Healthy patients always make the same error

Healthy patients always make the same error

Healthy patients think that they are not at risk for serious medical problems. Though maintaining a healthy weight, exercising regularly, not smoking, and eating plenty of vegetables and fruits while limiting meat, fat, and fast foods does decrease the risk of developing diabetes, high blood pressure, heart disease, and cancer, it doesn’t completely eliminate it. The chance is there, just a little less. But patients wrongly assume that staying healthy means no chance of illness and, as a result, they routinely skip preventive screening tests because they have no symptoms of illness, have no family history of disease, and are “healthy.”

That is the error that many healthy patients make.

Staying healthy means that in addition to a healthy lifestyle, screening tests and interventions such as mammograms, Pap smears, immunizations, colonoscopies, and high blood pressure and cholesterol screenings and treatment are equally as important. Premature death can be avoided.

Quality of life can be maximized. Unfortunately, these interventions, particularly the treatment of high blood pressure and cholesterol with prescription medication when necessary, are often seen as unnatural and equated with illness.

That perception is also part of the problem.

Doctors are no better either

Even Oprah’s doctor, Dr. Oz, who arguably is one of the healthiest people in America, isn’t immune from this perception error. He practices what he preaches with a very healthy lifestyle by eating well, exercising, and meditating. When Dr. Oz turned fifty, in June 2010, he got a colonoscopy, a recommended test to screen for colon cancer, not as part of his desire to stay healthy, but because he felt compelled to demonstrate the importance of it to his television audience. After all, Dr. Oz had no family history of colon cancer. He otherwise felt fine. If it wasn’t for his self-titled television show, Dr. Oz admitted that he would have procrastinated until age sixty, ten years after Americans are supposed to begin colon cancer screening.

Shockingly, his doctor discovered an adenomatous polyp, a precancerous growth, which was removed. If it hadn’t been for his self-titled television show, he would have delayed his colonoscopy. The small polyp would have grown and become a fully developed cancer requiring extensive abdominal surgery as well as chemotherapy. Likelihood of survival is low when the cancer is discovered late. It is very likely his tumor would have caused problems before Dr. Oz’s own plan of getting a colon test at age sixty.

In other words, Dr. Oz saved his own life by having a preventive screening test done when it was recommended. Like many patients and doctors, he had a bit of arrogance going into the procedure because he works incredibly hard on staying healthy. The colon cancer screening test was simply a thing to check off on his to-do list. A mere formality. It wasn’t necessary. It wasn’t urgent. It was not to be taken too seriously. No one likes to be a patient, particularly a cardiothoracic surgeon, who is often in complete control.

Dr. Oz noted rightly that,

“Lifestyle is not the cure all by itself … Part of being healthy and staying healthy is getting screened for cancer, high blood pressure, high cholesterol, and diabetes. Part of doing everything right is getting screened.”

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

Image credit: Shutterstock.com

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  • Jean Oliver

    I think you are greatly exagerrating the Dr. Oz scenario. I am not a doctor but I have done extensive research on colon polyps and what you have said is quite presumptive, especially not knowing what type, size, etc. of polyp the doctor had. The vast majority of colon polyps, even adenomas (which they term “precancerous) and especially the small, tubular ones, do not progress to cancer. I think it is a bit of fear mongering to say that Dr. Oz would have gone on to develop cancer and required surgery, etc. I am one of those healthy people you are referring to and I have made an informed decision not to participate in cancer screenings. A lot of press has recently been given to the problem of over treatment resulting from mammograms, PSA screenings and PAP smears, thus the current dialing back on the frequency of these tests. As far as colonoscopies, they most probably do prevent cancer but they also have risk, are expensive and the large majority of the polyps that are removed during them would not have progressed to cancer (could be considered a form of over diagnosis). There is rarely, if ever, any press given to other methods of colon cancer screening, such as FOBT and FIT tests, which have been proven in controlled trials to reduce deaths from colon cancer. They are also non invasive and cheaper than colonoscopies. People should be given enough information to make informed choices, which they rarely are. Although not always, I can’t help but think that a lot of doctors have other concerns when making recommendations: financials ones as well as a fear of legal action in the case of missed diagnosis. Articles like this do nothing to change my mind. I still do not see the need to see a doctor unless I am symptomatic. I can monitor my blood pressure at home and have my cholesterol checked at various locations. If those numbers show problems, then I would seek a doctor’s help, otherwise I am steering clear.

    • JPedersenB

      I also have made a well considered decision to avoid screenings. I understand very well the risks of my decision but think that the tests also carry significant risks. Until the medical industry reforms itself, I do not intend to be a profit center for my doctors, hospital, labs or drug companies!
      (P.S. I continue to be amazed at how easily doctors justify what they do to their patients.)

