Again I don't agree. What matters most is patient care. I suggest you read
some of the work by Roizen and you can get a feel for what unneeded tests do
for patients. Think of the "good" and dare I say it "harm" done by measuring
PSA. How many men have had their life destroyed by being diagnosed with
prostatic cancer, made impotent and incontinent with out any proven benefit.
How many of them have sued, how many know they were not 'saved' but were
possibly malinformed and given qestionable treatment.
Elizabeth
All this is interesting stuff but is it really important or just
senario --building? The only thing that will really make me sit up is case
law or things like guidelines from government health departments or royal
colleges. Has anyone had legal action taken against them after having added
on a test and the hospital paid out damages? Perhaps Bob Forrest could
answer this one.
>>> Mohammad Al-Jubouri <[log in to unmask]> 04/21/04 10:44am >>>
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
-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]]On Behalf Of Mohammad Al-Jubouri
Sent: April 20, 2004 5:04 AM
To: [log in to unmask]
Subject: Assaulting patients with added tests
Just to put things into perspectives in this debate using some real life
examples.
I regard adding the following tests after consideration of clinical details,
as good practice:
- A high blood sugar first time - add HbA1c
- Hypercalacaemia - add PTH
- Hypocalcaemia - add PTH, magnesium
-FSH < 0.1, high oestradiol - add Beta hCG
-unexplained metabolic acisosis - measure anion gap and osmolal gaps
-Unexplained hypokalaemia - add magnesium
-Hyponatraemia - add osmolality, and somtimes TSH and cortisol
-isolated rise AST/ALT- add CK
-High fasting triglycerdies - add blood sugar
-low alpha 1 antitrypsin - add phenotyping.
These are just examples and I am sure that list members can add many more. I
recall one interesting case, where a lipaemic sample (4+) was reported by
the BMS staff and on clinical authorisation of the lipid profile both
cholesterol and triglycerides were normal. So I have to look at the sample
myself and the serum was really whitish gel like consistency after taking it
out of the fridge. Howevere it was as clear as a bell after it was left at
room temperature. Without hesitation I asked for total protein to be done
and this was 134 g/L and on electrophoresis a big IgM paraprotein was
discovered. I considered that it was within my clinical freedome as a
laboratory professional to add these tests to explain the anomalous finding.
Clinical biochemists have used their expertise for years using these
biochemical probes at their disposal for the good of patients. If the law
says that this is an assault, then we need to change the law not the good
practice. I have been practicing this for many years without receiving any
complaint from patients or clinical practitioners and I would suspect that
this the experience of other colleagues in the UK.
Can we please just stop using the examples of adding HIV or genetic tests
for the counter-argument, as no body is adding these.
Best wishes
Mohammad
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
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Please note, archived messages are public and can be viewed
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community working in clinical biochemistry.
Please note, archived messages are public and can be viewed
via the internet. Views expressed are those of the individual and
they are responsible for all message content.
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