Do More Screening Tests Lead to Better Health? Choosing Wisely



hi my name is dr. Mike Evans and today I'm wondering if more is better specifically if more screening tests are better I mean it kind of makes sense it's just a test so it doesn't seem like there'd be a big downside and it might pick up something early so to explore this question let's paint a picture so you've been going to a family doc or a GP for many years and when they see you for an annual checkup they do a whole bunch of tests I should point out now that we're talking about screening the kind of tests we do when you're symptom free so if you did have symptoms say a sudden onset of severe fatigue or it hurts when you pee or you have a strange lump that is a different story and we'd be much more likely to order tests to find out what's going on I'm also making the assumption your average or low risk so for example if you've been on a chronic medication likely to cause osteoporosis or if you have a strong family history of a disease we might take a different course of action I will link you to some online risk assessment tools below and at the end so that you can see where your own risk is at so let's say your doc always tested your thyroid and your vitamin D levels a chest x-ray and ECG tracing for your heart tested you for osteoporosis maybe your woman under 21 and you've had a Pap test or in your 40s and had a mammography ordered okay now imagine you moved and switch to a new doctor and she or he doesn't order any of the screening tests in fact she doesn't even want you to come in for an annual opting instead to invite you for a prevention visit every few years so you might wonder hmm was my last doctor better more thorough great question so let's look at these tests one at a time let's start with the one that is most debated whether low risk women should have screening mammography to detect breast cancer in their 40s this is a hot potato right now and the subject of much debate something that the number of lives saved are so small that all the cost and effort in the high rate of false alarms investigations unnecessary biopsies etc are not worth it for individuals and we should be investing something with a better return as a collective others feel that it's the best option we have that it's getting better and the treating early could get better treatment options they just feel better knowing where they are at even though they know mammograms aren't perfect for me this last point is key knowing that the tests aren't perfect we want them to be black and white this tells me whether I have or or don't have the disease but as you learn as we walk through these tests in fact they're all about trade-offs while screening tests can find illness it can also misdiagnosed people as disease when they are not or tells people they are fine when they are not there's more precision for high-risk people and less precision for low-risk people we see this ripple effect with mammograms possible earlier diagnosis and treatment which is what most of us picture I think but it's also important to consider how you would manage the much higher probability of a false alarm and possibly triggering invasive procedures to show in the end it was nothing to be concerned about understanding these possible repercussions pretest is key I should point out again here that if you do have a lump or you are at higher risk don't let this debate delay you from having discussion with your healthcare provider what family Doc's will tell you is that we focus on the testing but it's it's actually about the relationships I know that sounds funny but if you have a good relationship with your doc this leads to screening that's more personalized that takes into account your values the science and your own unique risk the prevention is partly about the right screening but the bigger game in town is you having healthy behaviors and partnering with you to make positive change in your life ok let's look at some of the other tests in our basket for some tests we simply don't have the trial showing they are effective these tests might be ordered out of habit maybe because they can be helpful in high-risk people so I would say thyroid and ECG testing fit here a 2015 review in the annals of internal medicine show not one single study that directly assessed benefits and harms of screening for thyroid dysfunction and low risk people the United States Preventive task force or the u.s. PTF looked at what research data was available and conclude that routine screening is not recommended unless there are symptoms and signs of thyroid disease or you're pregnant there's a screening electrocardiogram or ECG of your heart making difference.the resting ECG is problematic as it sends a mixed message approximately one third to one half of individuals with a healthy heart have ECG abnormalities approximately 30% of individuals with proven heart disease have a normal resting cg and most coronary events occur in individuals without resting ECG abnormalities the u.s. PTF reviewed the science in 2012 and recommended against screening ECGs if you are low risk for heart disease next is measuring vitamin D levels in the blood which is interesting especially to us in the northern latitudes of Canada and again I'm talking about the average person not somebody who has malabsorption kidney disease or other risk factors I suppose there are three pieces to the vitamin D puzzle question number one is whether vitamin D supplementation helps so that's probably its own whiteboard but but I would say that it's a one vitamin left standing with smaller trials showing benefit for bone heart health cancer and so on on the other hand we thought this about many other vitamins and then larger high-quality randomized control trial showed they actually didn't help we are still waiting for these larger trials of vitamin D second is a test itself called 25 hydroxy vitamin D there's some debate about the test and considerable variation between labs the ideal level of vitamin D in a person's body has not been rigorously established for the population in general or for specific ethnic groups finally there's a flipside approach and that is instead of focus on testing we focus on lifestyle change like eating well and getting outside and if we are at risk say in the winter or if we are dark skinned or institutionalized instead of testing we simply take a vitamin D supplement now let's look at osteoporosis again we are missing high-quality research trials to tell us exactly whom to screen but we also know that osteoporosis related bone fractures are common as we age women are at higher risk and these fractures can cause loss of Independence function and premature death so expert groups mostly feel that the two groups that will benefit from screening with bone densitometry are one women and men over 60 five and two people with one or more risk factors such as having a low impact fracture low weight we're matured arthritis and so on see the risk assessment tool for a longer list your bone density score dictates how soon you will have to do follow-up testing but the key message is that once we have a snapshot we get a better sense of your bones if we leave some time in between testing so for example if you are at low risk you can actually wait five to ten years sooner if you have risk factors but most people can wait two years on to our next test should you get a chest x-ray well for people that have smoked a pack a day for thirty years or more we have emerging evidence in favor of a low dose chest CT scan but as far as a chest x-ray a large randomized trial of about a hundred and fifty thousand men and women aged 55 to 74 so that a single view screening chest x-ray done every year did not make a difference in the number of people dying from lung cancer so finally let's look at pap smears where we take a swab from a woman's cervix to check for cancer our story here has changed we should say we need to do a PAP annually on all sexually active woman now the science tells us that we're getting many false alarms without benefits for younger woman the smarter strategy is to have a Pap test at age 21 if you're sexually active and if it's normal then repeat every three years we stopped at age 70 but only if there are no problems in the previous ten years which means three normal Pap tests okay hopefully you can see with these various tests is some are complicated so I'll have no evidence and some need to be done but only for people at higher risk or at longer time intervals speaking of time intervals even the concept of an annual physical is not based in science it's not usual practice outside of North America it's easier for us to remember every year but that doesn't mean it's best for our health for example high risk people get screened more often but optimal interval screening for common lab tests like cholesterol is every three to five years or every three years for diabetes I achieved mixed feelings about this I love the opportunity to just focus on prevention with my patients but like most family Doc's I've shifted from blind annual testing on everybody towards customs to jeez to consider your values and your individual risk factors and encouraging healthy behaviors like moving more healthy eating helping people think better and being opportunistic about making positive change so as your new family doc okay I would say so by less testing she or he is likely improving your house and applying signs not only to treatment but to prevention like a lot of things in life when we think about it more isn't always better better communication and knowing yourself allow you to choose a little more wisely hope this helps