      • http://www.facebook.com/ann.silberman Ann Silberman

        I was always a super healthy eater, active lifestyle, low body weight person, my cholesterol was perfect, blood pressure low, healthy enough to live 100 years I thought. I skipped my screenings because I didn’t think they were necessary for ME, and now I have Stage IV metastatic breast cancer at age 54. I have been in treatment for 3 years, it spread to the liver and my lifespan is very, very short.

        It CAN happen to you. Too many people live in denial, make up reasons why they don’t want to do something, to keep their denial system going. Sometimes, you are rudely awakened. Good luck to both of you.

        • http://twitter.com/davisliumd davisliumd

          Thank you for sharing your story. I hope others will learn from your experience.

          You aren’t alone in this. I blogged about Elizabeth Edwards fight with breast cancer as well. She didn’t have a mammogram for four years.

          http://davisliumd.blogspot.com/2010/12/elizabeth-edwards-breast-cancer-and.html

          All my best.

          • southerndoc1

            “Although I’ve never met her, I am certain that given a choice had she had the healthcare system around her which optimized her chances for the right decision, she would have never wanted to leave her children at such a young age”

            I’ve never seen a physician try to put a guilt trip on a dead person before.

            As someone who knows several of the individuals involved, when I first read your post, I thought it was the most condescnding, self-righteous piece of medical writing I had come across during my thirty year career. Two years later, I feel exactly the same way.

            Using the medical history of a complete stranger for aggrandizement of your practice and yourself (“Buy my book!”) is despicable.

            I hoped, two years ago, that you would have second thoughts and remove your post about Ms. Edwards. I underestimated how shameless you are.

            (Just from an intellectual point of view, you may want to explore the logical fallacies in retrospectively applying population statistics to individual medical histories.)

          • http://twitter.com/davisliumd davisliumd

            I’m apologize if I seemed presumptuous to presume anyone of us would want to leave our children sooner than we would like. The point of the piece was directed at our health care system and failings of it. It was not directed at Mrs. Edwards or anyone else. Nor am I blaming patients. I apologize to individuals who may have felt that way.

            Since you know first hand of the individuals involved, please let us all learn from your experience.

            I talk about the system I work in not as a way of self promotion, but to demonstrate that there is still unfortunately are differences in how care is delivered in this country. I certainly didn’t promote my book as you claim. It is simply a resource much like KevinMD is as well.

            Also, thank you for demonstrating the logical fallacies in applying population statistics and individual medical histories. This certainly is a challenge in health care.

            This is also the error that many healthy patients make as well.

        • Homeless

          You don’t know if you had had a mammogram whether it would have changed your prognosis. Statistics say probably not.

      • http://twitter.com/davisliumd davisliumd

        I agree that there is both risk of screening as well as risk of not screening.

        I am confused and concerned, however, about not wanting to be a “profit center” for your doctors.

        As a practicing primary care doctor (as many others), recommending screening tests isn’t “profitable”. Most primary care doctors don’t own radiology imaging centers (mammograms) or do colonoscopies and therefore can’t necessarily “profit” from these preventive screening recommendations.

        As a practicing primary care doctor and the reason for this post (as well as writing my book), the goal is to ensure patients are informed about the options that exist today which were not available decades ago. I have no problem in giving patients both the pros and cons of screening and not screening.

        As adults, they can choose not to do testing.

        As long as they have all of the information they need to have informed consent.

    • http://twitter.com/davisliumd davisliumd

      Thanks for the comment. I certainly agree that patients should have the information they need to make informed choices and that is why I wrote my book – The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy.

      I did want to clarify a few points you made. We can agree to disagree about the Dr. Oz scenario. While you may say I “greatly” exaggerate the extent of the risk, I often notice that healthy patients tend to also discount the risk. Had he let it go is it possible he would have had more invasive colon cancer? Absolutely. Without acknowledging this possibility, this is not, in my mind, informed consent.

      Yes, there has been concerns about how adequate screening tests are. Certainly PSA testing for prostate cancer has been controversial for quite some time. I’m unaware of such data regarding Pap smears for cervical cancer screening or screening for colon cancer, so please post if you have such information.

      I completely agree that colonoscopy is not the only form of colon cancer screening. I discuss exactly the screening you describe – FIT tests – in this post. http://davisliumd.blogspot.com/2011/03/colon-cancer-screening-guidelines.html

      As I wrote – When Dr. Oz turned fifty, in June 2010, he got a colonoscopy, a recommended test to screen for colon cancer.. That was his choice to get a colonoscopy. Note, I said “a recommended test”. I didn’t say “the” recommended test for the reasons you indicate above.

      Over the years, healthy patients do exactly what you said. They wait until they have symptoms.

      That is the same error that they always make.

