In “Experimental Man,” journalist David Ewing Duncan puts every aspect of his physical makeup under the microscope with the mission to discover what medical technology can tell him — and us — about our future health. An excerpt.
Check-up with my internist
Before plunging into my tests, I visited my internist for a routine exam to establish a baseline of my health according to today's standard practices. On a bright day in June I met with Josh Adler, a fortyish general practitioner on staff at the University of California at San Francisco. He is also the medical director of its ambulatory care clinic, a building crowded with patients, white-coated physicians, nurses, and attendants pushing wheelchairs. Some patients look ill, others nervous, several healthy, and a few bored with waiting. Intravenous devices on stands, portable X-ray machines, defibrillators, and computers tucked here and there in hallways and on desks barely hint at the high-tech arsenal of cutting-edge technology available at this world-class medical center in the early twenty-first century.
Behind closed doors, deeper in the complex, are magnetic resonance imaging machines, catheterization labs, and high-resolution ultrasound scanners. But virtually all of this is reserved for the ill or those with current medical conditions. For the healthy, the procedure for getting a physical isn't markedly different from what my grandparents and perhaps their grandparents would have recognized: a small room smelling faintly of antiseptic with a blood pressure device and the stethoscope wrapped around a doctor's neck. One small difference is that Josh uses a digital thermometer to take my temperature, which is a normal 97.8 degrees Fahrenheit.
Josh's exam room is on an upper floor of a clinic built on a ridge with a dramatic view of Golden Gate Park and the Pacific Ocean. On a very clear day, the floor-to-ceiling windows give an impression of a building floating high above the treetops in the park. Far off in the distance to the north I can see the light gray cliffs of Bolinas, where a few weeks later I will go fishing with Josh Churchman.
Josh Adler says hello and leads me into the exam room. One anomaly in this physical is the extra time he gives me to chat about my project. Normally, in this age of managed care, he would have to be thorough but quick. I will be returning to him several times during the next year to show him my Experimental Man results and to get his impression as an internist on the front lines of medicine. What did he think was useful in my tests? What had he been trained to deal with, and what were the possible dangers in any of the testing or in the results?
Josh is lean, with longish unkempt hair, clothes that look slightly frumpy, and glasses with a frame the size of those old "aviators" people wore in the 1970s. He exudes empathy and intelligence, which combine with his slightly rumpled look to make me, as a patient, feel as if I have a doctor who cares far more about me than about fashion and will be there for me even late at night if I need him. Josh smiles a lot and patiently waits for me to finish talking. Unlike those physicians who seem harassed and busy, he is calm and unhurried. Josh has strong opinions about my project. Mostly, he thinks I am delving into technologies and tests that are still a work in progress and are not yet ready to be useful for healthy patients. Like many physicians, he hopes the project will be helpful as an investigation into the state of the technology, but he thinks I'll find little of value.
"I think the technology is exciting, but our ability right now to collect data far exceeds our ability to know what to do with such information. We are in a phase where we are able to collect data about human beings without any real sense of how to use this information in a way that would help a person or change his or her life. For instance, I'm trying to figure out how to guide my patients through certain genetic tests, which produce results that are sometimes hard to interpret."
"Do you have people asking you about genetic tests?"
"Not that many. I do have people asking me about genes for Alzheimer's, breast cancer, and colon cancer — I think there is some science behind these tests and a lot of media attention, so people ask about them. What people really want to know is that they're not going to get these diseases. But very few of these tests can predict that."
Take the BRCA tests for breast cancer, he says. Mutations of the BRCA1 and BRCA2 genes are carried by 5 to 10 percent of breast cancer patients. Patients with breast cancer in their families often take the tests, but having the gene does not mean a person will ever get breast cancer. Also, 90 to 95 percent of the people with the disease do not carry the gene. "Testing positive for the BRCA genes gives a person an increased risk of getting breast cancer," says Josh. "Trying to explain this to people is difficult, and to help them make choices about what to do. In many cases, if there is no physical sign yet of the disease, it is helpful because we can keep a close eye to see whether it develops."
Many other tests are next to useless, he says. "Most of them are association studies that give a person a slightly elevated risk factor for something like diabetes. But I can tell you that without a genetic test. A person's diet, age, and family history tell me more than a genetic test. What people want is a yes-no answer, and they will not get this with these tests."
Josh is wrapping a blood pressure cuff around my arm as he talks. He pumps it up with air and watches the metallic liquid in the device rise and fall.
"Your blood pressure is slightly elevated," he says. "But that's not unusual when people come to visit their doctors. On the other hand, you're reaching an age when blood pressure begins to go up in about twenty-five percent of people. We'll keep an eye on it."
"Is there any danger in taking these tests?" I ask him as he begins my ear exam.
"The genetic tests aren't dangerous," he says, "but the scanning could be. You have a small radiation risk with some of the CT scans. But the real danger involves taking the next step beyond the test. What happens with most of these tests is that we won't know what they mean, and there will be the possibility that there is something serious. You might come to me with a CT scan with a nodule on your liver. Could it be cancer? It's unlikely, but we don't know. The next step to find out for sure would be a biopsy, and that could be dangerous — there is a small chance of infection, bleeding, or accidentally making a perforation, like poking a lung. So I see my job here as protecting you from getting hurt."
