In order to avoid being criticized for adding tests, which will often be 
paid by the patients (at least here in France), shouldn't we ask the 
patients if he/she agrees first?

Dr Joseph Watine, PH, AIHP, PharmD, AAHU, EurClinChem
Laboratoire de Biologie Polyvalente
Centre Hospitalier Général
12027 Rodez Cedex 9
France

>From: Mohammad Al-Jubouri <[log in to unmask]>
>Reply-To: Mohammad Al-Jubouri <[log in to unmask]>
>To: [log in to unmask]
>Subject: Re: Assaulting patients with added tests
>Date: Wed, 21 Apr 2004 10:44:46 +0100
>
>Thanks Elizabeth
>
>I don't have any problem with discussing added tests with the requesting 
>clinician (a time taxing process) if this is feasible. We have sometimes 
>real problems in communicating urgent results to the requesting clinician. 
>I mentioned this single anecdotal case for the flavour only, but I hope 
>that you would have realised that it wasn't the only case that changed my 
>practice. In my humble experience I did publish few cases and there are 
>many others published by colleagues:
>
>1. Xanthoderma: an unusual presentation of hypothyroidism.
>Al-Jubouri MA, Coombes EJ, Young RM, McLaughlin NP.
>J Clin Pathol. 1994 Sep;47(9):850-1.
>
>2.Myxoedema revealed by simvastatin induced myopathy.
>Al-Jubouri MA, Briston PG, Sinclair D, Chinn RH, Young RM.
>BMJ. 1994 Feb 26;308(6928):588.
>
>3.Hypertriglyceridaemia: a pointer to diabetes mellitus and alcoholism.
>Al-Jubouri MA, Young RM.
>Ann Clin Biochem. 1993 Mar;30 ( Pt 2):201-2.
>
>Computerisation is wonderful, but I did mention adding tests after 
>consideration of clinical details (which sometimes mean phoning the 
>clinician to get the hard data), and our existing lab systems are not 
>clever enough to do that. We can only do reflex testing for e.g when 
>potassium < 2.8 add magnesium and so forth.
>
>I agree with Ian that alpha 1 anti-trypsin phenotyping is going to diagnose

>a specific genetic condition, but this is usually the purpose of asking for

>alpha 1 antitrypsin level in the first place and it is a good practice to 
>follow up low levels with phenotyping.
>
>All what I am saying here, is adding tests is a normal laboratory practice 
>in the UK, performed for the good of patients. Laboratory practitioners 
>will have their individual experience with what test to add and when, 
>influenced by the very many cases they discovered over the years. This is 
>the clever bit of their jobs and it is insulting to label it as an assault.
>
>Best wishes
>
>Mohammad
>
>Elizabeth Mac Namara <[log in to unmask]> wrote:
>I have never said that certain tests might not be useful all I have ever 
>said is they should be first discussed with the doctor who ordered the 
>original tests. No one has yet given me any idea as to why such a 
>suggesstion is wrong. What can be lost by talking to the person 
>respponsible for the patient. We are not alone in the laboratory and 
>whether we like it or not the ordering physician, not us is the person who 
>has the right to decide about what should be done in his name on his 
>patient. Not us.
>
>Many of the tests you suggest are of course realistic but if you feel that 
>way why not make it automatic. A computer will always do it better as it 
>will never miss. Then you can let all the docotrs know that under certain 
>circumstances specific tests will be added i.e. a high total bilirubin will

>always result in conj bilirubin being analysed. I do this myself and so 
>would never discuss it with a doctor, they expect it and never order a 
>conjugated bilirubin.
>
>But have you ever done a study on the cost benefit analysis of what you 
>suggest below? What percentage of times to you conform with your 
>suggestions. If it is not you reviewing the tests is it always done?
>
>An anecdotal finding of a disease, once upon a time, is not a guideline to 
>be followed. Yet that is what is being suggested. I know many doctors when 
>in the ED missed acute pancreatitis now do amylase on almost all acute ill 
>patients. They  always cite one patient they missed or a colleague missed 
>once upon a time. But it does not make their practice either a good idea 
>for either the doctor or the patient. Much has been written on the harm 
>unnecessary tests do patients. Look at some of the work by Roizen. I have 
>not seen it lately but it is lovely and very relevent to the present 
>discussion.
>
>Elizabeth Mac Namara

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