Saturday, November 25, 2006

Standardized testing - Reflections on the mundane

This week, I spent Monday through Thursday seeing patients and reviewing labs.

The “reviewing labs” aspect of my job occupies on average 5-6 hours per week. Initially, these hours of flipping through page after page of number-riddled lab forms and typing the labs into the computer seemed numbingly mundane compared to spending time with the patients themselves.

More recently, I have upgraded the experience from numbingly mundane to somewhat tolerable.

Here is why.

Physicians look over lab numbers in the same way that a mathematics teacher grades papers. However, the grades they assign, rather than reflecting a pupil’s intellectual progress, reflect the complex arithmetic of a struggling human body.

For example:

Question #1: Hgb = 8.2 X

If the body lacks micronutrients, the body is unable to add iron to red blood cells, and as a result they become smaller and fewer. A hemoglobin score below 12 is incorrect, but depending on my mood I sometimes give partial credit, especially if the average size of the RBCs is reasonable (suggesting decent iron stores). If the body reports a hemoglobin less than 10, I mark it wrong. If the value is half that, I call the patient to make sure they are still alive, and ask them to come in for evaluation and treatment of severe anemia.

Question #2 : AST = 290 X

If the body is receiving medicine that is metabolized by the liver, and the liver multiplies its serum transaminases by two or more as a result of the addition of that medicine, I mark it wrong. If the liver does not adjust and subtract those transaminases from the blood when I repeat the test, then the medication at fault must be substituted or discontinued.

Question #3: CD4 count = 290

Every math teacher has a favorite question that always ends up on the test. It is my theory that teachers ask such questions for two primary reasons: (1) To make the student feel good and to bring out his or her best. (2) To make the teacher feel justified in his efforts to educate a room of distracted young people; that is to say, to remind himself that he is indeed an effective teacher.

The CD4 count is my favorite question to ask. It is also my favorite to grade, for the grades almost always keep getting better and better.

HIV infection compromises nearly every normal calculation of the human organism. When the virus is suppressed, the body tutors the immune system, and the body thrives. When unfettered with disease, the body is simply brilliant.

I like CD4 counts because they allow the recovering organism to show off a bit. CD4s also allow me to remind myself that, though challenging at times, what I am doing here works.


This past Wednesday, there was a stack of CD4 lab results back from the public laboratory, where all of our bloods are processed. The top form was that for patient #3104. I entered the number into our electronic medical record system and learned that #3104’s name is Busi Dlamini.

Busi is a 9 year old who was started on ARVs shortly after the clinic opened in April, 2006. Her CD4 count was very low at that time, a mere 54.

According to her medical chart, her CD4 count was 134 three months later (July, 2006), and when drawn this week it was 320, demonstrating a nice, steady rise. The medicines were working. Because of this single number, Busi was very likely going to live for many, many years.

I signed my name below the value, documenting that I had reviewed it and entered it into the computer.


There are those that want their name in lights.

Then, there are the teachers, who deserve their names in lights, for their vocation determines our children’s future.

Then there is me. I do not have the patience to be a effective teacher. I do not want my name in lights. I am content to have my name next to Busi’s CD4 count of “320”.


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