What's the difference between diagnostic tests and screening tests? How do doctors decide which ones you need? Why are some conditions under-screened or over-screened for? And where do you turn for answers?
Host Jonathan Fialkow, M.D. sorts out the facts with guest Douglas Inciarte, M.D., chief of family medicine at West Kendall Baptist Hospital.
What's the difference between diagnostic tests and screening tests? How do doctors decide which ones you need? Why are some conditions under-screened or over-screened for? And where do you turn for answers?
Host Jonathan Fialkow, M.D. sorts out the facts with guest Douglas Inciarte, M.D., chief of family medicine at West Kendall Baptist Hospital.
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Dr. Jonathan Fialkow:
Welcome back Baptist Health Talk podcast listeners. Hope you're all masking up and staying safe. I'm your host, Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at the Miami Cardiac and Vascular Institute and Chief Population Health Officer at Baptist Health South Florida.
Dr. Jonathan Fialkow:
For today's podcast we're going to discuss health screenings. Which ones to get, which ones to skip. We talk about prevention quite a bit in healthcare. We say that people should always get proper preventative care. We raise concerns when we say that more money and attention should be spent on preventative services rather than what we tend to do, which is wait for people to get sick and take care of them. But what do we mean when we say prevention? I had this conversation with my patients all the time. Well, arguably it's when we as healthcare practitioners will look at someone who looks stable, doesn't have symptoms and say, "Is there anything going on right now that can cause problems in the future, that's preventable?"
Dr. Jonathan Fialkow:
And of course, what do we ultimately want to prevent? Well, that's death. We won't be able to prevent death, but we'd like to delay it for a long time and make sure it's on our own terms. And we want to maintain a good quality of life during that time period. Which brings us to the concept and the understanding of screening tests and how th ey can sometimes be confused with diagnostic tests.
Dr. Jonathan Fialkow:
In the United States, we do have medical guidelines for several high value screening tests for things like colon cancer and cervical cancer, osteoporosis, and more. Yet, we tend to under screen certain conditions and over screen and test others. Here to help us unpack the confusion and give guidance about the proper indications and timing of screening tests is Dr. Douglas Inciarte. Dr. Inciarte has many credentials and roles within Baptist Health, which include he's the director of the West Kendall Baptist Health Florida International University Family Medicine Residency Program. And he's the Chief of Family Medicine. He's also an associate professor of family medicine at the Herbert Wertheim College of Medicine at FIU. Welcome, Doug.
Dr. Douglas Inciarte:
Jonathan, a pleasure being here. Thank you so much for inviting me to this podcast.
Dr. Jonathan Fialkow:
Great. And I'm sure we're going to have a good dialogue. So you know, you and I have these conversations often, but for our listeners, let's start with some basics. Why do we screen, why do we take someone that looks good and say, "We're going to have you do a test or we're going to do something to you? Ostensibly I feel good. Why don't you just leave me alone? What's the purpose of screening?
Dr. Douglas Inciarte:
Yes. The purpose of a screening is basically to prevent. Prevent, and as part of the preventative care. To include also catching, if there's any decline in the health of the individual. -----It's also part of knowing if you have a disease you had the disease. So it helps a lot the again, prevention, and it has to be as well with preventing future health decline in the patient.
Dr. Jonathan Fialkow:
So when we talk about this early detection of something that could be preventable, there's a lot of things that are sold as screening tests to people in the community. What really makes a good screening test? When we as practitioners or a medical organization say this is something that should be done in people periodically, what differentiates those screening tests from all the things that people say, "Just do this every year and get this done or spend money on this test?"
Dr. Douglas Inciarte:
Yeah, it's an interesting question. So number one, it has to be with benefits. Is this really, this test is going to give you benefit? Is going to give you the real information that you're going to need? Second, is this something that it's going to not going to give any harms? So a testing that you don't have to do that is going to create harm to the patient. And then of course the cost. This is something that is going to give you the cost is going to give you the information and the benefits with no harms.
