VIDEO: Do More Screening Tests Lead to Better Health? @docmikeevans

Many of you will be familiar with the hilarious and helpful work of Dr Mike Evans and his team. Their white board videos are a great blend of up-to-date evidence, patient perspective, and useful advice.

In Do More Screening Tests Lead to Better Health? you'll find more than just the answer to that question ("No.").

With a focus on healthy, well-feeling, average risk individuals, the video emphasizes that the harms of doing a test (and the sequelae of that test) may be greater than the benefit. This is a tough bit of information to accept particularly if you've already had lots of 'preventative tests' done and have felt reassured by them. However, it's really time to re-evalute their usefulness.

It's not that we should do nothing to prevent disease; instead of wasting a person's time and resources on unnecessary tests, the time can be better spent devoted to support around lifestyle choices that we know will lead to better health. Take a look:

Social Determinants of Health (#SDOH); the bigger solution

When thinking about the health of a population, it seems that many acknowledge the role of public health and preventative medicine. We talk often about the context of the patient, their "Social Determinants of Health."

On a 1:1 clinical encounter, I often feel like I'm hardly doing anything useful. I'm just treating some numbers, doing something to the patient, not really doing anything for the patient.

It Seems I'm  'spit-polishing' the giant dent in the car, when I help an obese, diabetic patient adjust their dose of insulin.

You could take it in for repairs... but maybe better to have prevented this? (Image from Bob Ottenhoff)

It's not clear how much of a difference this test-ordering, medication optimizing, target-setting, or patient educating makes. It feels like we are "helping" but at the same time, it feels often that we are just occupying time and resources when we could be investing these in a more effective way.

Dr. Leana Wen, writing Help patients by addressing the health of the community for KevinMD, puts it well:

We need comprehensive strategies that promote health and target problems “upstream.” We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. An MRI here, a prescription there — these are Band-Aids, not lasting solutions. Our communities need innovative approaches to pressing issues like homelessness, drug addiction, obesity, and lack of mental health services.

The Canadian Centre for Policy Alternatives "gets it." Their paper, Sustainable health care begins with the social determinants of health: It’s time to get it right concisely summarizes the data and emphasizes that solutions that decrease spending on the medical aspects of health (eg. private healthcare) will only worsen economic disparity, worsening health.

How do we convince governments, who must work within the bounds of election cycles, that a long-term plan that addresses patients bigger needs is the wisest choice?

The Preventative Visit and Choosing Wisely

The preventive health visit is not synonymous with an 'annual physical'

I always felt lost when asked to do a general exam on a healthy person. Every physician performed it differently. Do we check for breast masses? Feel the thyroid? Look at the tongue and mouth for squamous cell carcinomas? Check the belly for a pulsatile mass? Listen for a murmur? Heck it would take hours to go over every mole and mucosa, to palpate every bump and move each joint. So what were we doing?

The American Choosing Wisely campaign, in the list of Society of General Internal Medicine suggestions, recommended in 2013 that physicians stop “performing routine general health checks for asymptomatic adults." (see some backing data)

Many were outraged by this, and a similar decision in Ontario by the provincial government to de-list the annual physical exam, such that physicians would no longer be paid to provide this service to patients who don't require it. The concern was mainly that very important preventative health and screening measures would no longer be undertaken.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

But, a preventative health visit is not the same thing as an annual physical. For example, we've got decent evidence that pap tests are important screening tools for cervical cancer, and have changed our guidelines to use them less frequently. And we are not suggesting dispensing with this. However, recent studies have shown that the pelvic exam (feeling the uterus and ovaries, essentially) really is not essential and many organizations are beginning to recommend against this practice. We had been doing pelvic exams out of "tradition" for the longest time - how much else is driven by tradition?

I come back time and time again to the Milstein paper from Health Affairs, Why Behavioral And Environmental Interventions Are Needed To Improve Health At Lower Cost. We know that prevention is key, but we don't know how, when, or where to deliver it. Dispensing lifestyle advice in the office probably doesn't work (eg. GP advice is ineffective in improving metabolic outcomes in high risk patients). Clearly we need something different to achieve a persuasive, meaningful impact.

A colleague recently sent me an article, from the American Journal of Preventative Medicine (access required - ePub ahead of print, Jul 2014),  which addresses concerns with the way our push for efficiency and appropriateness may be drawing attention away from the real issue of prevention. Wong, Gaster, and Dugdale write:

. . . the Choosing Wisely Campaign sends the wrong message at a time when prevention remains more important than ever, and as the data supporting it grow more complex and more nuanced. The preventive health visit has and will continue to evolve . . . The preventive health visit currently remains an effective tool for increasing adherence to evidence-based service guidelines. This is no time for us to abandon it.

I would personally need to learn a lot more about what "effective" is meant to construe in the above sentences before agreeing wholeheartedly. I don't disagree that we need to spend a lot more effort looking at prevention, but I don't think Choosing Wisely contravenes that effort. 

What do you think?

Providing Contraception Lowers Birth Rates in Colorado

It isn't hard to see how investing in the right care can go a long way.

How unsurprising is it to read that giving people free contraception leads to lower birth rates? I don't want to bore you but population studies like these help governments realize that intervening in health 'upstream' has cascading effects, and they are often positive.

Good health, better choices, lower costs, and less social fallout are the result of the Colorado Family Planning Initiative. They supplied intrauterine devices (IUDs) at no cost to low-income women.

Doing so decreased abortion rates, the rate of pregnancy in high-risk populations, and demand for social support programs. It also saved millions of dollars.

Speaking practically rather than politically, I cannot see the benefits of this program being outweighed by the drawbacks. The loudest objections are to things like 'the violation of parental rights' when teenagers receive contraceptive treatment without parental consent. It is my personal belief that if a person is old enough to choose to have sex, he or she is old enough to choose to inquire about and select a means of birth control.

Although pregnancy is not a "disease," it may be seen by some patients or clinicians, at some times, as undesirable or unsafe. This common-sense project demonstrates that there may be some merit in the idiom "an ounce of prevention is worth a pound of cure."

Read more here.