MEDICAL TESTS ARE BAD FOR YOUR HEALTH

by Kevin Wohlmut

I was warned by several people, when I applied for the Peace Corps, that passing the medical exam would be much harder than the actual work I would be asked to do on the job. Little did I know that it would cost me $1,000 of my own money and three stress-filled months of delay, just to pass the medical exam for a volunteer job which technically does not pay me anything.

When I applied, they asked me for a full physical, including a broad-spectrum blood test. They asked my doctor to test for 45 different factors in my blood, ranging from things as simple as my blood type to things as complex and deadly as cholesterol, glucose, and HIV.

Obviously, as they explained, Peace Corps volunteers often find themselves out at the fringes of civilization, so if they get hurt or sick, the Peace Corps must know their medical needs very precisely.

What they failed to remind me of, however, was that some of those blood tests (e.g. the cholesterol) require that the subject was supposed to fast for 8 or 12 hours before giving the blood sample. When I made the appointment with my doctor, I just told the doctor, "Oh yeah, and they want some blood tests too," and so my doctor also failed to warn me I should have fasted.

That morning, the only food I had eaten within 8 hours was a single banana. So my doctor said, "Well what the heck, let's try it and see if it comes out OK."

So it wasn't a big surprise when some of the results came back screwy. Apart from the glucose and cholesterol, a liver factor called "Bilirubin" was beyond the normal range. The Bilirubin was 1.7 milligrams per DL, whereas the normal range was a maximum of 1.5 mg/DL The ratio of "B.U.N." to "Creatinine" was very high, even though individually the BUN and Creatinine were within normal limits.

(The other factors were normal, including, for the record, negative on HIV. Just in case anyone reading this was thinking of having sex with me. Well, I can always hope.)

So the Peace Corps said that I could not receive medical clearance to be hired, until I took another blood test to confirm, and/or got a medical diagnosis for what my "condition" was and what medications, pills, surgery, etc. would be necessary during my term as a volunteer. It's not so much that they wouldn't hire me if I had a medical condition -- just that they needed to know exactly what it is.

I grumbled to myself that they should have warned me to fast, but I ponied up another $200 for a second blood test. (This is, of course, separate from the $75 for each doctor's time. And I don't have health insurance, so this is coming straight out of my pocket.) This time, I fasted properly. For some reason, either the doctor or the lab simply "forgot" to test for BUN/Creatinine, even though I specifically asked them. But that's a whole different piece of incompetence.

In the second test, the "AST" (a liver enzyme) was suddenly higher than normal, and the Bilirubin increased, to 2.4 mg. (The cholesterol and glucose dropped back to acceptable levels, if not truly great levels.)

But there was no way I could convince the Peace Corps of that.

The Peace Corps medical office apparently operates like much of the American medical establishment, only worse. It's all totally robotic. "If Blood Factor X2 is 25% higher than reading 655Y, then you have a medical problem and you must be rejected."

Frankly, based on several recent experiences I've had regarding sleep apnia and Ghiardia, I feel that the private sector of medicine is only marginally less robotic than the government sector. Hey remember those old "Harry and Louise" ads, where paid "average citizens" voiced their concerns that a federal Health Care plan would NOT let you "chooooooooooooooose" your own doctor? Well guess what? You can choose your own doctor, but your doctor is a robot who glances at your test numbers for five minutes before seeing you, and then assigns you treatment based on a mathematical formula where he plugs in your test numbers. He's too afraid of being sued (if you happen to drop dead after he says "you look fine") to deviate from the algorythm by so much as a decimal point. So much for "choice" in the medical system.

So there was no go. The Peace Corps medical office insisted that I had to have some sort of explanation and/or diagnosis for the numbers. Flukes and botched tests apparently don't exist in their parallel universe. I had to get another blood test and keep seeing doctors until I got an explanation, assuming I still wanted to volunteer.

Also, the Peace Corps warned me that drinking any tiny amount of alcohol whatsoever, in the WEEK leading up to the blood test, might throw off the liver enzymes. I'm not a habitual drinker, I didn't know for certain that I had drunk any alcohol for a WEEK before the test, but it was always possible that I had had one beer or glass of wine with dinner at some point. "Great," I grumbled, "yet ANOTHER thing I wish they had mentioned before I spent $200 on a blood test."

My regular doctors were consistently puzzled, whereas I also heard from a friend of mine that he had a similar problem with liver enzymes in his blood tests. He said his doctors had been testing him on and off for eight years without ever finding an explanation. The only symptom he ever had, was that his health insurance raised his rates when they found out about the test results.

