I might give up having an annual physical at all, except
that I need refills of the two medications I take regularly: Synthroid for my
hypothyroidism (no generics, please, we’ve tried that already) and Premarin,
which I’ve taken since 1980 because I had a complete hysterectomy and want to stave
off bone loss. So I go for my physical, get my blood work, mammogram, and DEXA
scan, and deal with the consequences.
An individual test result, looked at in isolation, can be
misleading. In health care, as in most of life, context is everything.
Unfortunately, because of the way medicine is practiced today, context is very
limited or absent altogether. Most doctors don’t know their patients well; many
don’t know them at all. Record-keeping systems are constantly changing which
can lead to the loss, misfiling, or intentional destruction of older documents.
One topic of conversation with my doctor yesterday was my high BUN/creatinine
ratio. This is an item to be taken seriously because it is an indicator of
kidney function. In my case, creatinine is a perfectly respectable .9 (normal
range .5 to 1.3) but BUN or blood urea nitrogen is a whopping 32 (normal 7 to
20), resulting in a ratio of 36 (normal 6 to 25). On a more positive note, my
GFR, another measure of kidney function, is 66, perfectly fine.
My doctor was concerned but I pointed out that the ratio,
for me, has been high for years, maybe even decades. In the past doctors have
attributed the high BUN to dehydration associated with fasting before blood
work. “Still,” the doctor said, “it’s higher than last year and the year before.
It seems to be going up.” We talked about whether I’m dehydrated (no), whether the protein supplement I take
could be affecting it, and she wants me to repeat the test on a day when I’m
not fasting. I agreed.
My doctor only has test results
for me going back a couple of years but I started getting and keeping copies in
2000 when my doctor at the time wanted me to take statins. After my appointment
I went back through the file and found that the BUN/creatinine ratio has bounced around a
lot; in 2005 it was 36! Protein in the diet can have an impact on BUN; cardiosmart.org, the website of the American College of Cardiology says, "Do not eat a lot of meat or other
protein in the 24 hours before having a blood urea nitrogen (BUN) test." Exercise can affect it too. One website for weight lifters recommends not lifting
weights or doing cardio the day before the test. (I had probably done both the
day before this year’s.)
I haven’t had the mammogram or
DEXA yet but so far this year’s flap has been relatively minor compared with the
breast cancer non-event a few years back and the heart disease false alarm last
year. Doctors devote their lives to helping others. In order to help as many
people as possible they rely on test results and on generalizations based on
large research studies. Since their time with individual patients is very
limited, they sometimes interpret idiosyncratic variations as disease. In
addition to a very real concern for patients, the prevalence of malpractice
litigation inclines doctors to err on the side of caution.
I believe that having health
coaches in doctors’ offices would do a great deal to reduce unnecessary testing
and anxiety on the part of both doctors and patients. A health coach would have
the time to review my medical records and know that my white blood cell count
is sometimes low and that my BUN is always high. Instead of making assumptions
about my physical condition based on my age and sex, a health coach could
actually find out how many pushups I can do and what I eat for breakfast. The
main reason to respect Western medical care is that it is based on science and science
depends on accurate information about specific situations. A health coach who
knows me could be a valued ally in my annual fight to prove that I am healthy.
