Healthy Here, Sick There: Which Range Is the Real One?

If you have been following my blog for the past months, you probably won’t be surprised to hear that I don’t think much of the laboratory provided 'normal ranges'. I mean, I don’t think anyone should put the blame on the pathology companies either, as they are trying to make a living like you and I, doing their best in processing your doctor’s requests. On top of that, they are not your health provider; they don’t shoulder the responsibility of clinically interpreting the results. That is your physician’s task, and they get paid good dollars for carrying such a big responsibility.

When the labs report your results, they are only trying to be helpful by going that one step further. In case your doctor needs help to recognise what is 'normal and expected' from 'abnormal and unexpected', these labs often report your results with accompanying ranges. The reality is that if you are running a pathology lab, most doctors will desert you if you only produce reports without ranges, when your competitor next door has it all laid out for your doctor to have an easier life. So, let’s be kind to these labs even if you don’t agree with their reporting.

I don’t believe we should apply the same level of forgiveness to doctors, though. In our society, we give each individual a job or a title because we want to trust that they are going to do their job well. The labs have a job in analysing your blood, urine, sputum, faeces, and all sorts of other gross stuff coming out of ailing bodies, and we expect them to do it well. Not many people go out and visit these labs every month or so to check that they are still fit for purpose; because we trust that they are, and in the rare case that they are not, we trust that someone will set them right again. If an entity keeps failing to perform, we eventually vote with our feet. This is the same for nearly everything in modern capitalistic society.

'Nearly', because doctors are absolved from the same level of scrutiny. Let’s expand on this while keeping relevant to the subject at hand today. We expect labs to do their job well in analysing our samples. When the report is back, we expect doctors to be able to clinically interpret them according to our individual circumstances to help us find the solution to our ailment. When we are told something is normal or abnormal, we trust that the practitioner knows what they are talking about. And that cannot mean just reading the results against their ranges.

I’ll give you a real-world example. B12, a major vitamin for nerve health, is a popular test nowadays. But depending on which pathology lab you got your blood test done with, you will hear some very different news from your doctor. When a lab reports <150 pmol/L as the cutoff for deficiency for adults, others will report 162 and 185. If you go a little bit further down the road, the number becomes a staggering 351. Guess what: your B12 status can change from excellent to borderline to deficient as you walk from one end of the street to another.

There are countless other examples. ALT, the liver enzyme we talked about previously in the blog on insulin, can be high for a female adult when it reaches 30 U/L or 45 U/L. Uric acid can be 0.35 or 0.4 mmol/L in females and 0.45 or 0.5 in males. Aspergillus antibodies can be 40 or 50 mg/L. Total cholesterol can be 4.0, 5.0, or 5.6 mmol/L. PTH can be 1.2 or 1.6 pmol/L. 24 urine free cortisol can be 110 or 230 nmol/d. TSH can be 3.0, 3.5, 4.0, 4.5, or 5.0 mIU/L. Thyroid antibodies can be 4.1 or 11 IU/ml. ASCA IgG and IgA can be 7, 8 or 10 U/ml. CRP can be 3.5 or 5 mg/L. Insulin can be 3 or 5 mU/L. Testosterone in women may or may not have a lower limit. DHEAS has too many different ranges to list. I could go on and on if I wanted, but I think I have proven my point here.

So, as you are walking down that street, your B12 status is not the only one that changes. Your liver may turn fatty (ALT) and then better again; you may suffer from gout (uric acid) and then it magically disappears; you may be ridden with mold (Aspergillus) and then you fought it off; you may be dying from heart disease (cholesterol) and suddenly gain full health; your stress level is so high (cortisol) it could come out of your ears and then suddenly it vanishes; you have Hashimoto’s or you don’t; you have Crohn’s disease or IBS; you are inflamed or you are clean; your hormones are too low or they don’t matter; your adrenals are working or they aren’t, etc. See my point?

I’ll give these results anytime to my 10-year-old child, and he can tell you what you will also hear in the consulting rooms. But as much as I love him, I wouldn’t go to him for complex medical opinions, as we all need someone who knows what the results mean deeper than just at the surface level. I believe that doctors deserve their title, pay, respect, and position because they should know, for every item on the report page: what it means; how it came about and where; what it interacts with; when it is masked or overrated; what else influences it; what different studies have found to be a low level or high level; which context it lies in; and what we don’t know about it yet. This was, in fact, the purpose of our degrees. It is definitely not just to be a decoration on the wall.

If you are a patient and you are reading this, you can start by demanding that your doctor know more. If you are still ill and getting worse, continue to press and seek answers. When there is demand, your doctor naturally will start to skill up. When there isn’t one, they may not know what is amiss.

If you are a doctor, don’t worry, we have traversed this path before. We all passed medical school exams, meaning the knowledge was there; we just have to dig it back out. It will be hiding somewhere between the folds of our cerebral cortices, especially after all the sweat that our hippocampi broke in those five years, coupled with the ups and downs our amygdalae registered. Do it for your patients. They entrust their lives to your ability to fix them. When they come back with their smiles, you’ll get the heartfelt contentment no other remuneration can offer.