22 Comments

  1. Thanks you Sir for a very informative and thought provoking article

  2. Everyone's health is extremely important ! worldhealthinc.com

  3. I hope you get cancer and die

  4. I would also note that Texas Governor Gregg Abbott put into place Abbott's law which has helped advanced lab companies as he himself had a relative pass away even though there was advanced testing that couldve helped diagnose the problem earlier and/or prevent the loss but his PCP refused to do it for fear of losing money as part of his agreement with an ACO

  5. I disagree when it comes to more testing. Obviously you wouldnt want a PSA test when you are 26 but you should consider an NMR, GGE, TGE or VAP test (no longer available) if you have family history of heart disease or diabetes as a basic lipid panel is inaccurate 65% of the time. Also with just a TSH or Vit D 25 OH you're getting a small portion of a MUCH bigger picture. If you are a doctor that just needs time for a 5-8 minute consultation so you can reach your bonus with your ACO then basic screening makes sense at the expense of your patient. Imagine saving a life with more testing versus trying to convince people that there's nothing wrong. You risk more credibility and risk more financial benefits from your patient who could've been helped with an LP(a) or HDL2b or ApoA1 test. Now your patient is dead and you passed on multiple years of flu shots, referrals, testing, etc. You shouldn't look at it as just being financially beneficial but also rewarding as a care giver.I love your videos and I find them very informative as well as greatly well made. But I will say that Canada yanked Vit D testing which has been linked to heart disease in multiple studies so its probably better if you don't find it necessary in most cases.

