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Getting The Most Out Of Midlife

How much medical testing is too much?

April 30, 2011|By Amanda Leigh Mascarelli>>>

Midlife brings with it a host of health concerns — the risk of heart disease, high cholesterol, high blood pressure, diabetes and osteoporosis, to name a few. So as people reach middle age, they're bombarded with an overwhelming number of recommendations for screenings, tests and just-to-be-on-the-safe-side preventive measures. The list includes mammograms, prostate cancer screenings, colonoscopies, CT scans, cardiac stress tests, thyroid tests, bone density tests, calcium scores and carotid artery ultrasounds.
When it comes to screening and early intervention, we apparently can have too much of a good thing.
"As our technology gets more sensitive and is able to see more things, and as we test more often and we change the rules of what's abnormal, we now recognize that we all harbor abnormalities, and our tests are increasingly able to find them," says Dr. H. Gilbert Welch, author of "Overdiagnosed: Making People Sick in the Pursuit of Health."
"The biggest problem with over-diagnosis is it triggers over-treatment," adds Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. "It's a side effect of our relentless desire to find disease early."
Take, for instance, a patient whose physician recommends a CT scan of the coronary arteries to screen for heart disease. The scan also captures a portion of the lungs, revealing tiny nodules that could be from scar tissue, an infection — or possibly an early-stage tumor. The nodules are probably harmless, but the scan raises enough concern that the physician recommends a follow-up chest CT — the patient's second dose of radiation in six months.

Once physicians start down the pathway of looking for disease, "you get a lot of unnecessary X-rays and imaging, with a lot of exposure to [ionizing radiation] that probably is more dangerous than any information that you're going to get from those X-rays," says Dr. Glenn Braunstein, an endocrinologist and chairman of the department of medicine at Cedars-Sinai Medical Center in Los Angeles.

Not to mention the patient's new fear that he or she has cancer.

Reasons to test

Experts acknowledge that the fear of being sued can sometimes influence a doctor's decision to order more tests. A patient may come in complaining of chest pain, and the doctor may be fairly certain it's not heart-related. But then she may think, " 'Well, there's a 0.1% chance that it is, and what if I didn't do the stress test?'" says Dr. Christopher Cannon, a cardiologist at Brigham and Women's Hospital in Boston.

But in other cases, such as with cholesterol checks, pressure from patients can prompt doctors to order tests they might otherwise skip, Cannon says. In many cases, "the tension is more the demand of the patient, of 'I want to know, do I or don't I' " have a certain condition, he says.

Yet another reason for excessive screening: It's easy.

Consider the PSA test to screen for prostate cancer. Once considered routine, the American Cancer Society no longer makes a blanket recommendation that men get the test; the U.S. Preventive Services Task Force says there's no good evidence either for or against the test for men younger than 75, and it advises men 75 and older to skip it. But patients may not realize this.

"It would take a lot longer for the doctor to go over the data for why screening with a PSA in his age group is not a very effective approach for picking up prostate cancer because there's going to be many more false positives than true positives," Braunstein says. "That's a 15-minute discussion, whereas it's one minute to write the order for a PSA. And if you don't write the order for a PSA and that's what the patient wants, then you've got an unhappy patient."

Dr. Nortin Hadler, a rheumatologist at the University of North Carolina and author of "Worried Sick: A Prescription for Health in an Overtreated America," estimates that only about 20% of our health and life expectancy is based on measurable risk factors for disease. The other 80% can be boiled down to quality of life, which Hadler sums up with two questions: "Are you happy in your socioeconomic status?" and "Do you like your job?"

"It's very powerful," he says.

Hadler points to a Finnish study that examined health effects on municipal workers during a severe recession that took place from 1991 to 1996. The number of deaths from cardiovascular events such as heart attacks and strokes doubled in workers who were not laid off but who were exposed to the stress of major downsizing (defined as layoffs of 18% or more), researchers reported in 2004.

Defining 'sick'

Meanwhile, the definitions of what it means to be "sick" have shifted. Over the last two decades, the threshold for treating a number of conditions — including high blood pressure, high cholesterol, diabetes and osteoporosis — has been lowered.

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