Paul Levy: Listening In On the Doctors
Monday, June 11, 2012
Here’s an example. Bear with me, as it is a little technical, but you will get the gist. On a physician discussion page, one doctor related a story of a friend who described what happened following her yearly check-up:
She was symptom-free, but urinalysis revealed microscopic hematuria, leading to more tests and eventually to a nephrectomy for a small carcinoma.
Wikipedia – my source for all that matters! – tells us that hematuria is the presence of red blood cells in the urine. “It may be idiopathic (i.e., of unknown cause) and/or benign, or it can be a sign that there is a kidney stone or a tumor in the urinary tract (kidneys, ureters, urinary bladder, prostate, and urethra), ranging from trivial to lethal.”
The doctor asks his or her colleagues:
Yearly check-ups for asymptomatic patients have not proven to be necessary, but what about for this patient? Presumably without an early diagnosis the tumor would have eventually caused visible hematuria and the diagnosis would have been made a few months (years?) later. Would it have made a big difference in survival? And how often is microscopic hematuria a clue to an underlying tumor? Was she just lucky?
The anecdotes start flowing:
Over the last 5 years I've found nearly 20 malignant bladder and kidney tumors in this same way.
I did a CBC on a totally asymptomatic 75 year old male, just as a baseline for the future. It was lower than I expected. It was a bit lower the next month, leading to a GI evaluation which uncovered a right colon malignancy that subjected him to surgery. He eventually died 13 years later from cardiovascular disease unrelated to malignancy. I often reflected on how an $8 test prolonged his life.
There is little evidence that a widespread recommendation for a yearly visit will significantly contribute to any one individual's health and wellbeing. What the real reason for a yearly visit, IMHO, is to create and maintain a relationship with a physician who KNOWS you.
There are some tests that cause more problems with false positives and lead to extensive further testing and unnecessary procedures.
I don't know. How many does it take before a saved life is important enough to risk additional testing?
There may be more than a few deaths from additional testing for the false positives. There may be not even that as they are never publicized.
It does not make sense for healthy people to see a physician yearly; screening & education can be done by nurses, aides, community health workers. Even in this patient's case, a screening with a nurse would still have found the hematuria, which could then be followed up on by a doctor.
The most compelling reason for annual check-ups is to have a patient subjected to the complete attention of an attentive physician.
Here’s the one I found to be most thoughtful:
When you consider that any type of "routine" screening may have led to an earlier diagnosis, you must also consider whether the earlier detection made a difference in the outcome. In some conditions it clearly does, but in others - not so much. Additionally, you must also consider the potential harm of screening, in that a number of patients will be false positives, and receive unnecessary and perhaps risky or painful further evaluation. We all have patients whose condition has been picked up on a screening examination and perhaps improved their outcome, but you must consider the value in an evidentiary, not emotional, context. Remember - the plural of "anecdote" is NOT "evidence."
A doctor friend had a similar reaction: “I find these discussions among doctors to be fascinating as they react pretty much like a lay person - anecdote, anecdote, anecdote. Notice only a few concentrate on the complications of working up a false positive.”
A friend who has been through extensive medical treatment made the case even stronger: “I have to say that one of my top learnings, after 3+ years in this game, is that for the most part doctors aren't taught a thing about thinking scientifically. And their peer culture doesn't enforce it. There is no shame or shock at all when a doctor says something that's scientifically absurd.”
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