New medical tests: How useful are they?

Some say certain medical tests lead doctors and patients 
on wild goose chases. Others swear by them.

By Wendy Underhill

     Laboratory tests are commonly used by both allopathic (conventional) and complementary medicine practitioners. Everyone has heard of a cholesterol screening, or a throat culture for strep, or a urine test to detect a bladder infection. But have you ever had your hair analyzed for heavy metals? Or have you had a stool sample tested for parasites?

     Some relatively new laboratory tests have gained in popularity among complementary medicine doctors and holistic MDs. So we wanted to know, how useful are such tests? And do tests have a down side, other than cost? Do test results sometimes give us (and our doctors) an inaccurate picture of what's going on inside of us?

     We discovered that practitioners do indeed have divergent views on the new lab tests: some use tests frequently, some rarely.

     Laboratories have devised tests for just about every part of you: your blood, urine, hair, saliva or stool. But after you have the data, you need to understand the results. One doctor may interpret a hair analysis to show a mineral deficiency. A second doctor may read the same analysis as normal. The result: tests in and of themselves vary widely in their usefulness, depending on how they're interpreted.

     Given that there are so many variables, there is no one right answer to the "test or not to test" question. So instead of looking for "Truth" with a capital T, we've gathered subjective points of view about diagnostic laboratory tests, with hopes that readers will put their own good sense to work as well.

Tools of the trade: Common caveats to testing . There is one commonalty to all lab tests, be they conventional or otherwise: they must be performed with strict adherence to the rules. For some tests, for instance stool samples, patients may need to avoid eating certain foods or drugs beforehand. For others, such as urine samples, getting a "clean catch" is significant. Blood samples, of course, would be drawn by professionals, and kept clean, sometimes refrigerated, at all stages. There are even specific rules on how to get a good hair sample. If the procedures aren't followed, the results can be meaningless. . Two practitioners looking at the same tests might recommend different treatments. The difference may depend on which modality they are comfortable with, say herbology or nutrition. But it also may depend on how carefully the practitioner fits the test results into the larger clinical picture. . One of the oldest scams in the world is to "give" somebody a disease by suggesting it, and then get paid to "cure" it. Whether it's an intentional scam, or a matter of practitioner and patient both believing what they want and need to believe, it's worth keeping in mind. . Expense can't be ignored. While patients may be able to go to their insured practitioner and get some tests done, most of the tests mentioned above won't be covered by insurance and will be paid out of pocket. Sometimes it's cheaper to try a treatment than to try a test. . It's not always the practitioners who are driving the laboratory testing business. Some patients really like tests. The doctor can say, "It looks like you need detoxification," but those folks won't do it until they see some hard numbers. . Not all tests are created equally when it comes to validity, and there's almost no way for a patient to evaluate this. Nagel says tests are being proven in clinical practice: "We're essentially doing research as we go." . Some people get better without tests and without any treatment: it's called the placebo effect. Both doctors and patients need to ask, "Did this healthy improvement result from the treatment, or would it have happened anyway?" . All in all, the trick is to look for the right tool (or test) for the job (or patient). And then remember: if it ain't broke, don't fix it.

Functional medicine

     Glenn Nagel, ND, a naturopath in Colorado Springs, uses an array of diagnostic tests in his practice, primarily ones that check biological functioning. These aren't always the ones offered in an internist's office. The reason: standard blood work is meant to detect disease only, he says.

     He's looking instead for less-than-optimum situations that aren't yet in the disease category. The buzzword for his approach is "functional medicine." Nagel's favorite simile is of a car that has the wrong octane fuel in it. It may run, but does it run well? No-it's not functioning at its best, but it can and will function well again when the right fuel is added. In his practice, that means he's "always trying to identify causes (of symptoms) before there is a disease."

     One of Nagel's patients, Audrey Gannon, was suffering from ongoing nausea in 1999. She went to a gastroenterologist and had a colonoscopy, a gastroscopy and other tests done. The diagnosis: "acute gastritis," a term that's as specific as "a head cold," and was treated with what she terms "all kinds of drugs," without much if any improvement. She wanted to know more: why did she have acute gastritis? And, of course, she wanted relief.

     So she sought out Nagel. After months of diet work-giving up cheese was the hardest, she says-they agreed that she'd have a comprehensive digestive stool analysis done, a $295 test that she paid for out of pocket. (The earlier tests and examinations performed by conventional medical doctors were much more expensive, but they were covered by insurance.) Besides the cash outlay, the test required following specific procedures, taking a laxative, and collecting a watery stool sample. All in all, she says "I fought it for a while."

