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Dr. Miller: How worried do you need to be when you receive your lab results in the mail or online before your physician's had a chance to talk to you about them? I'm Dr. Tom Miller and we're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jerry Hussong. He is a clinical pathologist and also the Director of ARUP. He's also Medical Director of ARUP and we're going to talk about abnormal lab results that a patient sees and how important those might be and what guidelines a patient might have so they don't worry too much about it before they talk to their physician.

Now, Jerry, I'll have patients call me before I have a chance to talk to them about what I would consider normal lab results, but they will get those lab results and if any of the values, and there are many values that come back with a series of standard lab results, if any of those values are outside the normal range, they're usually marked in red. And sometimes they're barely over the limit. But patients can be very concerned about that and worry that the world is about to end. Do you have any comments about how patients should look at those lab results and think about them?

Dr. Hussong: Sure. I think to start with, it's really important for patients to realize that all laboratory test results are going to come with a reference range attached to them. And basically, really, reference ranges are ranges that we establish by looking at normal patients and we establish the reference range by looking at 95% of the normal population or having that as our criteria. So the range will include 95% of the total normal population and that's really . . .

Dr. Miller: But 5% could be outside that range.

Dr. Hussong: But 5% could be outside the normal reference range.

Dr. Miller: Normal is not always normal.

Dr. Hussong: That's right. And so it's really important to realize that you can be slightly outside that reference range and still not worry or be alarmed. It's important to realize a laboratory test should always be interpreted in the context of the reference range, but also in the context of many other things that are going on with the patient. So we put this in context with the physical examination that you're going to be doing with the patient, other laboratory test results and how far outside the range is that result.

Dr. Miller: That's one of the things the patient can look at if they have the ability to do that, is to look and see if the number's very far outside the reference range. If it's two or three times the outside limit then there may be an issue. But if it's just a little bit outside perhaps not such a big deal.

Dr. Hussong: And it may mean that there absolutely is nothing underlyingly wrong with the patient at all and they just have to realize that. In some context, this is why we're doing the test to see if there's anything abnormal with those laboratory testing results. But often, if it's only slightly out of the range, it may not have any indication that there's an underlying problem.

It's really important to realize though that there are some conditions that can really affect laboratory results. Extreme exercise, for instance, can cause you to have a protein in your urine. For instance, in times of dehydration if you've been out in the sun for long periods of time there may be some changes in your electrolyte results that you see. So you have to put it together with all of the other things that may be going on and other circumstances that may be affecting the patient.

Dr. Miller: One of the things that I've heard is that if you order a lot of tests and get a lot of results back, the chance that you'll have some abnormal results is normally higher anyways. Can you shed some light on that as a clinical pathologist?

Dr. Hussong: Yes. Sure. As you're thinking, the normal range is going to include 95% of the population but 5% of the population will not be included. As you exponentially increase that with a number of laboratory tests that you perform, you can imagine that your odds of being outside the reference range on any one of those tests greatly increases.

Dr. Miller: So basically, if I have 100 test results probably five of those are going to be normal but outside the reference range.

Dr. Hussong: Absolutely. That is a possibility that could happen with that. But, again, to realize that we're doing these tests for a reason and sometimes the abnormal results indicate that there's something abnormal going on with the patient. But if they're just slightly outside the reference range it may not indicate disease or an underlying issue at all.

Dr. Miller: So the key thing is to take a deep breath and make sure you get in touch with your physician so he can interpret the findings and help you understand them. And essentially, if they're not too far outside the reference range not to worry too much but definitely to talk to the physician about an interpretation of the lab results.

Dr. Hussong: I think that's absolutely right.

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Dr. Miller: Do you need standard laboratory screening studies during your examination? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Jerry Hussong. He is a clinical pathologist and the Chief Value Officer for ARUP Laboratories here at the University of Utah. Jerry, it's pretty typical for most physicians in primary care to order a set of laboratory studies, a full blood panel, a complete metabolic panel and sometimes a lipid panel and we do this almost routinely, reflexively. And I guess for the patients out there, maybe you could tell us what's the value of getting these tests if you are totally healthy? Do you think they're necessary?

