Screening medical tests- desirable or distracting-updated

To make an intelligent decision about your own screening, you need a physician who reviews your past and current medical history, your family history, and your health goals.

This post has been updated June 11, 2021

Both doctors and patients have mixed emotions about diagnostic tests done to screen for disease. We physicians want to help patients stay healthy, prevent disease, and treat problems early and effectively.But the time spent counselling, ordering, performing, and reviewing these tests means less time available to manage patients’existing medical problems.

I agree with Dr. William Zinn, family physician in Boston, who wrote

“Keeping track of the ever-increasing health maintenance requirements and cancer screening sometimes make it hard to remember why the patient came to the office in the first place.”

JAMA, January 7, 2020

For patients the issues are similar. While they want to stay healthy, prevent disease, and get treated promptly, they don’t like the inconvenience, time away from work, cost, and sometimes discomfort the tests require.

What are screening tests?

A screening medical test is done to uncover a disease or disorder in a person who may or may not be a risk for it and who otherwise feels well and has a normal exam. Suppose we are considering screening a group of people for disease X. Let’s start by dividing them into 3 groups.

  • Those with no symptoms, feel fine, at average risk of health condition X.
  • Those with no symptoms, feel fine, at increased or high risk of condition X.
  • Those who have symptoms suggestive of condition X, or have had other testing that suggests they might have it

Screening for X in groups 1 and 2 might be appropriate, based on medical guidelines, physician judgement, and patient preference. For group 3, with symptoms of condition X, testing would be considered diagnostic; a doctor would test for X, and possibly other conditions that the symptoms suggest.

Diagnostic vs Screening

That might seem like a picky difference, but there are several implications for both doctors and patients.

Documentation- The medical record needs to reflect accurately why a test is being ordered and done. This is necessary for billing because inaccurate coding can make doctors and clinics liable for fraud. Also, the government and other payers are starting to judge doctors’ quality of care based on medical record audits of care given or not given, and why.

Interpretation and Follow up-A test is rarely interpreted in isolation. The history and exam together with the test lead to a diagnosis.

Reimbursement– Most if not all insurances, including Medicare, reimburse differently based on whether a test is diagnostic or screening. And this usually determines how much the patient pays for each. Screening tests are usually covered 100% while diagnostic testing may require a deductible or copay .

A Country Doctor Writes blog explains this dilemma in detail –

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

read more at this link

This link at FamilyDoctor.org helps explain

Health Insurance: Understanding What It Covers

Cervical cancer screening frequency also now takes into account a woman’s HPV, human papilloma virus, status. Go here to learn

When should a woman begin cervical cancer screening, and how often should she be screened?

a microscope image of a cell infected with HPV

A koilocyte is a squamous epithelial cell that has undergone structural changes as a result of infection by human papillomavirus (HPV). This image of a koilocyte shows human ectocervical cells (HEC) expressing HPV-16 E5 oncoprotein, and immortalized with HPV-16 E6 and E7 oncoproteins. Formation of koilocytes requires cooperation between HPV E5 and E6 oncoproteins. The cell culture is stained with hematoxylin and eosin (H&E).National Cancer Institute \ Georgetown Lombardi Comprehensive Cancer Center, Ewa Krawczyk, public domain

Does disease screening make a difference?

Screening tests don’t prevent disease although they may be helpful for health maintenance or improvement. They may prevent progression or complications of a disease, but don’t prevent it’s onset. They may not even prevent death from the disease, although we like to believe they do. Screening may diagnose the disease before symptoms develop, so the patient lives longer with the disease, but not affect the eventual outcome.

Doctors can now offer patients another option that is more accurate than the stool blood test and less invasive than colonoscopy.

Stool DNA testing looks for certain DNA or gene changes in cells that can get into the stool from polyps (pre-cancerous growths) or cancer cells.  It may also check for blood in the stool. For this test, people use a take-home kit to collect a stool sample and mail it to a lab. Cologuard® is the name of the stool DNA test that is currently FDA-approved. This stool test needs to be done every 3 years.

So when should we offer screening tests?

If there is a clear benefit to patients from an effective treatment available to make a difference in the disease course or

If knowledge of the condition helps the patient and family make choices about managing the condition’s likely course or the need for family members to be screened

If the test is reliable enough to identify most people with the disease without falsely identifying people who don’t have it. The scientific terms for this are sensitivity and specificity.

When the benefits clearly outweigh the risks and costs.

a mammogram image
a mammogram revealing a breast cancer image source- National Library of Medicine, Open-i

How to decide for yourself

These are just some of the factors involved in deciding when to undergo screening tests. To make an intelligent decision about your own screening, you need a physician who reviews your past and current medical history, your family history, and your health goals. Then the doctor can make recommendations based on your needs and desires with the help of expert guidelines published by medical organizations who carefully review the medical literature.

Review the graphics in this post for recent guidelines from professional organizations and discuss with your physician. Help your doctor help you by scheduling a health maintenance visit rather than bringing it up when you are there sick or for chronic care. These discussions deserve your physician’s full attention.

further information from the National Institutes of Health.