Dr. Jonathan Fialkow:
So arguably, when we talk about things like, "Let's just do a cat scan on everyone every day of their whole body and we'll pick something up," but not safe. A lot of radiation. Very costly. So in the equation of what to do includes as you just articulated, costs, safety, other components, otherwise just look for everything at all times. And I appreciate that.
Dr. Jonathan Fialkow:
Something that I as a cardiologist always reference is, and I mentioned it in the introductory comments. Before we get to particular screenings, this was screening tests the diagnostic tests. And the example I always use is a stress test. People come in and say, "Time for my stress test?" No. A stress test properly is if you have symptoms that could be heart-related, the stress test will diagnose it, but it's not a test to do just regularly. Might have false positives, which makes it... I mean, abnormal with nothing really going on, which makes a safety issue. Not cheap. So how would you look at the difference when people come to you between a true screening test, which you recommend, versus a diagnostic test, which arguably doesn't need to be done routinely?
Dr. Douglas Inciarte:
So again, it has to be with a, "Do you have the disease? Yes or no? Do you have symptoms? Yes or no?" When you have symptoms, that's when diagnostic testing is going to be allowed do you have shortness of breath? Do you have chest pain? Do you have symptoms that actually I can feel like you're going to need to have an extra testing, which is going to actually prove if you have the disease or not. And in those cases we look at it in the scientific world, when we go to med school, sensitivity, specificity, right? When you're talking about specificity, which in other words is, "Do you really have the disease?"
Dr. Douglas Inciarte:
But in than a precedent of symptoms, then we utilize some diagnostic testing. And there's examples where we actually do both. You mentioned the colonoscopy. Colonoscopies, we'll give you a screening, but also diagnostic because you're actually right there, you can actually take a piece of your intestine if you have a polyp in the case of a patient. And then of course you can have the pathologist to tell you this is really something that needs more attention.
Dr. Jonathan Fialkow:
So that's a great explanation. And again, I really want the listeners to think about something that's being done as a first screening or for diagnosis and don't confuse them. So let's go through some of the main screening type of tests that we recommend for people. You mentioned colonoscopy, let's start with that. When should it be done? How frequently? What would you say to someone who says, "Well, I'm concerned about X, Y, and Z." What's what's your experience in that standpoint? So let's start with colonoscopies.
Dr. Douglas Inciarte:
Excellent. So the colonoscopies now with the recent guidelines from the USPSTF, which is, for our audiences, is the United States Preventative Service Task Force. Which is basically our grow in the country and even in the world of what to do in terms of screening and guide as what's appropriate based on your age and risk factors. So nowadays actually colon cancer screening is age 45, just came a month ago or so. And when typically was 50. And nowadays it's 45 years old. So one of the ways to do against screening and diagnostic is the gold standard, which is a colonoscopy.
Dr. Douglas Inciarte:
Now there's other testing also that we offer in the office which is a fecal blood test. Fecal, called blood test, which is done every year. It's basically a sampling of a stool, three samples of a stool and a card, and then goes back to the lab and then gets analyzed if you have blood or not. There's another one which is the FIT-DNA, which is another screening tool. It's not diagnostic, it's only screening. Where you basically put the sample in a container and they send it to a lab and is evaluated. It's done every three years, which has a lot of great sensitivity and great experience. Those are the three ways, the most common ways that we do that. And there's another way with just as the rectosigmoid technique which is we don't do as often as we did in the past.
Dr. Jonathan Fialkow:
When you have a patient, and again, the purpose of the screening colonoscopy is safe, validated with outcomes to prevent, to detect a colon carcinoma or something that can lead to colon cancer early to prevent the colon cancer death. Do the patients, do you give them a choice between those techniques? Or is one better than the other but if they really don't want that they get another one? How do you differentiate between those options?
