Why I Always Get and Keep Copies of Medical Test Results

Yesterday was my annual physical, a day I always anticipate with dread because it represents my annual battle with The Way Things Are in the health care business today. Inevitably this battle involves my doctor, a kind and intelligent person who has only my best interests at heart. She is the one I would want beside me in a medical crisis. But there is no crisis – I am perfectly healthy – and this year, like most years, I will have to prove it, by achieving normal results on various medical tests or by justifying any result that is out of line.

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.