Of course, my friend there has health insurance. I currently do not have health insurance. So every time I take a blood test, that's $2-300 out of my pocket. By the way, the Peace Corps reimburses applicants to a maximum of $125 for everything, including the dental work that they require (Your dentist needs to sign a letter that includes X-rays, saying that all your dental problems have been taken care of before you leave.) My dental work alone cost me $400.

So the Medical office of the Peace Corps was consistently balking, whereas meanwhile, the Regional Director, the guy who would actually be doing work with me in the foreign country, was constantly leaning on me: "Can you get the results any faster? Hey, have you called your doctor again yet? Can you move up the next appointment?" Because, of course, he has to cut through miles of bureaucratic red tape (e.g. obtaining foreign working visas) and he needs significant lead time to do so. But there's no point in starting that process if I'm not going to be medically cleared.

So I was stuck in limbo. No medical clearance, and not much specific hope that I would be able to get one. Other Peace Corps friends suspect that the medical clearance is the process the Corps uses to "weed out" people who aren't serious about working for them... and that was the month I really gave a lot of thought to giving up on my application.

But purely by chance, following the phone book, I hit upon a different strategy: I took my next blood test at a place that handles Workman's Comp medical claims, instead of a hospital or clinic. I figured, a hospital or clinic is trying to prove that you're sick; someplace that's handling Workman's Comp claims, probably has a lot of corporate pressure upon them to prove that you're NOT sick.

Call me cynical if you like, but the strategy seemed to work. Suddenly the BUN/Creatine was normal, the AST and ALT (liver enzymes) were suddenly quite squarely normal, glucose and cholesterol looked just fine, (and the full Hepatitis panel the Corps now asked for, turned up negative).

Does your doctor's hidden agenda affect the medical results? One anecdote doesn't prove that. Still, that's a useful strategy to keep in mind if you ever seriously need to pass a medical test.

But the Bilirubin was still higher than the other two previous tests. It was now at 2.7 mg. (But just for perspective, your skin becomes jaundiced when the Bilirubin reaches about 20-30 mg.)

I complained to the Regional Director that it was silly to block my clearance when I don't have any symptoms, and no doctor can "name any specific disease or syndrome" that I allegedly had. The Regional Director must have passed on my concerns to the Medical Office, because I soon received a snotty e-mail from the medical office saying "It is not the responsibility of the Peace Corps to name any specific disease or syndrome among the applicants. You cannot be medically cleared until we have an explanation and/or diagnosis along with treatment options. We recommend you take another blood test and see a specialist, either a gastrointestinologist or an internal medicine specialist."

So I scheduled a $75 appointment with an internal medicine specialist, and braced myself to pay another $200 for the blood test.

The internist took one look at the three previous blood tests and said, "Oh, you have Gilbert Syndrome." (It was apparently discovered by Frenchmen because it is pronounced 'Jill-BEAR' Syndrome.)

So... drum roll please... I asked him, "What is Gilbert Syndrome?"

He responded, and I quote: "It means you have high Bilirubin -- and ABSOLUTELY NOTHING ELSE." (Emphasis his, not mine.)

We went through with the fourth blood test ($$Ka-Ching!!$$) because we figured the Peace Corps would probably keep rejecting me if I ignored their request for another test. Meanwhile, I looked up "Gilbert Syndrome Bilirubin" on Google.

http://www.medic8.com/healthguide/articles/gilbertsyn.html

http://www.emedicine.com/med/topic870.htm

http://www.liverkids.org.au/gilbert.htm

http://www.gastro.com/html/liverdisease/gilbert_syndrome.shtml

Gilbert Syndrome apparently affects 2 to 7 percent of the population. It is a congenital (inheirited) condition. Studies have failed to find any serious medical problems associated with Gilbert Syndrome. It does not reduce your life expectancy or cause other complications. For the vast majority of people with this condition, there are no symptoms AT ALL, except for the blood test reading, so most go to their graves without ever even realizing they had this condition. It does not appear to progress, get worse, or lead to other diseases. There is no medication or treatment which will "cure" this syndrome, although certain pills and/or avoiding alcohol will temporarily allow you to process the Bilirubin better.

As one website put it, "Once the diagnosis is established, the most important aspect of management is to reassure the patient with regard to the benign and inconsequential nature of the disorder and the excellent prognosis and to prevent further unnecessary investigations."

It seems clear to me what's going on here. Doesn't it? This is pure speculation, but I suspect some chain of events like this:

The American Medical Association held a big meeting a few years back, and somebody in the hematology committee announced, "Hey, we have a great new blood test which will detect Bilirubin to one part per ten billion. So now we need to pick some numbers out of a hat which will represent the average level of Bilirubin in healthy blood, and a reasonable range of values." Other hematologists stepped forward with some numbers.

