August 15, 2008

What did that blood sugar test mean?

There's an interesting study that was reported on Science News today which illuminates the very poor way in which doctors communicate the results of medical testing to their patients.

Wide Variety Of Errors Found In Testing Process At Family Medicine Clinics.

What this study found was that "...medical testing errors led to lost time, lost money, delays in care, and pain and suffering for patients, with adverse consequences affecting minority patients far more often. ...The most common errors involved failure to report results to the clinician, accounting for one out of four (24.6%) reported mistakes. Test implementation (17.9%)[i.e. people not getting the test that was ordered] and administrative errors (17.6%) were the next most common. ...A quarter of the errors resulted in delays in care for patients, and 13 percent caused pain, suffering or a definite adverse clinical consequence. Eighteen percent resulted in harm."

This really leapt out at me because I've been hearing from a lot of people whose emails bring to life what these kinds of testing errors really mean for people with diabetes.

Typically the person who is experiencing what sound very much like diabetes symptoms will write, "The doctor gave me a blood test but I didn't hear anything back, so I figured it was okay."

As this study shows--and as I have experienced in my one case--not hearing from your doctor often does not mean that the test was fine. It means that the result never got to your doctor.

Today's doctors' overworked staff do not have the time to double check that a lab test that was ordered came through from the lab. As this study shows about one in four tests never get reported by the lab at all. And whether the report gets through or not has nothing to do with whether the results was normal or not.

So if you were tested for diabetes, and don't hear from your doctor, you need to demand that your doctor's office sends you a copy of the lab result. It is only when they go looking for your lab test that the staff will discover they don't have a copy.

But the problems with lab tests go beyond this. Even if the doctor says, "your test came back fine" you STILL need to demand a copy of the lab results. Why? Because of what this study calls "Administrative errors."

What this means is that when the test comes in to your doctor's office some LPN whose total medical training was a one year certification course at a Junior College looks at the lab sheet and unless something is flagged "abnormal" puts the test into your folder or adds it to the pile of unimportant stuff the doctor doesn't have to look at unless he has nothing else to do.

If you call to ask about the result of this test that was not flagged abnormal, the LPN "Nurse" will tell you it was "fine." But often with diabetes blood tests, the word "Fine" can hide a world of hurt.

Consider the fasting blood glucose test that comes in at 124 mg/dl. This is officially "not diabetes." The ADA defines a diabetic fasting blood sugar as being over 125 mg/dl. So there are, sad to say, LPNS and even doctors who will tell you that you don't have diabetes when you have a fasting blood sugar of 124 mg/dl.

Yes, I know it is crazy. But it happens, though any rational person can see right away that a blood sugar of 124 mg/dl is so close to 126 mg/dl as makes no real difference. Test two days earlier or later and you might very well have seen a fasting blood sugar of 127 mg/dl or more.

By the same token, a lot of family doctors still consider "pre-diabetes" to be a fad diagnosis and will not even mention to you that you have pre-diabetes when your fasting blood sugar is over 100 mg/dl.

This is a huge problem because a lot of research has made it crystal clear that the fasting blood sugar test remains near normal in many people with Type 2 diabetes, until several years after their post-meal blood sugar is going up over 200 mg/dl after every meal. And other research is finding that into a whole slew of diabetic complications from heart disease to nerve damage to early retinal changes leading to blindness begin to occur when these post-meal blood sugars are high, long before the fasting blood sugar is high enough to earn you a diabetes diagnosis.

If you are already diabetic and doctor does an A1c test to check on how your blood sugar is doing, you may also be told you are "fine" when your A1c is hovering around 7.0%. Again, that's because of the way labs report the A1c result.

My lab--at the county hospital--lists an A1c of 6.0 to 6.9% as "VERY GOOD". It lists the A1c of 7.0% to 7.9% as "GOOD." If your doctor mails you a postcard that says "your A1c test result was good" you really need to call up and ask them to mail you a copy of the actual test result, because if that "good" A1c turns out to have been 7.9% it is high enough that you have a thee and a half times higher risk of having a heart attack or stroke than you would have had if your A1c had been between 5.0% and 6.0%. That doesn't sound good to me at all.

In today's environment of PCP doctors who have so many patients they can't remember who you are or what treatment they prescribed for you the last time you visited, you can't assume that the doctor ever saw your lab result unless it was highly abnormal.

Even worse, if you change doctors, don't assume that your old lab results will be forwarded with your "medical records" to your new doctor. Often they are not. Labs often don't keep copies of your old tests for more than a year or two, either.

That's why it is a very good idea to get a copy of every lab test you ever have had done and keep it with your important personal records. Often the real meaning of a medical test does not become crystal clear for a few years, because it is part of a developing pattern. Without previous lab results it is hard for a doctor to know if a borderline finding is significant or not. And in today's world of sloppy medical care, those past lab results may no longer be available.