  6. Fantastic channel my friend!

  7. I agree, you shouldn't be getting tests done if you are at low risk. These screenings can cause more harm the patient especially if they are misdiagnose. Ther is no reason to be tested for things if they don't even apply to you.

  8. I don't believe that more screening test leads to you have a better health. Why get a test done if you don't have too? Isn't this just a waste of time and money?  If your doctor is constantly giving you screenings and comparing you to the average person, than you need to truly reconsider your doctor. Everyone is different and has different genetics and environment that might affect what their health is. Being compared to the average person, almost everyone should not be the same. Some screening tests are pointless. Like an example would be a person who has never smoked in their life getting a chest x-ray done. What's the point of this? If there is no logic to have a screening done, than it shouldn't be given. In all reality, I feel that the more screenings that you have done on you, the worst off you might actually  be. A person who is diagnosed with a bunch of different elements might have a poor self esteem after finding this out. Or they might be put on a bunch of medications that they don't need or that might even interact with each other. So, I'm a firm believer that you don't need a bunch of screening tests done.

  9. Another great video!

    If I remember correctly, mammogram prevents about 1 death for every 100 women who has 4 consecutive years of screening, while giving 9 false positives, and not detecting about 7-12 actual cancer cases. It has gotten less effective since the success of Pink Ribbon Campaign encouraging women with low risk to get screening. Many women with false positive would opt for mastectomy "just in case". It significantly reduce their quality of life.

    The thing is, patients like testing. They feel that they are getting more value. The reason I can't go to yoga class anymore is that yoga women complain so much about Health Canada not paying for yearly pap smears and mammograms. They kept talking about naturapathic therapy, chiropractic diagnoses, aura photography… People just hate not knowing, even when it is completely unhelpful.

  10. Has anyone ever told you Mike, that you sound a bit like Bill Murray?

    PS. Great videos!

  11. I'm a big fan of these videos. This is an extremely important topic. Keep up the good work Dr Evans!

  12. I am now your fan, Dr. Evans…. Thank you so much for this wonderful information. Will be following your posts.

  13. Wow, super cartoon video, I love it.

  14. I am doing a case study for health care ethics. In our case studying we are talking about the newborn screening tests on infants when they are born. I looked into it and the case of the one test could save only 4 lives in a year on average. Its not always a hundred percent that the test will be accurate. that being said, sometimes there is misdiagnosis. In certain cases, people become overly stressed for something that they might not even have. In other cases, people could receive negative results for something that should be positive. Overall though, theres nothing wrong with screening tests. Early detection saves so many lives.

  15. I agree that preventative health and teaching patients how to care for themselves properly is more efficient than taking the time to do so many screenings on a regular basis that have ample room for false positives. Not only do these tests cost a lot, but receiving a false positive can cause unneeded stress and panic in patients. If someone is at a high risk for developing cancer, heart disease, diabetes etc., I think there should be relatively regular screenings to make sure all is well, but it is also the patient’s responsibility to take care of themselves and also monitor their own health along with the help of their doctor. To create a better working and more accurate health system, patients must be willing comply to doctors orders for preventative health measures, and doctors must be willing to get to know their patients’ histories and risks for developing certain ailments.

  16. I believe that the amount of screening should no be increased. Many can result in false positives causing patients to undergo unnecessary procedures. However if one does have family history of a disease know to be passed on, the test required to check for this disease should be given.

  17. I personally feel the more screening tests, the better. Screening tests help to catch early signs of health issues and they are great for providing peace at mind for patients. Early detection, along with treatment, can produce better outcomes and lower the risk of dangerous or severe complications. In the case of mammograms, women who receive false positives and have invasive procedures and further tests should be more relieved than upset when they find out they do not have cancer. I would much rather be safe then sorry. As for women who received false negatives, they would've most likely received a false negative if it was a normal screening test or if they were looking for breast cancer specifically. It is certainly unfortunate that many tests have false negatives and false positives, but not giving screening test at all won't make those issues disappear AND it will put symptom-less people with major diseases at high risk of not detecting them early enough.

