In today's world of longevity and biohacking gurus, there's no shortage of lab tests people are recommending. If you go on some people's websites, they actually brag about how many lab tests they offer to quote, "Optimize yourselves," and making promises that they will find anything that could possibly be wrong with you. But what if I told you that these people are standing on shaky science and probably are just wasting your time and money? Today, we're gonna talk all about my framework that we use for ordering labs, and we're gonna talk more about the pros and cons of getting lab work done, so let's get started. Welcome back team to the Building Life on the Atheist podcast. Thanks so much for stopping by. I really appreciate it. For those of you who don't know me, my name is Jordan Wrennke, and I'm a dual board certified physician in family and sports medicine. And the goal of this podcast is to keep you active and healthy for life through actionable, evidence-informed education. And what we're talking about today is specifically ordering lab tests, when it's appropriate, when it's not appropriate, and all the nuance in between, so let's get started. First, we wanna talk about why we care, right? So lab work is a common part of a doctor's visit, right? People expect it, and it's ingrained into our Western medicine. In fact, about 30 to 40% of visits involve some type of lab work. Some people love it, others people hate it, and typically they'll fall into one or two categories, either those who wanna know everything, and those that don't. There's no right or wrong here, right? I'm not here to convince you one or another, saying like, "More information, less information." I just see both sides of things. I just wanna offer an opinion that may be contradictory in today's media. I'll have patients who say, "I want all these labs," and other patients who say, "Whatever, doc, "it doesn't matter to me." So there are people on both sides, and I just wanna talk about, overall, what we're looking at here. And this is important because many people, if not most, including physicians, grossly overestimate how helpful lab tests are. Lab work drives about 70% of our medical decisions today, and they definitely help make decisions, but they also can play a therapeutic and a psychosocial role as well, and provides reassurance to patients. So when I mean psychosocial or therapeutic, when I'm thinking, it's not placebo necessarily, but people enjoy getting labs done. It can sometimes be a therapeutic thing for them, saying, "Hey," or getting labs done, "My doctor cares about me. "We're looking into these issues. "We're gonna get to the bottom of it." So that can be very helpful. Ordering labs in and of itself can sometimes be helpful. And overall, the goal is to do useful tests that matter. In healthcare, there's something called the triple aim. And the triple aim is to improve population health, which is the health of a lot of people, to improve patient experiences, so higher quality care and more satisfaction for patients, and reducing costs. And in their world, they kinda come up with this idea of value. Value is the quality of care times patient experience over the cost. And so that's a bunch of gobbledygook, but essentially, the triple aim is trying to improve a lot of people's health, improve the experience, and reduce costs. That's like the big thing, right? 'Cause if we have labs, and the reason we care about this and healthcare entities care about this is 'cause if every single person's getting a bunch of labs, then that may increase costs. And at the end of the day, they're also trying to do the best thing for the most amount of people. So the triple aim, what generalized healthcare is going for, may not be the best situation for every person. We're saying one of the main goals is improve population health. And population health is everybody, right? But you're not everybody, you're just you. And so your circumstances may be different. And that's why it can sometimes be tricky with recommendations for labs. People will say, "Hey, we recommend this "for this population, "but you might not fit in that population, "so how does it work?" So there's a lot of nuance there as well. And so I just wanna say, it can be a little tricky. I understand that. And at the end of the day, though, we have to kinda make decisions as they go, what's best for you and everything we're doing. And so next I wanna talk about how labs can actually be harmful. First and foremost, labs are not perfect. They may cause unnecessary stress or anxiety if you get them wrong, right? Like if someone comes up to you and you do tests and you find some terrible thing, then that might be, oh gosh, very stressful, and you realize it's not there. So they're not perfect, so they can lead to wrong issues and wrong answers and lots of things. Also, it may not give you the answers you're actually looking for. A lot of times we'll order tests expecting to find something, and we may not. And like I mentioned before, error can be introduced by unnecessary testing and then can adversely affect the quality of medical care, meaning that there's always a chance that a certain lab test is incorrect, leading to inappropriate treatment or further studies. The worst case scenario is treatment that doesn't need to happen. A lot of times what will happen is we get lab work, we say, "Mm, I'm not sure about this," and we repeat the labs. That is inconvenient and that does stink, but it's not the end of the world. But the worst thing that we could do is get a wrong lab and treat based off of that, right? 