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TMI: Lab Tests, Patients, And Wasted Analysis

Let me kick the hornets’ nest again.   I still have misgivings about sending information like this to my patients:

screen-capture-8How does one not trained in what to overlook interpret the above?  To me, this lab result is entirely expected for this patient – given the other medical history that is there.  My concern is that this will either cause unneeded worry, or it would prompt a phone call to ask about labs that I would be quick to accept.  Yes, there are times when this may help the doctor who overlooked abnormal tests in error, but the majority of abnormal lab values are not significant.  The vast majority are insignificant.  I’d put the rate at nearly 10:1.

When we e-mail patients their lab results, we have two options: to send the actual report, or send an abbreviated form of it.   Here is what I sent this patient (for these actual labs):

screen-capture-9I had a woman complain to me when I didn’t send her this “sanitized” version of her thyroid labs.  She didn’t understand the lab report and just wanted my explanation.  Which would you rather have?  Do patients really need to know their MCHC, RDW, RBC count, and absolute eosinophil count?  Do they want to?  I don’t care about those numbers 99.9% of the time I look at them.

Here’s another example:

screen-capture-10“Doctor!  I am really worried about my Bun Level and Carbon dioxide levels.  I read that these can all mean I am dehydrated!  They also can mean I am going into kidney failure.  I don’t want to go on dialysis!  And what about the monocytes and MPV levels?  One website I saw said this could mean leukemia.”

Sound outlandish?  Sound like something that won’t happen much?  Wrong.  We spend a very large amount of time explaining these basically normal (MPV??  Absolute Monocytes??).  All lab tests need to be put in the perspective of the patient’s age, disease state, race, and medications they are taking.  They also need to be seen as a single point on the graph and so must be looked at in comparison with previous lab tests.  How would I interpret this?  Normal.

Do you, my readers, REALLY want to see the absolute monocyte counts and MPV?

Here’s another:

screen-capture-11screen-capture-12

Look at all the extra information put at the bottom of the lab report.  What does it mean?

Most of this is fluff meant to keep the lawyers happy.  The average patient will not quite know where to look here and will either just be confused by it or become anxious and want to question this as being abnormal.  ”I thought you said my diabetes control was good, but the diabetes test was high according to this!” or “A hemoglobin of 6.5 is dangerous, isn’t it?”  I have had both of these comments from patients.

Here’s a typical echocardiogram report:

screen-capture-1screen-capture

What percent of patients want all of this?  I don’t!  I really could care less about everything above the “Impression” section from the cardiologist.  I was not even aware that pressure had a halftime.  None of these findings are significant.

The cardiologist has to include all of these in his note for herself because of documentation requirements and because the fine details mean something to her.  But they mean nothing to me, and I would prefer just getting the “Impression” sent to me.  Why should patients be different from me?

Wouldn’t you rather get from me something that says: “Your echocardiogram looked good”?

I really think that giving full access to all information opens a hornet’s nest of its own.  We will spend a lot of time educating our patients to the nature of medical information and medical terminology.  Again, I am fine with having folks who feel they need this information; but I am a little skeptical that they really do need it.

I don’t need most of this stuff, and would be much happier if I got only what I asked for.

*This blog post was originally published at Musings of a Distractible Mind*


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One Response to “TMI: Lab Tests, Patients, And Wasted Analysis”

  1. Ted Eytan says:

    Hi Rob,

    It might be useful to think of this in a different way. If patients' actual clinical data is available to them, they will ask questions, and the result will be that our profession will discover the impact of test results that don't reduce uncertainty, either because the output of the test isn't understood, or the test should not have been ordered in the first place.

    Consider that in the first quarter of 2009 alone, over 5,000,000 “raw” test results were viewed by Kaiser Permanente patients online through that health system's patient portal, at kp.org.

    I believe that cumulative experience is showing that patients would like to know their results, they would like to know them in the context of a great patient-personal physician relationship, and they would like our health care system over time to improve the transparency and understandabilityof the data it produces about them. I don't think we can even start on this journey if we keep what happens “behind the counter” a secret.

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