Friday, October 03, 2014

A Testing Situation

from Jacqueline

Much has been written about the over-testing of America.  From cradle to grave, we are tested for educational, health, financial or employment purposes.  Teachers bemoan the fact that they are training kids to pass tests, not provide a well-rounded education. The college application process requires test scores – despite the fact that professors are the first to admit that testing is no indicator of academic success at tertiary level. However, I have come to believe – and many studies support this – that with regard to our health we are completely over-tested, and it is a contributory factor to out–of-control healthcare costs in the USA.  But it’s an emotional flashpoint – as well as a legal wrangle.  At a big company I worked for years ago, people talked about the CYA memo – today it would be the CYA email, sent to multiple recipients. The Cover-Your-Ass message is at the heart of so much medical testing, and it is closely linked to the propagation of fear.  Let me tell you about a recent experience.

A few weeks ago I went along for my annual “GYN” exam.  Men – do not stop reading – you have wives and daughters, and no doubt you’ve had a test or two on your crown jewels, so this sort of thing could apply to you, too.  

After the exam, the physician’s assistant looked through my notes and said, “I notice that there has been a case of breast cancer on your mother’s side of the family.”  I nodded.  It’s been there in my notes for years, without comment.  Then she said, “I think you need to have DNA testing.”  So I asked, “Why?”  And she answered, “So we can assess your risk.” 


At this point I explained that my family offers an excellent statistical example – my mother was one ten kids, seven of them girls, and I have more cousins than I can count – with the majority of them female, and all around about my age, give or take a few years.  We do not exactly have a breast cancer epidemic, and there is no ovarian cancer.  “I’m more likely to have a heart attack or a stroke,” I said. “Or a thyroid problem.”  But she insisted it was the best thing to do.

“So, let’s say that there’s a result that indicates I have a high likelihood of either breast or ovarian cancer – then what?” I asked.
“Well, we would counsel you on lifestyle choices,” she replied.
“Such as?” I asked.
“Diet. Exercise. Alcohol consumption – do you consume more than 7 drinks a week.”
I laughed. “I would be hard pushed to knock back more than 7 in a month.”
“Then your diet?” she asked.
“I gave up red meat thirty eight years ago, dairy fourteen years ago,” I said.  “I eat mainly organic chicken or fish, but only three or four times a week – the rest of my diet is vegetarian.  I have to eat gluten and wheat free and I am not a sugar junkie.”
“Oh,” she said.  “How about exercise.”
“Walk the hills for an hour and a half each day, and I train in a demanding equestrian sport three hours each day, five days a week. I also enjoy a brisk sit every now and again.”
“Oh,” she said, again.
“I’ve pretty much hit the lifestyle choices already,” I added.  “I’m not overweight and I don’t smoke.  Almonds are my weakness.”  I paused.  “And if that leaves doing an Angelina Jolie – forget it – I’m not having anything lopped off out of fear.”

Still she pressed me – and I knew that fear button was the one she had her finger on.  I felt myself caving.
“How much is this test?” I asked.
“About $4000," she replied
“I can tell you now, I am not paying $4000 to be scared."
"Oh, your insurance will pay all but $400 of it," she said.

I could feel myself getting uppity – but no more uppity than the physician’s assistant was getting with me. Clearly not many people questioned the advice!

I told her I would consider. She said they would take my saliva sample anyway.
I paused. “Oh heck, you might as well go ahead with it then,” I heard myself saying.

I arrived home and I realized I was annoyed.  I was really ticked off – with myself.  I called my pal who’d had the test and asked her opinion – she was shocked that I had been advised to have the testing, as usually you have to have several risk factors (be from an African American or Jewish background, be a smoker or overweight).  Then she said, “Oh well, it’s not a bad idea to get it done.”

I called the medical office and talked it over one more time, but because I could feel the woman getting really exasperated with me, I just let it go, and have tried not to think about it.  I have an appointment for my “post-test meeting” to go over the results in a couple of weeks.