'Cause there's harms to any treatment. So that's something we're always thinking about. Labs are not perfect and there's lots of risks to them as well. On top of that, labs are inconvenient and not without their own harms and risks. Obviously, blood draws stink. Nobody like loves getting their blood drawn. It's inconvenient as well. You gotta go somewhere usually in the general, the general scheme of things, you just go there. But then also can sometimes also be really expensive depending on your insurance. Specifically, a lot of times what's happening is these newer tests, these new cool tests that people are talking about online can be hundreds and hundreds of dollars. And that can be a lot of money for people. A lot of times your insurance won't cover a lot of things as well. And so it can be very challenging, costing lots of money. On top of that, low value testing, which means just kind of blasting labs, doing just random labs, it can contribute to a huge work burden and provider burnout by requiring additional review and followup. And so ordering labs mean clinicians have to follow up on those labs, right? In the traditional model, right? You go to your doctor, they see you, they order labs, they've got to follow up on those. This leads to messaging with the patients, messaging with the results. They have to explain the results and explain any sort of abnormal results. And the biggest thing is that a lot of times you'll find what's called essentially inconsequential, I call them barely abnormal lab tests. And they don't really have medical impact, but it takes up your time, right? 'Cause if you think about it, you get a lab test back, right? And you see some red on there saying, "Hey, this is abnormal." And the clinician with their years of experience might say, "Oh, those are pretty much not relevant." And they're talking about maybe just slightly off chloride, or you talk about someone's maybe a little bit bicarbonate, or chloride, or all these little things that are off by one thing, but it's red and flagged red, so you worry about it. And so it takes time to explain those inconsequential barely abnormal ones. That can take up time. And anytime doctors are spending on minutia, they're not taking time to talk about something truly important. And I'm not gonna say that this is ultimately the most important thing the patients care about. Like, I don't care about the work of the doctor. I get that, and I'm sensitive to that. But I'm just saying, in general, this is one of the barriers to labs, in terms of just the burden it places on clinicians, and healthcare in general. If you have a lot of people getting lots of labs, it's taking up lots of time, and so it's just something we have to consider. And so once again, I'm not saying, "Whoa, are we as the physicians," but I'm just saying this is the realistic life of a physician. And at the end of the day, a question we have, too, is why do we even order labs, right? Well, a lot of times there's multiple reasons. One is 'cause we have no idea what's going on, or someone doesn't have necessarily clinical experience. A lot of times, sometimes clinicians will take a shotgun approach. It's very common. You essentially just blast a bunch of labs, hope you find something. It's very common in those with less training, who aren't as quite sure about what they're looking for. And it's very, very common these day and age. People talk about how many lab tests they wanna get you, right, hey, for your longevity, we're gonna check these 300 biomarkers. Oh, by the way, the lab test is $1,000, and what do any of those really mean? We don't know. But more is not necessarily better. That's something I wanna talk about as well. But you can have shotgunning if you're saying, "Hey, I don't know what's going on," you don't have clinical experience, or if you're truly in a conundrum. On top of that, we wanna answer, right? As physicians and as patients, we're uneasy with diagnostic uncertainty. We want to get an answer. So we want that for you. So sometimes we do additional labs to dig deeper and deeper, and then we order more tests. And also, clinicians do not wanna miss anything, right? Unfortunately, we live in a kind of litigious society, and we're worried about getting sued. Just be honest with you. If you miss something, and something bad happens, that can lead to lots of issues down the road in getting sued. And so sometimes doctors will order things just to be sure, even when a test is indicated, because they wanna just make sure they're not missing anything. Another reason why we get labs is sometimes patient desire. I'm not blaming patients at all for anything here. I'm just simply stating that sometimes physicians do get pressured from patients to order labs. And once again, I'm not saying that's good or bad, I'm just saying this is the reality. A lot of times, patients will equate that more labs has equal better care, right? The more I know, the better. That's not necessarily true, and it's not anyone's fault for thinking that, but perception is not necessarily that more is better. That might be some people's ideas, and it's not necessarily, and I'll kinda pack why that's the case, and we've kinda touched on it a little bit. But a lot of times we'll see people saying, "Hey, the more I know, the better." And that may or may not be always the case. We'll kinda talk about it. One question I do wanna address is, sometimes like, why won't my