Originally published in The Ottawa Citizen August 26, 2003
Original Title: Under the hood

The human body is like a car with its own built-in obsolescence. With proper care and maintenance, we can extend the quality and years of life. Cars are a good example of how benign neglect can lead to numerous breakdown and repair cycles until the car eventually falls apart.

Indeed, women seem to be more aware of this reality than men are. Women take better care of themselves and actively participate in preventing negative health consequences. Men usually wait for the car to break down before driving, pushing or towing it to the nearest garage never asking for directions along the way. It is usually through firm persuasion from their partner that men will pay a visit to their doctor.

Regularly scheduled maintenance is important for disease prevention and wellness promotion. However, not all people require the same diagnostic tests, treatment or reparative procedures.

The longstanding tradition of complete “physicals” is a waste of healthcare dollars. There must be evidence to prove that medical interventions, procedures, counseling, social service strategies, behaviour modification techniques and treatments are effective at each stage of a person’s life. This approach follows the central tenet of “do no harm”.

Patients, through no fault of their own, think that a complete physical exam gives them a ‘clean bill of health’. Taxpayers foot the real bill for a medical service that does not yield useful results. Indeed, routine physicals, x-ray tests, wide spectrum blood tests and other procedures that scans for potential disease is like walking with outstretched hands in the dark. You may feel something but you are not sure what it is. It may be safe or potentially dangerous. The only way to know is feel around further to try to ascertain risk.

Routine testing is fraught with false positive results. These results oblige the physician to forge ahead with further testing to prove or disprove the veracity of the initial test. Patients unnecessarily experience fear and angst. So much for “do no harm”.

Focused regular examinations targeting age-specific risk factors provide information that is more relevant.

The Canadian Task Force on Preventive Health Care (http://www.ctfphc.org/) helps fulfill this role. The Task Force rates a wide variety of preventive health interventions using evidence-based research and recommendations. They try to answer whether these procedures provide accurate, reproducible and clinically relevant results. Other health prevention organizations use this information to target their specific clientele.

The Task Force determines the relevance and evidence of certain procedures, examinations and data collection based in part on age, race, family history and past medical history.

It applies a letter grade rating scale to define the usefulness of each medical procedure, screening test and physical examination process for specified age groups.

For example, a common test many assume to be of value is a chest x-ray to screen for lung cancer. The Task Force rates this as “fair evidence to exclude” (a “D” grade) from an annual physical exam because it does not reduce lung cancer rates.

The Task Force breaks the population down into to specific categories: prenatal and perinatal, pediatric, men and women 21 to 64 years of age, pregnant women, men and women greater than 65 years and patients with first degree relatives with disease.

The 21 to 64 year old age range subdivides further. For example, colon cancer screening usually begins at age 50 and not earlier because there is little evidence to support colonoscopy in a younger patient with no family history of the disease.

The content of your annual general check-up may vary over time because of these different categories and targeted goals.

Let us look at newborn care and the recommendations for a woman over 65 years of age.

Newborn care is an area that benefits from the incorporation of these criteria into clinical practice. The “A” recommendations include checking for a “lazy eye” (amblyopia), child maltreatment, hip dysplasia, a hearing exam, childhood immunizations (tetanus, diphtheria, polio, whooping cough, hemophilus influenza B, hepatitis B and chicken pox), checking for disorders of physical growth, iron deficiency, exposure to tobacco smoke and counseling parents for injury prevention.

Specific recommendations for women over 65 include ongoing screening for breast cancer, testing for cognitive deterioration or impairment, evaluation of falls and injuries, treatment of high blood pressure, providing pneumococcal pneumonia vaccine (pneumovax) and an annual influenza vaccine. Other recommendations include treatment and prevention of osteoporosis, hearing tests, PAP smears for cervical cancer screening, prevention of household and recreational injuries and vision testing.

A screening test often ignored asks patients whether they wear their seat belts and how they position the belt and whether they use a helmet when cycling, rollerblading, skiing or skate boarding. Automobile and sports injury rates outnumber some common disease rates.

There is also fair evidence (“B” grade) to support the effectiveness of advising regular physical activity for the primary prevention of cardiovascular heart disease and hypertension, obesity, type 2 diabetes and osteoporosis.

These lists are by no means complete. They provide a framework for care. The website has detailed information and reports that explain why they are included or rejected as therapeutic or diagnostic options.

I recommend a visit to the Task Force website to review what maintenance schedule you should be following. Bring this information to your next scheduled check-up. Both you and your doctor can develop a five or ten year health prevention and treatment plan tailored specifically for you.

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© Dr. Barry Dworkin 2003