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Why am I having this test doctor?

Jonathan consults his doctor regularly and each time he comes to the clinic he expects to go next door for a blood test or X-ray. Like many people he believes that a positive test means he has a specific condition and a negative test implies that all is well. So he has come to conclusion that a doctor who doesn’t order a test is not doing his job.

No test is that good. A ‘positive’ test often requires more investigations or a repeat test to rule out the rabbit being pursued down the proverbial hole. A test is only a useful tool in the hands of the doctor who factored the risk of a specific diagnosis. Therefore a teenager with a severe sore throat, fever and fatigue is likely to have Glandular fever and a positive test is likely to have a high positive predictive value.

On the other hand being tired all the time is more likely to be related to some non-physical cause such as stress, lack of sleep or worry than it is to an under active thyroid gland or anaemia. And yet test ordering is a common outcome in consultations. For example ‘hypothyroidism’ or an under active thyroid gland is thought to be present in 3.8% of the population. The majority of those with the condition are older females. In a study where doctors were given feedback about their test ordering Thyroid function tests were the commonest test ordered with up to 21 per 1000 patients having the test. When doctors were offered feedback about test ordering the number of patients in the practices receiving the feedback reduced but not significantly. Australian experts advise that:

Signs and symptoms of hypothyroidism may vary depending on patient characteristics and the severity of dysfunction. Classic symptoms include fatigue, weight gain, cold intolerance, arthralgia, constipation, menorrhagia, irregular menstrual cycles, and dry skin and hair. Physical signs include coarse skin and hair, bradycardia and goitre but these may be absent in mild hypothyroidism.

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

However they conclude that:

Requests for thyroid tests are increasing, although in many cases clinical need is not evident.

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

I offer some more thoughts on video.

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Doctoring Warrants A Plan

Most people who attend a family doctor are unlikely to be seriously ill. Many however will benefit from making different choices about how they live because it is now normal to be overweight or obese, it is common to drink too much and take very little exercise. People who attend doctors may have a so-called minor illness which will improve in a matter of a few days without any specific intervention but they will also have many risk factors for long-term illness that would be better addressed now, and certainly before they manifest as diabetes, heart disease, cancer or dementia.

Therefore the aim of the game, if we want to call it that, is to trigger people to make changes in their lifestyle while there is still time. The doctor will be one of the two people in the room when these matters can be in focus. At the doctor’s disposal at that time are five assets; the doctor (or more explicitly the persona of the doctor); the room in which they meet; what they both can see, hear, smell, taste and feel in that space; the actions that can be taken which range from nothing through to a referral to another expert.

Before the interaction the doctor has to have a plan as to how the interaction will unfold. The Art of Doctoring requires close attention to each of the assets at the doctor’s disposal. It is crucial to have considered how these are to be deployed before entering the fray.

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What good is a cold?

It is often quoted that 50% of people will succumb to an upper respiratory tract infection in the course of a year. The usual pathogens involved are viruses.

Rhinoviruses with more than 100 serotypes are the most common pathogens, causing at least 25% of colds in adults. Coronaviruses may be responsible for more than 10% of cases. Parainfluenza viruses, respiratory syncytial virus, adenoviruses and influenza viruses have all been linked to the common cold syndrome. All of these organisms show seasonal variations in incidence. The cause of 30% to 40% of cold syndromes has not been determined.

Purushothama V. Dasaraju and Chien Liu.

The natural history of a cold is typically complete resolution within seven to ten days. There is no cure and regardless of what treatment is offered most people are miserable during that time with a runny nose, cough, sneezing, fatigue and sore throat. This is one of the commonest reasons people seek medical advice if not the most common reason. Colds are typically seasonal, highly infectious and responsible for a huge cost to society . Not to mention the risk of being offered inappropriate treatment, especially antibiotics.

We might ponder a philosophical question- Who benefits from a cold? Certainly viruses do- they spread from host to host at an alarming rate. However viruses that cause a cold do not mutate like the flu virus does, so spreading through the community doesn’t support their evolution. The condition is not fatal therefore it does not appear to support the host’s natural selection. So what is the point of an infection that makes us miserable up to three or four times a year? We lose time off work, we take medicines that provide temporary relief and life simply becomes a little more difficult. Possibly the only part of society that benefits are those who sell medicines!

Research now suggests that not everyone suffers to the same extent.

The epidemiologic data suggest that endurance athletes are at increased risk for URTI during periods of heavy training and the 1-to 2-week period after marathon-type race events.

Nieman

Even after adjustment for other variables, men were significantly more likely to ‘over-rate’ their symptoms in comparison with the clinical observer than were women.

Macintyre

We found that high physical activity was associated with a lower risk of contracting URTI for both men and women.

Fondell et al

Data analysis showed that higher incidence of URTI was significantly associated with increased training ( tennis) duration and load, and competition level, on a weekly basis.

Novas et al

The risk of self-reported manifestations of the common cold was higher in workers who reported symptoms of depression.

Kim et al

Most of the relevant studies show a significant relationship between psychosocial factors and the onset or progression of acute respiratory tract illness. However, the psychosocial variables were not consistently evaluated across the included studies, and different methodological approaches were used to examine the association between psychosocial factors and acute respiratory tract illness.

Falagas et al

And finally most intriguing of all

Training in meditation or exercise may be effective in reducing ARI illness burden.

Barrett et al

This suggests that the URTI may serve as a barometer for stress in many people. This perspective may help those who advise or care for people who are experiencing symptoms of an URTI to consider what if anything can be done to address the other issues in their lives that may be problematic. By corollary people presenting for help with an URTI require the most skilled healthcare and not just a lecture on how paracetamol is the only treatment available.

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