physician order labs? I come to my physician, I say, "Hey, I want these labs. "Can I get these?" First things first is they actually may be uncertain themselves. It's not, this is not a lab test that they routinely order, meaning, "Hey, I do this every day. "It's a BMP, it's an A1C," whatever, things you do every day, and they don't know what it is or how to make sense of it. It requires a big amount of work on their part. They may have to reach out to a specialist, or maybe even worse, they'll just refer to a specialist to handle that, and that comes with additional cost for the patient and the health care system, and is inconvenient and just really stinks in general. And a lot of times you go there, talk about it, and it's nothing, so we just wasted time and money. And once again, I'm not justifying that this is a good reason not to order tests. I'm not saying that, but just put yourselves in this situation for one second. You are a clinician, you're seeing about 20 patients a day, right? That's the standard primary care physician, 20 patients a day, and this situation happens multiple times a day, where people want labs, you're ordering labs, and you're getting lots of results back, it can become overwhelming. So sometimes clinicians fight against ordering labs they don't think are necessary, because it's a self-preservation mode. And once again, I know this is not ideal, but really, this is the reality of traditional medical model and the culture that we live in. So that's one thing. Another reason why doctors kinda push back sometimes is 'cause we have been taught to be judicious. So we're typically taught that we should order labs if it's gonna change our management. So just randomly checking labs is not necessarily a normal part of our process, unless they're indicated or kind of recommended. And once again, not saying any of this approach is right or wrong, I'm just trying to help you as a patient understand why we order this or why we kick back. But this is kind of the general consensus from physicians. We're not gonna order something if it's not gonna change our management. And we have lots of big medical societies recommending against aggressive lab screening. In fact, there's this Choosing Wisely initiative was started by the American Board of Internal Medicine Foundation. And the goal of this whole project is to promote the appropriate use of resources when ordering labs, radiology, and procedures. So you can kinda go through their website and see, "Hey, in what situations would we recommend "getting these labs or these images or these procedures?" They kinda say, they kinda use that triple aim idea, that hey, how can we deliver the most amount of care, the highest quality care, but for a good price? And that's kind of a big thing that's part of our medical system is being judicious. And on top of that, we also follow guidelines. So it's impossible to stay up to date with everything in medicine, just cannot happen. So there are clinical guidelines. They're a great way for a group of people, they come together and they look over the research and share their expertise, and they kind of provide recommendations on how to manage these issues. And they create these recommendations for a little slice of a specialty. And so as someone who's working in primary care, specifically, you rely on your specialists from gastroenterology, from surgery, from hematology oncology, you name it, they come up with these guidelines to kinda help guide management for us 'cause we just can't stay on top of everything. And doctors tend to lean heavily on those. So they follow the guidelines, we're taught to be judicious, and they might be uncertain themselves. Those are a couple of the reasons why they might push back and not wanna order labs. And so now I wanna talk about what, as physicians, we are typically recommending, how we think about ordering labs. And if you think about it, there's three main Ps. So the three main Ps are pretest probability, the chance of being positive or negative, which is something called the sensitivity and specificity, which I will talk about. And then you have to think about the pros and cons. And every test we order isn't perfect. There is no perfect test. And something I just wanna foot stomp home is that there's no perfect test and no test is 100% accurate all the time. First, let's talk about that first P, that pretest probability, what that means. I'm gonna break down what these are. And we should think about these things before ordering tests. The pretest probability is the estimated chance that the patient actually has the disease before the test is run. So just stepping back there, pretest probability is how likely someone is to actually have the disease that we're testing for, right? And the pretest probability, if it's low, then a negative test is pretty much expected, meaning that if there's some disease that's very rare, it's less likely we're gonna find it in that test. So we would have to confirm a positive test as well. So meaning, do I really believe this test? So let's step back for a little bit. If the pretest probability is very low, so we think that, hey, there is not a very high chance that this disease is in this area. Like I haven't heard of it in 30 years. And you test for it and then you get a positive, are we really going to believe that test? So the pretest probability is so low, it's more likely that it's a false positive test, something like that. So I think like dip theory is an example. Like dip theory, like