medical tests

Consumption

Posted on by writenp

I find the magnitude of consumption of health care frightening, and I’m a health care provider. I’m not talking about preventative care, which I think, if anything, more people should consume.  And of course people must seek care for sickness and trauma. I am referring to medical testing and specialty care.

Medical tests such as blood work and imaging studies (x-rays, MRIs, CT scans, and ultrasounds) are overconsumed. Most health care providers, in their personal lives, are quite prudent about their own consumption of medicine in general.  We know that every test has a downside and we want to be sure the information it will provide overcomes the potential risks.

Many people, particularly those with very good insurance, think when it comes to testing, more is better. I understand that some people really want assurance that there is nothing wrong. My Spanish-speaking patients frequently ask me — “favor de chequear todo” — to test for everything – including all cancers, to get a clean bill of health.  Of course that is not possible.

Another type of excess consumption occurs when patients want to consult a specialist for the most minor of complaints, ones that could easily and safely (not to mention more economically) be taken care of by their primary care provider. Specialists are a great resource but if one sees a myriad of specialists more than your primary care provider, sometimes health care suffers. It is very possible no one is stepping back to take a holistic approach to you as a whole person, not just a foot or a heart or a GI tract.  Patients don’t always tell their PCP which specialists they’ve been to and specialists don’t always send a report, especially if the patient has not provided a PCP because they don’t need a referral.  Contrary to popular belief, providers don’t all know each other and records don’t magically get sent to your provider’s office. This is especially problematic when medicines are prescribed and there is not a complete list which would make checking for potential interactions possible.  You as the patient need to be pro-active about this, for your own good health.

While it is true referrals are a pain for all concerned, the concept of a gate-keeper for your health, i.e., the PCP, is a good one. Yes, insurance companies use the referral mandate as a way to cut costs, but the upside is that your PCP knows what is going on with your health. We can help you determine which kind of specialist to see, if warranted. Often this is not as clear-cut as one would imagine.  So even if you don’t need a referral, you might want to talk to or message us about what is going on and why you think you need to see a particular specialist.

That being said, there are some medical offerings I wish my patients would consume more of.  Screening colonoscopies and flu shots come to mind.  I sometimes have to have to push very hard for both.  Hope you got your flu shot this year – it’s still not too late. While it’s true it’s not as effective at preventing the flu as it’s been in past years, the efficacy is still around 30%.  Way better than nothing.  Plus the flu shot mitigates the severity of influenza if you are unlucky enough to still catch it.  I was very grateful for even this level of protection when I was taking care of patients with influenza last week.

Stay healthy, and be mindful of your medical consumption.

©2018 by Eileen Healy Carlsen, FNP-BC.  All rights reserved

To Test or Not to Test: of PSAs and Pap Smears

Posted on by writenp

The United States Task Force on Preventative Services (USTFPS) creates guidelines for providers to help them determine which preventative tests to do when, for which patients and if at all. We in community health rely on this task force perhaps more than other providers due to its global perspective. Basically their mandate is to decide, through a rigorous review of the research, whether certain tests or counseling interactions actually save lives in the long run, whether the benefits outweigh potential harm, and whether they are cost-effective. You can find out more at https://www.uspreventiveservicestaskforce.org/.

To make things more complicated, there are other specialty physician organizations with their own guidelines and the recommendations are often conflicting.  So what to do and how to decide?

If you have a good relationship with your health care provider, that is the best place to start. Discuss your risk factors for certain diseases, your age and state of health, your family history and your state of mind when it comes to medical tests and results. Personally, I am as conservative with tests as I am with prescribing medication.  There are potential downsides to every medical intervention, even tests.

Many people are surprised about this last notion.  They believe testing is good and want every test available, all for the assurance that they are healthy. But tests can have false positives – meaning they might indicate you have a condition when you don’t and thus lead to further testing or unnecessary interventions.  False negatives happen too, when the test says you’re fine but you are not.  Your provider will be able to tell you the false negative and false positive rates of most tests, as well as potential side effects, to help you make an informed decision.

