Due Diligence in Community Health Screening

In our "more is better" culture it is hard for people to understand that more tests do not equal better health. Physicians feel it necessary to order tests for multiple reasons; defensive medicine, patient requests, belief that it will find early, more treatable disease. Good examples of the latter is the controversy over the PSA test and yearly mammograms. In our community it is common for people of all ages to get "Life Line Screening"(the most well-known) or screenings done by other companies. It is offered at health fairs, as a perk for employees and their spouses, and at many churches. In my experience, most of the individuals undergoing these tests have almost no risk factors for the tests being run and many are too young for them.

Recently a middle-aged patient of mine came in with the results of her community screening in hand, done by a company called Stroke Prevention Plus. The first thing that I noticed was extremely high systolic blood pressure readings done by a technician looking for peripheral artery disease. This patient is a normal-sized woman who works out regularly. She's never had a systolic blood pressure over 120 in my office much less 160. On the day I saw her it was up a little--125.

The oddest thing about the results was a black and white "photo" stuck with a piece of scotch tape in the middle of the page. It was from an ultrasound. In the middle of the photo was an arrow pointing to the edge of a black shadow and in the upper left-hand corner were the letters "L thyroid". There was no identification on the photo whatsoever. Among the sheets that were mailed to her was a non-specific "Jane Doe" letter about "incidental findings" that could occur with the testing she had undergone. Nothing was addressed specifically to her. 

My interpretation, looking at the little photo and the arrow, is that the radiologist noticed a cyst on her left thyroid while interpreting the carotid ultrasound. I am speechless that she would be notified of a possible abnormality in such an impersonal and unprofessional manner. What if it is a cancer and she ignored it or wasn't smart enough to understand the significance of that photo? What if she thought everyone got a photo like that attached to their result sheets?

Does the company, Stroke Prevention Plus, think that they did their "due diligence" and are absolved from further followup of these abnormalities by this notification? Since they've performed over seven million health screenings, and no doubt monetarily flourished in the process, do they feel it unnecessary to inform a patient in a CLEAR manner what they "incidentally" found? Do they feel that they have done the patient a favor because they could have ignored the results? What an odd decision on the company's part! I'm thankful this patient is well-educated and understood that she should talk to me. I worry about other people who are not so capable.

 This post was modified 6-12-2012 to reflect the fact that this patient was screened by another company whose forms directly resemble Life Line's. Life Line has better protocols in place for followup. This does not negate the fact that there is no scientific support for screening such as Life Line in the general population, aging or otherwise, quite the opposite. http://www.minnpost.com/second-opinion/2012/03/buyer-beware-direct-consumer-health-screenings, http://www.sciencebasedmedicine.org/index.php/ultrasound-screening-misleading-the-public/, http://www.kevinmd.com/blog/2011/06/examining-evidence-community-health-screening.html.

The Magic Pill

When patients come in to one of my two exam rooms to wait for me, they see written on the white board THE MAGIC PILL "Walking five times weekly, 30 minutes (minimum)" Originally I had written the exercise recommendation for a specific patient but did not erase it. It generated so many conversations from patients coming in for other reasons that afternoon that now it resides permanently on the board (except when a helpful cleaning person erases it).

What has been surprising to me is that most patients WANT to talk about it. They frequently reference that they are walking, they want to walk or they hope to walk. It has been a great conversation generator. In addition to that it has given me the opportunity to talk about studies that illustrate how good walking is, or more generally, how important exercise is to well-being and longer living.

There are numerous studies linking improvement in depression with physical activity and a list of several of them can be found here. Thanks to direct-to-consumer ads, especially on TV, patients often have a magical idea of how anti-depressants work. When we talk about the number of side effects associated with these drugs, especially weight gain, medications become much less appealing.

Another important discussion often begins with how many patients have been told to stop moving because their back/knees/hips hurt. This is bad advice and it often comes from medical professionals. Of course it is USUALLY necessary to quit activity with an acute injury but if you stop too long muscle atrophy sets in and joint stiffness occur. More and more studies point to how important it is to keep moving. Denise Mann writes about this in a great article on WebMD entitled "Dealing With Osteoarthritis? Try WebMD's Joint-Friendly Walking Program".

Brisk walking (defined as a 15-20 minute mile) can reduce heart disease (NEJM), improve function in osteoarthritis of the knee (Annals of Int Med), and prevent the development of diabetes (J of Epid), among other health benefits.

To sum up I want to introduce a video I first saw in Dr. Mandrola's blog because it is entertaining and educational:

Patient Information Retention and the Internet

A patient with hypertension asked me about the nutritional value of sea salt versus table salt. He had heard advertisements suggesting that sea salt was less dangerous to hypertensive patients like him and wanted to know if that was accurate. I whipped out my iPhone and quickly looked it up on the MayoClinic.com website. Within seconds I could confidently tell him that there is little nutritional difference between the two types of salt--sea salt is processed differently using an evaporative process  whereas table salt is mined, processed and has additives to keep it from clumping. Table sauce usually has iodine added to it as well. As a consequence sea salt retains minerals that vary depending on its source and thus has distinctive taste. So the difference is a cooking distinction but there is no medical benefit to its use. Individuals with hypertension need to be careful of their salt intake regardless of the source. Patient (and I) were suitably impressed.

MayoClinic.com

Thirty minutes later I diagnosed a patient with a rare problem called Complex Regional Pain Syndrome (more commonly called RSD for Reflex Sympathetic Dystrophy). She developed her symptoms immediately after a minor surgical procedure and they were classic for the diagnosis. I spent a long time discussing what this meant; the poor understanding of its cause, possible treatments, prognosis and other possible diagnoses. I suggested that she look up information on MayoClinic.com and to see me back in two weeks after beginning steroids and sending her for PT. In the past I would have had misgivings about patients seeking information on the internet. As better resources have appeared on the web I am thrilled to be able to give patients a trusted information site. They are relieved to have access to another source of information and one that their physician is comfortable with. This reassures them that the information will be accurate. 

Studies suggest that patients retain somewhere between 14-50% of what they are told by their providers (see references below). Giving patients an authoritative site that they either write down or take a picture of on the white board I use makes it easier for them to recall what I said and further research information later. On their followup appointment they can ask further clarification with complicated issues or if it's something easy, they can email me with their question. Since 80% of internet users are searching for healthcare information I am happy to supply them with accurate sources.

References:

     Kessels RPC (2003). Patients’ memory for medical information. J Roy Soc Med 96:219-222.http://www.webcitation.org/query?url=http%3A%2F%2Fjrsm.rsmjournals.com%2Fcontent%2F96%2F5%2F219.full.pdf%2Bhtml&date=2012-06-03

     Jansen, et al (2008). Does Age Really Matter? Recall of Information Presented to Newly Referred Patients With Cancer. J Clin Onc http://www.webcitation.org/query?url=http%3A%2F%2Fjco.ascopubs.org%2Fcontent%2F26%2F33%2F5450.full&date=2012-06-03 

     J R Soc Med. 2003 May; 96(5): 219-222.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC539473/