Are Annual Health Check-Ups Of Any Use?

Comprehensive health check-ups have become all the rage. There is a general feeling that doing a non-targeted check-up once a year helps pick up disease early and prevent future problems.

For corporate chains, health check-ups have become big businesses to the extent that many chains have actually opened out-patient health check-up centres that include “5-star” facilities that we otherwise find only in spas and high-end beauty salons.

The problem of course is that there is no evidence that non-targeted health check-ups in asymptomatic individuals work. Not only that, there is a real possibility of harm, both physical and emotional with such testing, especially when non-important pathologies are picked-up.

To elaborate further. Getting a colonoscopy done once every 5 years after the age of 50 to look for colon cancer and polyps has been proven to save lives. Getting a mammogram done every one or two year after the age of 50, though not without recent controversy, is also known to save lives. Blood pressure measurements and blood sugar evaluation help as well. Beyond these, unless there are symptoms or a high possibility of specific disease, non-targeted health check-ups and packages have no relevance.

This particular piece titled “The 50,000 USD Physical” is an interesting narration of what can go wrong with a health check-up. Coupled with these guidelines from the Society of General Internal Medicine, this article should serve as a warning lesson to all of us in the fraternity involved with health check-ups in asymptomatic individuals.

Suffering

This article by Lee T H in the recent issue of the NEJM actually discusses “the word that shall not be spoken”, i.e. “suffering”. What is even more interesting is that he describes this in the context of a healthcare company’s business strategy – to reduce suffering from disease, from complications and from dysfunction of the delivery system.

It is an interesting thought and an article worth reading.

If you would like a copy, please email a request.

 

The Master Surgeons

Dr. Pauline Chen as a piece in the NY Times about how the skill of a surgeon makes a huge difference, but has always been difficult to measure.

And yet, by word of mouth, it has always been possible to know of surgeons who are “amazing”, “lightning fast” and “gifted”. The anesthetists, nurses and resident surgeons are in the best possible position to compare and evaluate, along with the surgical ICU doctors. This knowledge obviously rarely gets passed on to patients.

It is the same in radiology. All radiologists are not and can never be the same, which is why radiology cannot be commoditized or “teleradiologized”. And over a period of time, everyone in the community knows who the brilliant ones are, both from a diagnostic as well as an interventional perspective. The patients may never come to know.

Social Media and Doctors

This is an interesting article in the recent JAMA by Lerner B discussing what is appropriate and what is not as far as the use of social media in medicine is concerned, especially at the level of resident doctors.

Not friending patients, not posting compromising pictures online, not discussing inappropriate issues including sexual and otherwise are standard, quite obvious points that need to be followed by all.

Communication with Patients in Radiology

This has always been a sticky subject.

As a rule, we are encouraged not to communicate radiology reports directly to the patient, but preferably through the referring doctor, who apparently knows better the clinical relevance of the findings. Hence typically we restrict ourselves to giving good news to patients, when their scans are normal, or lesions have improved, but prefer to hide behind the veil of “your treating doctor knows better”, when the findings will have a significant impact on the patient and his/her management.

Amber and Fiester have addressed this beautifully in the March issue of the AJR and taken this subject head-on. They are very categorical that “In this new paradigm, we argue that it is an ethical duty of the radiologist to communicate results to all patients who desire that information.”

I completely agree. If we want to stay relevant, then we need to interact with our patients more and more. This has already been happening with ultrasound, because, unlike in the US, we radiologists in India and similar countries directly interact with our patients while doing ultrasound and can’t escape talking to the patients and discussing findings. We need to take this ahead with CT, MRI and x-rays as well.

In the November 2013 issue, Dr. Saurabh Jha has a tongue-in-cheek letter-to-the-editor, which is also quite interesting and worth a read because of the reality check and practical questions he poses.

Empathy in Radiology

Everything that we have been discussing about empathy in radiology is discussed in such detail by Dr. Richard Gunderman in the latest issue of Radiology.