Dr. Douglas Inciarte:
Yes, obviously, it depends on the communication that we have and the trust that we have with the patients. And it always comes around, "Okay, I think for you as your doctor and our relationship, I think the best test for you at this point, it will be a colonoscopy," and explain why. And always when you explain the why and why, again, this is a screening testing that will also help you and diagnose you and prevent further health decline in the future, which is basically the colorectal cancer is such of a great tool for them to do. Then this is where we put the safety side that we know the safety of this testing is it's pretty good.
Dr. Douglas Inciarte:
The cost the insurances will recognize this has so much value that the cost it's very less for that for the patients to do. Some patients will have concerns about the prepping, "Hey, how's this prepping done?" They have to get prep, they have a specific diet. And then we always reassure them this is actually worth to do. Even the procedure, some patients will come back to the clinic and will say, "Hey, this procedure was just a fly. I went to the suite, they treat me very well, went through the lab in Baptist, I basically was in the table and then suddenly I just closed my eyes and I woke up. It was a second." And everything went well. And it was worthwhile to tell because again, we'll give you that information and you know that every 10 years you're clear for any problems with your colon.
Dr. Jonathan Fialkow:
I always laugh and say with our workload, when I had my colonoscopy. In the morning, totally painless, came home, slept for an hour and I had the rest of the day off. And I go, "Wow. What a wonderful way to get a day off from work is to get a colonoscopy." But it really is a safe and painless procedure. It is. How about, let's talk about osteoporosis, both in terms of a briefly what it is and what we would do in terms of screening for patients, women more particularly regarding that medical disorder.
Dr. Douglas Inciarte:
Simple words of osteoporosis is weakness of your bones. And it's done after it's age 65, around 65, depending on also if you have any chronic problems such as lupus, such as if you're exposed to steroids. Obviously if you're young and you have a sudden fracture, which is you just fell from your bed, for example. And then you had a fracture of your ankle, that probably will prompt you to have a screening test for osteoporosis. But it's done commonly at age 65, depending of course, any comorbid conditions. Some patients, especially our female patients will have premature ovarian failure. Those are the ones that are indicated to at least have a screening tests with a bone scan every two years. And this is a screening is done every two years that we do commonly in patients at age 60.
Dr. Jonathan Fialkow:
Safe, fast, cheap.
Dr. Douglas Inciarte:
Again, safe, cheap. And again, it's harmless, it's an x-ray scan and it's quick to do. And again, cost is low.
Dr. Jonathan Fialkow:
What are the other general screening tests that we recommend as we care for our patients, Doug?
Dr. Douglas Inciarte:
Mammogram. Breast cancer screening. That's our top, top, top number one that we do with every patient that we see in the clinic for their physicals every year. Highly recommended to do. If when we read about the guidance and what to do, there's going to be differences between some societies and the American Cancer Society's and all societies involved with breast cancer screenings. We continue to do that at age 40. There are some indications that we'll push it to 50 years old, but we know that it's a sensitive screening that our female patients will ask to do. No harm, low cost, and very effective and will give us a lot of information. So we do that every year.
Dr. Jonathan Fialkow:
And again, we'll go through plenty, but just speak specifically about a chest x-ray, is that a proper screening test?
Dr. Douglas Inciarte:
Not a proper screening test. Again, it has to be with more diagnostic. If I have a patient come with a physical and they have shortness of breath, they have a cough, it's has been more than six months, there is a decline of my health and I wanted to have again, in a way a diagnostic tool will be the chest x-ray. Otherwise, no.
Dr. Douglas Inciarte:
The only thing that if we again indicate a study that has to be done it's going to be for lung cancer. And that's going to apply for the heavy smoker. Which as you know if you have a history, a 30 pack year, or we have concerns that we need to do the screening right away. And again, now it's well covered by insurances, including Medicare as well. When you come when you're 65 and you come for your annual physical, if it's indicated a CT, it's a low dose, which basically has less radiation, it's a low dose cat scan, a test, and it's pretty effective to do as well.
