Dave Thomson)
writes:

>A new study published in the J Acquire Immune Defic Syndr Hum
>Retrovirol 1997;14:281-289 finds (as expected):
>
>-the rate of HIV testing in regions which eliminated anonymous testing
>increased by only 45% whereas it increased by 63% in regions which
>continued anonymous testing !
>
>-elimination of anonymous HIV testing generated substantial community
>opposition, and had adverse effects on the relationship between the
>public health departments and the advocacy community.
>
>-suggests that "[A] policy that strongly encourages confidential*
>testing while maintaining the availability of anonymous* testing may
>maximize the effectiveness of both testing and partner notification."
>
>(REMEMBER FOLKS, ANONYMOUS TESTING IS NOT THE SAME
>AS CONFIDENTIAL TESTING - confidential just means they 'promise'
>not to tell anyone !)
>
>It's beyond me why the AMA would stand behind this Coburn HIV
>"Prevention" Act of 1997.


    The AMA is against any bill which moves power and authority in
medical matters away from doctors.  You can be cynical about this or
not (do the doctors simply want to stay in the loop so that they can do
more good, or so that they can get more money?), but that's the way it
is.

    The US has long had a policy that medical tests need to be ordered
by a physician, and there aren't very many exceptions (an important one
is home pregancy test kits, but they squeeked by because they don't
really test for a DISEASE).  Partly this has been a result of doctor
lobbying, but it's also a result of laboratory lobbying.  A lab which
finds a funny result and hands it off to a doctor, has washed their
hands of it-- it's now HIS problem, insofar as liability goes.  When
the patient deals directly with the lab, there's nobody to sue but the
lab when the right thing isn't done about the result.  Deep pockets,
you know.

                                              Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: misc.consumers,misc.consumers.frugal-living,talk.politics.medicine,
	sci.med
Subject: Re: Medicare etc.. Long, please forgive
Date: 5 May 1999 05:22:11 GMT

In <7gnp44$b6c$1@nina.pagesz.net> henryj@nina.pagesz.net (George
Conklin) writes:

>   Sorry.  In the USA you have no right to have tests done
>without orders by a MD, even if you are paying for the
>results out of private funds.


   Quite so, the reason isn't the one you think it is.  The test
companies would be quickly run out of business by patients who
misinterpreted results and did something that was unwise.  The test
company despirately needs a doctor name and number to sent the results
TO, in order to get off the hook.  Now it's the doctor's problem.
Companies are glad to send a copy to the patient before doctor, or even
fax one to the patient, so long as they have a doctor's order to do
this.  Again, it's liability thing.

   In a rational society, and certainly in any society where you can
apply for a licence to carry a concealed pistol and cannot be refused
unless a felon or mentally incompetent, you ought to be able to sign
away your rights to sue for bad interpretation, if you waive you
privelege of having a doctor involved.  However, in this society you
cannot sign away such rights.


> First you must pay the MD to
>write the order, if he/she so chooses.  Then the results are
>not sent to you, but back to the physicians whom you must
>PAY to interpretate those results for you.  The physical
>results are not yours, although you have paid for them.

   You can negociate with your doc about where the results are sent
besides him/her, before you pay.  And there are also companies which
keep a doc on staff will order blood tests for anyone.  You pay part of
that doc's salary, but with a large company that's not much.

   If you have a nice doctor you won't get charged for writing a
prescription or signing a request for a test (which YOU have previously
filled out with correct addresses, phone and FAX numbers, etc).  The
time needn't be more than 30 seconds, and most doctors will go freebie
on that.  Of course, if you want to talk to your doc about it for 20
minutes, that will be extra.

From: jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox)
Newsgroups: sci.med.laboratory,sci.med
Subject: Re: Consistancy of lab values
Date: Wed, 16 Jun 1999 22:37:01 GMT