"To make sure you as the physician do no harm, as Hippocrates said?"
"Exactly."
He tells me that my ears look fine and checks my eyes and throat. He asks me to lie down on my back.
"Turn your head on the side," he says. "This is a very low-tech test to see if there is pressure in your jugular vein, which would indicate a problem with your heart." He listens for a moment.
"It's particularly important to contrast the tests you're taking with the more obvious and simple aspects of health care," he continues as I sit up. "You don't need a genetic test to tell you to eat healthy — though some people may need a test to convince them to do this. Don't smoke, and be sure to exercise, get a good night's sleep, eat plenty of vegetables. These are things that really do make a difference."
"And we don't need those fancy tests to tell us this," I comment. "Which makes me wonder if after all of these tests, I'll basically learn what I already know: that I should eat right, exercise, and sleep well."
"It wouldn't surprise me," he says.
We're both quiet again as he uses his — very cold! — stethoscope to listen to my insides. "Breathe deep and hold it," he says several times, doing the "hmmm" routine that doctors must have done to the mild frustration of patients since the invention of the stethoscope. About this time, Josh is called out of the room for a moment, and I'm left alone in my boxer shorts sitting in that tiny room. It is an odd moment that leaves me feeling abruptly vulnerable. I am in my underwear in a strange little room with no windows, the supplicant to the learned man in the white coat who at this moment has an enormous amount of power over me, to inform me whether he thinks I am sick. He is the augur in this room, the expert who can with a few words about an unexpected finding change my life and my conception of myself.
My confidence in my health and in running tests for this book is dipping, and I feel a pang of apprehension — an ever-so-slight wish not to be here, to take the risk that my personal vision of myself might be challenged.
Josh returns and apologizes for having to step out. He tells me that everything looks fine — so far. "We'll get the chemistry back in a few days, but I don't expect much there, either."
I let myself exhale and then jump back into reporter mode, remarking that the exam seemed remarkably low tech. Other than the stethoscope and the blood pressure device, much of the exam could have been done by the ancient Greeks.
"Perhaps, though I'd like to think we have learned a few things since then. It's more along the lines of an exam that developed in the past two or three hundred years, with much knowledge added since then, though the critical part of the exam is still the patient history — the conversation about how you feel, your family's history of illness, and so forth. This leads to about seventy-five percent of the diagnoses we make. The rest of it, including blood tests and the rest, is a lesser part of it."
"Do you think that will change with all of this new technology and knowledge?"
"It already has changed in certain arenas, in diagnosing things like prostate cancer or presymptomatic diabetes with various blood tests. Although in the history we try to identify who is at risk."
Josh had already taken most of my medical history and had come up with an unremarkable story that says I'm basically healthy. The only significant ailment I have had is a disk in my back that was herniated twelve years ago. They didn't operate, I tell Josh, but it took me six months to recover with physical therapy, and the back still bothers me now and then.
"So, Doc, what is my prognosis?" I ask when he is finished.
"Based on your physical and your family history, you are not at risk for any major disease that I can identify," he says. "Everything was normal in your exam, except your blood pressure — which we will watch, though I'm not overly concerned. Otherwise, the prognosis for you living a long and healthy life is quite good."
Josh orders a typical regimen of tests: white blood cell count, hematocrit count, and blood sugar. He suggests an EKG for my heart, which uses electrodes attached to my chest to check the electrical action of my beating heart, just to be sure the blood pressure isn't indicating something more serious than he thinks.
"At this point, you could order many more tests if you wanted to, right?" I ask. "Setting aside cost for a moment, why wouldn't you test me for anything that's not dangerous?"
"As I said, the only important clues in this exam would be from the family history," he says. "There also is no evidence that you are functionally declining. Beyond this, there is no way to know your risk, except as an average risk. I don't see a need to subject you to endless batteries of tests for no reason. It is costly, and we need to reserve them for people who really need them."
A few days later I get back my lab results, and everything is normal except my cholesterol. It's 209 — slightly over the threshold of normal, which is 200 or less. Josh says not to worry. "We'll watch it," he says. "Cut back on meat and fatty foods."
"So I'm still healthy?" I ask, feeling that vulnerability creeping in again.
"You are not going to die today."
Fundamentally, I trust Josh Adler that I'm fine — a prognosis that fits in nicely with my core belief that I'm healthy. But I'm about to find out much more about myself than Josh can tell me — information that may give me some useful advance warning about Sontag's nighttime side of life but might also frighten or confuse me. For some people, knowing vast quantities of information, much of it incomplete and a work in progress, about risk factors and possible outcomes could plunge them into a kind of twilight between the kingdoms of the sick and the well.
The plan of my investigation and of this book is divided into four parts — genes, environment, brain, and body, with a short epilogue called "eternity" that will have a surprise result for me concerning my longevity and will assess technologies that may radically increase life span. Each of these sections will contain personal stories that could be your stories, too — my life's experience as a human organism and how the secrets inside my genes, cells, and organs have influenced my own and my family's lives. I'll weave in as much science as I think the reader can bear, while also pondering the usefulness and meaning of my results, the science, and what they might mean for society.
Excerpted from “Experimental Man” by David Ewing Duncan. Copyright (c) 2009, reprinted with permission from John Wiley & Sons.