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Health Information An Expert Opinion: When to Test and When to Treat

Sometimes less is more when it comes to health care.

Modern medicine has given us many marvels. Robots that help perform minimally invasive surgeries, limb transplants, laser treatments — and the list goes on. Advances in health care have also led to thousands of tests that can detect many diseases and conditions, as well as effective treatments to fight a wide range of illnesses. But while it seems like more testing and more treatment would be better for our health, that is not always the case. "Sometimes less testing and less treatment can actually result in better health care," says Steven Rothschild, MD, a family medicine practitioner at Rush University Medical Center.

Discover Rush Online asked Rothschild to answer some questions about common tests and treatments — and to explain how taking a more conservative approach to health care can, at times, be the best approach.

Q: What is the downside to having so many diagnostic tests available?

A: There is absolutely a place for testing. Early detection and prevention efforts are extremely important in treating and preventing a number of diseases andconditions. But many tests have inherent risks to them. There is radiation in X-rays; patients could have a bad reaction to dye used in certain imaging tests like MRI; and medications can have negative side effects. While risks are often rare, there is very little testing you can do with no risks. So the more of these tests that you have, the more risks you accumulate.

Q: So how can people decide whether or not to get certain tests?

A: For each situation, physicians need to help patients determine when to test and when not to test. Every person is different and there is not one correct answer. That's one reason why it is important to have a good relationship with your physician. Being open and honest about your health, family history and lifestyle can help your physician determine the best course of action. Determining whether or not to test for or treat something depends a lot on your risk for the problem. False positives (when test results incorrectly show that you have a disease or condition that you do not have) can lead to further, more invasive testing and unnecessary mental anguish of wrongly believing you have a certain disease or condition.

One of my jobs as a physician is to figure out if people are in higher risk groups for certain conditions. If a person is in a higher risk group, the risk of false positives from testing is much lower. If a person is in a low-risk group, the risk of false positive is much higher. Without that information, physicians can’t interpret tests or assess the likelihood that the test will be a benefit.

Q: Let's discuss some common health tests and treatments. When should people typically get their cholesterol checked?

A: The American Heart Association recommends that all adults age 20 and older should have a fasting lipoprotein profile, which measures total cholesterol, low-density lipoproteins (LDL), high-density lipoproteins (HDL) and triglycerides. This test should be done once every five years for healthy adults who feel otherwise fine. If your cholesterol is high, your doctor will put together a treatment plan and will likely order follow-up testing to see if the treatment plan is working to lower your cholesterol.

In addition to getting your cholesterol checked, it's important to stay on top of your blood pressure. High cholesterol and high blood pressure are two of the biggest risk factors for heart disease, which is the No. 1 killer in this country. If you are trying to keep healthy, those two factors are pretty good markers of where you stand and what your risk is for developing heart disease. Healthy adults should have their blood pressure checked every one to two years, and those with high blood pressure should discuss necessary follow-up testing with their doctor.

Q: When should people consider taking cholesterol-lowering medications?

A: Cholesterol-lowering medications (statins) are important. The introduction of these medications led to a dramatic plunge in the number of heart disease deaths. While an emphasis on blood pressure control and the risks of smoking certainly have helped lower heart disease deaths, statins have saved more lives than anything. There is a definite place for them.

That said, you have to look at the whole picture. Rather than immediately putting someone on medication, I would absolutely rather start treating someone with high cholesterol by taking an aggressive approach to lowering fats in their diet and increasing physical activity — that's assuming that their lifestyle is contributory to their high cholesterol. Of course, not everyone's lifestyle contributes to their high cholesterol; there are often genetic factors and other things at play. In those cases, getting on medication is the best course of care. But for the vast majority of people with high cholesterol in this country poor diet and lack of exercise are the problems — and modifying those things is where treatment should begin.

Q: How do you determine when women need mammograms ?

A: Mammograms are very important for women over 50. But between ages 35 and 50, it is more controversial. It's not that a woman who is 35 is less important than a woman who is 50, and it doesn’t mean that there is no risk for developing breast cancer at 35 (though the risk is typically low). Rather, it is about the limitations of the test itself. Mammograms are not as accurate in detecting tumors in dense breast tissue (that has less fat and more glandular tissue), which is much more prevalent in a 35-year-old woman compared a 50-year-old woman. Therefore, the test itself is not as accurate and does not make as significant of an impact in detecting breast cancer in younger women as it does in women over 50. That can then lead to unnecessary breast biopsies, which can be stressful and uncomfortable.

However, women who are at a high risk for developing breast cancer — including those who have a family history of breast cancer or the BRCA1 and BRCA2 genetic mutations — should start getting mammograms at 40 or earlier depending on their doctors' recommendations. Discussing your family and health history with your doctor helps him or her determine the most effective time for you to start getting mammograms

Q: When should women get a bone density test ?

A:Healthy women at menopause and others at risk should get their bone density tested once around the start of menopause. If the test detects osteopenia (often a precursor to osteoporosis) certain medications can be very effective at preventing osteoporosis. So I encourage bone density testing, but it is not one of those tests that women need to have annually. However, if the test detects osteopenia or osteoporosis, I recommend repeating the test in two to four years to monitor any changes.

Q: How has the standard of care for treating common conditions like sinus infections changed over the past five years?

A: Sinus infections can be difficult because if you're missing work and feeling really lousy, you want to do something to get better. According to the Infectious Diseases Society of America, sinus infections are the fifth leading reason for antibiotic prescriptions. Yet, 90 to 98 percent of sinus infection cases are caused by viruses, which are not affected by antibiotics. As more and more studies show that antibiotics do not change the course of acute sinus congestion, doctors are moving away from prescribing antibiotics for sinus infections. The best ways to treat sinus infections caused by a virus include using pain relievers to relieve sinus pain, doing saline irrigation with a neti pot and drinking plenty of fluids.

People need to understand that testing for and treating conditions are selective processes. When there is strong evidence supporting the effectiveness of a test or the treatment, patients can feel OK about getting that test or taking that medication. But there is so much information available that it can be hard for people to figure out what they need and what they don't need.

That's why the relationship with your doctor is so important; he or she can help you make the best decisions for your health. Often people are intimidated or uncomfortable talking to their doctors and being honest about how much they exercise, their diet, whether or not they smoke or drink. So it is important to find a primary care doctor whom you can talk to and trust implicitly. Your doctor needs to know as much about you as possible in order to provide you with the best care.


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Please note: All physicians featured in Discover Rush Online are on the medical faculty of Rush University Medical Center. Some of the physicians featured are in private practice and, as independent practitioners, are not agents or employees of Rush University Medical Center.

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June-July 2013


 

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