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The “Master” health check-up

Too much of a good thing

22 March 2009
H-Health check ups

A fter relentless nagging by

your spouse, you have finally When a little is good, a lot is not better
gone through a “Master Health Periodic health check ups are
Check-up” and are greatly recommended with the belief that early
relieved to learn that you came diagnosis and treatment can favourably
through unblemished. An alter the outcome from many of the
impressive array of medical diseases of ageing and degeneration that
hardware was deployed. You are are common today. Despite enthusiastic
reassured by the knowledge that advertising, there is evidence that the number of
science and technology, in the tests needed is small, simple and inexpensive.
space of less than a century,
has given us the means to look
at ourselves in minute detail: to the level even of the code that determines why we are the way
we are. No other living organism has the ability to understand its own inner workings.

Rationale of the “Master” health check up

Diseases of ageing and degeneration (non-communicable diseases) have replaced infections as
common causes of illness and death in modern societies. These diseases have a long quiescent
stage when there are no symptoms. Left untreated, over the years, they will progress to
complications that can be difficult to treat. If a test can detect these diseases in their pre-
symptomatic stage, then prompt institution of measures might decrease the costs and morbidity
associated.
So far so good. The scheme, however, fails in its execution for several reasons: too many tests,
ordered too often, for unproven reasons, driven by non-medical incentives.
There is clear evidence that the package needs to consist only of a handful of simple, cheap
interventions. Adding more is unscientific and wasteful.

Essential components of a
routine health check up
Although common wisdom might
suggest that the more tests
obtained, the greater is the
likelihood of picking up disorders
in their early stage, the evidence
clearly runs counter intuitive. A
routine health check up needs to
include only a limited number of
simple, inexpensive interventions.
The chart alongside lists them.
Loading the list with more costs
money but yields no benefit.
Recommended panel of tests
✪ Head-to-toe physical examination
✪ Body weight, body mass index (BMI), waist and hip
circumference measurement
✪ Blood pressure
✪ For women: Breast examination & Pap smear
✪ Blood sugar – fasting and 2-hour postprandial
✪ Lipid profile (cholesterol panel)
To date, there is no evidence that additional tests are
of benefit

The Master health check-up: too much of a good thing?

© Dr Arjun Rajagopalan
1
 PUSH Post

Recommended schedule of testing

✪ 35 – 60 years – every 5 years (If the check up is normal).
✪ After 60 – every 2 years (If the check up is normal).
Follow your doctor's advice if any abnormality is detected on the check-up

See a doctor promptly for the following:

At any time, there are some
Red flags: see a doctor promptly for these events warning signs that should never be
ignored. Even though many of
these situations are due to simple
✪ A fever persisting beyond 10-15 days.
problems that can be easily
✪ Unexplained weight loss. resolved, postponing seeking
✪ Sudden appearance of a lump. medical help could be dangerous.
✪ Change in the nature of a stable lump or mole. All of these are warning signs that
✪ Bleeding from any body cavity – sputum, urine, motion, should not be ignored even if a
vaginal. recent health check up was
normal.

Tests of doubtful value

It is common to see a large number of additional tests added to the panel under the mistaken
belief that more is better. They are of no proven value and will only increase the cost to the
patient.
Say “NO” to

TEST WHY?

Resting ECG (Rs 125) False negatives: The ECG can be normal in the presence of
significant coronary artery disease – 25-30% of patients with heart
attacks have had previous normal ECGs.

Stress ECG (Rs 750)
False positives: A positive test can occur in the absence of
disease. Stress ECG (treadmill testing) should never be a part of a
routine health check up. It should be ordered, preferably by a
specialist, only after a careful history suggests the presence of
coronary disease.

X-ray chest (Rs 175) Limited value in non-smokers and those without lung problems
like asthma or bronchitis.

Liver function tests (Rs 300) Can be normal in the presence of liver disease.

Lung function tests (Rs 500) Very poor correlation with lung status.

Abdominal ultrasound (Rs 500) Will pick up “abnormalities” of no significance. Ultrasound scans
are not sensitive enough for early diagnosis of many disorders of
the abdomen.

A firm, polite refusal will save Rs 2,500 with no danger to the person

The Master health check-up: too much of a good thing?

© Dr Arjun Rajagopalan
2
 PUSH Post

Appropriateness of usage – the crux of the problem

A bewildering array of medical tests are available today; the range is so large that doctors
themselves are inadequately informed about the capabilities and limitations of many. A
“shotgun” approach is used to compensate for lack of precision in knowledge.
Inappropriateness of medical testing arises from:
● Too many tests,
● Ordered too often,
● For unproven reasons,
● Abetted by unethical motives.
Too many tests: Doctors tend to think of tests in panels: several investigations clustered under
a common label. Complete blood counts, liver function tests, kidney profiles and lipid panels
are some common examples of this panel approach to testing. This shorthand saves time but is
wasteful. Quite often, the whole panel is ordered when only a small subset is necessary. It
requires time and thought to pick only those tests that would contribute information to the
patient's management. Under the guise of being thorough and not missing important findings,
doctors commonly order more tests than are needed. The practice of defensive medicine – all
too common in this age of frequent medical litigation – heightens the tendency to over
investigate.
Ordered too often: When a test is abnormal, the doctor prescribes a treatment, and
periodically orders the same test to monitor the degree of response. This is good medical
practice. The problem arises when tests are ordered more often than they need to be.
Unproven reasons: Medical textbooks will state explicitly the “indications” for ordering a test.
Where the value of a test is in doubt, they will say so, and either recommend against or issue
caveats regarding its use. Doctors commonly order tests, with scant regard for guidelines, using
various excuses: pursuing a hunch, relying on personal (but unverified) experience, conceding
to the demands of patients, and worst of all, following the recommendations of sales
representatives.
Unethical motives: The provision of incentives to doctors to order tests – monetary, physical
and otherwise – is reprehensible and deserves to be condemned in the strongest language. Yet,
it is all too common. Commissions and kick backs are rampant. The patient suffers because it is
his money that is being taken to provide the incentive to the doctor for no service at all; worse
still, when it is to bear an expense that may not be medically necessary,
The patient has no protection against being made a victim of these practices. He has to trust
his doctor implicitly and follow recommendations with the hope that the doctor will always do
the best for his patient. It is in this respect – the fiduciary responsibility that the doctor takes
on behalf of the patient – that thoughtless and unethical ordering of investigations constitutes
an unpardonable medical offence; and is so difficult to control and correct.

TRY THIS ONE OUT FOR YOURSELF – INDIA SHINING

Perform a Google search on “master health check”.
Repeat using “master health check + India”. Make your own conclusions.

The Master health check-up: too much of a good thing?

© Dr Arjun Rajagopalan
3