nobody has it, people are fully vaccinated, but I test for it and it's positive. Do I need it? Do I just believe that test? Like, no, we're gonna confirm that, right? So if it's very unlikely to start, very unlikely to have a disease when you start, it might not be wise to order that test particularly. And then if pretest probability is high though, then a negative test is also not very reassuring. If there's a high likelihood of someone having a condition and the test is negative, we may not believe that to be true. So if someone's entire family tests positive for COVID, and then they test negative, but have all the symptoms, would I believe that test? And so probably not. And that's the question here is, do I even need to order that test? Obviously, if someone needs to know for a work excuse or whatever, but would it change my management? No, would I need to know? 'Cause I just presume everyone has it. They have similar symptoms. It's most likely COVID. And if I got a test and it were positive, I'd say, yep, that's what I thought. If it were negative, I'd say, I don't believe that. So this is what I mean by pretest probability. How likely is it to have that? And there's this sweet spot, right? Too low and you have lots of false positives, too high, and we have lots of false negatives. And so we kind of use the disease prevalence, how much is out there, the history of the patient, the physical exam to make an informed decision on whether we should have that test. And so that was our pretest probability. Now we went to the next P, which is, is it positive or negative meaning sensitivity and specificity. And these are kind of statistical terms. I know hang with me, this is kind of nerdy, but it's actually really important for understanding what testing is and just all medicine and even just understanding lab tests and basic stats. And so sensitivity is the proportion of true negative results. So once again, sensitivity, true negatives. Think about that. If this is high, so if you have a high sensitivity and the test is negative, we feel very confident that this result is real and that that's true. So the way I think about sensitivity is the acronym SNOUT, S-N-O-U-T, meaning sensitivity rules out to disease. These are great for screening tests, right? So if we have a really high sensitivity, that's awesome 'cause it's showing us if we have a negative, we feel very confident. So screening wise, we're screening and if anything pops, if it's negative, we feel, yep, this test is very good. And if it's positive, then we say, okay, we might have to do a little digging. On the other end, we have specificity and specificity is the proportion of true positive results. So if this is high and the test is positive, we feel confident that the result is real. And the acronym I use for that is SPIN. So specificity helps rule in disease. And this is a great for a confirmation test. And so ideally we're gonna use these together, right? So a test with a high sensitivity, but low specificity has a higher chance of a false positive, meaning let's step back. I know there's a lot of words, this is so confusing and I apologize, hang with me. So I said high sensitivity, but low specificity, what does that gonna look like? Well, high sensitivity, we're gonna be confident and negative is actually negative, right? But low specificity, we're not as confident in a positive test because it may be a false positive. So we'll have to have more workup. So let's do a real life example here. So the anti-nuclear antibody or ANA test, this test for lupus or systemic lupus erythematosus, SLE, it has a sensitivity of 100% and specificity of 86%. So when we say sensitive 100, we mean that we'll never have a false negative, meaning any negative test will be negative. However, there is a false positive rate around 14%. That's that difference, right? 86%, 100 minus 86 leaves us with 14, meaning that we will have a false positive around 14% of people. And so that's pretty ideal in terms of from a negative perspective, right? We feel negative, we feel good. And that's pretty much how ANA is. It's like, hey, if it's negative, I feel good that this patient had lupus. If it's positive though, we have those false positive and it can be a wide spectrum of things. And that's why the lower specificity you have, the less confident you feel like it's actually right. Like, oh, I don't know, this could be a false positive. And so we think about those in lab work as well. And one thing we have to also think about on top of all this is that lab work may vary for many reasons. There's a surprising amount of variation in blood work. Before prepping this podcast, I kind of thought, okay, yeah, lab work, I'm sure there's some variation. Looking at it, it blew my mind how unreliable labs are consistently. And what you think is a trend may not actually be anything at all and may fall within the normal acceptance amount of error. Due to the nature of the test and also just natural variability of human physiology, you can think about exercise affects things, fasting, what you eat, the supplements you take, your circadian rhythms, your normal physiologic functions, all these things can fluctuate. And that's something we have to think about. And today I actually had a resident come up to me and say, "Hey, this person's A1C was 6.1 and now it's 6.2, so we're heading the wrong direction." And I was like, well, actually, are we? Is that within the normal variation between normal physiology, the lab, the lab functioning, all that