The Truth About Lab Testing
What I wish every patient knew
Lab tests are one of the most over-hyped elements of modern medical care.
I order a tiny fraction of the labs my colleagues run.
Yet patients often tell us we got better results, with less lab testing, than their prior doctors.
How are we able to do more with less?
I wrote about this here:
The public has become accustomed to lab test pricing that is ten or even a hundred times what it actually costs.
I view lab interpretation as one of the cornerstones of the doctor-patient relationship. Labs should be ordered thoughtfully, with full consideration of the case, and with the best interests of the patient foremost - not profits.
We offer lab testing for our patients for much lower prices than you will find available elsewhere. I have yet to find another practice or clinic that can match our prices. They are one of the benefits of membership. Our labs are often only 10-20% the cost of retail labs, let alone insurance pricing (which is grossly inflated).
I wrote in more detail about this problem here:
Why I'm Writing This
I am tired of watching patients waste money and time on lab testing that they do not need. I am tired of watching them suffer from over and under-treatment because of improper, inadequate, or excessive lab testing. I want to empower you with information to make better decisions about what labs to order, why, how, when, and where to purchase them. Most of all, I want you to know how to think about lab testing so that you can, in collaboration with a competent practitioner, get the best results possible. I am obsessed with helping people get great outcomes. Labs are a critical piece of that puzzle.
If you appreciate this kind of content, would you take a moment to share it with someone who would benefit from it? I make this content as widely available as possible to help others. You never know how it might change someone else's life. Thank you for sharing my work - I truly appreciate it.
The Hidden Dangers of Over-Testing
Over-testing can cause real harm to patients. Patients do not readily appreciate this, but physicians do. Once you see one patient harmed by over-testing that led to over-treatment, you think twice about what you order, when, and why.
A Real Case That Changed Everything
Let me give you a real-life example from a colleague of mine.
A man presented for a routine physical. His physician ordered a prostate specific antigen test to screen for prostate cancer. The level came back as abnormally high. The physician referred him to a urologist, who performed a prostate biopsy. In a prostate biopsy, an ultrasound probe is inserted into the rectum to visualize the prostate, and a needle is used to then biopsy (take samples of) the prostate through the wall of the rectum.
Unfortunately, the biopsy needle injured the nerve that runs near and through the prostate that innervates the penis.
He is now permanently impotent, due to this nerve damage.
All of this arose from running a lab test that he might never have wanted in the first place, if his physician had taken the time to discuss the risks and benefits with him.
How We Handle PSA Testing Differently
When I order a PSA, if I order it, we have a conversation about this exact scenario so that we can avoid it. We might not run the PSA at all. We certainly don't jump to a biopsy if the PSA is abnormal. We order a non-invasive MRI. We also run the PSA and % free PSA in the first place, which is vastly superior in terms of predictive power.
This takes time with a physician. This is why time with my patients is what I value most.
What Every Patient Should Know About Lab Testing
1. Lab Results Vary Greatly from Day to Day
First, lab testing is incredibly unreliable. In my own labs, I note a 20% variation in almost all values from week to week. In some cases, the variance is far greater.
For example:
One week my ferritin might be 120. The next it might be 60.
My TSH might be 1.5 one week. The next week it might be 4.5.
We use a large commercial lab for our testing. Our internal data do not agree with their publicly available data.
In other words, what you are publicly told about the reliability of labs and what most doctors believe about labs is wrong.
I have a podcast coming out soon where I review my own labs. I thousands of dollars worth of labs, just to show you what I already knew from my practice.
Subscribe to make sure that podcast lands in your inbox!
I am not sure to what degree this is about instrumentation (i.e. are the machines inaccurate?) or the day-to-day variation in labs among patients (i.e. how much does your physiology vary day to day?).
People make decisions about what to take and how much of it to take based on one or two data points each year. When you step back and look at how much variability there is in the data, this seems absurd.
People are being over and under-medicated due to this. We solved this problem in my practice by testing more judiciously and by spending more time with patients to see how symptoms lined up with lab tests.
How I Discovered This Problem
The results I was seeing in my patients didn't make sense based on their symptoms. People with normal thyroid labs, for example, still had hypothyroid symptoms. I would start a man on testosterone and his next level would be lower than his first level.
I started to test my own labs week by week. I spent thousands and thousands of dollars on this little quality-control project within my practice.
The variation in my labs was about 20%, at least, and 100-400% in some cases.
My diet and lifestyle are about as consistent as possible.
If my labs vary this much as a healthy 36-year-old with an extremely consistent environment, diet, and daily routine, how much do your labs vary?
This comes back to an old principle of medicine that I learned from older practitioners.
We treat patients, not numbers.
Numbers still have value. Some labs are more consistent than others. But the hard truth is that most of the labs I see patients ordering before they see me in consultation are either much too expensive, or are entirely unnecessary.
2. Many Labs Are Worthless
Some labs vary more than 10-20%. For example, hormone testing can vary so widely as to be almost worthless (in some cases). I do not order most salivary or urinary tests because of this.
