We all want to be optimal. But, and this is a big “but,” when I order lab and other testing, there is a normal range. There is not an optimal range. The premise of a normal range is something that applies to a large population. The problem is that doctors apply it to individual patients. The reason this is a problem is that many times, patients feel well and have routine tests done to try to prevent problems, but they have the dreaded “High” (H) or “Low” (L) result on their lab work. Many times, the abnormal result is not of any significance even though it is a H or L on the piece of paper, but the patients don’t know this. There are times when the abnormal results reflect a current problem or a trend toward a problem that needs to be addressed. Sometimes, patients order lab work without a doctor’s order. When they get their results, they will have questions that they need answered, especially if the result is a H or L. So, they call me and I have to explain the results (for labs I didn’t order).
Frequently I find many patients with hormone levels that are within the normal range, but the patients are experiencing symptoms that would be indicative of low hormone levels. I find that treating them and raising their levels within the normal range can produce significant results. They are still normal on paper, but clinically markedly improved. A normal range should not dictate a treatment plan but should be used to guide treatment. In this era of “Evidence Based” medicine, the focus has shifted to treating the piece of paper rather than the patient, which I believe is not always in the interest of the individual patient sitting in front of me. I have had many men come in and tell me they are having symptoms of low testosterone and that their primary care provider told them that their testosterone levels were in the lowest part of the normal range, therefore they would not treat them even though they clinically had low testosterone symptoms.
This is the difference between optimal and normal. I practice that the object of treatment is to help the patient achieve better functioning and health, not solely to get testing numbers inside the normal range while discounting how the patient feels and functions.
Another example is thyroid problems. If you have lab tests indicating low normal levels and you have symptoms of low thyroid, then the mainstream medicine masters allow you to treat the patient for what is termed “sub-clinical hypothyroidism.” I fully agree with this allowance to practice what I feel is good medicine. However, as noted above, they do not make the same exception for patients with low normal testosterone levels and treating their symptoms.
Since every person is unique, but still a human, applying set rules to everyone will not provide benefits to everyone. Treatment, at a minimum, needs to take into consideration overall current health, age, sex, medications, activity level, mental health, and the patient’s wishes. The problem is that the normal ranges are derived from a Bell Curve in which the normal range is the 95% under the curve with 2.5% above and below the curve. Normal does not mean that everyone within the 95% is healthy. Normal is just the values assigned to 95% of a given population.
Adding to this, each lab establishes their own normal ranges for their population of patients, so the definition of normal lab values varies from lab to lab and population to population. Frequently when I review lab results for a patient from two different labs, the value on one will fall into the normal range while the same value on the range from another lab will determine it as either high or low.
A high or low value does not always mean something bad for the patient. Context is especially important. In some instances, patients feel better with values above or below the normal range. Weighing the risk of a high or low value helps to guide therapy. This is specific to the patient and not applicable to everyone.
The dictates of mainstream medicine are summarized under the title “Evidence Based Medicine (EBM).” EBM are “guidelines” for the treatment of many conditions and diseases. Deviations from the EBM will draw the ire of insurance companies, Medicare, Medicaid, and Tricare. Most professional medical groups (the medical specialty boards such as family practice, diabetes/endocrinology, National Institute of Health, etc.) have a hand in deciding what the EBM will dictate. I use the analogy of deciding who the next Pope will be and the medical community is clamoring to see the smoke and be told how to practice medicine. Most patients would think that EBM is completely based on “Science” and would be above undue influence. Unfortunately, it is based on opinions and consensus by medical academics and their interpretation of the research. This may well have been influenced by grants and the pharmaceutical industry. EBM may also be misused to establish the Standard of Care in medical malpractice cases. This is bad because this sets the expectation that if you vary from the EBM narrative, it is malpractice.
Normal is a nebulous concept. I prefer optimal as it incorporates function and performance instead of reflecting numbers on a piece of paper. Everyone is abnormal in some regard because we are all individuals and different. Optimal will be different for each person and that is the goal on earth.
Our quality of life here on earth is especially important but should not be the most important aspect of our time here. It is far more important to make sure we are optimal in God’s eyes. In my opinion, normal is established by human consensus and optimal is established by God. You may ask how you can optimize yourself for eternity. It is by accepting Christ as your Lord and Savior with all your heart and your mind, following the inspired Word of God in the Bible, working toward reaching Heaven, and using your God-given talents to help others do the same. Please learn more if you are unsure how to start your journey with God. Finding a church home is paramount to finding the support we all require for this journey. Ours is Fairview Baptist Church in Edmond, Oklahoma.
David Jayne M.D.
Edited by Ann Jayne