From the Oxford English Dictionary, the “Holy Grail” of the English language, perfunctory (adj.) means “ done in a careless or superficial manner, slight, careless, negligent. 1. Of a thing. Done merely for the sake of getting through the duty, done as a piece of routine, or for form’s sake only, and so without interest and zeal; formal. Mechanical; superficial; trivial.”
So why would a word that evokes an image of routine, boredom and non-caring have anything to do with our current healthcare predicament? It is my belief that it is just this word, this attachment to form, that has our doctors wallowing in a sea of mediocrity rather than reaching out to embrace the amazing potential that modern science offers in the application and delivery of health care. So let’s examine some specifics.
Without question, a vast majority of laboratory studies are performed in a perfunctory manner. I know this because I ask patients to bring in their old lab work for a part of their clinical review. I am finding that they all have had the same lab work performed. Now I have to wonder how it is that across a wide swath of the patient population, with diversity in genetics, environmental exposures and degrees of health, all would merit the same choices for a laboratory evaluation. But yet this happens. I fact, I would wager that this has happened to you. But don’t just take my word on this one, you can open up your medical file drawer and take a look.
Peering into my crystal ball, I am going to prognosticate (another great SAT word) the laboratory studies that have been obtained for you at your last doctor’s visit. The orb begins to speak. It tells me that you received a CBC, or complete blood count, that checks your white cells (a measure of infection) and your red blood cells (which carry oxygen) along with several other cellular parameters. Changes in white blood function indicate an active infection when elevated, and can suggest a cancerous process in the blood, lymph or bone marrow when either significantly elevated or lowered. Occasionally we see a low red cell count (anemia) in a woman with heavy menstrual periods, rare medical conditions such as sickle cell disease or thallasemias, or significant nutritional deficiencies in iron or B vitamins. But as a whole, in the absence of signs of advanced or significant illness, this test gives little information as to the status of our general overall health.
The second test that I see materializing in my ball is the CMP, the complete metabolic panel. This panel looks at sodium, potassium, chloride and other basic ions. It also examines the general function of the kidneys, whether the liver is sustaining cellular damage, or if the gall bladder is backed up. Of course this is important information; it reports on vital indices in respect to one’s health. But again these studies are almost uniformly normal, only showing changes in established liver or kidney disease. Most people with altered ions on their CMP, such as potassium, sodium or glucose, are already either sick with illnesses such as high blood pressure, diabetes or kidney disease. Here the test is less diagnostic, but more a measure of the disease’s progression. The CMP does little to screen for illness or chronic disease risk factors in a generally well, asymptomatic individual.
But wait, there is another image coming into focus in the back of the swirling glass. Yes, the infamous cholesterol or lipid panel is coming into view. This is the domain of the good versus bad cholesterol, and the murky stratification of cardiovascular risk based on words such as LDL, HDL and triglycerides. Too often the simple observation of a number- say a total cholesterol greater than 200- reflexively prompts a doctor to write a prescription to lower the cholesterol with a medication such as a statin drug. We all know these parameters, but we sadly don’t know the back story. Yes, in certain individuals elevated cholesterol may predispose to early heart disease. But this does not apply to everybody. Consider the fact that approximately 50% of people who have heart attacks have normal cholesterol. Apparently this is the “low hanging fruit” for heart disease prevention, but current research suggests that there are many more factors to consider when assessing an individual’s true cardiac risk. We will discuss some of these factors, and the way in which they can be examined with a more comprehensive and thoughtful laboratory evaluation. But they can’t be incorporated in a patient’s health assessment if they are never ordered.
So now we sit at our physician’s office, shivering in the crepe gown in the sterile waiting room, and the physician arrives beamingly with the good news. “You have normal labs. Your CBC, CMP and Lipid panel are all normal.” Everything is just fine. But is it?
Unfortunately the typical laboratory foray into an individual’s health stops at the paragraph above. The patient has three normal labs checked, and all three are fine. Now, I am hopeful that most reading this blog in fact do feel fine, but from experience I know that for many of us things aren’t quite right. We could be suffering from a degree of fatigue, our hair may be thinning, or maybe we aren’t really sleeping well. Maybe an aging man is noticing changes in this thinking, strength and mood, but nothing in this panel short of advanced disease would reveal any clues. Perhaps you are struggling with your weight, your libido, or the fact that your father keeled over with a massive heart attack at the same age that you are at now. But little in the “perfunctory three” is going to reveal any perspective into your lifetime health risks. These lab tests are performed as a matter of routine and because they are paid for by the insurance companies. They are perfunctory, cheap, and offer little more than a door prize for making it into the doctor’s office. They offer no real insight for the person wishing to maximize their health, wellness and life.
With the addition of a few simple, inexpensive laboratory tests, we can open up a far greater perspective, with more insight into our health. And the beauty of this testing is that many of the interventions into improving our health can be done without having to go on conventional drugs if the laboratory testing is indeed off.