Dr. Jonathan Fialkow:
So that, that's a great point and a great example for the purposes of this discussion. So someone comes in and says, "Shouldn't I get my lung scan?" And you're like, "You're fine." Well, the answer is no, it's not a screening test. But for a population of heavy smokers, then because of the higher preponderance of an outcome which could be cancer, then it would be a screening test. So again, these are very individualized and personalized when you see your primary care doctor.
Dr. Jonathan Fialkow:
Why do you find people in the community don't get proper screenings? I mean, the numbers do support that we have more people who should be getting screenings who are eligible than actually are. What do you see as the pushback?
Dr. Douglas Inciarte:
I'll put it this way. When we divide the populations, when we see male patients versus female patients, female patients, they tend to be more conscious about screening. They know when they're 25 they need to get to the offices to get their pap smears and their physicals and getting their labs. That's a population that we see more prone to come to the office and have screenings. And then for males, they typically, when they come to the office, it's because number one, they're very aware they wanted to be healthy or two, their wives calling to have their preventative service done. So this is the population that we know the male population is because of a fear. Is sometimes it has to be with more information, education of why it's so important to have prevention from seeing a provider in the clinic.
Dr. Jonathan Fialkow:
I think actually what you're saying is something is very interesting, if we peel back one step, is first they have to see the doctor. It's the first step which you always emphasize is you should have a primary care doctor. You should have a relationship with your primary care doctor in the practice, and that will afford you the opportunity to do screenings. Because again, when many people are busy and they feel fine they don't think about these preventive type of efforts. So I appreciate that.
Dr. Jonathan Fialkow:
What are the common tests that you see? We mentioned a couple that people ask for in the sense that they think it's screening, that you may say, "No, you really don't need that." Or, "You don't need it every year," or whatever. What are the kinds of things that you see that are out there?
Dr. Douglas Inciarte:
For the most part when we talk about screening tests and what type of labs we're going to do, we talk about the hematology labs. We talk about chemistry, the metabolic panel, which is, again, I always give the analogy to the patients this is kind of like the soup of your body. Sodium. Potassium. We're looking at your kidneys, we're looking at your liver. Let's look at your cholesterol, which is really important for our colleagues in cardiology, just to make sure that we check and we're following a lipid panel. A fasting lipid panel. And actually making sure that fasting lipid panel is prepared appropriately in terms of having the patients to have followed at least some diet before doing the testing.
Dr. Douglas Inciarte:
And then we also evaluate, which again, it doesn't have too much support to do every year where we also include a thyroid, which is a TSH. And those cases, a lot of people ask me about a urine test. And is not indicated to do a urine test every year, as we thought in the past that we always have to have a urine test. We always keep that in a little bit more depending on symptoms. And then finally, depending on the age of the patient, especially on male patients, then they will always like to ask about the prostate exam, which is done either that's done through the digital rectal examination, which private area for our male patients, and also having the PSA that prosthetic specific antigen that we do after age 50.
Dr. Douglas Inciarte:
There's always a caveat that some other patients when they're 80 they were ask, "Why not checking this or this, and why not I'm not eligible for a colonoscopy or for a PSA?" We'll tell them it's because based on your age, you don't need it. We know that scientifically we don't have to do it. But some patients will ask, "Hey, can I get it done?" And we see the benefits and the, and the harms and the cost and we put that in the equation as well. And we we negotiate and we talk about it.
Dr. Jonathan Fialkow:
That's a great point. We talk about when people should start getting screenings, at what age. There's also a time when you don't need them anymore. The data of the testing in the nation [inaudible 00:17:50] person doesn't support that this test will find something that is otherwise of concern or preventable. So that's a good perspective as well. I've seen certain data regarding our own population and national trends. What's going on with COVID? What are you seeing in your practice? Are people keeping up on the screenings, are people following through? If not, what can we recommend to them regarding that?
