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The routine checkup under scrutiny
Some tests may do more harm than
good
by Walter Rosser, MD
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It's hard to say no when a patient comes into
your office for the annual check-up and demands that you do a urinalysis
and blood test "to make sure that everything's alright." So you
go ahead and order tests such as a complete blood count (CBC), electrolytes
and urinalysis, but at the back of your mind you have the sneaking
suspicion that this isn't exactly the best use of available resources.
Indeed, a close look at the recommendations from the College of
Family Physicians of Canada (CFPC) reveals a surprisingly small
number of tests that have strong clinical evidence for being done
on a regular basis in average-risk, asymptomatic individuals (Table
1).
The periodic health exam is based on an auto-maintenance
concept. The idea is that checking every body part with scans, scopes
and blood tests on an annual basis may prolong a person's life.
Some companies still send their senior executives for these kinds
of all-round assessments, but one could argue that this practice
has more to do with the company keeping tabs on the executive's
health than with the individual's well-being.
Nonetheless, the periodic health exam is
valuable in that it gives physicians an opportunity to become familiar
with their patients, and to establish a trusting relationship. It's
also a chance to stress the importance of a healthy lifestyle and
promote appropriate screening and prevention strategies. In this
context, it's important to provide patients with accurate information
based on the latest evidence.
In Canada, the annual checkup had its heyday
in the late 70s. The growing demand on our publicly funded healthcare
system precipitated the development of the Canadian Task Force on
Preventive Health Care.1 This unique group was charged with finding
the evidence to support individual tests, and with determining the
best frequency for them. The Task Force has become a world authority
on recommending appropriate screening and examinations for prevention.
While it fell into limbo in the early part of the new millennium,
it's been revived under the sponsorship of the Public Health Agency.
Which
tests should you order?
The CFPC has come up with gender-specific forms that synthesize
recommendations from the Canadian Task Force and the U.S. Preventive
Services Task Force,2 as well
as equivalent British and European evidence-based suggestions. These
assessment sheets provide excellent guidance for an appropriate
health examination and can be obtained from the CFPC website (see
side bar for details). Note that guidelines with good-quality evidence
behind them are printed in bold, and suggestions supported
by fair evidence are in italics. You'll be surprised at how
few recommendations are in bold print.
It's important to avoid providing false reassurance
to patients by ordering a test for which there's little or no evidence
of benefit. But keep in mind the distinction between screening and
diagnostic evaluations: screening is done on people in the absence
of symptoms or signs of the disease being screened. If you order
a test because a patient has suspicious symptoms, it becomes
diagnostic.
Ever since the first Task Force Report, controversy
has surrounded its evidence-based recommendations for the periodic
health exam. Currently, 4 topics are being widely discussed and
will be briefly reviewed in this article.
Breast
cancer screening
Breast self-exams and mammography are promoted and supported by
extensive networks of breast screening programs and centres. A systematic
review by the Canadian Task Force on Preventive Healthcare found
no benefit from self-examination -- on the contrary, the practice
increased the number of unnecessary biopsies, suggesting that the
procedure may cause more harm than good. Many women complain of
feeling anxious about doing the exam themselves. These negative
effects on quality of life can't be justified in the absence of
evidence of benefit.3,4 As for
the clinical breast exam by a physician or nurse, it has never been
evaluated independent of mammography, so we don't know how effective
it is on its own.
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