I recently had to give a “shidori” lecture to the 1st MBBS batch that has just entered G S Medical College. The whole focus was on empathy and respect for patients…radiologists or otherwise…all doctors need to cultivate this to be successful practitioners.

 

 

Encouraging patients to speak up

While we all have patients who are garrulous and discuss things that are completely out of context, the vast majority of patients just do not find it easy to ask all the questions that would help them with their problems. More importantly, a large number of them have no clue about the questions that they should be asking. In the end, all that people land up asking are questions like, “It is not dangerous, right?”, “What food should I eat?”, etc, which do not help either the doctor or the patient.

In a recent issue of JAMA, an article discusses this issue well. It also references a website setup by the Joint Commission that has resources that help patients with the questions that need to be asked. As professionals, we need to encourage patients to educate themselves and to be better informed – this helps us as well as the patients no end and makes for a much better relationship.

Of course, in one sense it turns around the “No turn-back” issue on its head as well, doesn’t it!

 

The Male Doctor and the Female Patient

This is cross-posted from my lay blog that showcases my Mumbai Mirror column.

Starting today, once a month or more frequently, I will also address the changing paradigms of the doctor-patient relationship.

Last month, a family physician’s name was dragged into the spotlight when a female patient of his cried “rape” after a consultation, where he and she were alone in the consulting room for some time while the receptionist sat outside and the husband went off to attend to some work.

This piece is not about the rape allegation or whether the doctor was wrong or has been wronged. The doctor however did make one mistake. He spent time alone with a female patient in his consulting room, with the door closed!

In today’s day and age, each male physician has to adhere to one zero-tolerance rule. “NEVER see a female patient alone, irrespective of age, without a female attendant or a relative in the same room”. NEVER, EVER!

We wear seatbelts to protect ourselves from injury. We exercise to ward-off ill health. Similarly, we need to take measures to prevent any incident that can possibly smear our name and reputation. There are many such potential volatile situations, but none more than seeing a female patient alone in the consulting room.

I am paranoid! I don’t even see female employees alone in my office, except for a few who I have known for donkeys’ years and even then only for short periods of time, or with the door of the office open. If I am doing appraisals, I actually have the manager wait just outside the door…if a female employee goes out crying for whatever reason, it needs to be understood that there was no personal or physical manhandling of any sort.

Similarly with patients! By staying alone in a room with a female patient, the male doctor exposes himself to the possibility of an allegation of inappropriate behavior. How difficult is it to have someone else in the room?

In our country, rarely do patients come alone. There is invariably an attendant, a relative or a friend with the patient (sometimes 4 or 5 of them). Have that person(s) stay in the room! It is very difficult to make a rape or abuse attempt stick when you are alone and the persons accusing you, many. Assuming for whatever reason that a female patient has come alone, then get a female staff member to wait inside the room. And if that is an issue, then request another patient or relative to be inside the consulting room, after explaining the situation and taking permission from all concerned.

Many doctors will have a bunch of excuses. “I can’t afford to have so much staff. My consulting is small. That patient was a 70-years old lady. I am 75 years old. My child patient is only 8-years old.”

Rubbish! Just as we now all have professional indemnity insurance (just a few year ago, doctors used to laugh at the concept), and just as we now take detailed informed consent for all procedures (something that was often not done for many, many years), we need to take adequate measures to protect ourselves.

I repeat! NEVER see a female patient alone in a room! No exceptions!

And for female patients who are visiting male doctors! Please insist on someone else being in the room with you and ensure that you are never alone with a male doctor. This is in your interest as well as the doctor’s. Preferably, try and anticipate a situation like this and take someone along with you! It will save everyone a lot of trouble.

