Early diagnosis, preventative care and aggressive disease management are mainstays of American medicine today. Proponents argue that early diagnosis and prevention are the keys to healthy living. Skeptics suspect that many of the screening tests for early asymptomatic disease and preventative treatments we undergo lead to overdiagnosis, unnecessary expense, exposure to diagnostic and therapeutic interventions which themselves have risks, and that often cause more harm than good.
As a physician and as a patient, how do we decide which of the many preventative care interventions should we choose, and which should we decide to forego? It’s not easy, but here are five things to do, and five more to think carefully about or just avoid. These opinions are based as carefully as I can on evidence, yet in each case you’ll find those whose opinions differ.
5 preventive services to do
1. Childhood immunizations. The evidence that childhood immunizations are safe and effective is overwhelming. Don’t believe the naysayers who are encouraging delay or skipping immunizing your child altogether. They are wrong in their opinion. I can live with those who forgo immunizations for religious reasons, but those who believe it is safer for their child, they are way off base.
2. Quit smoking. This may seem obvious, but I still hear patients tell me that they don’t really believe smoking is that bad for them. Just quit. It’s not easy but find a way.
3. Get HIV testing. If you are in any way at risk, get tested. Early treatment and awareness of HIV status can lead to safer sexual practices and better long term survival.
4. Get your flu shot. You may have heard that the flu shot is not 100% effective, feel that the last time you had a flu shot you got sick, or many other anecdotal excuses for not getting immunized. The truth is that flu shots put you at much lower risk of influenza, that influenza is a serious, sometimes fatal disease, and the flu shot is quite safe. Get your flu shot every fall and protect yourself and others.
5. Exercise regularly. Whether you prefer mostly cardiovascular exercise, mostly resistance training, or a balanced combination is far less important that getting regular exercise. Exercise improves your physical, emotional and cognitive health. The hardest part is just tying your sneakers and getting the first foot out the door. Just do it!
5 preventive services to think twice about
1. Taking a daily vitamin. The evidence for taking a daily multiple vitamin is at best scant. One large study in older women showed a higher death rate in women who took daily vitamins. Evidence for taking other daily vitamin supplements is also scant, with the possible exceptions of vitamin D for those in northern latitudes, iron supplementation in breast fed infants, and in specific vitamin deficiency situations.
2. Shotgun screening for disease. Offerings like Life Life, a mobile ultrasound screening for atherosclerotic vascular disease, kidney, liver and other conditions is not only unproven, but puts you at risk for overdiagnosis and expensive additional follow-up tests. Avoid these.
3. Prostate cancer screening, and maybe therapy. Prostate cancer is a major problem. It is the second leading cause of cancer death in U.S. men behind lung cancer. One in 6 men will develop prostate cancer and 1 in 36 will die of prostate cancer. So it is especially frustrating that the current screening tests like PSA and digital rectal exam may not only not significantly reduce prostate cancer mortality, but may actually lead to more harm than good.
The problem is that prostate cancer is quite variable in its natural course of progression, and we don’t have good tests to determine which prostate cancers will behave aggressively and which will be quite indolent. There is a great deal of debate as to whether PSA screening for prostate cancer puts you at higher or lower risk of morbidity and mortality, and even if you are diagnosed with prostate cancer whether to treat and how best to monitor or treat the cancer is problematic. This is just a confusing and still evolving decision making dilemma. The USPSTF currently recommends against screening asymptomatic men for prostate cancer with either PSA or digital rectal exam, and I currently lean towards their recommendation.
4. Annual (vs. every 2 year) mammographic screening. The USPSTF recommends every other year mammograms for women age 50-75. The American Academy of Radiology recommends annual screening after age 40. The concern of the USPSTF is that annual screening may lead to more false positive tests, more unnecessary biopsies and radiation exposure for follow up testing, and has not been shown to give better outcomes. Many physicians still recommend annual mammography in women age 40-75, but how much of this recommendation defensive medicine or profit is driven is unclear. I think getting only every other year mammography is certainly a viable option, and possibly a better alternative to annual screening for average risk women.
5. Asking for antibiotics for mild to moderate respiratory, sinus and ear infections. The evidence is mounting that antibiotic therapy for most cases of bronchitis, sinusitis, otitis media and pharyngitis is not only unnecessary but has a much higher chance of causing harm than helping you.
I read a very interesting article by Dr. Lemmon on his blog Bittersweet Medicine makes the case that in order to help prevent one case of rheumatic fever or strep-induced kidney disease, the purported reasons to treat strep throat, we will need to prescribe antibiotics to 1,000,000 patients while causing 100,000 rashes and inducing 100,000 cases or diarrhea or yeast infection. This was written prior to the much higher risk in recent years of C. difficile colitis, a potentially life threatening antibiotic induced infection.
If you present to your physician asking for or insisting on an antibiotic prescription for your condition, you are more likely to get the prescription even if your physician believes it is unnecessary. You are unnecessarily putting yourself at risk by asking your physician to deny you what you request because it is what’s good for you. We are human, and sometimes take the easy way out and oblige your request.
Edward Pullen is a family physician who blogs at DrPullen.com.