Dr. Hussong: So when we think about some of the common laboratory tests that are offered as part of an annual physical exam or for a specialized sort of inquiry into patient's health, there probably are some that we should think about that really should be done once a year. And these would include the complete blood count or CBC, the chemistry panel, even though it can be a limited chemistry panel or metabolic panel as some people may refer to it, as well as urinalysis or UA. Those are the ones that we probably should be thinking about as just sort of routine annual tests. There may be a number of other tests that the physician may want to order to address a specific problem that the patient may have, but as a part of the screening test those are the ones that we want to be thinking about.

Dr. Miller: What in those laboratory studies do you think that we might be looking for that would be important for the patient?

Dr. Hussong: Sure. So when we're thinking about a complete blood count or CBC, we're really looking at it to see if the patient may have anemia, for one, to see if the red blood cell count is adequate or potentially even decreased or increased. We also might look at the white blood cell count, which may be an indication of infection that may be going on or an indication of possibly a leukemic process that could be going on. Some patients will present with low platelet counts, which could be an indication or reason why they're experiencing increased bruising as they might see.

Other things that we see with the metabolic panel or the chemistry panel is things evaluating kidney function such as the BUN or creatinine. We also will monitor glucose as a screen for diabetes and then a number of the other biochemical electrolyte like things such as sodium and chloride.

Dr. Miller: Certainly important when patients have any of these illnesses, but I think what you're saying is that a person who feels very well may have some of these abnormalities, which could be an indication that there is early disease that they might begin to have treated or respond to in a way that would prevent it from being a bigger problem down the road.

Dr. Hussong: Exactly. And this is really just a small number of tests that we use to screen for some sort of wider range of problems that the patient may be having. It's really sort of a truncated panel of all the different types of tests that the physician could order, but really allows us to get a global sense of the overall health of the patient during their physical examination.

Dr. Miller: Now these time-honored tests, and I've ordered them myself and I continue to do so, basically are not terribly expensive. Is that correct?

Dr. Hussong: The tests that we were talking about just now, they're very inexpensive and I think that's important for the patients to realize. There are lots of specialized, newer tests that are out that can cost up to thousands of dollars, but these are very inexpensive tests that can provide a lot of information to the treating physician.

Dr. Miller: And how about a thyroid test? We sometimes order that if we suspect the patient may have a thyroid disorder if they're fatigued or if there's a sudden gain in weight. Do you think that's a useful screening test or should we just maybe order that when there are indications to do on the clinical exam?

Dr. Hussong: I don't think it's a great screening test just overall if someone doesn't have any signs or symptoms that indicate any thyroid disease. I think if there is worry for that it's important to go through sort of a stepwise process ordering a TSH, for instance, to start with and maybe a T4 but not to go to some of the specialized tests for thyroid function analysis unless you have a real indication and have some of these preliminary test results back first.

Dr. Miller: Great. Now the other thing is patients sometimes forget to ask and physicians sometimes forget to tell them whether they need to be fasting for these tests. What's your opinion on that for the series of screening tests you mentioned, the CBC, the complete metabolic panel or cholesterol panel?

Dr. Hussong: So not for these tests, but there are a number of tests that we do in the pathology laboratory that do have special requirements as you say whether it's fasting or other things that they need to do or certain times of test, times of the day when the blood should be drawn whether it's morning or after a meal and so for these basic tests there is no specific requirements to be thinking about to have these routine tests done.

Dr. Miller: What about the cholesterol panel? Sometimes I'll tell people to fast for the cholesterol panel.

Dr. Hussong: It's probably a good idea. You want to get a real indication as far as where the patient sits in regard to their cholesterol levels but, at the same time, you don't want them to just have had a huge meal that may artificially elevate their cholesterol.

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updated: November 20, 2018
originally published: July 7, 2015

Dr. Miller: What does a pathologist do, exactly, and how can they help you stay healthy? I'm Dr. Tom Miller, and we're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on the Scope.

Dr. Miller: Hi, I'm here with Dr. Jerry Hussong, and he is a clinical pathologist and also the chief value officer for ARUP Laboratories. Jerry, aside from what we see on CSI and some of these shows on TV, what does a pathologist really do, and how does that relate to the person who is having an annual examination or seeing a physician for a particular problem?

Dr. Hussong: Everybody thinks a pathologist is a person responsible for doing an autopsy. And it's not just autopsies that the pathologist does. Really, pathology is the study of disease, of the cause of disease and the effect of disease.

Dr. Miller: And actually, autopsies are a small part of what a pathologist generally does. Is that right?