  18. I personally think that the amount of tests patients receive should be lowered. There are to many unnecessary test done that in the end may end up just scaring patients. Such as the Breast cancer test mentioned, there are false positives to many tests and in some cases patients are such low risks for diseases that unless there are symptoms the test isn't needed. If there is a family history or and indications then the doctor should definitely recommend these tests, but other than that I agree with the vide more is not always better. Between false positives and even in some cases a misdiagnosis these tests can be causing more harm than good to the patient. The stress from waiting for results to a wrongful diagnosis of something such as breast cancer can turn a patients life upside down. The specific tests mentioned all have a good amount of false positives, so until the tests are more accurate they should not be done unless they are completely necessary.

  19. I understand why doctors would lessen the amount of tests patients are receiving because of all of the false positives and inaccurate reading they are receiving, but I believe each patient is different. Like DocMikeEvans said each patient needs there own set of testings. If a patient has a high risk of breast cancer in their family, of course they should be tested more regularly than a patient who does not have high breast cancer in their family. I believe each patient should be treated as an individual, if the testings make the patient more comfortable and worry less, than they should stick with the regular screenings and testings. If the patent does not have any symptoms or any family genetic make up for the disease, and have a good peace of mind about not getting tested, then they should be able to chose to have less testings. With this kind of communication, patient-doctor relationships will become stronger. Communication is key, and it matters how the patient feels. If they believe they have control over their bodies, and can work along side their doctor they will feel more comfortable with decisions made.

  20. I think this issue is very important in healthcare right now. Especially since the new recommendations went into place for women getting mammograms. However from previous knowledge and the information provided in this video I do think screening should not be increased, unless there are previous risks, or knowledge of family members that have had diseases that could be passed on, or of course if the person chooses to have them done based on personal beliefs. There are so many false positives that can occur, which can lead to unnecessary treatments that could put stress on a person. Unless these false positive problems are fixed with new technologies, I think screenings should either be lessened or continued as they are now. I do see how recommended screenings by a doctor can improve the patient-doctor relationship, however I think this can be done in other ways too. If we start focusing on prevention more and lifestyle changes, many of these diseases the screenings check for would probably decrease.

  21. From this information, in my opinion more screening tests does not lead to better health. Many of these screening tests can lead to false alarms and put people through various procedures they don’t need because they thought there was a problem. Because there is a chance for false alarms, and people having procedures done they don’t need could worsen their health. These false alarms create stress about one’s health not better it. For example, Dr. Evans mentions Mammograms, ECG screenings, Vitamin D screenings and more. We all know that mammograms lead to false alarms of breast cancer so how could mammograms lead to better health. Yes having early or multiple mammograms could detect cancer early enough to treat it but it can also misdiagnose a woman who never had anything to worry about until the false alarm came along. As for ECG screenings, those are very confusing as well. Resting ECG sends mixed messages, and they are also not recommended if you are a low risks for heart disease. Why have a test done if you’re not at risk. More screening tests should only be done for people at higher risks with signs and symptoms. The 25 Hydroxy Vitamin D test has much debate about it because there isn’t an ideal Vitamin D level established for general population. The bottom line is with all these chances or misleading information form screening test more screening test just simply can’t lead to better health.
    I can agree more with the prevention visit every few years. Having a doctor that cares about ways to help you to prevent from becoming ill is better than one who just want to run many tests to make sure there isn’t anything wrong. Having a preventive lifestyle to change bad habits to lower risks of developing anything is better for the patient. It focuses on how the patient feels, and their values because every patient is different. Prevention visits lead to better health. Less test are better because through all the prevention visits the patient’s health is getting better overtime which indicates there are no high risks for certain things which leads to less tests. There would specifically be no need for any screenings unless a major sign or symptoms arose.

  22. I agree that certain testing should be limited depending on the patient. However, I also agree that thorough testing does build a better relationship between physician and patient. If the patient feels like they are being well taken care of it will improve their attitude and overall experience when visiting a physician. For example, if a patient has gone through various testing, there is a good chance that they will listen to their doctor if he or she recommends making changes to improve life quality whether or not the tests came back positive or negative.
    It also depends on the patient to a certain extent. Some people will want full testing done and others might not want to in fear of a false positive because at the time they feel fine. It comes down to relationships and communication. A great physician will know how to cater to their patients and make decisions that will not only keep them healthy but also produce the best level of well-being.

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