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.