Self-testing 26. October 2008 William Davis (9) Here are the results of the latest Heart Scan Blog poll (84 respondents):When you ask your doctor to perform a specific blood test, does he/she:Do it without question? 38 (44%)Do it but express reservations?25 (29%) Do it very grudgingly?13 (15%) Refuse outright?9 (10%) I was encouraged that 44% of respondents are/were able to obtain the blood work they requested without resistance. Sadly, however, the majority do either encounter reluctance or outright resistance. Why would your doctor impose barriers to your ability to obtain laboratory tests? Well, several potential reasons:1) He/she feels that they are charged with your health safety, and you might be led down a misleading, potentially dangerous path. 2) He/she feels that the tests are truly unnecessary and that you will be wasting the money of the "system."3) He/she doesn't understand the tests, or is unfamiliar with them.4) He/she feels that the doctor should be in complete control, not you. How dare you try to usurp the doctor-as-dictator of your health!In reality, number 1 is understandable but rarely occurs. I have indeed have had requests, though rare, for outrageously inappropriate tests for the issue at hand, usually due to a misinterpretation of some information by the patient. I'm not sure how often number 2 truly is. For instance, it is not uncommon for the doctor to have an ownership stake in the laboratory. There are several large primary care groups in Milwaukee who are notorious over-users of laboratory tests, with extraordinary batteries of dozens of tests every few months on the flimsiest reasons , clearly motivated by . . . money. On the other hand, there are physicians who do consciously try and order tests rationally and cost-effectively. I suspect that this is a minority. I feel quite confident that number 3--your doctor's ignorance--is probably the most common reason he/she is reluctant or refuses to allow you access to a test. Most respondents I suspect are referring to many of the tests that I have been advocating, such as lipoprotein testing, lipoprotein(a), and vitamin D blood levels. I am uncertain how any of these could be construed to be dangerous. But ignorance of the value of these tests is rampant and resistance is nearly always based on not having explored these issues and having no appreciation for their importance. Of course, the beleaguered primary care physician is, no surprise, inundated by so much information across such a wide range that he/she has become expert at nothing, barely able to even deliver the full scope of genuine up-to-date primary services any longer. My colleagues, the cardiologists. . . well, you know my feelings about their attitudes: If it doesn't make money, then why should I bother? Devote months or years studying something that doesn't ring the cash register? I see this dilemma as yet more evidence of the growing disenchantment with the doctor-as-gatekeeper model, the centuries old paternalistic "I will tell you what to do and you will do it." It worked when the doctor was educated and had access to knowledge you could never realistically obtain because you couldn't read, or you were too poor to afford books and education, or because medical information was made privy only to select people.It's not that way anymore: The information you have access to is the same information my colleagues and I have access to: a level playing field. Along with the changing rules of the game, the game itself must eventually change. I believe that people should have access to self-testing. Indeed, there is a growing industry of direct-to-consumer laboratory testing, such as that offered by Life Extension and LabSafe . For the most part, these offer tests without potential insurance reimbursement. But the landscape is changing: We are just beginning a new age of self-empowerment, self-directed healthcare. Whenever I say this, some people are angered that the majority of people will be too lazy, stupid, or poor to join the movement. What I am not saying is that we should agitate to make the system a patient-only directed process and completely remove the doctor. What I am saying is that the patient should and will play an increasingly important role in determining the content and direction of his/her care, especially as the patient becomes far more knowledgeable about issues relevant to his/her health. The new tools of health measurementIf there were a new mantra of the new science of insight into health and long life, it would be “measure, measure, and measure.” Never before in history have we had access to the analytical, laboratory, imaging, quantifying health tools that we have today. We can locate, scan, measure, all down as far as the level of basic codons of the genetic sequence.The health-inquiring public has so far been permitted just a tip-of-the-tongue taste of these quantitative phenomena in such things as cholesterol values (“know your numbers!”) and blood pressure. Women now discuss their bone density scores over coffee, men their PSAs (prostate specific antigen). But a curious irony has emerged: Like early 20th century males uncomfortable with women battling for suffrage, healthcare professionals, themselves comfortable with measurements and numbers, are distinctly uncomfortable when some of the same information falls into the hands of the healthcare consumer. These phenomena play out in especially dramatic fashion in the world of heart health. The public now has broad access (many without a doctor’s order) to an extraordinary array of health measurement tools that can potentially yield enormous benefits for prevention of the most common conditions, information that can be applied by tracking over time.Measures like heart scan scores, vitamin D blood levels, lipoprotein(a)--measures that most doctors have little or no interest in obtaining, yet they serve crucial roles in maintaining and tracking your health. The new paradigm is emerging: the tools are getting better and better, they are becoming more accessible.