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Chapter 25: Checking
up the Medical check-up
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We
shall have to refrain from doing things merely because
we know how to do them.
- Sir Theodore Fox.
The Lancet, 1965 |
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Nowadays, most patients head for their doctors'
clinics (or hospitals) for check-ups more than for
any other reason. The ostensible objective is to
ward off disease. In fact, of late, the annual medical
check-up has become a ritual in many companies for
many executives. While most patients assume that
this is a standardized routine, a debate still rages
in the medical profession regarding what tests ought
to be performed, on whom, beginning when and how
often.
Often, patients seem to fall into two extreme categories:
those who get no routine medical care and those
who excess medical care including screening tests,
even though they do not really 'need' them. Periodic
tests and examinations should not become routine
or part of a standard 'one-size-fits-all' package.
In order to be really effective, they need to be
tailored according to a person's age, sex , family
history and personal risk factors. Unfortunately,
due to the widespread fallacy that the human body
is no better than a machine, we have been taught
that the body needs 'routine maintenance' which
should be performed by a doctor, much as your mechanic
tunes up your car periodically. However, medical
experts have debunked such an analogy as being a
gross oversimplification. They have emphatically
stated that screenings and early detection are not
a universal panacea to ward off all ills.
At present, many people rather effusively gush:
'Doctor, give me the works, I want a full check-up!'
Many clinics now readily pander to this demand by
providing a wide range of 'executive health check-up
schemes,' but often these 'schemes' can be more
harmful than beneficial ! In fact, routine tests,
such as electrocardiograms, chest X-rays and full
blood screening, have been found to provide little
overall benefit for the healthy individual. If such
is the truth, then one may well ask, why have these
health check-up schemes have become so popular ?
The answer is simple: they bring in the 'moolah'!
After all, much more money can be raked in by screening
droves of healthy people, rather than by only taking
care of sick patients. And then there is the additional
lucrative bonus that the screening tests will 'pick
up' abnormalities, thus converting a formerly healthy
person into a patient who needs medical attention!
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While it is true that the concept of routine testing on a regular basis sounds attractive (after all, isn't prevention much better than cure?), remember that your body is not a car! The major drawback of the tests conducted at present is that they are not very accurate. In other words, a large number of "false positives' crop up; i.e., patients whose test results are abnormal but have no illness in reality! Not only does an abnormal test result create a lot of anxiety and stress but it also leads to a merry-go-round of further tests and consultations in order to determine whether or not the original result has any significance.
In fact, the only routine tests that the US Preventive Services Task Force recommends are those for blood pressure, cholesterol, colorectal cancer, breast cancer and cervical cancer. This task force refused to recommend widespread screening against other diseases for two reasons: either the tests had been found to have no merit, or there was not enough evidence to prove their benefit (i.e., they did not help to improve either life expectancy or the quality of life). In fact, screening tests could have a major negative impact on one's health, which is why they should be undertaken with a great deal of discretion and caution!
The US Preventive Services Task Force soundly criticized
physicians for frittering away their valuable time
on screenings of questionable value instead of counseling
people about the harmful effects of smoking, lack
of exercise and other risks arising due to a faulty
lifestyle.
The only tests the task force recommended were:
- Periodic check-ups for blood pressure for all adults. (High blood pressure is a leading risk factor for coronary heart disease, stroke, renal disease and heart attack.)
- Total blood cholesterol measurement for men between the ages of 35 and 65 and women 45 to 65 (high cholesterol constitutes a risk factor for heart disease.) The frequency of testing was, however, not specified.
- Screening for colorectal cancer for individuals over 50, by testing the stools for the presence of blood, or through sigmoidoscopy. Colorectal cancer is common in USA.
- Mammogram (an X-ray to detect the early signs of breast cancer) for women between 50 and 69, every one or two years.
- The PAP smear test , to screen for cervical cancer, for sexually active women once every three years.
- Vision tests for children, before entering school, and for the elderly.
- Tests for elderly people (or those with specific complaints) to assess hearing loss.
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Another simple but helpful test comprises measuring intraocular pressure to screen for glaucoma ( which may cause blindness). The role of
- routine blood sugar testing (to screen for diabetes);
- of thyroid hormones in the blood (to screen for thyroid disease); and
- of bone densitometry in menopausal women ( to screen for osteoporosis) is still unclear.
It is worth remembering that even the experts differ in their recommendations! For example, presently, a major controversy is raging as to whether mammograms should begin at the age of 40 or 50. The rate of false positive results has been higher among younger women, possibly because the women in the 40 to 50 age group have denser breasts than those over 50. Recent studies show that young women stand a 50 per cent chance of obtaining a false positive result over 10 years of annual mammograms. Such women endure intense anxiety and sometimes disfiguring biopsies before learning that they don't have cancer after all !
Another controversy relates to the need to screen a prospective candidate for prostate cancer, either by rectal examination, or through a blood test for determining the presence of PSA (prostate-specific antigen). The PSA test measures the level of a specific protein in the blood that can indicate cancer and other prostate abnormalities. The drawback with this test, as with most screening tests, is that an elevated level of PSA is not diagnostic of prostate cancer. In fact, a number of patients who are normal will be found to have elevated PSA levels. Then, in order to prove that they are not suffering from prostate cancer, they will be subjected to a prostate biopsy, and sometimes even surgery to remove the prostate altogether. The adverse consequences of widespread screening include
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- a large number of false positive results, causing needless anxiety and concern;
- unnecessary biopsies; and
- harmful effects of aggressive treatments for slow growing cancers that may never have caused symptoms in a patient's lifetime and could have been left well alone.
As for testing for the early detection of other hidden cancers and early heart disease, the Task Force believes that physicians' time could be put to more productive use by discussing unhealthy behavior patterns with patients. After all, a doctor can do far more good for his patient by getting him to stop smoking than by subjecting him to a battery of tests or prescribing, a motley bunch of pills for him!
Therefore, the vital question is: what can you do
to get maximal benefit from a medical check-up?
Remember that you do not need to go in for a check-up
every year; individuals in their 20s and 30s, who
have no symptoms, can safely undergo a physical
once every 2 to 5 years. When you go for your periodic
check-up, take all relevant medical records: for
instance, your medical and family history; and all
the medications you are taking (or have taken).
Also, spell out clearly (to the doctor) the details
about your lifestyle. Your doctor should talk to
you and listen to you during your check-up, since
disease prevention is as important as detection.
People without any indicative symptoms do not need
a chest X-ray, electrocardiogram or complete blood
work. Since these do not provide the doctor with
any clinically useful information. Therefore, you
do not have to subject yourself to the 'delights'
of such tests just because they are offered as part
of the package! Many patients naïvely believe that
the more the tests the better, the outcome. They
are invariably enticed by expensive packages which
offer more tests and, consequently, 'better value
for money'. However, such a belief is not true!
A cost-effective check-up can be very simple, and
should include the following: a physical examination;
measuring height, weight, pulse and blood pressure;
blood tests for cholesterol; and screening for colorectal
cancer. For women, apart from the preceding tests,
the physical should include a PAP smear test and
screening for detecting breast cancer.
Modern medicine has finally realized that simple
common sense measures are much more effective than
complex and exorbitant tests and scans for maintaining
an individual's health. The trouble is that these
measures are greatly undervalued by patients due
to their simplicity! Therefore, it would be rather
futile to squander money on unnecessary tests during
your check-ups. Remember that common sense is as
important as a computerized report in preventive
medicine!
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