Testing, testing, testing
Labs and hospitals can promote or advertise without the proof from science or public health guidelines. In health economics there is a term called supplier induced demand which plays on our genuine anxieties and fears. Covid was a good case study. (HT PHOTO)
The evidence suggests that all-encompassing blanket testing when you are healthy doesn’t help. Many countries don’t promote or offer them. No scientific organisation recommends them. What’s instead recommended is selective targeted testing
Sanjay Nagral
April 24, 2023, Hindustan Times
An anxious Mr G and his family sat in front of me last week with a pile of medical records on the table. I was the third doctor they were consulting. Hale and hearty at 82, his life had suddenly turned topsy turvy. There was something ominous in his pancreas, he was told. He had undergone a CT scan, MRI, PET scan and at least 50 blood tests. One doctor had advised a biopsy, the other surgery. ‘But what are your symptoms’ ? I asked. ‘Nothing. No symptoms. I am fine.’ he said. ‘But why did u have so many tests then?’ I asked. ‘Because I had my yearly health check-up and on the sonography they noticed something in the pancreas,’ he answered. Looking accusingly at his family, he continued ‘We have a family package. They force me to do health check-ups every year.’ Mr G’s ultrasonologist was diligent at his job as he had picked up a small three centimetre fluid-filled lesion in the pancreas. In medical terms, a ‘cyst’. There are many types - some benign, some borderline and some malignant. This had triggered the barrage of testing.
Labs and hospitals can promote or advertise without the proof from science or public health guidelines. In health economics there is a term called supplier induced demand which plays on our genuine anxieties and fears. Covid was a good case study. (HT PHOTO)
Every few weeks, I see patients like Mr G who have undergone one of the plethora of health check-ups now omnipresent and have been found to have something small in one of the organs in the belly which have never troubled them. Health checks now come in various shapes and sizes - ‘Comprehensive’ , ‘Executive’, ‘Family package’, ‘Early cancer detection’ ‘Cardiac’, ‘Pre-employment’. There is even a pre marriage check-up. This is a growing industry enticing us. Seems logical. Check your body periodically to spot abnormalities early and treat them. But do they? Do routine checks help detect and prevent future health problems? If so, which is the best package? What’s the harm any way if one can afford to pay? Why not pick up problems before they strike suddenly?.
The benefits of such preventive health checks have been studied especially from a cost effectiveness public health angle. The evidence suggests that all-encompassing blanket testing when you are healthy doesn’t help. Many countries don’t promote or offer them. No scientific organisation recommends them. What’s instead recommended is selective targeted testing. Starting with physical exams. For extremely common diseases like hypertension or diabetes after a certain age. Or tests to pick up diseases running in families early, like thallasemia. Or for early detection of very common cancers in a country where simple tests are available. For example, breast or cervical cancer in women. Or prostate cancer in men above a particular age. The tests are often simple. Regular breast self-examination for example. Or a pap smear. ‘But what’s the harm if I get them done?’ you may ask. ‘I can afford it’. Of course you could. But it’s somewhat more complicated. What should you do, when, how often and how do you interpret the results.
Our bodies have lots of abnormalities, which are harmless which live and die with us. In the belly, harmless cysts in the kidney, liver and ovaries are present in large number. We do not know whether many abnormalities will necessarily progress . The key is a term called ‘natural history’. How will a large majority behave if nothing is done? Are there any predictors of complications? In my practice I often see patients with stones in the gall bladder which are not causing symptoms. Recent estimates show that they are present in around 5% of adults. The only effective treatment is surgery in the form of removal of the gall bladder. But we don’t know how they behave in the long term. Some will get pain; many will remain asymptomatic throughout life. On the other hand, surgery has its own risks. It’s a balancing act of weighing one option against another.
Recently a well-known cardiac surgeon penned a piece in a leading newspaper suggesting that all adult Indians should undergo a CT scan of the heart to diagnose silent coronary artery disease before they have symptoms. In a rare but important rebuttal two senior cardiologists from AIIMS debunked his recommendation with data. They suggested that there are much simpler tests to predict cardiac risk. And that CT scans may result in overtreatment. Why was he recommending it? Why are blanket routine check-ups promoted so heavily? It may be good intention. But it is also because there is a market for it. Labs and hospitals can promote or advertise without the proof from science or public health guidelines. In health economics there is a term called supplier induced demand which plays on our genuine anxieties and fears. Covid was a good case study. Doing a health check is easy but getting good advice on what to do is a challenge because a large section of healthcare are incentivised for doing more tests and procedures.
Mr G, his family and I had a long discussion on the pros and cons of treating the fluid lesion in his pancreas or leaving it alone. There are studies which show that such a lesion is unlikely to progress to a cancer. And that the risks of surgery in any case were high. Although there are intangibles, there are now ways to quantify them. We jointly decided that we keep it under observation and that he gets on with his normal life. This is of course easy for me to advise but a dangling sword for Mr G. I am not sure what he will finally do. But modern medicine is far from perfect. There is space for acknowledging uncertainty. Watchful waiting as a shared decision with a patient is also treatment.