     The test report showed that she had no lactobacillus (a "good" bacteria) but signs of a "bad" bacteria that is implicated in diarrheal diseases, and that she had "somewhat impaired protein digestion." The laboratory also tried several inhibitory substances against Gannon's bacteria to find out which would be best at helping her get rid of the pathogenic bacteria.           

     On the basis of this report, Nagel made his recommendations: herbs were used to rid her system of the "bad" bacteria, and acidophillus was prescribed to return the "good" bacteria. Months later, Gannon is still careful about her diet, but she's off herbs and out of any doctor's office. She says "it was not a dramatic thing," but she's happy and healthy now.

 

When to test?

     This happy result notwithstanding, Nagel isn't a test- driven practitioner. In complicated cases they can help point the way, but in simpler cases clinical judgments are enough. Then there are the cases in between. If he believes that a patient has food sensitivities based on symptoms and history, he may go one of two routes. The first is to suggest a "therapeutic trial" of a healing regimen, which probably includes an elimination diet, wherein suspected irritants are eliminated from the diet and the patient reports any changes that occur.

     Or, he could order a food antibody assay. Think of this as a blood test for food sensitivities. It is different from the skin tests that allergists tend to do, which won't pick up most food sensitivities. (The blood serum screening for food allergies, some say, can be particularly unreliable.) The results of the assay may show a number of foods earmarked as irritants. Nagel had one patient whose results came back indicating that 50 out of 100 foods screened showed sensitivities, whereas none showed up when the man had a skin test done. Fifty foods, though, wasn't a very useful result. "The leap is to see if the foods are causing symptoms," he says, which brings him back to an elimination diet, what he calls "the gold standard" for food sensitivities.

     In deciding whether to go with his clinical judgment or to order tests, Nagel often asks patients, "Do you have more time or more money?" If they've got money, testing can sometimes get to the bottom of the problem quickly, or at least point in the right direction. If they've got more time, going with a probable treatment plan may work.

     Nancy Rao, ND, a Boulder-based naturopath, has other reservations about testing. "I have veered away from a lot of testing, unless they're really giving us good information," she says. Coming from a scientific background-she worked in labs and came close to choosing biochemistry as her profession-Rao says she's concerned with testing that is "not well-founded." False negatives and positives can turn up, and interpretations of results that don't include what's normal for that person can muddy the diagnostic waters, not clear them, she says.  

     So Rao works with or without lab tests. An example: diabetes. The standard test is a glucose tolerance test; if you score outside the "normal" range, you probably have diabetes, according to conventional medicine. She's seeing more and more insulin resistance testing being done, which helps identify pre-diabetic conditions, a good thing. But she can often hear from patients what is going on and work with their diet and supplements to correct the situation, whether or not she's got a piece of paper that pinpoints insulin resistance.

Testing the tests      Richard Spurlock, MD, a pathologist with Kaiser Permanente in Denver, says that doctors in his traditional milieu like tests that have "been tested by time."       These doctors use tests with which they are familiar, and may be less likely than complementary practitioners to try something new until it has been repeatedly used by peers, with the results published in professional peer-reviewed journals such as the Journal of the American Medical Association or Biochemistry.         Getting a new test in the mix, then, takes time. One example: Spurlock says there is "some indication that some of the technology we have is able to pick up cortisol in saliva" and that it can be just as sensitive as a blood test. He says that for traditional doctors, "it's promising, but it's kind of too early."      "The general guy who's doing a family practice, he's not going to do saliva testing," he says. "If you go to some of the large research centers where they may do research on patients, that's fine, but the person who's out in the trenches is generally not going to pick up these things on the edge."      Most medical doctors have been trained with the old dictum, "first, do no harm." In terms of testing, he says, this means don't try something that hasn't been proven to be effective or reliable beyond a reasonable doubt. The standard for acceptance of a new test is simply higher, and that means the rate of acceptance of new tests is lower, among convention doctors.      But how can a test, one that merely samples a body product, do harm? By leading the search for a cure in the wrong direction and wasting time.             Overall, Spurlock says, when it comes to testing, "We don't want to be the first or the last" to give them a try.