On Wed, 16 Jun 1999 17:54:05 +0100, Charles Coughran
<ccoughran@DELETE_TO_REPLY_UCSD.EDU> wrote:
>
>Fred Morenberg wrote:
>
>> Please help me resolve a dispute over the consistency of values from
>> different labs.
>
>> Both my friend and I have had blood tests for both total and free
>> Testosterone.  Both came back referenced in the same values. that is pg/ml
>> for Free T and ng/dl
>> for Total T.  problem is that we have two different "normal" ranges.
>
>> My contention is that had we both sent our blood to the other lab, our
>> results should have been the same.  The difference between "normal" ranges
>> given by the labs, is
>> because that value is based on the labs  interpretation of what should be
>> normal.  There is no absolute  fixed value (Range) for normal for most
>> tests.
>
>Well, you're going to have to buy the beer, you're wrong.
>For virtually all sensitive lab assays there are several
>different methodologies available.  Each method will produce
>a slightly different answer.  Even if two labs are using the
>same method, slight differences in reagents, techniques,
>lab standards, etc. will cause them to have slightly
>different answers.  These are very sensitive assays.
>Think about what the unit pg/ml means. Every lab determines
>the normal range for the testing methodology and
>the specific reagents and components it uses and
>that is why the normal ranges vary lab to lab.  If you
>sent your blood to the other lab, and everything is
>working the way it should, you would get a different
>absolute answer that was in the same relation to the
>seconds lab normal range as the first labs answer
>was to its normal range.

There's more to it, however.  Even if you sent the same blood from the
same person to the same lab twice you might get a slightly different
answer.  No lab test is absolutely precise and consistent.  You also
can't assume that you would expect a higher answer from the lab that
has higher values in its normal range for the same blood.

The original poster (Fred) is actually correct that there is no
absolute "normal" range for most tests, and that it is arbitrarily
chosen by the lab, but it is also not necessarily true, as Charles
pointed out in his reponse, that you should expect the same result
from your blood from each lab, because there may be different methods
involved.

I said the reference range is arbitrary, but let me make it clear that
most labs do not simply pick "normal" ranges, more appropriately
called a reference range, out of a hat.  The standard method is to
test a large population of presumably normal people, and define the
reference range to be such that 95% of the normal population falls in
this range.  This number is chosen because if you pick too high a
value, say 99.9%, you would have such a large reference range that
truly abnormal people may appear to fall in the "normal" range.
Conversely, if you choose too small a number, then too many normal
people's results will be marked "abnormal."

Once you have chosen 95%, it is important to realize that 5% or one in
20 normal people may have an abnormal result on any test you do.  On a
large panel of tests on a normal person, then, you are actually more
likely than not to have an abnormal result on at least one of them.

Another issue that arises pertains to the population used to get the
95% reference range.  Normal African-American children are frequently
flagged as anemic because the reference range for hemoglobin was
derived from a population of white children, who tend to have slightly
higher hemoglobin concentrations.  The standard growth curves for
infants used around the world were based on a population of
formula-fed North American infants.  Breastfed infants tend to be
leaner, and thus appear to be growing too slowly when they may be
perfectly normal.  People in India all seem to have restrictive lung
disease if you compare lung volumes with the standard charts derived
from white people.  And so on.

Physicians who provide their patients with copies of their lab reports
should be prepared to discuss these issues, as interpretation of lab
values is obviously quite complex and should always be considered in
conjunction with the clinical history and exam.

--
Jonathan R. Fox, M.D.

From: jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox)
Newsgroups: sci.med,sci.med.nutrition,alt.health,misc.health.alternative
Subject: Re: blood test results....HELP HELP HELP
Date: Mon, 06 Sep 1999 13:56:01 GMT

On Sun, 05 Sep 1999 15:10:11 -0500, Mari Hall
<found.dead.in.texas@airmail.net> wrote:

>jec wrote:
>>
>> please can anyone help?? I had lab work recently and full blood
>> workup...where can i find a web site that explains blood test results???
>> john
>
>Your doctor should have given you the sheet from the lab with the
>results on it (assuming you are in the US); Labcorp, Smith, Klein
>Beechem, etc. all give that paper, it has "normal' limits on it and the
>result of your test. It even tells what tests, Chemistry, C-125, sed
>rate, etc.

This topic comes up every few months here.  I believe his doctor
should NOT necessarily have given him the sheet from the lab unless he
specifically asked for it.  There are two reasons.  First, it may
contain "normal" limits for the lab tests, but chances are most normal
people will have at least one test fall outside that range.  There is
a lot more to interpreting lab tests than simply seeing if they fall
in the "normal" range.  Second, getting a copy of lab tests frequently
causes panic in people.  See the title of this posting -- "HELP HELP
HELP" -- which is a typical response of someone who has been given lab
values he doesn't know how to interpret.