Then some nonconformist doctor piped up and said, "Hey wait a minute, there are people whose numbers just naturally fall outside that range, but they're still healthy. What do we do about them?"

The AMA committee chair answered, "I know -- let's name a syndrome after them!"

In other words, the concept of a "Bell Curve" seems to have flown out the window for this particular test.

Also note that this explains the apparent "meteoric" increase in my Bilirubin as the tests went on. The web pages about Gilbert's Syndrome explain that someone with this syndrome may experience a rise in Bilirubin, when they fast. Like, oh, you know, when you're fasting for a blood test or something like that. My first blood test was almost normal -- because I didn't fast properly beforehand. My subsequent blood tests had higher Bilirubin -- because I was fasting properly. (Including the fourth, and last, blood test -- reading 2.0 mg.)

For some reason, when I looked up "Bilirubin" on the Internet after my first two blood tests, the DOZENS of web pages that I read all talked about Jaundice, Hepatitis, and Anemia, but they did not discuss "Gilbert Syndrome." But when I searched for "Gilbert Syndrome Bilirubin", I found at least ten or twelve pages devoted to this particular syndrome.

Why the obscurity? It seems surprising that my regular doctors had never heard of this syndrome, which one website called "among the most common medical conditions ever diagnosed".

On the other hand, it shouldn't be surprising.

The American medical system presumably doesn't pay much attention to this syndrome because it is not possible to make money off of a disease with no symptoms.

For example, I'm trying to imagine the TV commercial for the fictitious drug which might cure this particular syndrome:

[BEAUTIFUL SUPERMODEL IN NEGLIGEE CAVORTS IN A GREEN FIELD] "Do you have high levels of Bilirubin in your blood? Go to your doctor right away and ask to be tested for eligibility for Ryeandrubinol, the new drug which helps people like you control their Bilirubin." [MORE CAVORTING] "Because some people live long and perfectly healthy, happy, normal lives without ever even realizing that they have a condition known as hyperbilirubensis, or Gilbert's Syndrome." [CAVORTING STOPS AND SUPERMODEL LOOKS DOLEFULLY INTO THE CAMERA] "But you wouldn't want to be the sort of person who goes through life without knowing something like that, would you? So ask your doctor about Ryeandrubinol today." * During clinical trials, Ryeandrubinol was associated with certain side effects such as continuous projectile vomiting, rectal bleeding, Sudden Inexplicable Adult Death Syndrome (a variant of SIDS), Tourette's Syndrome, and susceptibility to flesh-eating bacteria. Women who are pregnant or might ever conceivably wish to become pregnant during their lifetimes, must not take Ryeandrubinol, nor handle the pills, nor approach within fifty feet of a person who has ever taken this pill. Patients undergoing treatment with Ryeandrubinol have been known to set off airport metal detectors and nuclear radiological alarms, even when the pills are not on their person. So be certain to carry your doctor's prescription information with you at all times while travelling. If symptoms such as eyeball disembodiment occur while using Ryeandrubinol, discontinue use instantly, induce vomiting, proceed to the nearest exit in a calm and orderly manner, and consult your physician. [SUPERMODEL] "So ask your doctor if Ryeandrubinol is right for YOU."

Again, Gilbert Syndrome apparently affects something like 2-7% of the population. The Peace Corps gets literally thousands of applicants each and every year; I forget the figure but I think it's something like 2,000 applicants.

Am I really the first person who has ever had to deal with this Bilirubin problem?

I don't know why I'm upset, really. I guess it was too much to expect some kind of apology or something from a Federal government agency. Even though it was THEIR OWN ignorance which put deadline pressure upon ME to resolve THEIR OWN IGNORANCE.

But, a few hours after I Faxed the internist's note to the Peace Corps, they e-mailed me and said, "Thank you, you will now be medically cleared as soon as we receive the hardcopy."

No: "Sorry we wasted three months of time that was crucial to your application process."

No: "Sorry we can only reimburse you for ten percent of what you spent on educating our own doctors about a common medical syndrome."

The Regional Director followed up with an e-mail that said, "Great, now we can start working on your Visa. I hope we have enough time, we're really down to the wire on this."

I couldn't put it any better than my friend Seamus: so I paid $1,000 to wait for their incompetence.

When I Faxed the internist's note to the Peace Corps, I followed up with an E-mail citing the web pages about Gilbert's Syndrome and explaining that it was completely harmless.

And then the Regional Director had the temerity to write me back and say: "I read your long message today..."

Long message?!?!

I wait three months for no reason at all, I told them THREE MONTHS ago that this number meant nothing and then I was proven right -- and then he doesn't even want to read one page of explanation?!?!