      • Jean Oliver

        In your piece on Dr. Oz you state that if he had not had the colonoscopy and had the “precancerous” polyp removed he WOULD have developed cancer. You did not say that there was a POSSIBILITY that the polyp would have turned cancerous, which is probably correct. It is not a given. Google “Hype Alert: Dr. Oz Colonoscopy”. That gives a better explanation of what I am talking about.
        As far as PAP smears, again there is never any informed consent. They have long been required for birth control pills whereas the only test that should be required for BC is a blood pressure check. BC has no ties to cervical cancer but patients are rarely told this. Also, cervical cancer is usually caused by a strain of HPV, which is sexually transmitted. Therefore, virgins and possibly long term mutually monogamous women get little benefit from them. Why then the recommendation to have a PAP at 21, regardless of sexual activity? There is also much documented information on the over treatment of “precancerous” cells with colposcopy, biopsies and LEEP treatments. Most often, especially in young women with healthy immune systems, these infections clear up on their own. Google “Unnecessary PAP Smears” for much information on this.
        As far as mammograms there is much evidence of overdiagnosis, especially of DCIS. Many of these cancers would never progress to harm a woman but once they are found, of course they are treated because “you never know”. Also, many aggressive cancers may be found with mammography but eventually they will go on to be fatal. The woman just ends up knowing she had cancer longer (lead time bias). If the same woman would have waited for diagnosis until she was symptomatic, she would also have died but wouldn’t have lived as long KNOWING she had cancer. I do understand that some are helped by screening, some are harmed but the vast majority see neither benefit nor harm. I would prefer to live my life without being so medicalized. After all, there are no early screening tests for other cancers: pancreatic, lymphoma, leukemia, lung, stomach, ovarian, brain, etc. I don’t live in fear of getting them nor do I live in fear of getting breast, cervical or colon cancer. I do believe the benefits of screening have been greatly oversold.

  • Homeless

    I agree with Jean Oliver…

    I am not healthy, a lesson I learned at age 26 that no matter how well you take care of yourself, stuff happens. Since then I have been diagnosed with 4 more chronic conditions…all of which were diagnosed because I had symptoms. I chose not to participate in screening mammography because of the reasons sighted by Jean.

    I eat well, exercise, don’t smoke…all those things that healthy people do. I look healthy…fit, well nourished, clear skin…and medical providers often assume I am healthy because I don’t fit the profile of a sick person.

    • http://twitter.com/davisliumd davisliumd

      Certainly there are illness that exist today where there is no screening test available. So you are correct, diagnosis only occurs when patients have symptoms.

      Yet over time, medicine becomes more precise. For example, in the past diabetes was diagnosed when patients lost weight, were urinating a lot, and had double vision. Today, if a blood test is done periodically, especially among those at high risk for the illness, changes can be made to decrease future risk of the disease.

      So for those illnesses where we can screen early to save lives, we should offer all patients the conversation both pro and con. Stuff happens. Some stuff, however, can be avoided.

      • Homeless

        RE: “I often notice that healthy patients tend to also discount the risk.”

        I am not a healthy patient and I discount the risk. I actually don’t discount the risk…I understand that I might die because I didn’t get that mammogram. I choose this over the possibility of over-treatment. So perhaps Jean feels the same and it has nothing to do with being healthy.

        RE: “Certainly there are illness that exist today where there is no screening test available. So you are correct, diagnosis only occurs when patients have symptoms.”

        Any diagnostic test can be used as a screening test in asymptomatic patients.

        RE: “Over the years, healthy patients do exactly what you said. They wait until they have symptoms.

        That is the same error that they always make.”

        While you suggest discussing pros and cons, this statement implies you feel healthy patients should be screened. Of course, your observations on those with regret isn’t scientific.

        • http://twitter.com/davisliumd davisliumd

          Of course any diagnostic test can be used as a screening test in asymptomatic patients.

          I’m not advocating that. Plenty of people are offered diagnostic tests (like Lifeline screening) which have no scientific value as “screening tests”.

          As I stated earlier, choosing not to be screened is an individual choice. My role is to ensure patients have all the information that they need. I understand your point of view and Jean’s and I respect that.

          I would however also not want to assume that everyone has the same level of understanding of the risk that you and Jean do because they didn’t have the time or desire to do that research and as a knee jerk response simply say no.

          http://getbetterhealth.com/patients-are-rejecting-valuable-treatment-based-on-false-information/2011.08.19

          • Homeless

            RE: As I stated earlier, choosing not to be screened is an individual choice. My role is to ensure patients have all the information that they need. I understand your point of view and Jean’s and I respect that.”

            That’s not the thesis of your blog post. You write:

            “Staying healthy means that in addition to a healthy lifestyle, screening tests and interventions such as mammograms, Pap smears, immunizations, colonoscopies, and high blood pressure and cholesterol screenings and treatment are equally as important. Premature death can be avoided.”

          • http://twitter.com/davisliumd davisliumd

            Dr. Oz says the same thing as I did.

            This is consistent with my post. Many patients say no to screening without understanding the risk of not being screened.

            You and Jean have chosen not to be screened. I may disagree, but respect that.

          • Homeless

            You don’t agree that screening can be hazardous or you don’t agree that Jean, JPedersonB and I have made the right choice?

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