A few years back, I was on my lunch break in the hospital tea room. A scene from House or Grey’s Room or Emergency Anatomy or whatever was playing on the grotty T.V on top of the microwave. An intern appeared to be doing brain surgery alone in a broom cupboard with cleaning gloves. Elective surgery. On a weekend. With her hair out. The medical team, cleaner and representatives from bed management, hand hygiene, budget and rostering all laughed sadly into their lunches.
Had it been an eighties teen movie about time-travel and megababe princesses, that would be fine. But House also asked us to believe that the characters were grittily annoyed when the gritty coffee spilled. They had outbursts of gritty TV grief when patients managed, against all the TV odds, to actually die of a cardiac arrest.
But a story is only believable if the characters act in accordance with the rules of their universe, which is why we will read Game of Thrones. If, in a given universe, people learn brain surgery in a weekend on Playstation, and the electrophysiological anatomy of the heart has an on/off switch under the sternum, which will work if only you’ll press it hard enough while shouting the right combination of love epithets, then that’s fine. I will play. But you have to obey your own rules. The gritty coffee spill universe is not compatible with the brain-surgery-as-a-TAFE-course universe. My problem with TVMed, as a doctor and a consumer of noughties medi-drama, is that it called itself fiction, not farce. The upshot being the transformation of healthcare into a pinup girl – easy, cheap, no consequences, but most of all, no nuance.
I love Americans, even the super American ones, but those in TVMed are more uncomfortable with uncertainty than many far more uncomfortable things. They don’t approve of nuance. They like to label things, and then they like to do something about those things. Time, as a diagnostic factor or a recovery aid, is not allowed. The delicate art of watch-and-wait is not a thing. Our Americanization is now extending to how we view 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. The reality of health involves uncertainty, individual responses to common diseases, and recovery time. People are nuanced. Ogres are like onions.
TVMed has contributed to these bizarre expectations of medicine – what it can and should do, what it costs, how well rested the nurses look and how easily you can get a private room in a public hospital. It’s where I first heard the phrase “check in to the hospital,” which is something you can do if you are Pharaoh, or maybe Putin. In TVMed/America, people are wheeled into hospital through a full body MRI scan, and lie in a (carpeted!) private room, looking suspiciously well groomed. Doctors order every test they can think of and stand in front of perspex screens drawing mind-maps and flirting with the anaesthetist (ok, that last part is a bit true). But as anyone who’s ever been seriously unwell knows, you either front up to hospital half dead, your condition therefore fairly well elucidated, or your symptoms are pieced together by a GP or sub-specialist, in the un-catered outpatient environment.
There’s a steady upward trend in young people coming to ask for their yearly “bloodwork.” They even say it with an American accent. Because on TVMed, 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. Over eight hundred 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 about the problem and we’ll work out a plan, which may or may not include a blood test.”
“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 are any red flags we’ll 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 the hospital, lights and sirens. Foreclosing an opportunity to receive personalised medical care by declaring what one needs is not a wise consumer choice.
In another great scene from House, a woman with a mysterious seizure disorder presents herself to the greatest investigative TVMed genius living and the first thing she says is, “I wonder if you could run a CBC?”, as though
a) ordering the most basic blood test hasn’t yet been thought of by anyone,
b) ordering a blood test is the best use of this doctor’s abilities, because really, even genius doctors are just over-educated fountain pens, and
c) she’s read on some kind of lady doctor blog that what she needs is a complete blood count.
The study to which we often refer in support of the self evident, is a paper from 1975. It demonstrates that dogs bark, or rather, that around 82.5% of diagnoses are evident from the history, the story you tell. Examination provides a conclusion in a further 8.75%, leaving 8.75% of diagnoses to be mopped up by laboratory tests. We can pick holes in the numbers and sample size for sure, but most doctors would agree that this generally reflects their experience. Medical technology may have advanced a lot, but people haven’t. We still get pretty much the same diseases as we did in 1975. The exceptions are the tilt towards things we’re getting for being fat and sedentary, and away from things for which we now have vaccines (meningitis, cervical cancer, severe gastroenteritis) and those being detected early by evidence based, age appropriate screening tests.
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 also hoping there is a medical cause of their ennui, their weight gain, their existential fear. Rarely, there is. But blood tests themselves are nuanced, as the pathologists moan quietly in their labs to no one at all. 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 lean back in the chair. “I was sure there must have been something wrong.” If the All Knowing Bloodwork didn’t come up with an answer, they’re ready to make do with this lousy GP. It’s a shame I spent $300 Medibucks getting them to trust me.
Then we talk. About fear, joints, their pattern of pain and sleeplessness. The unbelievably crap year they’ve had. Did the rash come first, or the cough? We examine again. What exactly happened four months ago when all this started?
“I told you, nothing. Actually …”
It turns out it’s the goat’s milk soap. Blood test couldn’t have told us that.