Due Diligence in Community Health Screening

In our “more is better” culture it is hard for people to understand that more tests do not equal better health. Physicians feel it necessary to order tests for multiple reasons; defensive medicine, patient requests, belief that it will find early, more treatable disease. Good examples of the latter is the controversy over the PSA test and yearly mammograms. In our community it is common for people of all ages to get “Life Line Screening“(the most well-known) or screenings done by other companies. It is offered at health fairs, as a perk for employees and their spouses, and at many churches. In my experience, most of the individuals undergoing these tests have almost no risk factors for the tests being run and many are too young for them.

Recently a middle-aged patient of mine came in with the results of her community screening in hand, done by a company called Stroke Prevention Plus. The first thing that I noticed was extremely high systolic blood pressure readings done by a technician looking for peripheral artery disease. This patient is a normal-sized woman who works out regularly. She’s never had a systolic blood pressure over 120 in my office much less 160. On the day I saw her it was up a little–125.

The oddest thing about the results was a black and white “photo” stuck with a piece of scotch tape in the middle of the page. It was from an ultrasound. In the middle of the photo was an arrow pointing to the edge of a black shadow and in the upper left-hand corner were the letters “L thyroid”. There was no identification on the photo whatsoever. Among the sheets that were mailed to her was a non-specific “Jane Doe” letter about “incidental findings” that could occur with the testing she had undergone. Nothing was addressed specifically to her. 

My interpretation, looking at the little photo and the arrow, is that the radiologist noticed a cyst on her left thyroid while interpreting the carotid ultrasound. I am speechless that she would be notified of a possible abnormality in such an impersonal and unprofessional manner. What if it is a cancer and she ignored it or wasn’t smart enough to understand the significance of that photo? What if she thought everyone got a photo like that attached to their result sheets?

Does the company, Stroke Prevention Plus, think that they did their “due diligence” and are absolved from further followup of these abnormalities by this notification? Since they’ve performed over seven million health screenings, and no doubt monetarily flourished in the process, do they feel it unnecessary to inform a patient in a CLEAR manner what they “incidentally” found? Do they feel that they have done the patient a favor because they could have ignored the results? What an odd decision on the company’s part! I’m thankful this patient is well-educated and understood that she should talk to me. I worry about other people who are not so capable.

 This post was modified 6-12-2012 to reflect the fact that this patient was screened by another company whose forms directly resemble Life Line’s. Life Line has better protocols in place for followup. This does not negate the fact that there is no scientific support for screening such as Life Line in the general population, aging or otherwise, quite the opposite. http://www.minnpost.com/second-opinion/2012/03/buyer-beware-direct-consumer-health-screeningshttp://www.sciencebasedmedicine.org/index.php/ultrasound-screening-misleading-the-public/http://www.kevinmd.com/blog/2011/06/examining-evidence-community-health-screening.html.

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Doctor, I need…

It’s not that I dislike patients researching their symptoms or their concerns on-line. Actually, the patient with the “petit papier” of  questions is my favorite kind of patient. They are usually well-informed and have questions I enjoy answering. Often it is educational for me because I have to do a little research to be sure my response is accurate. The far end of this pendulum swing is the individual demanding unnecessary tests or drugs. I’ll address the medication problem in another blog, today I want to concentrate on tests.

Yesterday I began to write this entry and low and behold the New York Times has an opinion piece by H. Gilbert Welch on this topic appearing in today’s issue. I strongly believe prevention is important and put myself forward as a physician interested in keeping my patients well. But prevention is different from finding problems early. Prevention has to do with avoiding lifestyle behaviors that promote illness–bad choices with sexual relations, drinking to excess, smoking, an unbalanced diet, no exercise, etc. Prevention is NOT obtaining every laboratory test known to medicine, getting a “total body scan” or having surgery to remove a body part that is low risk for cancer.

Recently one of my patients, a 32-year-old,  asked for a vaginal ultrasound because she “wants to know her body better down there”. What? She suggested that I use the “NPC Guidelines” for ordering the exam. The what? When I Googled that organization the closest I could come up with was the National Phlebotomy Certification. When she was told that insurance would not pay for an ultrasound without symptoms (and that I did not recommend such a thing) she decided that she had some discomfort “down there”. I am caught between not wanting to deny a patient a test only to find out later she had something horrible that keeps me talking to attorneys and being annoyed that the insurance company will be paying for an unnecessary test. If she was willing to pay cash for it I would happily order it. But no, no one wants to do that. Our society somehow doesn’t put value on piece of mind, unless someone else is paying for it.

The worst-case scenario is the patient who insists on getting a CA125 blood test. You know, the “ovarian cancer test” that makes the email rounds once or twice a year. I’ve drawn this test on numerous individuals at their request, one time it was elevated. In this particular case she received multiple vaginal ultrasounds over two years, multiple pelvic exams, got an opinion from a gynecologist and an oncologist and ultimately when she stopped smoking for one month (she subsequently resumed cigarettes) the CA125 dropped into the normal range. WAIT–she smokes? Her number one cancer risk is what–maybe LUNG CANCER??? Would it not make more sense to STOP SMOKING????? By the way, the CA125 blood test’s purpose is to watch for recurrence of ovarian cancer in individuals who already have the disease but are in remission. It is not a screening test. It’s not meant to be a screening test. When you try to make a test into something it is not, people end up with unnecessary tests, sometimes very uncomfortable tests and lots and lots and lots of worrying.

Lifestyle changes — YES. Shotgun approach to finding early disease — NO!

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