Routine full blood work, EKG in low-risk patients, chest x-rays for a healthy person, stress test in someone asymptomatic and not at risk for “control”, diagnostic transvaginal ultrasounds, medications for dementia or osteoarthritis, and the list I could go on. The list of medical studies and prescriptions that have been requested from us, or from a family member, over the last few years is easily recognizable, either in a health situation or even as part of a “full annual check-up” that attempts to prevent disease or improve well-being. But many times these common medical practices are prescribed out of habit or at the request of the patient, despite the fact that there is not enough scientific evidence that has demonstrated its benefit. And, sometimes, they can even involve health risks.
“It is known that all health activities seek to produce benefits, but potential harm could also occur,” he told NEWS the doctor Paschal Valdez, expert in medical clinic, professor at the UBA and member of the intensive care team at the Vélez Sarsfield Hospital. And he added: “when analyzing which medical studies to indicate, we should not think of them only in terms of cost-benefit, but today we already have to talk about cost-safety.” According to Valdez, who is part of the Society Medicine Argentina“this concept includes not only analyzing the pros but also the possible harm that a study can cause or the collateral effects of a medical procedure. “Many times in medicine not much is said about the adverse effects of a procedure“, He suggested.
This debate stands out especially when considering the studies indicated for asymptomatic people, based on the idea that everything should be -and can- be prevented without limits and at any cost, “despite the fact that scientific evidence does not support this concept,” Valdez wrote. in the book’s introduction “choosing wisely“where more than 150 outstanding doctors, from different specialties and from all over Latin America, synthesized what are today the practices and studies that are “transmitted” from generation to generation of professionals and that many prescribe on a daily basis, despite the lack of scientific evidence on their effectiveness and even that they can harm the patient.
Who orders?
One of the basic problems with the “inadequately indicated” medical studies reviewed in the book occurs in a typical situation: when a person arrives at the consultation and asks for a check-up. “The first thing is which professional should recommend the studies, specific analyzes?The specialist or a clinician? the doctor wonders Luis Cameramember of medical clinic of the staff from the Italian Hospital, specialized in geriatic medicine, and who became known for integrating the team of presidential advisers during the pandemic.
As he explained to NEWS “The position that seems appropriate to us is that the decision on whether a person should have a mammogram, a colonoscopy or a prostate study should not be made by the gynecologist, gastroenterologist or urologist, but rather by the clinician, generalist or geriatrician. responsible, since it has a holistic and integral vision of the person, more than of their organs”.
According to Cámera, if a patient requests a study, “it is important that the clinician analyze if that request really corresponds, since it happens in many prepaid medicine organizations and companies and in the media diffusion that the decision has been left as a priority to a specialist. We believe that this is questionable because shared decisions must prevail“, explained the also member of the Argentine Society of Medicine.
According to the opinion of these two referents, “we are in favor of those who take control of a person’s health being the family doctors. And they propose to extend this idea to each age stage. “Those who should accompany these decisions throughout life are the pediatrician, the clinician and the geriatrician and that they can help administer preventive studies with the greatest possible “wisdom”. That means that they are the best trained to analyze and advise the patient and decide each study together, after reviewing costs, Benefits and possible damages of some practices.
defensive medicine
According to Cámera, it is also known that “some colleagues ask for a battery of studies “just in case”, even as a form of “defensive” legal medicine so as not to be eventually “accused” of future malpractice. It is true that defensive medicine arises in the face of the increase in these lawsuits, something worrying because experience says that one in three sued doctors ends up leaving the profession,” said the expert. “The truth is that it is a complex balance, because today speaks of empowered patients (something very positive) and many are already asking for studies or treatments. That is why sometimes the doctor must “negotiate” and be flexible. We have to avoid falling into extremes: it is not “with my body I do what I want” but neither is it “doctor, you decide for me”. The key is dialogue and getting the famous “informed consent” is something more than a paper that is signed without reading and being able to move on to a patient-centered medicine.
In the mentioned book they are reviewed in detail dozens of studies and current medical tests that are usually indicated daily in clinics and institutions but that do not have adequate evidence to support their indiscriminate performance. Between the suggestions The most striking of the book reviews dozens of common places of each specialty and some of them are listed:
- Do not request routine laboratory tests (“checkup or routine”) to asymptomatic adults with no history significant and with normal physical examination.
- Do not perform prostate cancer screening in those over 70 nor do it without discussing risks and benefits in men aged 55 to 69 years.
- It is usual for hospitalized patients to have their blood daily for control. “But if the patient is stable, you really don’t need to do it that often.”
- Many patients ask for a transvaginal ultrasound because gynecologists usually order it. But there is no professional association that can explain its usefulness in the basic checkup to look for pathologies. “It should be used but for follow-up, not for early prevention. It is requested almost out of habit and also because the biomedical complex is an industry that has its own interests and that “pushes” or facilitates certain requests,” Valdéz explained.
- Do not request electrocardiograms (ECG) or other cardiac imaging in low-risk patients without cardiovascular symptoms to screen for coronary artery disease.
It is true that most of the “not recommended” interventions to be done in a generalized way are usually promoted by medical societies or international organizations, something that facilitates their adoption. “The problem arises from the process of building recommendations where -sometimes- the information is inadequately valued and erroneous conclusions are reached”, explained the Carlos Gonzalez Malla, a clinician who has worked on this subject. And he added: “sometimes there is interest and anxiety in adopting innovative practices that seem to offer great benefits, but then reality proves the opposite. And it happens that patients demand studies that are not really necessary in order to “check” their health. state of health, without taking into consideration that the excess of tests can end up causing more harm than well-being”. It is that many “normal” check-ups can give a feeling of security, while the individual continues to maintain harmful lifestyle habits for your health, even while your tests continue to come back good.
The most effective in prevention
There are some practices that are more health education than medical and that are conclusive for better public health. Today it is known that any woman can add 14 years to her life expectancy and a man at least 10 years. How? adopting basic measures that do not need sophisticated medical interventions but “that appeal to general prevention education to improve quality of life and have better health,” explained Cámera. “This is achieved mainly if each person, through their initiative and decision, eats well, eating little flour and lots of vegetables and fruits; if they exercise properly; they don’t smoke or take drugs; they eat with little salt and little sugar and drinks alcohol moderately. With those half dozen behaviors and low cost interventionsit is possible to improve the life expectancy of most people without carrying out complex medical studies”. This lengthening of life and its quality is achieved empowering the population in preventive behaviors.
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