David E Bratt MD

Of late, we seem to be mov­ing rapid­ly to­wards a test cul­ture in med­i­cine. Maybe it's the in­flu­ence of the now large com­mu­ni­ty of for­eign­ers in town. They and their doc­tors seem to be­lieve in tests and are quite dis­ap­point­ed at my lack of in­ter­est when they come to me with the re­sults, which, when ab­nor­mal, are usu­al­ly quite mi­nor but of­ten mean an­oth­er bar­rage of more in­va­sive, dan­ger­ous, painful, ex­pen­sive and quite un­nec­es­sary tests.

Hypochon­dri­acs all, but hypochon­dri­a­sis is con­ta­gious where mon­ey is plen­ti­ful and get­ting rou­tine check-ups makes in­tu­itive sense-rou­tine check­ups can pick up ear­ly signs of dis­ease and get you on treat­ment that could save your life. Or can they?

Well, they can't. The lat­est re­view shows that such vig­i­lance does not re­duce the risk of dy­ing from se­ri­ous ill­ness like can­cer and heart dis­ease, far less mi­nor ill­ness­es, and may cause un­nec­es­sary harm.

Dan­ish re­searchers have just con­clud­ed a re­view of 14 long-term tri­als (with a me­di­an fol­low up of nine years) in­volv­ing 182,880 peo­ple, half of whom were of­fered gen­er­al health checks and half not. Nine of the tri­als found no dif­fer­ences in the num­ber of deaths be­tween the groups dur­ing the study pe­ri­od, in­clud­ing deaths from heart dis­ease or can­cer, two con­di­tions that are most com­mon­ly as­sessed dur­ing check-ups.

Over­all, the analy­sis failed to find any dif­fer­ences in hos­pi­tal ad­mis­sions, dis­abil­i­ty, wor­ry, spe­cial­ist re­fer­rals, ad­di­tion­al vis­its to doc­tors or time off work. One tri­al did find a 20 per cent in­crease in di­ag­noses among those get­ting more fre­quent health checks, and oth­ers record­ed an in­crease in the num­ber of par­tic­i­pants us­ing drugs for hy­per­ten­sion, but these did not trans­late in­to bet­ter health out­comes.

Pre­ven­tive screen­ing re­mains con­tro­ver­sial-and con­fus­ing-for health­care con­sumers. The in­tu­itive pow­er of screen­ing for dis­ease to pre­vent it is hard to counter, but the lat­est ev­i­dence, from oth­er groups such as the Unit­ed States Pre­ven­tive Ser­vices Task Force (USP­STF) shows that the da­ta don't al­ways sup­port the idea that screen­ing leads to bet­ter health.

When fac­tor­ing things such as the cost of screen­ing and fol­low-up tests to con­firm false pos­i­tive or false neg­a­tive re­sults, the reg­u­lar check­ups aren't al­ways ben­e­fi­cial. A false pos­i­tive test is one that says some­thing is wrong when there is noth­ing wrong with you. A false neg­a­tive is one that says you are not sick when in­deed you are.

That's the case with breast or prostate can­cer, in which stud­ies show that mam­mo­grams or prostate spe­cif­ic anti­gen (PSA) test­ing can lead to over-treat­ment of tu­mours that are un­like­ly to cause se­ri­ous dis­ease dur­ing peo­ple's life­times, but cause un­nec­es­sary phys­i­cal and emo­tion­al strain in­stead.

The USP­STF now rec­om­mends that women wait un­til age 50 (not 40) to get year­ly mam­mo­grams, and that most men not get the PSA test at all. Things have got so bad that a com­pendi­um of 45 clin­i­cal don't-do-these-tests has been as­sem­bled by nine med­ical so­ci­eties for the sake of elim­i­nat­ing com­mon­ly or­dered but of­ten un­nec­es­sary tests and pro­ce­dures.

Such ser­vices, which are not root­ed in ev­i­dence-based med­i­cine, con­tribute to the high cost of health­care and some­times harm a pa­tient's health, as in ex­ces­sive ra­di­a­tion ex­po­sure in the course of di­ag­nos­tic imag­ing or com­pli­ca­tions of a surgery af­ter a false pos­i­tive test re­sult.

The lists of ques­tion­able ser­vices (five for each spe­cial­ty) are part of a cam­paign or­gan­ised by the pres­ti­gious Amer­i­can Board of In­ter­nal Med­i­cine (ABIM) Foun­da­tion called Choos­ing Wise­ly and is backed by nine pro­fes­sion­al Amer­i­can so­ci­eties: the Amer­i­can Acad­e­my of Al­ler­gy, Asth­ma & Im­munol­o­gy, the Amer­i­can Acad­e­my of Fam­i­ly Physi­cians, the Amer­i­can Col­lege of Car­di­ol­o­gy, the Amer­i­can Col­lege of Physi­cians, the Amer­i­can

Col­lege of Ra­di­ol­o­gy, the Amer­i­can Gas­troen­tero­log­i­cal As­so­ci­a­tion, the Amer­i­can So­ci­ety of Clin­i­cal On­col­o­gy, the Amer­i­can So­ci­ety of Nephrol­o­gy and the Amer­i­can So­ci­ety of Nu­clear Car­di­ol­o­gy, all clear­ly no-non­sense pro­fes­sion­al med­ical or­gan­i­sa­tions.

That leaves doc­tors and pa­tients with the dif­fi­cult chal­lenge of fig­ur­ing out how much test­ing is enough. The re­searchers are not ad­vis­ing doc­tors to dis­con­tin­ue screen­ing and treat­ment if they be­lieve a per­son has a health prob­lem, but they sug­gest pub­lic health­care ini­tia­tives that sys­tem­at­i­cal­ly of­fer gen­er­al health checks to the pub­lic do not make sense.

That means that physi­cians may need to spend more time with their pa­tients to bet­ter de­ter­mine their in­di­vid­ual risk for cer­tain dis­eases, some­thing that may re­quire a big­ger in­vest­ment of re­sources ini­tial­ly, but may pay off in health­care sav­ings down the road. Spend­ing more time with their pa­tients! Now, there's a rad­i­cal idea worth in­ves­ti­gat­ing.