Dr. Hussong: A very small part, and that's just a small part of anatomic pathology, but there's a whole other area of pathology called clinical pathology. Pathologists are physicians who specialize in diagnosis and management of disease through laboratory test medicines.

Dr. Miller: So I can say as an internist, the assets that pathologists bring to the table are incredibly valuable, and yet a patient may never see a pathologist during the course of their treatment.

Dr. Hussong: Often, they will not see a pathologist. They may see a bill from a pathologist, and wonder why they didn't see the pathologist and what is this bill from, but it's really for producing the laboratory tests our clinical colleagues then use to treat the patients.

Dr. Miller: And so what's so important about your role is, I imagine, making sure that the test results are accurate and precise.

Dr. Hussong: So a pathologist is usually the laboratory director who is legally responsible for the quality and the accreditation of the laboratory in which the tests are going to come out of. Laboratories are regulated by state agencies, and each state has their own specific requirements for regulation. All laboratories undergo accreditation by CLIA, which is the Clinical Laboratory Amendments Act, that really oversees the quality of testing. But the pathologists make sure that those tests results are accurate, and that is how we serve patients and serve the physicians that are taking care of patients.

Dr. Miller: You know, I've always felt like the world of quality as resides in pathology is sometimes ahead of some of the other fields in medicine. I mean, the way you guys take such particular care to make sure that the results are accurate and spot-on, and that samples that go to the surgical pathologist and anatomical pathologist, you have checks and balances to make sure that diagnosis are well vetted and well carried out.

Dr. Hussong: And there is a huge amount of work that goes into validating tests before we ever bring those tests online. So we go through extensive validation, checking, there's a lot of work that goes through and into the process before we bring the test online. And then once the test is online, we have to go through a continuous ongoing review and validation that nothing is going on or wrong with the test as we continue to offer the tests clinically.

Dr. Miller: A lot of ongoing quality assessments and . . . I think your work is very concise and very precise, if I might say. And that's sometimes a little bit different than what we experience in the clinical realm in our day-to-day work with patients. So when you say tests, what kinds of tests are you talking about for the patient? Are we talking about blood tests, are we talking about tissue samples, what are we talking about?

Dr. Hussong: It can be all of those. In anatomic pathology it often is a tissue sample, so a biopsy is taken, maybe a patient is undergoing a colonoscopy and they get colonic biopsies that are then sent to the pathologist to look at and see whether there is any disease process going on or if the tissue is healthy. But it also can include a number of clinical laboratory tests, which can be evaluating blood, urine, cerebrospinal fluid, and pleural fluid, any of those types of those specimens as well.

Dr. Miller: You know, I don't think people understand, or patients necessary understand, that when we order a laboratory study, it's really up to the clinical pathologist in charge of the laboratory quality control to make sure that that test is valid and accurate.

Dr. Hussong: Absolutely, and laboratories undergo proficiency testing throughout the year where there are standards that are sent out by regulatory agencies where you actually do the test and provide the result back to the regulatory agency, and they check you in relationship to other laboratories across the country to make sure you are doing high-quality laboratory testing.

Dr. Miller: So it's almost like a patient has the safety of mind, or presence of mind, that they don't really have to worry about this. It sounds like wherever you go in the country for a laboratory study or if you're going to have a tissue sample evaluated by an anatomical pathologist, that there is quality control associated with that test, no matter whether you have it done in Florida or whether it's done in California or Arkansas or any particular state.

Dr. Hussong: Absolutely. I think the key is to make sure that the laboratory is accredited by an accrediting agency, whether that is CLIA or one other of the deemed agencies such as the American College of Pathologists.

Dr. Miller: Now, there are some large laboratory companies, I think, in the country that actually run blood samples for private physicians and they're under the same regulations. Is that true?

Dr. Hussong: The exact same regulations, and they will have a medical director who will oversee and be responsible for the laboratory testing out of that laboratory.

Dr. Miller: So mostly for patients that are listening and families that are listening, it's really peace of mind to know that we have a clinical pathologist behind the study and quality of the tests and test results.

Dr. Hussong: Absolutely, and it's important for patients and families to realize that the pathologist is a part of the health care delivery team. They may not see us, but we are going to provide useful and valuable information to the clinicians, who are then going to take that information to use and treat the patients that they are seeing.

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