Part of the reason I would like to work in Mexico for the next two years, is that Mexicans generally don't care quite so much about being concise -- they have less of a tendency to reduce important decisions down to Scan-Tron bubble numbers, than Americans do.

The difference between "concise" and "verbose" is the difference between:

"The Bilirubin in your blood is two miligrams outside normal, therefore the Peace Corps cannot hire you."

versus:

"You have a natural and harmless tendency to accumulate Bilirubin in your blood, which will not interfere with working in the Peace Corps, won't require any treatment, and is clinically documented to pose no risk. Therefore you can work for the Peace Corps."

Oh, yeah, and the difference between concise and verbose is also that it took three months and $1,000 of my own money to convince the Peace Corps that answer (b), the verbose one, is the correct one.

I'm singling out the Peace Corps here, and they're an easy target because they're a vast unfeeling government bureacracy. Of course they can only go by the numbers; of course they have absolutely zero institutional memory and can't make any judgment calls.

But I'm convinced that the private-sector medical establishment has fallen into the same trap. And that trap is, perhaps, indicative of greater 21st century American culture, where the entire work force basically works on an assembly line in one form or another.

That could be a whole 'nuther rant, and I won't bother to go into detail about the medical problems themselves... but, in brief:

• A few years back, I had persistent diarrhea after swimming in a polluted stream during a camping trip. It took me three visits to the doctor to convince him that I was serious about wanting something done. They took a stool sample, and a week later a nurse called me up and said, and I quote, "Your Ghiardia test turned up negative, so you don't have a problem." I had to tell her, and the doctor, "Look lady, I do so have a problem, do you really want me to come over there and show you my problem in person? On your desk blotter, perhaps?"

In other words: "When Test Number 355X has a value greater than 5Y, you have a problem; otherwise, you do not have a problem." Over-reliance on numbers.

• My crewmates on a sailboat complained about the volume of my snoring (a form of sleep apnia). After a hugely long and impersonal testing process, basically I was prescribed an air pump to wear over my head at night. When I explained that, this problem arose because I was spending time on a sailboat -- where plugging an electric air pump into a wall plug every night was completely out of the question -- the medical personnel kept insisting, "Just try it, you'll like it, you won't ever want to go to sleep without it again."

In other words, change my life plans to fit their prepackaged solution, rather than solve or even pay attention to my problem. "Drone #755-57-1472 has a problem with air intake while in his dormant phase; the air pump increases intake by 20%; therefore Drone #755-57-1472 must use the air pump during his dormant phase. Q.E.D. Logical. The numbers prove it."

In my opinion, it all stems from over-reliance on numbers.

The internal medicine specialist suggested I take a Copper Serum blood test in order to rule out other diseases which might affect my Bilirubin. Fortunately, I had been fasting and abstaining from alcohol for a week in order to prepare for the blood test I assumed I'd be taking. But when I got down to the blood lab, they warned me that -- BESIDES the alcohol and fasting -- "The results may be botched if you have taken any vitamin or mineral supplements, or herbal supplements, during the past week." Of course this threw me into a panic because I drink Ginseng Tea about once a day and usually take a multivitamin about once a week. Fortunately, the Copper Serum tests came back normal.

But this also relates to my point about over-reliance on numbers and tests.

Geez, if these tests can be botched if I happen to eat anything other than porridge and water for a week beforehand... then it strikes me that the things they are measuring are probably too picayune to be a good indicator of my health.

Lemme be clear here. I'm not saying all tests are worthless. But let's compare:

• If your doctor says, "Oooooh, you have very high Bilirubin in your blood, you have abdominal pain, and your skin is tinged with jaundice. Your health may be in serious danger, you should be tested for Hepatitis and we'll start you on some medication."

-- Well that is GOOD DOCTORING. There are tangible problems and symptoms there.

• If your doctor says, "Oooooh, you have very high Bilirubin in your blood, your Creatinine is down, and your Hepatic AST is two miligrams beyond normal. Good thing you had that blood test or nobody would ever have known. I'm going to order a dozen expensive new tests and start you on some medication,"

-- Well that is BAD DOCTORING, since apparently any of those tests can be botched by eating a banana the morning before, or by totally nonsensical syndromes.

Do we have a health care problem in this country? I think it goes far beyond the hugely serious problem of how do we pay for it. (Just ask me how much that air pump for sleep apnia cost. Go ahead. Just ask me.)

I would presumably be less cynical if I had, say, Leukymia, and the doctors cured it. I suppose I should count myself lucky that my syndrome happens to be completely bullsh#t and harmless.

But look: passing a medical test for a job; diahrrea; snoring. These are common every day problems that affect millions of people. If I get a hugely expensive runaround and impersonal service on these common medical problems, then the system as a whole has a major problem with it.