PUSH Post The “Master” health check-up

Too much of a good thing
22 March 2009 H-Health check ups

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fter relentless nagging by your spouse, you have finally When a little is good, a lot is not better gone through a “Master Health Periodic health check ups are Check-up” and are greatly recommended with the belief that early relieved to learn that you came diagnosis and treatment can favourably through unblemished. An alter the outcome from many of the impressive array of medical diseases of ageing and degeneration that hardware was deployed. You are are common today. Despite enthusiastic reassured by the knowledge that advertising, there is evidence that the number of science and technology, in the tests needed is small, simple and inexpensive. space of less than a century, has given us the means to look at ourselves in minute detail: to the level even of the code that determines why we are the way we are. No other living organism has the ability to understand its own inner workings.

Rationale of the “Master” health check up
Diseases of ageing and degeneration (non-communicable diseases) have replaced infections as common causes of illness and death in modern societies. These diseases have a long quiescent stage when there are no symptoms. Left untreated, over the years, they will progress to complications that can be difficult to treat. If a test can detect these diseases in their presymptomatic stage, then prompt institution of measures might decrease the costs and morbidity associated. So far so good. The scheme, however, fails in its execution for several reasons: too many tests, ordered too often, for unproven reasons, driven by non-medical incentives. There is clear evidence that the package needs to consist only of a handful of simple, cheap interventions. Adding more is unscientific and wasteful.

Essential components of a routine health check up
Although common wisdom might suggest that the more tests obtained, the greater is the likelihood of picking up disorders in their early stage, the evidence clearly runs counter intuitive. A routine health check up needs to include only a limited number of simple, inexpensive interventions. The chart alongside lists them. Loading the list with more costs money but yields no benefit.

Recommended panel of tests
7 Head-to-toe physical examination 7 Body weight, body mass index (BMI), waist and hip circumference measurement 7 Blood pressure 7 For women: Breast examination & Pap smear 7 Blood sugar – fasting and 2-hour postprandial 7 Lipid profile (cholesterol panel) To date, there is no evidence that additional tests are of benefit

The Master health check-up: too much of a good thing?
© Dr Arjun Rajagopalan

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PUSH Post Recommended schedule of testing
7 35 – 60 years – every 5 years (If the check up is normal). 7 After 60 – every 2 years (If the check up is normal). Follow your doctor's advice if any abnormality is detected on the check-up

See a doctor promptly for the following: Red flags: see a doctor promptly for these events
7 A fever persisting beyond 10-15 days. 7 Unexplained weight loss. 7 Sudden appearance of a lump. 7 Change in the nature of a stable lump or mole. 7 Bleeding from any body cavity – sputum, urine, motion, vaginal. At any time, there are some warning signs that should never be ignored. Even though many of these situations are due to simple problems that can be easily resolved, postponing seeking medical help could be dangerous. All of these are warning signs that should not be ignored even if a recent health check up was normal.

Tests of doubtful value
It is common to see a large number of additional tests added to the panel under the mistaken belief that more is better. They are of no proven value and will only increase the cost to the patient. Say “NO” to TEST Resting ECG (Rs 125) WHY?
False negatives: The ECG can be normal in the presence of significant coronary artery disease – 25-30% of patients with heart attacks have had previous normal ECGs. False positives: A positive test can occur in the absence of disease. Stress ECG (treadmill testing) should never be a part of a routine health check up. It should be ordered, preferably by a specialist, only after a careful history suggests the presence of coronary disease. Limited value in non-smokers and those without lung problems like asthma or bronchitis. Can be normal in the presence of liver disease. Very poor correlation with lung status. Will pick up “abnormalities” of no significance. Ultrasound scans are not sensitive enough for early diagnosis of many disorders of the abdomen.

Stress ECG (Rs 750)

X-ray chest (Rs 175) Liver function tests (Rs 300) Lung function tests (Rs 500) Abdominal ultrasound (Rs 500)

A firm, polite refusal will save Rs 2,500 with no danger to the person

The Master health check-up: too much of a good thing?
© Dr Arjun Rajagopalan

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PUSH Post Appropriateness of usage – the crux of the problem
A bewildering array of medical tests are available today; the range is so large that doctors themselves are inadequately informed about the capabilities and limitations of many. A “shotgun” approach is used to compensate for lack of precision in knowledge. Inappropriateness of medical testing arises from: ● ● ● ● Too many tests, Ordered too often, For unproven reasons, Abetted by unethical motives.

Too many tests: Doctors tend to think of tests in panels: several investigations clustered under a common label. Complete blood counts, liver function tests, kidney profiles and lipid panels are some common examples of this panel approach to testing. This shorthand saves time but is wasteful. Quite often, the whole panel is ordered when only a small subset is necessary. It requires time and thought to pick only those tests that would contribute information to the patient's management. Under the guise of being thorough and not missing important findings, doctors commonly order more tests than are needed. The practice of defensive medicine – all too common in this age of frequent medical litigation – heightens the tendency to over investigate. Ordered too often: When a test is abnormal, the doctor prescribes a treatment, and periodically orders the same test to monitor the degree of response. This is good medical practice. The problem arises when tests are ordered more often than they need to be. Unproven reasons: Medical textbooks will state explicitly the “indications” for ordering a test. Where the value of a test is in doubt, they will say so, and either recommend against or issue caveats regarding its use. Doctors commonly order tests, with scant regard for guidelines, using various excuses: pursuing a hunch, relying on personal (but unverified) experience, conceding to the demands of patients, and worst of all, following the recommendations of sales representatives. Unethical motives: The provision of incentives to doctors to order tests – monetary, physical and otherwise – is reprehensible and deserves to be condemned in the strongest language. Yet, it is all too common. Commissions and kick backs are rampant. The patient suffers because it is his money that is being taken to provide the incentive to the doctor for no service at all; worse still, when it is to bear an expense that may not be medically necessary, The patient has no protection against being made a victim of these practices. He has to trust his doctor implicitly and follow recommendations with the hope that the doctor will always do the best for his patient. It is in this respect – the fiduciary responsibility that the doctor takes on behalf of the patient – that thoughtless and unethical ordering of investigations constitutes an unpardonable medical offence; and is so difficult to control and correct.

TRY THIS ONE OUT FOR YOURSELF – INDIA SHINING
Perform a Google search on “master health check”. Repeat using “master health check + India”. Make your own conclusions.

The Master health check-up: too much of a good thing?
© Dr Arjun Rajagopalan

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