I personally think that after the physician has interpreted the lab
values to be normal, a postcard or phone call to the patient saying
that they were normal is sufficient in most cases.  If there are
abnormalities, a phone call or office visit to discuss them is
warranted.  There is no reason to cause distress and panic in the
patient by sending the actual data unless the patient asks.

--
Jonathan R. Fox, M.D.

From: jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox)
Newsgroups: sci.med,sci.med.nutrition,alt.health,misc.health.alternative
Subject: Re: blood test results....HELP HELP HELP
Date: Mon, 06 Sep 1999 17:37:44 GMT

On Mon, 06 Sep 1999 16:48:11 GMT, kurtullman@sprintmail.com (Kurt
Ullman) wrote:

>In article <7r0pul$ia3$2@bgtnsc01.worldnet.att.net>, "John Gohde"
><johnhgohde@worldnet.att.net> wrote:
>
>>>warranted.  There is no reason to cause distress and panic in the
>>>patient by sending the actual data unless the patient asks.
>>>
>>>--
>>>Jonathan R. Fox, M.D.
>>
>>That is right ... All patients are blooming idiots who can not handle
>>factual information like a simple lab report.  Perhaps, you are simply
>>trying to avoid malpractice lawsuits.
>>
>>You don't qualify to be my doctor, ... Doc!
>
>        Ah, he did say UNLESS the patients ASKS. At least pretend to listen to
>what the guy says before teeing off on him (or in some cases her).    This is
>letting the patient decide how much information they want which is a form of
>patient autonomy, is it not??

Indeed.  If John Gohde interprets what I said as implying that all
patients are blooming idiots, I don't really care if he thinks I
qualify to be anyone's doctor.  I wouldn't want someone with a burr up
his asshole like him to be my patient anyway.

When I go over lab results in person with patients, I do show them the
actual lab values.  And if they want a copy of it, I am happy to
supply it.  I don't just mail the actual results to the patient
without explanation so that they can panic and start asking people on
newsgroups what they mean.  To me, that is irresponsible.

And I agree entirely with the concept of patient autonomy.  What
burr-boy doesn't realize is that, in my experience, most patients do
NOT want to see the actual results, and become bored and/or annoyed
when I show them numbers.  They just want my interpretation of them.

Given that most patients do not want to see the numbers, and that
showing them the numbers without explanation frequently causes
unnecessary distress, it's obviously more prudent to show the numbers
only to people who ask, or only in a situation where the physician can
explain the meaning.  Note that this decision has nothing to do with
any judgment of the intelligence of the patient at all.

--
Jonathan R. Fox, M.D.

From: jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox)
Newsgroups: sci.med,sci.med.nutrition,alt.health,misc.health.alternative
Subject: Re: blood test results....HELP HELP HELP
Date: Wed, 08 Sep 1999 01:03:31 GMT

On Tue, 07 Sep 1999 06:04:02 -0700, Gordon Held <gheld@thegrid.net>
wrote:
>
>"Jonathan R. Fox" wrote:
>>
>> I personally think that after the physician has interpreted the lab
>> values to be normal, a postcard or phone call to the patient saying
>> that they were normal is sufficient in most cases.  If there are
>> abnormalities, a phone call or office visit to discuss them is
>> warranted.  There is no reason to cause distress and panic in the
>> patient by sending the actual data unless the patient asks.
>
>That's one viewpoint where the philosophy of the physician deciding what's best
>for the patient is instituted without the input of the patient.  I think
>nowadays most patients, certainly those with enough interest in their
>healthcare to spend time on this ng, want the "whole story" and look to their
>physicians for information and advice not binary answers.

To me, lab results are a diagnostic tool, and, as I said in my post, I
am happy to discuss the results with the patient.  The fact that I may
not necessarily show them the actual numbers unless they ask does not
imply that I subscribe to the model of paternalism by the physician in
the process of making treatment decisions.  I actually rather believe
in joint decision-making by the patient and physician.  Usually, the
actual numbers on the lab report don't figure into the patient's
decisions.  It's the physician's interpretation of them that does.

>Certainly there are patients who would have distress and panic by seeing the
>actual data.  I wonder if they don't have some distress and panic anyway.  They
>may have more distress and panic by not being allowed to see the data.  I know
>I would.

Very true.  But, yet again, I never said I would approve of a patient
not being allowed to see the data.  I simply said that if the data is
presented to the patient, an explanation should accompany it.

--
Jonathan R. Fox, M.D.