Many medical organizations have recently been promoting focused and individualized lab testing for routine screening or when pursuing a diagnosis. Research has shown that the “shotgun” approach to lab testing usually leads to further invasive testing which has not been proven to significantly alter morbidity or mortality.
Additionally, tests rely on pre-test probabilities and can have false-positive or negative results and even lead to adverse events from the follow-up testing. In response to this, medical organizations have created many resources to help educate and guide physicians from over-testing. The American College of Physicians (ACP) created a high-value care subdivision that discusses many evidence-based approaches to provide the best possible care while reducing unnecessary costs. The American Board of Internal Medicine (ABIM) created Choosing Wisely which is a resource in which many medical organizations create evidence-based suggestions to help guide patient care. For example, in Choosing Wisely, the American Association for the Study of Liver Diseases (AASLD) recommends not repeating hepatitis C viral load testing outside of antiviral therapy. The American College of Rheumatology recommends not testing for ANA sub-serologies if the ANA is not positive and there is low clinical evidence or suspicion of immune-mediated disease.
The goal of Choosing Wisely is, to reduce medical overuse/misuse, reduce patient harm and to provide better patient care. There are currently around 490 recommendations from many different organizations. Some recommendations are quite useful and should be instituted, while others should be followed with caution. One potentially problematic recommendation comes from the Society of General Internal Medicine that states:
For asymptomatic adults without a chronic medical condition, mental health problem, or other health concern, don’t routinely perform annual general health checks that include a comprehensive physical examination and lab testing.
This statement could prove detrimental and, in my opinion, may lead physicians to miss important diagnoses. Many “healthy” people do not physically display evidence of disease but in fact, may have laboratory evidence of something slowly going awry. The iceberg theory states that an iceberg has only 10 percent of its mass protruding above the water, while the remaining 90 percent is underwater. This theory relates to patient care in many ways. An illness usually starts off slow and remains “underwater” for a considerable amount of time. It is at this time that physicians can make the biggest difference by catching the disease early before the final “10 percent” surfaces. In my practice, I have uncovered many diseases in young and otherwise healthy patients who did not display any outward signs of disease. Had I not tested these patients, I would not have uncovered the asymptomatic diseases that were slowly wreaking havoc. I have been able to diagnose patients with familial hyperlipidemia, completely asymptomatic full-blown diabetes mellitus, anemia, pre-diabetes and liver diseases (specifically fatty liver diseases). By catching these diseases early, I have been able to counsel my patients and even start them on a medication as deemed appropriate. Additionally, I have noticed in my institution in particular, that much effort is made into not testing or not screening, that physicians, particularly the ones in training, miss diagnoses or get confused on which patients actually warrant further testing.
In the USA, the incidence and prevalence of fatty liver diseases such as nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) have significantly risen. The only way to properly diagnose such diseases is with liver chemistry tests and imaging studies such as a liver ultrasound. If we are strictly trained to order fewer tests on asymptomatic patients, I fear that these diagnoses will be missed. If left untreated, such diseases can eventually lead to liver fibrosis and cirrhosis. Current treatment options for NAFLD and NASH are aimed at avoiding further liver damage, immunizing against hepatitis A and B and instituting lifestyle changes (although many more are in the pipelines).
In conclusion, limiting the amount of unnecessary or wasteful testing is important as is screening patients for asymptomatic diseases. I am a proponent for using health resources wisely, but I also want to be thorough and not miss catching a silent disease in my patients at an earlier juncture where an intervention will alter the course of the disease. My suggestion is that we should continue screening patients for diseases such as liver disease, diabetes, high cholesterol and anemia even in the absence of symptoms as they may not be present.
Additionally, abnormal labs can be used as a tool to counsel patients on lifestyle changes and give feedback on how the changes they have instituted affected their labs. This does not mean that it has to be done yearly but can even be spread out every few years. For example, if I find that a lab test is normal or stable, I will spread out the testing time to a few years if appropriate. I believe that by doing so, we can catch diseases earlier, help counsel our patients and help prevent the iceberg from progressing to its full mass.
Shmuel Golfeyz is an internal medicine physician.
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