An example is the PSA test, which is a blood test for a protein called prostate specific antigen, which is elevated in men with prostate cancer.  It can also be elevated in men who ride bicycles a lot, or who have an enlarged prostate, or have had a recent infection. Before 2012, we routinely tested men 50 and over, and younger men with family histories, risk factors or symptoms. If the PSA number was above a certain range, the test was repeated and if still high, they were referred to a urologist for a prostate biopsy.

Biopsies are never pleasant but prostate biopsies are particularly unpleasant given the location of the gland. Urologists try to take samples from many locations on the prostate, often guided by ultrasound or MRI, to find the cancer cells. Sometimes they do.  And sometimes they don’t.  As you can imagine, this is anxiety-provoking either way.  To compound the dilemma, many prostate cancers are very slow-growing and may not require treatment. But currently it is impossible to ascertain this definitively so depending on their age, most men are advised to, or want to, get treated.

Because of all this, in 2012 the USTFPS recommended against screening most men. A new guideline that came out just this week amended this slightly, recommending discussing screening with men aged 55-69, and then making an individualized decision.  I think that’s what most of us were doing anyway. A lot of times a man in his 50s would come in for a physical (pushed by his wife or girlfriend), and ask for the PSA test. We would discuss it and he would decide against it and with his permission, I would offer to talk with his significant other as well. Lots of times this would be a relief. The “man on a mission” did not want to go home, as it were “empty-handed,” having failed to get the test she requested.

Now on to the Pap smear, the screening test for cervical cancer. We actually call it a Pap test now because it is no longer a “smear” collected on a slide and preserved with a fixative.  It is liquid-based, collected with two tools usually: a small plastic “spatula” and a small brush. It is a better test because it requires fewer cells (so less repeat Pap tests for an inadequate sample), it can be done on days of light menstruation, and it can also be used to test for HPV, the human papilloma virus.  This is huge because HPV, a sexually-transmitted virus, is the cause of most cervical cancers, and the presence or absence of HPV in an abnormal Pap test guides our treatment and follow-up.  HPV can occur without symptoms and there is no cure or treatment for the virus itself.  Sometimes it manifests as genital warts “the HPV you can see,” and these can be treated, but eliminating the warts does not eliminate the virus.

The efficacy of this liquid test along with the ability to test for HPV is the reason behind the latest USTFPS guidelines on Pap tests: basically less is more, and later is better. This is welcome news to women, who never look forward to getting this test.

Now we don’t do Pap tests on women younger than 21, regardless of sexual activity. (We do of course test for sexually transmitted infections (STIs) and give safe-sex and contraceptive advice.)  This is because most young women have a low-risk strain of the HPV virus, which clears on its own. Before the guidelines, we were getting lots of abnormal pap smears for women under 21 which required other, more invasive tests and interventions, all of which could have been prevented by waiting. The jury is still out on how the new generation of women vaccinated against HPV will influence future guidelines.

Currently we test every 3 years from 21 until age 30. At age 30, women have the option of having the Pap test every 5 years along with an HPV test, or every 3 years without. Women older than 65 don’t need further testing if they have had regular screening in the past and do not have risk factors. This has taken a lot of getting used to, both for providers and patients. Women, as much as they dread the test, wonder if it’s okay to wait that long, is it safe? Rigorous research has proven that it is.  Some providers were still testing every year and some women wanted the assurance. As insurance companies adjusted their re-imbursement to the guidelines, this has changed. Go to this link for the particulars: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening?ds=1&s=cervical cancer

The bottom line though (no pun intended) is that medicine is both art and science and patients are individuals.  There is no “one-size-fits-all.”  If I have a women who wants the test even though it isn’t due yet and is not warranted clinically by the presence of symptoms or past personal or family history, we will discuss it.  Sometimes, I find out she thinks the Pap tests for all STIs and she has had a recent risky sexual encounter.  Lots to discuss including other STI testing and possibly emergency contraception in that case.  Other times there is a nebulous family history, “my great aunt died of cancer ‘down there,” or she is worried after a friend had a bad diagnosis.  As a provider, I value my patients’ mental health as much as the physical.  In some cases, I will do the test to ease anxiety, after discussing cost in case her insurance won’t pay.

The takeaway message to this rather long post is that medical tests are complicated, imperfect, at times invaluable tools to maintaining good health.  Team up with your provider to get informed, be conservative and make sure you understand what you are getting into.