To Screen or Not to Screen

¿Hacer o no hacer pruebas de detección?

exploring the HEART of health maintenance

I appreciate all of you who are following Watercress Words, and if you aren’t I invite you to join the wonderful people who are. You can meet some of them in the sidebar, where you can click on their image and visit their blogs. Use the form to get an email notification of new posts. Don’t worry, you won’t get anything else from me.

I appreciate all of you who are following Watercress Words, and if you aren’t I invite you to join the wonderful people who are. You can meet some of them in the sidebar, where you can click on their image and visit their blogs. Use the form to get an email notification of new posts. Don’t worry, you won’t get anything else from me.

RoboForm Password Manager. What I use to manage passwords.

Go to this link to try RoboForm Free; if you like it you can upgrade to RoboForm Everywhere version with all the features I mentioned above. With Roboform, you will have one less thing to feel stressed about.

Health blogs you should read- blogs by docs (part 1)

These blogs open a window into the medical community. You may be surprised that physicians have the same concerns about health and medical care as you , and some that you are unaware of. Most importantly, you will find they are on your side; they care about you,their patients, probably a lot more than you care about them.

Why read Health, Fitness, and Medical blogs

Since I started blogging I have reviewed many health, fitness and wellness blogs. I find most of them interesting and/or entertaining. I find a few of them informative, stimulating ,and valuable.

  • health bloggers who write about their personal experience dealing with a particular medical condition, which I think can be powerful and helpful.
  • bloggers who discuss and promote a particular lifestyle or product that they believe has value to health and/or fitness.
  • blogs written by people with training and experience in some aspect of medical care, wellness, fitness and/or nutrition (all of which I define broadly)

I think all of these blogs have a place and all seem to have their audience. One of the first things I check when I read a blog is the “about” section, or its equivalent. I want to know who writes the blog and what their credentials are. Anyone who writes a blog about a particular topic should clearly and accurately state their credentials for that topic, or lack of, if that’s the case. (I state my credentials on the page “Meet Dr. Aletha”)

Health blogs worth reading

In this blog series, I tell you about health blogs that I think are worth reading. Most of them are written by physicians, medical scientists, other health professionals and affiliated professionals. Persons who spend the majority, if not all, of their adult life studying and pursuing a discipline, likely know that subject well.

I recommend these health blogs because they

  • offer valid medical information on a variety of topics.
  • offer sound advice without quick fixes.
  • discuss common everyday health concerns
  • discuss the healthcare system, how it works well and how it doesn’t.
  • offer insights on healthy living, both as individuals, families and a society.
  • show you how physicians think , feel and act , both as persons and professionals
  • will educate and challenge you.

These blogs open a window into the medical community.  You may be surprised that physicians have the same concerns about health and medical care as you , and some that you are unaware of. Most importantly, you will find they are on your side; they care about you,their patients,  probably a lot more than you care about them.

These bloggers’ viewpoints often surprise and challenge me; I don’t always agree with them and you may not either.  By recommending them, I don’t endorse their opinions, nor do I benefit financially.  

“Alert and Oriented”

the progress notes of Michel Accad, M.D.

(Doctors write progress notes  in the charts of hospitalized patients to document medical treatment and response each day)

Dr. Accad is a cardiologist and internist in solo private practice and teaches at the University of California San Francisco.

” ‘Alert and Oriented’ is a medical phrase that describes the mental status of a patient who, despite being in serious shock from trauma or disease, maintains clarity of mind and focus of thought.

EKG tracing of heart activity on a cardiac monitor.
Based on the heart rhythm, this patient is likely alert and oriented.

Sadly, the medical community enmeshed in today’s health care system is like a patient in acute shock. The only chance to survive is to remain alert and oriented.” (quote from the blog introduction)

Dr. Accad blogs about the healthcare system, the doctor-patient relationship, medical ethics, medical economics, and health care policy.

In this post he explains the

evolution of the food pyramid to the healthy plate nutrition recommendation.

healthy plate of vegetables , pita bread and hummus

In another interesting post, he explains

why mammograms may be over diagnosing breast cancer.

Breast cancer screening and treatment: One size doesn't fit all. bras hanging on a clothes line

The Accad and Koka Report podcast

Dr. Accad has joined Anish Koka, M.D. in a weekly medical podcast, The Accad & Koka Report. In their own words,

We discuss current topics in medical science, policy, economics, and ethics, always with an eye toward safeguarding the doctor-patient relationship .

Their conversations are aimed more at physicians than patients, but if you want to know what some physicians really think about the U.S. healthcare system, you might find out here. Here is an episode anyone might find interesting-what happened when a 90 year old patient of Dr. Koka was told

“You’ll be dead in a year”- A Patient’s Journey though the Healthcare System

exploring the HEART of health

I appreciate all of you who are following Watercress Words, and if you aren’t I invite you to join the wonderful people who are. You can meet some of them in the sidebar, where you can click on their image and visit their blogs. Use the form to get an email notification of new posts. Don’t worry, you won’t get anything else from me.

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