Dr. Douglas Inciarte:
COVID-19 Jonathan, more to come. I'm perceiving that some of our patients, again, because of fear of going to a clinic when they have diabetes, hypertension, when they have other comorbid problems, the majority of them when we see them in our practice, which actually we're seeing patients when they even were exposed or they have symptoms or they're actually in recovery from a coronavirus, one of the first thing that we really seeing is mental health decline. Seeing a lot of anxiety, depression.
Dr. Douglas Inciarte:
That's something that we really were seeing in primary care. That's when you ask any other providers in our practices, they will tell you there's a lot of people is really anxious about what's going on and including depression. Or they never had any mental problems and they started to have them because of the isolation caused by coronavirus. It's incredible. And there's more that we in primary care, we can end that up seeing at the end of the line when things are more stable and we hope that's going to be soon, but I think we going to see a lot of more diseases that we could tackle if we didn't have coronavirus or the front from the first place. So more to come. But number one is mental problems, Jon. A lot of mental problems.
Dr. Jonathan Fialkow:
And the conversation we're having is thinking of screening in the terms of a test. But we do screen in primary care for mental health issues with surveys and things like that as well. Right?
Dr. Douglas Inciarte:
That's correct. Every visit we do that Patient Health Questionnaire, too. We ask two questions.
Dr. Jonathan Fialkow:
[crosstalk 00:20:02] [inaudible 00:20:03] ... depression or things like that? So again, my take home point is go to primary care, listen to your primary care. The recommendations for screening tests are based on science, based on medical guidelines. If you're asking for something and the primary care doctor says you really don't need that it's based on science. You don't need that. So again, great stuff. And I appreciate it. That's why, again, I consider you a great resource for our communities and our burgeoning doctors in our family medicine residency program as well. Any final comments, Doug? Again, great information. I really appreciate your insights. Anything you want to emphasize or anything we left out? Obviously we aren't going to go through all screening tests, but I think the premise of what they're about, what they're for was brought forth in the conversation.
Dr. Douglas Inciarte:
Thank you Jonathan, this is incredible. It's been a lot of fun. One of the things that always will happen in the office, when you come and see your primary care doctor occurs also with a screening and discussing about screening. The other aspect to discuss is about diet. Lifestyle modifications, exercise, how much exercise you do. Some people will just don't know, okay, how much exercise and what type of exercise I can do. And then we address how important it is to not only to reduce burden of disease, but also to prevent death. How much exercise is so important in that aspect, including diet. Diet is so important. I always ask to patients, "What's your relationship with food?" And they will just look at me like, "I love food." It's like, "Well you know everybody loves food."
Dr. Jonathan Fialkow:
We have a great relationship with food.
Dr. Douglas Inciarte:
Right. And then of course that open up the discussion of what's your habits, why it's so important to just keep your habits. Always very important to ask about sleep. How's your sleep? Sometimes we just leave that out of the table. Are you sleeping okay? And sometimes you can tackle, "I'm not sleeping well. My wife cannot sleep with me." It's like, "Okay, why your wife cannot sleep?" "Well, because I snore so much." And then sometimes we have the luck to have a, the spouse, next to us. I turn around and it's like, "He snores too much. And then on top of that, he stops breathing." I'm like, okay well we got another factor that we have to consider here on our screening process, which is going to be sleep apnea, which is so interesting as well. So we can tackle so many problems down the road if we do treat sleep apnea promptly.
Dr. Jonathan Fialkow:
I love it all.
Dr. Douglas Inciarte:
Primary care doctor, go and see your primary care doctor. We're trained. We're here for you. We want to take care of you. We understand next steps and when it's appropriate actually to do testing and, and when it's also appropriate to send you to the right direction and what specialists you should see.
Dr. Jonathan Fialkow:
Well, again, great stuff. I appreciate the tee up. We have an upcoming podcast on insomnia and proper sleep hygiene. So keep it in our ecosystem of preventative care. Well, thanks Doug. Again, this was great information and I think very valuable to our listeners.
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