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 measurement

If 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.

Comments (9) -

  • Anne

    10/26/2008 2:08:00 PM |

    I answered "Do it but express reservastions" but the real answer is that some of my doctors have "refused outright" and some "Do it without question".

    When I asked to be tested for celiac disease, two doctors refused. Both told me I did not have this problem as I was not losing weight and did not have diarrhea. Their refusal may have been my good luck as that made me turn to alternative testing(Enterolab) that looks for gluten sensitivity and not just celiac disease.

    More recently I was told by my PCP I did not need a winter vitamin D test as my level was 46ng/ml at the end of summer. I changed PCP's and got my vitamin D level tested - it had dropped to 24ng/ml(same lab).

    I am glad there are labs that I can access without a doctor. I still use Enterolab to follow my gluten antibody levels. I now have doctors who seem to be willing to work with me and help me optimize my health.

  • Anonymous

    10/26/2008 2:18:00 PM |

    I think you missed #5, which is true for the large numbers of people in HMOs, where their doctor is a direct employee of the patient's insurer:

    5) The doctor receives a bonus for ordering fewer tests.

  • Anonymous

    10/26/2008 6:21:00 PM |

    Even though self testing through LE, Direct Labs, etc. requires that the user pay (i.e. no insurance payment), I have found that even then they are cheaper than doctor ordered tests because of outrageous prices for hospital initiated lab tests with large dedutible/coypayment charges.

  • Anonymous

    10/26/2008 9:12:00 PM |

    I am not impressed by all the wondrous diagnostic techniques developed for detecting common chronic conditions like heart disease. We already know what causes these chronic diseases. They are lifestyle diseases. Proper diet and exercise being the primary components of good health.

    Knowing the cause, we also know the cure for most chronic diseases: improve your lifestyle. People who have followed this plan usually make an amazing discovery. Lifestyle changes act almost like the proverbial universal cure. It is not just heart disease, but a whole range of other chronic conditions get reversed or effectively managed. Lifestyle diseases require lifestyle cures.

    How many more technologically advanced tests should you undergo before you adopt the cure? Really, why should you wait? Most people in the USA will die of or at least suffer from one or more avoidable chronic conditions in their lifetime. You can undergo testing until you are finally and definitively diagnosed, or you can proactively adopt the cure and more likely avoid all of the unpleasant consequences of modern chronic diseases.

    I don't oppose testing for anybody who wants it. But I see that an obsession with testing operates as an excuse to put off addressing necessary lifestyle treatments.

  • Anonymous

    10/26/2008 10:31:00 PM |

    After reading Jenny Ruhl's Diabetes 101 I decided I wanted to more closely monitor my blood sugar. My a1c is 5.5, which my doctor tells me is "fine" but it is on the high side of normal, and after learning that even small elevations of blood sugar can be damaging,(new information that my doctor may not be aware of)  I want to be monitoring my BSs closely.
    I've asked my doctor how to get a blood sugar monitor. I voted that he usually allows me to have tests I want, but I'm afraid he's going to think I'm a hypochondriac for wanting the BS monitor.

  • Joe

    10/27/2008 5:16:00 PM |

    I know my internist is unfamiliar with the tests; he told me "I'm not into the minutiae of lipid testing". So I went to LEF to get it done myself.

  • Anna

    11/2/2008 11:32:00 PM |

    There is no need to ask your doctor about a glucose monitor and risk acquiring the image of a hypochondriac.  

    Anyone can buy a glucose monitor and testing strips at any pharmacy in the US without a prescription, no questions asked.  There are free meter offers online at testing supply businesses, but they usually require a Rx.  I bought my meter and test strips OTC for nearly a year at Costco.  

    Without that diet diary and data already, I know my doctor wouldn't have taken me seriously, despite my Gestational Diabetes History (my A1c was 5.5%, too and my FBG was 92).  A it was, he still humored me by ordering a 3 hr GTT when I insisted, then later apologized to me when he called with the results (I already knew the results, as I used my meter during the GTT - what I wanted were the simultaneous insulin levels, which the lab screwed up!).

    Often there is a mail-in rebate for the meter, making the cost very low or free (check around and review the various meters for the features you want).  The simpler (fewer memory and analysis features), smaller meters are often below $20.   The major downside of any meter is the cost of the strip.  But for your own information, the out-of-pocket costs may well be worth it.  Plus, you've kept your privacy and avoided potentially problematic notes on your medical record, which could well be priceless if you can keep your BG normal and controlled on your own with diet, exercise, and the self-testing meter.

    BTW, I'm NOT recommending hiding diabetes from your doctor if that's what you're dealing with.  But for your own curiosity and ability to figure out what is going on with your own health,  especially if you don't have a cooperative physician, learning how to self-test on your own can be very useful.

  • Anne

    11/3/2008 1:10:00 AM |

    From what I understand not all states allow direct to consumer lab tests. Is that true?

  • anonymous

    7/16/2010 10:01:23 AM |

    As of 3/11/10 I've eliminated sugar, eat only grass fed ruminants cooked in coconut oil, eliminated all grains, grain and seed derived oils, almost daily 30 mins of midday sun, limit my fruit to 1/2 cup wild blueberries 3x/week and have kept my carbs under 50g/day.  39y.o. Male.  BP went from 140/90 to 120/81.  BW 270lb to 227lb.  I saw an internist for a physical at a major teaching hospital in a large U.S. city (he's a  professor at the associated medical school).  He called me with my lipid panel with a tone of concern.  TC 226, HDL 67, LDL 160, Trig 43.  He said I have to go on a "low cholesterol diet"  and follow up with him in 6 months to see.  I asked him to order a VAP.  "No, I don't do that.  Watch your chol intake and will look at other options in six months,"