stuff. So I don't really know what to make of that, but I think we used to think of, they're very, very specific and that's not necessarily the case. And after we've talked about the first two Ps, the last P are the pros and cons. And so first we must consider all of the pros and cons when ordering a test. We must also walk through, what could happen if we have a positive, as we've mentioned before, when you have a positive, you have to deal with it, right? Do you believe it? Do you have to do more testing? Do you have to do some sort of procedure? Do you have to do some sort of treatment? We have to consider what's gonna happen. And we have to discuss, would they do anything if the next steps weren't based? That's another thing. If you order something and the patient wouldn't do anything about it, why order the test in the first place? Just something to consider. And I'm not saying, once again, this is just, I'm just kind of playing devil's advocate here of like, this is generally like the general medical establishment. Like this is their way of saying, "Hey, this is how we order labs. This is how we think about them. And this is kind of why traditional medicine, what they think about." And here, I'm gonna kind of walk through the recommended order, kind of what to think about before ordering tests. I've kind of mentioned that before the framework. This is gonna be what they think. They think perform a clinical assessment. I think we can all agree on that. You wanna talk to a patient, get a history, figure out what's going on. Once again, consider the probability and the implication of a positive test. Would a positive test do anything for your treatment or next steps? And then we talk with the patient, right? Address the patient concerns, discuss the risks and benefits of the test and how that influenced the management. Talk with the patient, come up plan. And they also recommend following clinical guidelines when available, like we mentioned, and then avoid ordering labs to reassure the patient. Unnecessary tests with insignificant results do little to reduce patient anxieties. This is one of the recommendations that they have. I'm not saying this is necessarily the case, but a lot of times people order esoteric tests that are negative and aren't very good at reassuring patients. They found in studies that even negative tests, if patients are worried about something, a negative test, it doesn't necessarily reassure them 'cause they still have symptoms or something's going on. And so that's what they're saying based off of the studies they've seen. They recommend not ordering tests unless they're necessary 'cause they don't seem to really decrease anxiety as well. Now the recommendation is to avoid letting uncertainty drive unnecessary testing. So watchful waiting can allow time for the illness to resolve or decline itself. This is a great point. A lot of time, time is just our best friend. And it's a critical tool we can use to kind of help a concern either declare itself. So what I mean by declare itself is that a lot of time we have people who will say, we get this lab and we're worried, we're worried, and we just wait a little bit, recheck it and it's normalized itself. And where if we do maybe like back to back right away, we may have two positives. And so sometimes time can be beneficial. Obviously, if you're really worried about something very severe, don't wait just hoping for a positive. But a lot of times, if you wait just a little bit of time and recheck, we have a positive, a switch of the results looking for specifically. And then at the end of the day, we have to have shared decision making. Nothing really matters if we're not in it together. That's kind of why I feel like a patient and physician that's kind of a, I think it's a team, right? So you work together, figure out a plan that works for you. And so I also wanna touch base on like, what's the disconnect between clinicians and patients? 'Cause a lot of times you'll see this online. At least what I've seen, you know, coming to my clinic and what I see online, like most things, it usually comes down to expectations and communication. There's a really cool article that I read about patient and physician expectations with lab testing, specifically looking at inflammatory markers, but it works as a proxy for most of the lab things, lab tests, I think. Most patients view tests as a good thing, meaning they see it as a way to move forward, that their doctor is taking their concerns seriously. And however, doctors have lower expectations. They view tests as more of like a ruling out things and not necessarily, you know, expecting a specific diagnosis. And this is a huge disconnect. The patient expects to find something to really be valuable, whereas the doctor's saying, "I'm just doing this to rule stuff out. "I need to rule out big, bad scary." So there's this big disconnect there. And they also found in this study that physicians were more aware of the pitfalls and limitations of the tests, but that was rarely communicated with patients. And on top of that, most patients weren't included in the decision-making process when ordering labs. A lot of times, usually doctor made the decision and the patient agreed or acquiesced to saying, "Okay, whatever you think." And they even felt like there was no choice, saying they didn't understand that you couldn't, you didn't have to get labs, that they know it was an option. They kind of just figured you had to go with the flow. And patients also don't