Abstract
The aim of this multi-author book is to provide answers to a wide range of questions that are frequently asked of laboratory specialists by primary care practioners. It is intended as a guide for doctors, nurses and those in training. Following a short introduction to laboratory medicine with some discussion about primary care workloads and benchmarking, there is a succinct chapter on reference ranges, common analytical pitfalls and measurement uncertainty. The rest of this book is divided into 13 chapters which, by covering a number of common areas of concern for primary care practioners across the pathology specialties, span a very wide range of topics. These are usefully listed alphabetically. Each chapter covers a particular area of concern such as allergy, anaemia or diarrhoea, and provides ‘best practice’ guidance on when to test, how to interpret an abnormal result and any relevant management strategies in a clear and easy to follow question and answer format. At the end of each chapter, there are helpful recommendations for further reading. A particular strength of this book is its clear guidance on what to do with a ‘slightly abnormal result’ given that this is a common conundrum facing primary care practioners who are increasingly testing otherwise well patients. Another important feature is the intention to provide accurate and ‘best available guidance’. In actuality, much of this is consensus opinion (level 4) and there are many grey areas, for example, the management of subclinical hypothyroidism, which are not explored. On the whole, however, I think that this is a useful and timely book and that its authors broadly meet their objective.
Do I have any criticisms? I always appreciate text that is explained by clear figures, either drawings, graphs or algorithms and there are not enough of these in this book for the more visual learner. Most chapters are almost completely textual. For busy general practitioners, algorithms supplemented by text may be a more useful format. Despite increasing emphasis on populations, primary care remains a person-centred scientific discipline where there is generally much more focus on, to quote Sartre, ‘coefficient of adversity’ than coefficient of variation. In other words, primary care practioners have a holistic approach to the patient and take into account psychosocial context when assessing probability of disease or making management decisions, whereas laboratory professionals generally have (and this book entirely describes) a holistic approach to the result and take into account analytical and biological factors when judging probability of disease and advising on management decisions. Thus, a case-based approach with illustrative cases highlighting some of the real-life complexities may have made this book even more relevant to those working at the coalface in primary care.
Although there are recommendations for further reading, the lack of references can be frustrating at times. For example, I was interested in finding out which specific guidance documents recommend that further investigations should be initiated in primary care when transaminase levels exceed 1.5 times the upper reference limit as stated in the book. Having the references at hand would have been useful.
I am also not sure how much added value this book provides over the ‘Better Testing’ website to which the authors have contributed given that it is in the same format, and is arguably more accessible and easier to update or correct. On this note, some guidance in this book already requires updating, for example, the indications for surgery in asymptomatic hyperparathyroidism listed in the chapter on kidney function and electrolyte disorders.
Finally, laboratory medicine professionals working as we do at the interface between primary and secondary care, need to understand the conceptual differences in problem solving between primary and secondary care professionals and it was a pity that these were not more explicitly stated. In the words of Marinker, as primary care practioners generally work in areas with low prevalence of disease, their task is to tolerate uncertainty, explore probability and marginalize danger. The task of secondary care practioners, on the other hand, is to reduce uncertainty, explore possibility and marginalize error. This book does, however, go some way towards highlighting this difference.