But here’s what I think. I think I have been led astray by fear itself, by an organization making money out of testing, and in a very subtle way preying on trepidation about what might – or might not – happen in the future.  Several years ago, I remember reading that, despite the emphasis on family predisposition to (for example) breast cancer, in only 3% of cases of the disease is there a family connection.  I think it’s a CYA move, and I also think someone is making a lot of money out of me providing a saliva sample, which was then sent to a laboratory somewhere – at $4000 a spit, that’s a nice little earner.

It reminded me of two other events. Some years ago, at the company where I worked, it came time for the annual visit of the various insurance companies under contract with my employer. We had to renew with our healthcare provider, and we also had to meet with another insurance provider to hear about the various supplementary insurances we might want – long-term care, emergency room supplement, and another little offering called “Cancer Insurance.”  I listened to the brief run-through of the supplementary insurances, and then declined all of them – I couldn’t afford them, for a start. The agent looked at me and said, “Not even the cancer care?”  I shook my head. “No. I don’t want that kind of paperwork sitting on my desk or in my home.”  He shook his head and with something of a flourish, rapped his knuckles on the wooden desk.  “Knock on wood,” he said. I leaned towards him and said, “What you just did amounts to intimidation. You are trying to scare me into that insurance, and I am reporting you to my employer.  You will never set foot in this building again.”   

He smirked. His error. 

In his manner, by adding fear and superstition into the mix, what that insurance representative was doing amounted to blackmail.  He never returned – not on my watch anyway.

So, I have been wondering whether to ask that physician’s assistant to keep those DNA results to herself.  I don’t really want to know, but curiosity will probably get the better of me.  Ultimately, it won’t change anything, except it might add a bit of stress – and we know how bad that is for you. Heck, I might have my seven drinks in one night!

When I was in my mid-thirties, in the Jurassic period, I was sent for heart tests – a pesky little arrhythmia along with a heart murmur had decided to make my life more interesting.  First of all the cardiac tech listened to me while I explained to her that I didn’t understand how this had happened – I was a very fit woman.  Then she asked two very important questions:  “How’s your stress life?” and “Have you ever said, ‘I’m heartbroken.’”   She had me there.  I have never forgotten those questions.

It was later, while I was running on the treadmill, that she told me she also worked in the emergency room, adding, “And if there’s one thing I know in this world  - working here and in the ER – we all come date-stamped. When your time’s up, there’s nothing you can do about it.”

OK, so I can live with that – it’s called making every day count. And you don’t do that by living in fear – whether it is a fear of not getting into the college of your choice, of not getting that job or of having yet another medical test.  Some tests are worth it. Some are essential and help us live life to the full for as long as possible.  And we mustn't forget that there are some crucial tests that people have to fight for.  However, so many are costly, requested too often, and are just there to make money for the providers.  On the other side of the coin let's also bear in mind that those providers may be afraid of legal repercussions if we are not offered certain tests.  And for us, the mortals under the microscope, sometimes the pressure comes from trying to understand what is really important and also what does not serve us – so where our health is concerned, because we’re worried and not doctors, we end up being swabbed, injected, x-rayed and MRI’d until the cows come home.  And collectively, we end up paying even more for our insurances – a whole industry built on fear and maybe.

As I left the office, having offered up enough saliva to test my DNA – while wondering what sort of Pandora’s box I’d just opened – the nurse called after me.
“Oh, by the way, you’re overdue for a mammogram.”
I nodded, and muttered to myself something that sounded a bit like “Heck.”


  1. When they are in it to make money, they become a business; and, therefore, the trust level plunges. Unfortunately, the U.S. health care model is based on giving tests and distributing medications -- that's where the money is made. I had a doctor say I should have "X" vaccine because "You don't want to contract X, Sandy," he said. "It can be very unpleasant." When I read about the X vaccine, I discovered that only one out of every three people ever contracts X. Hmmm.

    1. from Jacqueline: Thank you for your comment - and how interesting - a "CYA" moment on the part of the doctor, I think.