To a certain degree, this has to do with the sample size. As in, one drop of urine or saliva is not necessarily accurate to what is going on in your body. When my mentor, Dr. Rosensweet, compared 24-hour urinary hormone tests (the gold-standard in menopause) to salivary and urinary tests, he found that results varied dramatically. These variations had a meaningful impact on treatment decisions.
When Symptoms Trump Numbers
Likewise, there are times when a test has a huge variance, but I see symptoms despite a "normal" result. For example, if a man has crippling symptoms consistent with low testosterone, but his testosterone is in the mid-range, I discuss with him how error-prone the lab test is.
If he wants to proceed with treatment (testosterone replacement), we proceed without additional testing. If he wants to check the lab again, we order a repeat test.
Notice that we discuss the risks and benefits of each course of action. I don't treat my patients like they are cookies that need to be cut out of a sheet of dough. You share all decisions, because there is no one-size-fits-all or “right” answer in many of these medical decisions.
What Conventional Medicine Gets Right
One thing I will give my conventional colleagues is that they are sticklers for reproducibility. They never use random or small urinary or salivary samples for the diagnosis of hormonal abnormalities or imbalances, because they are not reliable. They look down on integrative medicine because many practitioners lack this commitment to rigor in lab testing methods that drive treatment decisions.
3. Lab Results Alone Do Not Determine Treatment
One of the best profit models in health and wellness is to eliminate practitioners by having AI-generated reports of what to do based on your lab tests. This "paint by numbers" approach is always supposedly based on some "secret sauce."
I suppose that if you cannot find a decent practitioner to work with, then this approach is better than not having any testing to guide treatment at all. On the other hand, I cannot recommend it in good conscience based on my clinical experience.
Personalization through one-on-one consultation has a major impact on patient outcomes, for many reasons. We tested this hypothesis in my practice (informally and anecdotally) by allowing one group of patients to purchase lab testing and supplements without consultation, while another group just purchased testing, supplements, and consultations.
The results were clear. People who had consultations and coaching got better results.
"Paint by numbers" lab approaches will never get the same results as thoughtful consultation and coaching with a great practitioner. You are unique, and one-size-fits-all protocols reduce you to a person with no thoughts, feelings, or unique characteristics that might modify or guide our care.
Case Study: When Labs Miss the Real Problem
Let me give you a specific case study in how this approach fails.
Early in my career, I saw a woman who had severe food allergies and sleep issues. We found an abundance of lab abnormalities, but in taking her history I discovered that she was sleeping right next to her home's smart meter.
Smart meters emit radiation that interferes with sleep. I recommended that she start sleeping in a different bedroom. The change in her sleep was immediate. She started sleeping through the night, which had a major impact on her allergies and food intolerances.
Nutritional testing revealed a range of deficiencies and imbalances that we remedied with a personalized supplementation protocol. When I last spoke to her, she was on her way to a complete recovery from her symptoms.
She needed more than lab testing. She needed personalized recommendations that required the process of a thoughtful initial consultation. I have seen this make all the difference in the world in case after case. Labs alone do not determine treatment, they only guide it. AI cannot replace physicians.
Our Strategy for Ordering Labs
Here is my strategy for ordering labs in my practice:
1. Start with the fundamentals
We start with blood markers that are associated with performance and longevity. I will share exactly what we order in a future post.
2. Add mineral testing
We test hair for mineral levels, because we can deduce so much more than just mineral levels from hair testing, as I wrote about in this post:
From this, we are able to make recommendations regarding supplements, medications, and diet and lifestyle modifications.
Our Follow-Up Protocol
If any labs are abnormal, we check them again in six weeks or three to four months.
Why? Because one quarter (3-4 months) is about how long it takes to see meaningful changes in most of the important blood markers. Exceptions to this would be hormone levels and certain blood markers, like homocysteine levels.
We check abnormal labs again every quarter until they are normal
We iterate supplement protocols every three to four months, because of how rapidly nutritional needs can change on high doses of supplements (which we use for best results)
We adjust medications as needed, including hormones
Once someone's labs are in the optimal range for longevity and vitality, we can reduce our lab draws to every six months or every year.
This is how you deliver cost-effective preventative medical care, without over-testing or over-treating.
The cost-savings long term is astronomical. The fact that modern medicine doesn't operate on these principles is why we have a healthcare crisis.
I hope you found this post helpful. I hope it helps you make better decisions about what labs to order, why, when, how, and where. I hope it helps you get better outcomes. That is, after all, my goal in writing.
Until next time, be well,
Dr. Stillman
I just started reading your substack since joining the lifewave team and I love your work so much! I SO appreciate your incredible perspective and thoughtful integrity.
So true. Not getting any joined up thinking from practitioners or even pathologists and haematologists at the labs, I have resorted to AI and found it a lot more thoughtful. But then I have at least some insights as a veterinary clinician. Short of relocating to Florida AI remains my only option! Once you call it out for spouting the mainstream narrative, it gives one less rubbish than a lot of clinicians.