     Laboratory testing doesn't have much of a place in traditional Chinese medicine; it hadn't been invented thousands of years ago when the current Chinese medical system began. (It wouldn't be until the 19th century that the most rudimentary chemical analyses were created for medical purposes.) But Jean Kullman, a doctor of TCM in Fort Collins, says that she does work occasionally with Western diagnoses and Western tests to inform the Eastern diagnosis and treatment.

     Rao expects medicine and biochemistry to move closer and closer together over time, however. We'll be hearing more about fatty acids, lipids, metabolites and markers as the years go by, as these and other markers are beginning to be used to identify disease processes, she says.

     It's worth keeping in mind that standard laboratory tests (think of urinalysis at the gynecologist) were all new once, too. There was a time not so long ago when no one knew his or her cholesterol levels; now that's commonly measured, and it's used as a marker for potential cardiovascular risk. "Ask somebody what their short chain fatty acid is, and they have no clue," Nagel says. But a low level means the person may be at risk for colon cancer. Someday people may know that, just as they now know their cholesterol levels.    

 

Biochemistry for life

     Great Smokies Diagnostic Laboratories is a big proponent of increased biochemical testing (and also the premiere lab for functional medicine analyses). The lab is the only one of its kind that is accredited by the College of American Pathologists, a requirement for regular hospital-linked labs. The practitioners who use Great Smokies are 60 percent MDs, and the rest are a mix of osteopaths, doctors of chiropractic, naturopaths, nutritionists and others.

     The stool test that was used in Gannon's case was their first and still their most common test. In addition to the details results show about intestinal flora, the test also reports on absorptive markers that indicate how the stomach, intestine and colon are functioning, as well as parasites, making it far more complete than a standard fecal analysis. All reports from Great Smokies, whether the CDSA or immunological, nutritional, endocrinological, or metabolic analyses, offer treatment options and recommendations. 

     On the near horizon, Great Smokies will offer new tests on vaginosis, osteoporosis that goes beyond a static bone density test, environmental allergies, organic acids, and additional tests of hormone functioning.

     Audra Reiff, a doctor of chiropractic at Peak Health Chiropractic in Englewood, uses one of Great Smokies' existing tests to look at hormone function. Many samples of a patient's saliva from different times during a hormonal cycle are sent to the lab. (Using saliva is more practical than asking a woman to have her blood drawn every two or three days for a month.) This many-sampled test has largely replaced one-time blood tests for hormone levels in Reiff's practice because it measures the whole cycle, not a single point in time.

     The more complicated testing costs more: about $300 for up to 11 samples, as opposed to $80 for a single blood test.          

     Reiff also occasionally uses a saliva test to check on adrenal function. She says that in today's fast-paced culture, "we're all in this constant fight-or-flight mode," and the adrenal glands are therefore working overtime. Some women who appear to present menopausal symptoms are really experiencing low adrenal function. The test she uses from Great Smokies finds subclinical signs, "subtle differences so we can help the body before it becomes a crisis," says Reiff.

     For her, testing can be a way of ensuring that a plan of action is based on the specific needs of the patient. One patient, for instance, was taking essential fatty acids as supplements, one of the most-recommended supplements these days. Results of testing indicated that her body had difficulty breaking down fats, so she was adding to the problem. Testing in this case helped. "It gets results, and that's the bottom line," says Reiff.

 

Trace minerals

     Sometimes, the motherlode of information is found not in biochemical markers, but in identifying and measuring minerals in the body. Minerals can be essential for life-think potassium, calcium, and magnesium-or they can be dangerous-lead, cadmium, and mercury. A mineral analysis of hair, saliva, blood, urine, or fingernails can measure both the good and the bad minerals, and compare the measurements against a population-wide range.

     Any of these samples can be tested at Trace Minerals International, Inc., a Gunbarrel laboratory that does 60 to 70 percent of its testing for medical professionals outside the United States. (It is also the only lab in Colorado of its kind.) "In many countries, alternative medicine is not so frowned upon," says owner Eleonore Busch, PhD, "and the nutritional aspects as well as the environmental aspects of health are taken seriously."

     In some cases one kind of sample is preferable over another. For instance, hair gives a look at what's been going on for the person for a relatively long time. Slow-growing hair reflects what went into it as it was being formed. (This would suggest that a long-haired person has a better historical record than someone with a buzzcut.) Blood, the other substance commonly checked for minerals, shows only what minerals have recently been ingested or breathed.