  2. Jackie, I say don't do it. As you know, I was diagnosed with breast cancer 9 years back and genetic testing was brought up as there was a history in family on mother's side. I started the process and obtained medical records for two sisters and a niece. The first report came back and it was a grey area. After a long discussion with the oncologist we agreed that with that result not to take it further as very unlikely genetic. It would it take time to go through the whole process, but would also cause unnecessary stress not just for me, but for family. I believe I still have that first report and will send to you if you think it will help you decide. On a further note on testing. I am due for a colonoscopy in 2015 ....last done 5 years back. No way, I will be 80 then and there is no history of colon cancer in family so will not do unless have problems or symptoms of something wrong. When I told my doctor this, she nodded her head in agreement. rbb

    1. from Jacqueline: Thanks RBB. It may be too late to cancel, but I will try - I have been really on the fence about it. And regarding family - it's only the female line they're interested in. I once met a man who'd had breast cancer. His wife had never had the disease, but both his daughters had it. It devastated him to think he might have passed on something to his daughters.

  3. Sadly, we don't have "medical care" in this country -- we have a "medical industry," and it, like the insurance industry, is built on fear and intimidation.

    When my mom was in the hospital after her heart attack (she arrested 3 times, she did not want to be resuscitated, but she wasn't wearing her Medic Alert "DNR necklace, I didn't have copies of her DNR with me -- I do now -- and it all happened so fast, they'd electro-shocked her before I realized fully what had happened), they really pushed her to get a pacemaker.

    A pacemaker ensures the heart doesn't drop below 60 beats per minute. That has never been my mom's problem, and it wasn't after her heart attack, either. But that didn't keep the hospital surgeons from trying to intimidate and scare her into signing a consent and having it done. (My mom's stubborn and doesn't intimidate too easily.) Gradually, it occurred to me that Mom's need for a pacemaker must be rather dubious, based not only on my research, but also because none of the doctors made a point to discuss it with me -- they only discussed it with my mom, when she was alone, and they thought they could bully a then 73-year old woman who'd suffered a traumatic health event.

    After her release from the hospital, she saw two other doctors; neither of them saw any medical need for her to have a pacemaker.

  4. This is a gray area. For me, having a mammogram is routine. My primary doctor (I think GP in the UK) did not think a yearly exam was necessary but my gyn said yes. I thought a yearly exam was a good idea. Your post reminded me of something I learned my first year at university. I took a sociology class about health. Keep in mind this was years before Affordable Health Care in the USA. My young professor was pregnant when she taught us. She said something about preventive health care, meaning that we take vaccine to prevent polio for example. I also recall that Elizabeth Taylor the actress had a routine test when her doctor discovered a small brain tumor and she had surgery before it got out of hand. A friend and I were talking about our health insurance. She said the insurance is good as long as we stay healthy. We have to decide when a test is necessary. In Angelina Jolie 's case, her mother died very young in her 50s? From breast cancer and she wanted to do what she could to prevent it.

    I took a DNA test for another reason. It was to find out my ethnic makeup. I am 98 percent European including 38 percent Great Britain and 6 percent Ireland.

    My health is pretty good except for my allergies from cigarette smoking or air pollution.


  5. The last years of my mother's life found me taking her to various doctors multiple times every month. It was stressful for her (and me) but I never got the impression her doctors were trying to make a buck off her medical insurance. I felt strongly that they were just trying to keep her alive and comfortable, which raises another issue: Doctors in the U.S. are dedicated to keep people alive. If not for the medical care she received, she would have died twenty years earlier.

  6. James O. Born10/03/2014 11:45 AM

    All the elements I like in a post: Subversive distrust, well thought out argument and statistics! I love stats. I had no idea your family was so large. No wonder they forced you to move off the island and come to the US. They needed the room.

    Great post.

  7. replying to this is complicated.

    Huge JW fans just think our English friends should have a colonoscopy prior to symptoms. But they do not with the NHS.


  8. I have so much respect for the medical profession because I have had experience with the miracles of modern science, but at this late time in my life I have decided no more colonoscopies, no more mammograms, but yes on the flu shot and vaccines. I feel very fortunate to have these choices.