Your lab results are yours and you have a right to a copy of every lab result you or your insurance has every paid for. When you go in for a lab test, ask exactly what you have to do to get a copy of your test result. Sometimes you will have to fill in special forms. Other times you will have to fax a letter to some functionary. Whatever it takes do it. Get a copy of your labs and if they are blood tests, call on the very helpful people involved in the online diabetes community to help you understand what they mean.

You can find help understanding your test results by posting messages at Tudiabetes.com, Diabetesforums.com and diabetesdaily.com.


BOTTOM LINE: If you have a test, find out what the result was, learn what you can about what the test result numbers mean, and make sure your doctor spends the time to interpret the test appropriately. Especially if it is a blood test that relates to diabetes.

5 comments:

Lili said...

It's so true! And it goes the other way, too. I was told by my endo's nurse that my lab results were "normal." When I finally got a copy of the lab report, it listed my A1c as 4.5. I don't know about you, but I don't find that a normal result for a Type 1 diabetic! (It seems to be something abnormal going on with my hemoglobin, btw. It's definitely not reflective of my average bg).

But, see, the lab lists the normal range as "4.0 - 6.0." How could the nurse be expected to remember that's the range for nondiabetics?

Anna said...

Excellent advice. I have also learned to insist on a copy for my records, the hard way.

For more than ten years, my fasting BG was over 100, but because it wasn't flagged as abnormal, no one knew I was probably running high post meal BG all that time (especially as this was during my high carb baking days!). Now it isn't any surprise that I was diagnosed with gestational diabetes when I was pregnant ten years ago, but it sure was a shock to me then. Now I'm not so sure it was gestational diabetes, it just happened to be caught because of better testing during pregnancy. Not long afterwards, I moved to a low carb diet, which lowered my FBG to under 100 and lowered my weight, which further fooled my doctor about my BG control, but that's another story.

Also, my TSH was still technically in the "normal" reference range, but it was slowly creaping up over 15 years, with increasing and obvious low thyroid symptoms that prompted my doctor to order the TSH test many times. But because the lab didn't flag the TSH value as abnormal (the lab continues to use an outdated and controversially wide ref range), a thyroid disorder was dismissed as a cause and she suggested one Rx after another to manage symptoms (I tended to resist that approach). But mild hypothyroidism was likely a contributing factor for my years of infertility; treatment for hypothyroidism could have saved me a lot of grief, not to mention a lot of unnecessary fertility intervention and expenses. Many years later when I figured out the thyroid problem myself, I went outside my HMO for hypothyroidism treatment and most of those symptoms are gone or greatly diminished, but unfortunately, much too late to consider trying for a pregnancy again. I try not to think about "what if...".

Even more alarming, a few years ago, when I finally figured out that my health care network wasn't really providing the good care that I thought I was getting for over a decade, I paid for a copy of my thick record (about $45 and worth every penny!). I was shocked to see that 4 other patients' consultation and lab reports were in my file! The medical records department took this very seriously and cross-checked the 4 other files to make sure my records weren't misfiled there, but there is no way to determine if something of mine was misfiled elsewhere. The medical records specialist said *everyone* should insist on a copy of all results and maintain a personal file in a secure place (safe deposit box?). Now I always get a copy for every member of the family, no ifs, ands, or buts. It's not ever a problem (though the nurses sometimes grumble because they forget and then have to go find the doctor for permission), and many doctors already provide a copy without being asked.

There are many medical records-keeping systems out there that can help with the organization. Amazon lists many. Those with chronic and/or serious long,term health issues would be wise to keep an up-to-date comprehensive file, but I think healthy people would be wise to keep a record, too. I also find it useful to pay the small fee (my network charges about 25 cents a page, plus postage) to request a copy of the consultation reports that the doctor enters into the file; usually I request it about a month after an appt. It's sometimes quite interesting what a doctor says about the visit and how they interpret what the patient says, etc.

The Old Man and His Dog said...

Couldn't agree more. I now get a copy of everything and have my own file that I bring with me to the Dr. It includes my everyday testing, copies of my prescriptions, all lab work, and anything else I can get my hands on. Never fails that when I have a Dr. appt. we end up needing "my" file.

Anne said...

When a doctor says "normal" what (s)he may be really saying is "its not abnormal enough for me to worry about".

I have had lab tests omitted. I have had incorrect lab tests run. I was told my GTT that went to 202 was nothing to worry about since my fasting BG was "normal". It is scarey out there.

I tell everyone to get copies of labs. Some people take this advice, but two common replys are, "I would not know what I was looking at" or "I trust my doctor".

Even if the lab values are in the normal range, if you have copies you can watch the trends.

Bob Hawkinson said...

Absolutely right Jenny.
...ask and you shall receive. Otherwise you may have lost results or data that is iffy at best.
Wishing you "well" Bob

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