     Reiff uses hair analyses in her practice. With them, she says she can learn about nutritional mineral deficiencies in particular, although results indicating the presence of toxic minerals would be important, too. "By inference," she says, "you measure the contents in the body." Then she's ready to treat accordingly.

     That sounds simple enough. Busch, however, tells a story that indicates that there can be much more at stake than what supplements to take. More than a decade ago, while on vacation, Busch met a Dutch family who told her about a boy who was dying of aplastic anemia, wherein the bone marrow wasn't doing its job, and transfusions were becoming more frequent and less successful. Without a great deal of optimism, Busch offered to do a hair analysis.

     The boy, Oscar, "was loaded with lead," says Busch. He'd been tested for lead and a host of other compounds in his blood by previous doctors, but nothing had shown up. With the data from the hair analysis, the boy's doctors set about treating him for lead poisoning, and Oscar slowly began to improve.

     Some months later, when Busch was visiting her native Germany, Oscar made his way down to meet her. As they talked, she remembered that most German mothers keep the first lock of their children's hair. Had his Dutch mother done so? Yes-and that baby-fine hair was sent to the lab for testing. The lead level in that historic sample was even higher. It seems that as a baby he had a habit of scratching the walls with his nails and sucking his fingers afterward, ingesting lead from coats of lead-based paint that had long since been painted over.  

     That's a dramatic case. A more typical case might involve testing a smoker for arsenic, one of many elements of cigarette smoke. While smokers may know that harmful elements are present in smoke, "if they see it (in numbers) it can help them make decisions," says Busch.

     The results of tests from Trace Minerals International, Inc. include general recommendations, but no treatment plans. "We are saying to the doctors, 'Here are the levels. Now you know how to support this person,'" Busch says. Costs for complete analyses are $125, although less thorough analyses can be less expensive.

 

The art of medicine

     Given all of the above, one might reasonably wonder, will doctors of the future be nothing but interpreters of data?   

Jia Gottlieb, and MD from Boulder, stands in the path of such trends. He's been trained in acupuncture in China, and in addition to his medical degree, has a vast knowledge of alternative healing mechanisms and theories, as well as his medical degree.  

     "Both Western physicians and alternatively trained practitioners have the same difficulty, which is that we've all been trained in a culture that highly values what's known as objective measurement and information," Gottlieb says. "In fact, objective measurement is of necessity highly limited. It functions in the world of science, consensus and statistical normative values."

     That approach doesn't work with human beings. "What we experience is inevitably very subjective," he says. "And yet so many practitioners have been trained to rely on laboratory tests as the only real measure of a person's health that it has produced across the board a degeneration or loss of clinical skills."

     Those skills, which he calls "the art of medicine," include taking a careful history. Gottlieb says the history itself typically yields 80 to 90 percent of what is actually happening with a person. The result: Gottlieb doesn't do a lot of testing. He lives by the adage, "treat patients, not lab results." He fears that adage, passed down from doctor to doctor, is rapidly disappearing.

     Tests have their place, and he uses them routinely. Women get pap smears in his practice, for instance. But in many types of disorders, he says, it's not a biochemical problem-it's something more subtle. "I'm much more interested in self-help methods to restore balance and health gently," Gottlieb says, "without the hazards of potent pharmaceuticals or various herbs."

     He's not denying biochemistry its due, and mentioned Prozac as proof that it can rule the body. But he says also that the experiences the body has can change the biochemistry equally well as a drug. For instance, winning football teams show elevated testosterone 20 minutes post-game, and losing teams show decreased testosterone. That may not be a surprise, but knowing that their fans show the identical changes may be. This is an example where happiness (albeit the temporary result of someone else's game) changed the body at an elemental level. In his practice, he is simply seeking ways to make those changes through experience, not prescriptions.

     Following that model, he runs an eight-week class, called "Refresh. Renew. Revitalize. Create the life you want." The course is a mix of yoga, meditation and nutrition, and focuses on the choices life inevitably presents. People with myriad complaints, from back pain to digestive distress, headaches to addictions, take the class together.

     The bottom line: testing has its ups and downs, with dozens of variables. Finding which test prescription will help can take trial and error-a test in itself. At some point, a patient has to be willing to trust (or replace) his or her chosen practitioner. And in the end, the choice of whether to be tested, and which tests to believe, must be a subjective judgment on the part of the consumer since no objective standard of care yet exists when it comes to diagnostic testing.