understand which tests are being ordered or for what reason, according to this study. They don't know, you know, which tests, they don't know why they're being ordered. And oftentimes they were just told labs are normal. And hopefully this is getting better. Now with patient portals, you can log in and see your own results. But sometimes doctors will say a test is normal when the results are slightly abnormal. Kind of like we talked about this, inconsequential ones. So what's happened though is the physician has subconsciously clinically interpreted those numbers, right, but they didn't tell a patient hey, this was slightly normal, but we see this all the time, this is nothing to be worried about. So they just kind of said it was normal despite them doing some work in their brain saying to interpret that. And the patient's response to labs is linked to their expectations pretty much. The fact that the doctor ordered the test, they're expecting to find an underlying cause. And sometimes they even have disappointment when labs were normal. However, on the opposite end, doctors perceive normal results as a positive thing and assume that they are reassuring to patients. But the studies show that positive or negative results are not reassuring to patients, whereas once again, the physicians say oh, it's negative, it's great, it's nothing big, but it's scary. And the client and your patient says like, well, what the heck man, I still have these symptoms and I don't like it and it doesn't seem to help them. And on top of that, I think we're also getting better, but we kind of have been known for having paternalistic views in medicine. Not necessarily like a gender exclusive paternalistic, but more in the idea that it's a position of authority and that physician kind of has this authority. And both patients and doctors may feel that blood tests are too complex to understand for the patient. So that's why doctors say, oh, I'll just take care of it. And I think that's kind of getting better, but definitely still pervasive. And a lot of times doctors felt that labs were trivial. They're like, hey, this doesn't really matter and low priority for them. But that was not the same for patients. They felt they were very important. And they also mentioned once again, the issue with time and workload for physicians. And they felt that like, sometimes felt that physicians thought that protecting patients from anxiety was sometimes a justification with holding information from blood tests. However, lack of information and cheering actually tended to produce more anxiety. So if they didn't say anything, like no news is good news necessarily, not necessarily the best way to go with thing. And clearly the takeaway from here is that there's a disconnect between patients and clinicians. If you mix in a lack of time and resources, and this is why so many people feel like they were never listened to by the doctor. And I hear that all the time in our traditional system, just doesn't allow for time. But once again, this is another reason why we have a disconnect between patients and physicians. And so next I wanna dive into kind of the new era of labs. So direct to consumer or self-pay labs. And the day of being, of having the physician being the gatekeeper of labs is kind of coming to an end. There's now direct to consumer lab testing, and this is truly opening up Pandora's box. You can now skip medical labs, get labs from the private companies at your doorstep. And a lot of times this is awesome for patient autonomy, taking their health from their hand, which is great, but it can lead to lots of problems. And the first of those is laboratory interpretation, right? So one study I looked at when preparing for this was that it showed that about 15 to 20% of encounters that physician order labs on, they had questions about the labs. And I'm not saying that people can't order or interpret their own labs necessarily, but if 20% of people who do this for a living are struggling, then how do we expect regular non-medical folks to do? I'd expect them to struggle even more than that. So we're talking about 20, it's gonna be probably even higher than that, maybe a quarter, maybe you have to have, I don't know, even more. So a lot of people are gonna have questions and what do they do with that, right? Where do they go? What are the resources for it? On top of that, the standards are different too. These are not medical entities. So there's no real standards like they have in true medical labs. Like phlebotomy labs, they have a high standard to get it. You have to go through all these processes and checklists and standardizations and reports and all this thing to make sure that they are up to par. And that's not necessarily the same for these at-home companies. They're not astringent, so they're less trustworthy. And they found in one study about four times higher rate of abnormal tests in these at-home tests. So once again, is it good? Is it not good? Who knows? Is it worth it? I don't know. These at-home tests also make it clear that they are not working with patients, only consumers. So they are saying this is just for general educational purposes only, not to make medical decisions on. So if that's the case, can they be trusted? And once again, if we get these tests and they're abnormal, then we're gonna have to repeat them at a different time, at a different lab most likely. So it may lead to once again, unnecessary lab work that you had to repeat. And a lot of times, a lot of these new tests, we