I remember a great scene from the TV series House. A woman suffering a mysterious seizure disorder presents to Dr House and says: "I wonder if you could run a complete blood count?" As though running the most basic blood test hadn't yet been thought of by anyone and as if ordering a test was the best use of television's greatest investigative medical genius.
Fictional American TV doctors are uncomfortable with uncertainty. They like to label things, and then they like to do something about them. The use of time as a diagnostic aid is unheard of, as is talking, or examining the patient. The delicate art of watch-and-wait is just not done. People are wheeled into the emergency room via a full body MRI scan while the health insurance industry looks on in glee.
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As a doctor and consumer of noughties American medi-drama, I've noticed a shift in this direction among Australian healthcare consumers. Our Americanisation is extending to how we view our health, and how we want our doctors to view it – which appears to be through the eyepiece of a microscope. Or rather, via a computer looking through the eyepiece of a microscope.Â
There's a steady upwards trend in young, healthy people coming to ask for their "yearly bloodwork". They even say it with an American accent. Because on American TV, all young, healthy people require yearly blood tests to "make sure" they are young and healthy.
"Which blood test?"
"You know, all of them."
Point to Manual of Use and Interpretation of Pathology Tests on bookshelf. Two inches thick, small print. More than 800 tests.
"Why? What's up?"
"I just want to make sure everything is OK."
"How will a blood test tell us that?"
"I don't know, you're the doctor."
"Hey, that's right. Tell me the problem and we'll work out a plan, which may or may not include bloods."
"Oh there's no problem. I just want the blood tests."
"Ok. How about we discuss your genetic history, mental health, diet, exercise, sex and drug habits, I'll examine you and if there's red flags we look further."
"That's so boring."
"Don't blame me, it's your life."
They might need a blood test. Or an ultrasound, a camera in an orifice, the opinion of an immunologist. It might be time, or a cry, or to stop that medication. It might be an ambulance to hospital with lights and sirens.Â
Foreclosing an opportunity to receive personalised medical care by declaring what one needs is not always a wise consumer choice. The reality of health involves uncertainty, individual responses to common diseases, and recovery time.
Wiser Healthcare, a group of academic, medical and health consumer groups, recently announced an action plan to counter the culture of "too much medicine".Â
Its drive is that medicine is great when rationally administered. It must be based on the knowledge you get through history, examination and discussion and it's how we keep patients safe and save the Medicare purse money. Getting time-poor doctors to do this in a risk averse landscape is one thing. Getting patients to accept that sometimes a blood test is not what they need is another.
A small study from 1975, published in the British Medical Journal and drummed into medical students everywhere, concluded that around 82.5 per cent of diagnoses were evident from the story patients tell. Examination solved a further 8.75 per cent, presumably leaving 8.75 per cent of diagnoses for laboratory tests.Â
The numbers will have changed a little since, but people haven't too much. We still get mostly the same diseases as in 1975, excepting the rise in obesity-associated illness, and the drop in vaccine-preventable illness such as polio and meningitis.Â
A young person is most at risk of sexually transmitted infections and mental health issues, and that's brightest on my radar when they ask for a check-up. But many are hoping there's a medical cause of their ennui, weight gain or existential fear. Rarely, there is. But life-threatening disease can exist in the presence of normal bloods and tests must be interpreted in context or they can mislead. You are the context. During medical training we are taught to "treat the patient, not the blood test". I thought it was us, not our patients, who needed to hear this.
People are often disappointed with normal results. They sigh, "I was sure there must have been something wrong." If the All Knowing Bloodwork didn't solve things, they'll have to make do with this lousy GP. It's a shame I ordered $400 in blood tests, paid for by Medicare, to get to this point – where we can talk. About fear, their pattern of pain and sleeplessness. The difficult year. Did the rash come first, or the cough? We examine again. What exactly happened four months ago when those last symptoms started?
"I told you, nothing. Actually …"
And it turns out it's the goat's milk soap. Blood tests wouldn't have told us that.
Elizabeth Oliver is a Sydney GP.
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