Preventive Medicine for the Rich and Famous

There is an unstated assumption in healthcare that more care is better care. The truth is that just because healthcare is good doesn’t mean that more healthcare is better. Studies in fact show that areas of the U.S. in which there are more specialists, more healthcare technology, and more healthcare utilization are no more healthy than areas of the U.S. that use less healthcare. While it is self-evident that a certain level of healthcare is better than none at all, the benefits of increasing levels of healthcare probably stop much sooner than we think.

This assumption is just as prevalent in preventive medicine as in other areas of medicine. One only need to look at the growth of Executive Health programs to see that people equate more preventive care with better care and are willing to pay a premium for it. To the unfamiliar, Executive Health programs are comprehensive healthcare programs often housed at top medical institutions as a means of attracting high-end clientele. In exchange for a large fee, these programs provide executives and otherwise wealthy individuals with comprehensive healthcare and unfettered access to the institution’s faculty and resources. In addition to offering the convenience and efficiency of coordinated care, Executive Health programs simply offer more medical care than standard primary care practices. Many employ CT scans and expensive laboratory tests as a means of routine screening and offer ancillary services such as massage therapy and exercise physiologists as a standard package.

Feet away from where I practice and take care of general medicine patients is my own institution’s Executive Health program. The following list of standard preventive services were obtained directly from the University of Chicago’s Executive Health Personalized Health and Prevention website (accessible at http://www.ucmc150.uchicago.edu/exec_health/):

Your comprehensive screening and testing will include:

• Physician history and examination
• Comprehensive lab services
• Dermatology skin screening
• Hearing and vision testing
• Pulmonary function
• Cardiology: EKG and stress testing
• Registered dietitian consultation
• Exercise physiologist consultation
• Personalized Health Portfolio review with your program physician

We will add further tests by request from your physician or as needed based on the program physician’s assessment of your current health status.

In comparison, the “only” preventive health services from this list that I provide in my clinic are physical history and examination, lab services (although not nearly as comprehensive), and if certain medical conditions are met referral to a dietitian. As a dedicated general internist the question I had to ask myself is are my patients getting worse care than their wealthy counterparts down the hall? Is preventive health for the rich and famous better than that for the average Joe?

The most rigorous, widely accepted recommendations in preventive medicine are those made by the U.S. Preventive Services Task Force (USPSTF). The USPSTF is a body of experts convened by the U.S. Department of Health and Human Service for the primary purpose of making impartial assessments of the effectiveness of clinical preventive services. Surprising to most people is that the USPSTF does not take cost into account. They simply view the evidence (data from clinical trials and medical studies) and ask does the known benefits of a preventive service outweigh the harms. Preventive services for which the benefits or harms are unknown or for which the harms exceed the benefits are not recommended. Simple as that. Thus the USPSTF does not recommend screening for lung cancer in smokers with CT scans or x rays not because it’s too expensive or because the benefits do not justify the costs, but because to date there has been a paucity of evidence demonstrating any benefit to such screening programs. To put it more simply, no one has proven that screening for lung cancer actually saves lives and so they don’t recommend it.

The USPSTF thus provides a metric by which to compare the preventive medicine I practice in my clinic to my institution’s Executive Health program. Let’s compare point-by-point:

- Dermatology skin screening: In 2009, the USPSTF re-confirmed its grade “I” recommendation on using whole-body skin examination by a primary care physician for the early detection of skin care. (“I recommendation” means that the data are insufficient to assess the balance of benefits and harms. In other words, they do not recommend it routinely.)

- Comprehensive lab services: The USPSTF makes an I recommendation on most elements of the comprehensive lab testing listed on the Executive Health website including thyroid screening, diabetes screening (unless blood pressure is greater than 135/80), and anemia screening (except in pregnancy). With the PSA test for prostate cancer screening, the USPSTF recently re-affirmed its I recommendation for men younger than 75 years and in men over 75 actually recommend against it (“D recommendation,” meaning that there is moderate to high certainty the service has no benefit or that the harms outweigh the benefits).

- Hearing and vision screening: The USPSTF is currently updating their recommendation about screening for hearing disorders in adults (their most recent statement dated in 1996 found limited evidence to support such a recommendation). For glaucoma vision screening, the USPSTF has an I recommendation.

- Pulmonary function: The USPSTF recommend against screening for chronic obstructive pulmonary disease (COPD) using spirometry (D statement). It has not evaluated other forms of pulmonary function testing.

- Cardiology (EKG and stress testing): The USPSTF recommends against screening for coronary heart disease with EKG, exercise treadmill test, or CT scanning for coronary calcium (D statement). Not only did they conclude that such testing did not improve health outcomes, but also that they are harmful and lead to unnecessary invasive procedures, over-treatment, and labeling.

- Registered dietitian consultation: The USPSTF recommends intensive behavioral dietary counseling for adults with cholesterol disorders and other known risk factors for cardiovascular and diet-related chronic disease (“B recommendation,” meaning that there is at least fair evidence that it improves health outcomes and that the benefits outweigh harms). For individuals without any of these risk factors they make an I recommendation.

- Exercise physiologist consultation: The USPSTF has not evaluated exercise physiology consultations. However, in 2002 they concluded that the evidence was insufficient to support behavioral counseling to promote physical activity (I recommendation).

In summary, none of the preventive health services offered by the Executive Health program not offered by my clinic have sufficient evidence supporting their routine use. A few of the services they offer in fact have reasonable evidence showing that they do not improve health and in the case of screening for cardiovascular disease evidence showing that they cause harm. Even more concerning is the absence of other preventive health interventions such as tobacco cessation and adult vaccine administration that have been demonstrated to improve health and are supported by the USPSTF. While it is reasonable to assume that these services are in fact offered by the program, it is not hard to imagine their importance being downplayed in favor of more technologically involved though less proven interventions such as cardiac stress testing.

In reality, deciding which preventive health services are proven depend on your definition of proof. The USPSTF demands the highest burden of proof and so tends to make fewer recommendations. Other well-respected medical institutions such as the National Cancer Institute and the American College of Cardiologists often make recommendations that go beyond those made by the USPSTF largely because their standards are less stringent. And then there are physician practices and advocacy groups that make recommendations based on even lower thresholds of proof, sometimes as little as a single medical study or even anecdotal data. Thus what is not recommended by the USPSTF may well be recommended by another expert body or physician.

Given this variability in definitions of proof, my approach to preventive medicine is a practical one. At the minimum do all those preventive services for which the evidence clearly shows there is benefit and that the benefit exceeds the harm (in short those recommended by the USPSTF). If you want to do more then by all means go ahead (assuming the evidence does not show the service to be more harmful than beneficial), but not at the expense of neglecting those preventive services that are actually proven.

The rich and famous may have nicer cars and larger bank accounts, but they need not have better preventive health. I may not be able to greet my patients with a professionally brewed cup of coffee or offer them a personal masseuse after their physical, but with hard data by my side, I know that I can at least provide them evidence-based, thoughtful preventive care. It seems that in preventive medicine as in many arenas of life more does not necessarily mean better.

- Shantanu Nundy, M.D.