have no idea what they mean. And I see people all the time getting gut microbiome tests. They're checking various hormones and various nutrients all the time. And I'll be honest, we have no idea what these mean. I think a lot of people will speak confidently on that. And that's one thing I always push back on is when people are very, very confident that this lab work shows this, and it definitively shows this all the time in these newer tests that aren't quite as validated, then I always worry about it. A good example is gut microbiome, right? Nobody really understands it yet. If they say they do though, then I'd probably question it. If someone promises to fix your gut health based on a lab test, I'd be very skeptical. And the truth is, this is a new frontier. And we're learning a lot, but we just don't have a lot of actual information on these new things yet. Hopefully someday, hopefully soon, that'd be awesome. And I'll see tests all the time about random nutrients and vitamins that are kind of standard ones, right? So they're not our standard labs, so they can be very hard to determine what the normal range is and making interpretations off that is difficult. And so typically, there's gonna be off of previous labs and other people, but it could be very skewed. And anything cutting edge is going to have very few people trying to interpret that. That's why I will, you know, it's always, when someone's online saying they have a proprietary lab or grade, only they can interpret it, that's awesome for marketing. That's great, but obviously, that is gonna be a huge conflict of interest. If they are the only ones who can interpret it, then I would definitely worry about that. But that's just something kind of I think about. And then moving on from at-home testing, we also now can do self-pay. A lot of times you can go to a lab, like a Quest Diagnostics or whatnot, or LabCorp, and you can go get your own labs. And for me, this is a better option than that home test because at least it's a qualified and certified lab, and the results are probably gonna be a little bit better. Once again though, the biggest issue is with interpretation. Who's interpreting these? Do you have a trusted clinician to help you with, or are you just blasting your labs onto a Reddit forum and hoping that someone tells you what they are? I'm not joking, I see that all the time in like the biohacker world or, you know, anabox steroid use, people just blast labs online saying, hey, how is it? And random people are saying, oh, they're fine with this, do this, and it's just, there's a lot going on there, and so that's happening. And so just something to consider as well. If you get labs, who's gonna interpret them? And then specifically, I always wanna mention when we order labs, I wanna talk about reference ranges. So reference ranges, I hear lots of talks about reference ranges, so how they're off, right? If you go into like the functional medicine world, people will say, you know, the reference ranges are way off, it's much more narrow, it's this, that, and the other thing. Reference ranges will vary from lab to lab, but universally, they're relatively close. However, there are a lot of people who say, once again, trying to get to those optimal levels, and I have a problem with that idea because the desire to have incredibly precise reference ranges requires incredibly precise labs, and as I mentioned before, we know this is not always the case. So if labs will naturally fluctuate, and you have normal fluctuations out of the quote, optimal range, what do you do? Do you have to order more tests? Do you have to start a treatment plan for that? Do you have to go crazy? It's almost like these people are looking for a problem so they can fix it. And once again, maybe it's something, maybe there's something to it, maybe that the traditional reference ranges are not ideal, and we need to get more narrow on that. I don't deny that possibility, I just don't think I'm ready to jump on that train yet saying, hey, I confidently think that we can determine that really, really, really narrow ranges are exactly what we need to do. And I think a lot of times that just pathologizes. And like I mentioned before, a little bit of time, a lot of times you just give it a little bit of time and things will fluctuate back into the normal range. And so I just wanna go through now kind of my approach to labs. And by my nature, I'm just a little bit more conservative in my approach, just in general, from injections in the clinic to other dimensions, I'm just a little more conservative. So the more I learn though, the less I really trust any test. So that's making me more conservative just to not act on things. And there are some reasons I will order tests though. Absolutely, I mean, I order tests every single day. I don't wanna confuse you there and say like, oh, I don't order tests. I order them all the time. But I wanna be thoughtful when I do that. The first thing is for prevention or monitoring. And I typically order tests that we know are associated with bad outcomes, meaning looking at someone if they have diabetes or looking at their cholesterol levels, things like that. Or I'll do it when I suspect a certain pathology, right? If someone has symptoms, I'm trying to add another piece of clinical information to help make a diagnosis, then I'll do that. And I'll also order it when I know it's gonna change my management, right? Change my plan. If labs wouldn't change it, then I save the patients the stick and