I often tell my patients that if God appeared in a burning bush, and in a deep sonorous voice told me that I could only order one test for each patient, I know exactly which one I would choose. And I assure you that none of the three previously mentioned would make the cut. I would obtain a test known as a hs-CRP- a high sensitivity “cardiac” C-Reactive Protein. This is a very sensitive measure of inflammation within the body. It does not say from where the inflammation comes, figuring this out is part of the art of medicine, but is does say that an individual is inflamed. And with inflammation comes all disease; cancer, autoimmune diseases, cardiovascular disease, and dementia. A man or woman who lives a long and vibrant life has to have a low CRP; there is no other way.
Now we have a simple measure of a test that measures inflammation, a “holy grail” that serves as signpost towards all chronic disease. Naturally I believe that this should be a component of every routine examination, but ordering this test is not perfunctory. It requires a little creativity to address the processes that ultimately drive disease and illness.
I feel that a vitamin D level should be frequently checked on patients, and that the vitamin should be maintained in a level between 60-70 if possible. The vitamin, through the VDR or vitamin-D receptor, is responsible for turning on around 2000 of our genes. This is approximately 10% of our body’s total DNA. Low levels of the vitamin have been associated with every known disease. But look for yourself. Go to your favorite internet engine such as Google chrome or Firefox, and type in the following words: Vitamin D, ncbi (for the National Center for Biotechnological Information) and the disease or medical condition of interest. I can almost guarantee that you will find a current scientific reference that associates low vitamin D levels with the disease in question. I am guessing that many reading this blog have never had a vitamin D level tested. Even though we live and work indoors out of the sun, always wear clothes, and never forget to put on sunscreen when we do go outside, it infrequently occurs to our doctors that out vitamin D level could be low and need supplementation. On a whim I just entered the diagnoses Lupus, Multiple sclerosis, heart disease, Alzheimer’s and fatigue into my browser (along with the words Vitamin D and ncbi) and came up with dozens of papers that support the need for supplementation. Have you had your level checked? It is not perfunctory at all to do this but bordering on the medically creative. As we begin to expand our horizons for testing, we begin to step from the ‘perfunctory three’ to a place of medical insight and creativity.
What about your thyroid? Depression, weight gain, fatigue, skin changes, heart disease, infertility, diabetes, autoimmune disorders, and arrhythmias are all associated with even subtle changes in your thyroid function. And the autoimmune disease Hashimoto’s thyroiditis is on the rise I can assure you. I am seeing it in almost equal numbers in both men and women, which is a vast departure from the much higher incidence in females in the past.
I recommend that you never settle for the perfunctory TSH, which is a measure of the brain’s opinion of how much thyroid function you have- a molecular game of “telephone”. You have to measure the bio-available hormones, free T3 and free T4 to fully understand the system. And while we’re fighting perfunctory, let’s add in a reverse T3. This is the doppelganger of T3, a molecular mirror image that binds but doesn’t activate the thyroid receptors. It is all so important, but none of these factors can be aced upon if the test is never sent. TSH, free T3, free T4 and reverse T3. Ask your doctor for these by name.
I earlier alluded to the lipid test, one which measures total cholesterol, triglycerides and HDL, or high density lipoprotein. Of interest the component of the test most responsible for the clinical decision making, the LDL or low density lipoprotein, is not actually measured value but calculated mathematically from the other parameters. It is important to understand that this test and the information gleaned from it is horribly outdated, yet clinical decisions are made on its results daily. Recall that more than 50% of individuals with a heart attack have had a normal lipid panel.
Why is this? It is because this outdated dinosaur of a test is not even asking the correct questions to fully address our cardiovascular risk in relation to our cholesterol. For years clinicians have had access to advanced cardiac testing. Advanced testing poses questions that address the characteristics, subtypes and numbers of the cholesterol particles which are known to increase our risk of heart disease and stroke. In regard to heart health, using the antiquated lipid test to evaluate the health of one’s heart is like taking a paper bike to the Tour de France. So be sure to request that your cardiovascular health is doubly assessed by knowing your state of inflammation (hs-CRP), along with your true risk in regard to cholesterol and lipids via checking lipid fractionation via an advanced lipid panel.
Two other tests deserve mention to help us to break from the constraints of perfunctory medical care. The ion magnesium is notoriously low across the population, yet it is infrequently measured correctly, and thus not addressed and replaced. Magnesium is an important co-factor in more than 400 enzymatic reactions in the body, so I feel that it is important to know your levels. However should a magnesium be ordered, it is frequently done so as a serum level. This does not correctly approximate the levels of magnesium in our tissues. I recommend that you request a Red Blood Cell Magnesium to fully know your levels of this important ion.
Finally, step out of the perfunctory and get to know your homocysteine level. This molecule, a derivative of the amino acid methionine, is well documented to be an independent risk factor for cardiovascular disease through its toxicity to blood vessels. However it is infrequently ordered. From a functional standpoint homocysteine reflects one’s B vitamin status and ability to support a cellular process known as methylation. And how important is methylation? It is a process that activates our DNA, creates our neurotransmitters, and allows us to detoxify.
So step out of the perfunctory and get to know your body and how these important parameters relate to your health. If your doc won’t order these tests, find a doctor who practices functional medicine to get a more comprehensive and accurate picture of your health, wellness and aging process.
Dr. Scott Resnick