“Just because you could, doesn’t mean you should” was a “mantra” given to me by one of my family medicine teachers and I have come to appreciate its wisdom over years. Over the last decade as a practicing clinician, I have come to realize the limitations of modern medicine, started seeing patients as people with different goals and values and have been trying to equip myself with knowledge of patient centered healthcare.
Preventive Health checks in India have gained popularity in last decade or two. As a practicing physician in urban India, I come across patients who have been getting the “health checks” year after year. A huge number of patients are “self-referred” and get annual check-ups in hospitals and diagnostic centers. A good number of these check-ups are also offered through the employers and I have seen patients in their early 20s getting routine health checks as well.
I looked up the health checks offered and they come in various forms. I asked some of my patients to look at these packages and tell me which one they thought was the best package for them. Some picked the most expensive package; some went by the keywords like “full body check-up” or “advanced” check-up. Very rarely do I come across patients who understand exactly the tests they have been getting and the appropriateness of these tests. While there are some hospitals/centers that have put some thought in designing the “health package”, a majority of them take the “shot-gun” approach of offering multiple tests that all the patients undertaking these packages may not necessarily need. Some examples are routine ECGs/ECHO in young adults, pap smears in women older than 65 years, routine abdominal ultrasounds in young adults etc. Some even go to the extent of causing potential harm, for example, cancer biomarkers for several types of cancer- many of them have been studied to cause more harm than good. Also, In patients at little to low risk for heart disease, an electrocardiogram or stress testing can actually lead to harm. However, they seemed to be a common component of majority of health checks.
A recent analysis from Cochrane review concluded, “General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased.” Due to missing or unreliable data, the authors could not estimate costs, harms, or the use of follow-up medications and testing as the result of screening. Although all the studies used for this review are from western context, I think this study brings out a whole new perspective on how we should look at the preventive health care sector in India.
I am a family physician who strongly believes that “prevention is better than cure”. I am a “prevention enthusiast” who believes preventive measures done right can not only add years to your life but also improve the quality of life. As Dr. John Mandrola says, “The four legs of the wellness table are good food, good movement, good sleep and good attitude. Doctors can’t do this for people, neither can screening tests nor pills.” Moreover, in most of the western countries, the preventive health care recommendations are offered and to an extent “tailored” to meet the patient’s risks as opposed to Indian setting where one can walk into any center offering health checks and get a whole host of tests done. So, if there is strong evidence showing general health checks do not decrease the risk of deaths from cardiovascular events or cancer, why are they so popular? Two of major reasons in my opinion are lack of patient engagement and education related to preventive care on part of family physicians and a “belief” held by majority patients that these health checks will make them healthy.
There has been extensive discussion following the Cochrane review and there are few things that one can argue upon as being beneficial. For example, Checkups can be beneficial in getting people to think about their health. Also, if the health check-up is being offered by your family physician, there is value in getting tailored approach to your preventive health check. There is also evidence for some meaningful screening approaches, such as screening obese patients for diabetes risk, patients with a family history of disease etc.
I guess, the bigger question, to ask is not whether preventive health checks are needed but how should they be designed so that they truly impact the lives of majority of people undertaking these health checks.
Dr. Danielle Ofri writes, “a detailed conversation is much more likely to uncover lurking medical issues than the physical exam or blood tests”. Even in the hospital setting, the advantage of detailed history and exam supersedes any combination of labs and imaging. You can see the results here and here. In my experience, however, these are two things most neglected and many a time skipped in most of the health checks being conducted.
Now, Let’s talk about the preventive measures that are backed by strong evidence but don’t make it to the preventive health checks: Counseling against tobacco and alcohol use, mental health screening for problems like depression and anxiety that are increasing in great numbers, obesity, infectious diseases (TB/HIV etc) and certain adult vaccinations etc.
So, Can we design a health check that can steer a patient towards wellness and just not give a “sickness free” check? Can we have a healthcare innovation from India that is disruptive enough to make a business case for “prevention” without relying on battery of diagnostic tests?
This blog-post was initially published on SuccessinHealthcare, now re-posted here.
(Please note, I am a family physician and this article only addresses preventive healthcare issues in adults.)