the expense. Let's just give you an example. I was talking to a reporter the other day and they said, hey, do you do ApoB on every single patient, right? It's the hottest new test. Everyone needs to do it. Should you do it? And I said, no, it's not the case all the time 'cause let's just take this scenario, right? I have a patient who is super high risk for cardiovascular disease. They have an LDL that's through the roof, like 200 triglycerides, two or 300. Their HDL is low, below 30. Their A1C is over nine. Just a very metabolically unhealthy person. I do not need to order additional fancy labs like ApoB because it doesn't really matter this time. They are so uncontrolled. I need to start working on all these risk factors and then work it down. And then, yeah, maybe later we can talk about using that as a target, but I don't need to do it now. And so I try to be judicious to help with patients and kind of order things that are practical for them, that are helpful for them. And that's where I start. And then I always talk with the patient, right? If a patient really wants a lab to be drawn, I'll ask why. Trying to get to the bottom just to understand where they're coming from. I think that's the biggest thing is just talking to people and say, "Hey, why do you want this lab?" They might have a reason for it. Maybe they had a sibling who got something and they're very worried about it. But just getting to the bottom, I may be able to answer their question right then and there and don't need lab work necessarily about that. Also, honestly, my patients saying, "Hey, if I don't know what this is, I'm not gonna order 'cause I'm not comfortable with interpreting it." And I'll tell them that. I'll either defer and I can refer them if need be. And I think it's foolish to pretend that I can interpret every type of lab, right? You know, people see it online, say, "Hey, can you order this lab for me?" What people don't understand is if you ask your doctor to order a lab and they order it, they then have to own that and have to interpret it and understand it. And if they don't know how to do, that's a reason why I would say, "Hey, I'm not comfortable. I don't feel confident in that." And maybe I can work with the patient and say, "Hey, you wanna work together? We can maybe figure it out." And it may lead to another referral. And if they're okay with that whole scenario, then okay, maybe we'll do it. And I tend to not give a blanket yes or no, because I think both views can be potentially harmful, saying yes to everything and no to everything. So we kind of be careful not to be too stingy with them as it can lead to harms as well. And overall, my approach is a lot like passive modalities for pain, like if it's the patient understands the risks and benefits and it won't ruin them financially, then we can work as a team to find the best path forward. And if I don't know what a lab looks like, then maybe I'll ask for help, or maybe I'll ask from a specialist, or I can explain to the patient that I may take some time to research this and understand. If they're cool working together, then maybe I'll do that as well. And I try to be humble and say like, there's a lot of things I don't know, but if someone's willing to be patient, we can kind of work together, then we can think about it. Or they might just deserve to go straight to the specialist, 'cause it's something that I'll never truly feel comfortable with. And that's kind of my approach as well. And when I'm talking to patients, say, "What do you do before getting labs? Do everything the same, have your same routine." So I kind of say, if we want to see the effect of medication, stay on that medication, right? If you're on a blood pressure medication, I want you on that to see if it's working. And understand if you need to have fasting labs. If not, a lot of times we don't need a ton of fasting labs. Our lipid panel is one where we do typically ask to be fasted, but not important. Also understand, and we'll talk more about that here in the upcoming season, is how exercise affects your labs. So if you're exercising, will it affect labs? Will your supplement affect your labs? All those things. So when we're getting tests, we really want to kind of make sure that, "Hey, we're working together as a team, understanding what's going on, looking at all things together. And then at the end of the day, keeping your routine the same, so I can interpret those the best I can." And so overall conclusions here is, labs are neither good or bad. They're just a tool and an imperfect one at that. More testing doesn't automatically mean better outcomes. And lab tests aren't necessarily benign either. They can have harms in themselves. However, a balance and team-oriented conversation with your physician is recommended. So that's overall what I think about labs. That's the intro here. We're gonna talk more about labs the rest of the season, but this does conclude the podcast. Thanks so much for stopping by. I really appreciate it. I hope you found today's episode helpful. And if you did, it would mean the world to me if you left a five-star review in your podcast, platform, or choice, or if you shared it with a friend who you think might enjoy it. And if you never wanna miss a piece of content, consider signing up for my mailing list, which is linked in the description below. I'll just send out content from time to time, and I'll never spam you, I promise that. But that's it for today. Thanks so much. Now get off your phone, go be active,