The Vanishing Art of Clinical Science – Hyposkilia

This has been written by Dr. Anisha Sawkar Tandon, a consultant radiologist at the St. John’s Medical College, Bengaluru. You can reach her at anisha.sawkar at gmail.com

I am a practicing radiologist. Over the past few years I have noticed a disturbing trend that threatens to destroy the very nature of medicine. I have been witnessing increasing referrals for radiological investigations even before a clinical history has been taken. We radiologists are familiar with the experience of having to report radiological studies with absolutely the bare minimum clinical history or the complete lack of it. But what has begun to shake me to the core is the fact that even when I have gotten back to the referring clinician for more information, there have been innumerable instances where they simply do not know more just because they have not really talked to the patient in detail, leave alone examined the patient.

Here is an example of one of the situations that I was confronted with when reporting an MRI of the brain of a 58-years old lady who was sent from the emergency department. The referral form mentioned, “Rule out cerebral venous thrombosis (CVT)”. These were the only words of “history” provided. The MRI brain not only had no signs of CVT, but there were some symmetric basal ganglia changes that favored a metabolic encephalopathy, likely related to chronic liver disease. Since the Emergency department is easily accessible with a phone call, I could immediately contact them and ask for more details.

At first, since their question was “rule out CVT”, I attempted to elicit some history related to CVT. The disturbing answer that I got was, “The patient basically has altered sensorium and since CVT is one of the conditions that could cause CVT, we just wanted to rule it out!” I tried to find out more about the altered sensorium and the information I got in response was, “She basically looks like a psychiatric case and also has diabetes and hypertension”. After obtaining this invaluable information, I explained my findings and requested them to assess whether the patient had some form of liver dysfunction since the findings were definitely “metabolic” and not “psychiatric”.

These events had occurred at 6 pm in the evening. The next day, when I decided to follow up on what had happened to my patient, I found this sequence of events that had unfolded after my MRI brain report. The patient, had, at 7 pm undergone an ultrasound of the abdomen, which showed cirrhosis of liver with portal hypertension and ascites and suspicious nodules in the liver. At 8 pm, the patient had undergone a CT scan of the abdomen that confirmed the cirrhosis with regenerative nodules, portal hypertension and ascites. Meanwhile the results of the liver function tests showed findings consistent with chronic liver disease and the patient was known to be HbsAg positive for 5 years. The next morning, a clinical examination by a gastroenterologist and neurologist concluded that the patient was, in fact, in hepatic encephalopathy.

If you analyze this case, it worked out beautifully for the radiologist. What else could a radiologist ask for? An MRI brain, an ultrasound abdomen and a triple phase CT scan of the abdomen in one patient in one evening! What about the patient though? It’s scary to think that not one, but all of the above investigations could have been avoided by just basic history taking and an adequate clinical examination.

I understand that in a busy ER, not every patient with altered sensorium is going to undergo a 30 minutes detailed neurological exam, but a 30 minutes exam wouldn’t be needed if the simple task of talking to the patient had been accomplished which would have brought out the known Hepatitis B status. Whenever I see this kind of situation, I am appalled at what medicine has come to. There are so many more such instances in which an ultrasound of the abdomen is the first time that a large laparotomy scar has been noticed, or an MRI brain study is the first time when a craniotomy has been discovered and the referring clinician has had no knowledge of the same. It’s a different situation when such cases have been directly referred by some remote village primary health center “(PHC) and then perhaps the lack of knowledge by the referring physician can be overlooked. But it’s acutely disturbing when these cases are referred by our own colleagues, specialists in their fields and the first person to touch the patient’s hurting abdomen is a radiologist.

As a radiologist who wishes her field to thrive, I should have no cause for complaint. But as a doctor and a clinical radiologist, I am concerned about the kind of medicine we practice today, where the end result is unnecessary investigations and ultimately a burden on the patient and the system.

I would like to end by quoting Sir Robert Hutchison who said the following words, which sadly are very pertinent today

“From inability to leave well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Radiologists – The Who, What, Where, When, Why and How

The April, 2013 issue of the American Journal of Roentgenology has an article by Dr. Richard Gunderman discussing the who, what, where, when, why and how of being a radiologist.

It is a must read for every radiology resident and perhaps every practicing radiologist as well.

 

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