Abstract
Without preventive care, too many friends die because of late diagnosis, particularly of ovarian, colon, breast, lung, and pancreatic cancer.
Instead of ongoing monitoring, with the emphasis on earliest possible diagnosis, our doctors await the development of significant disease and too often, we hear dejected relatives exclaim, “by the time they found the cancer, it was stage four!”
We can do better.
We should do better.
We must do better!
Here, I explain the background of this problem and propose a protocol for relatively inexpensive, proactive preventive care which, applied across the spectrum of family medical practice, will allow comprehensive surveillance of our population’s health, in the interest of early diagnosis; the prerequisite to life-preserving medical care.
Caveat: the ideas put forward herein are my own. They represent a protocol for lifelong healthcare management of the individual citizen, as would, in my opinion, be best.
This protocol is offered in good faith as a suggestion for improvements in healthcare.
It does not imply criticism of the current paradigm, or of those who adhere to it.
The origin of this thesis
This essay was engendered by my ruminations on the medical and social “happenings” which my friends have had to, or failed to, endure, compared with my own preventive care: my complicated, but acceptably managed, course through the minefield of autoimmune and neoplastic threats with which we humans have to contend in this life.
I have had the misfortune to observe, among my friends and relatives:
A female professor’s non-Hodgkin’s lymphoma at age 74,
A female housewife’s death with Alzheimer’s disease at age 74,
A male MD’s descent into Alzheimer’s disease, beginning at age 78
A sub-genius man who became schizophrenic at 28, now struggling out of it at 50
A 16 year old male’s unmanageable schizophrenia, through age 40
Four (2 of each gender), born by Caesarean section, growing obese from age 18
Two brain tumor subjects (brother and sister) diagnosed too late at age 37 and 44
The death of an all-Canadian racket-sport champion, from ovarian cancer at 64
A brilliant university teacher, dead from colon cancer at 54
A debilitating stroke in a 75-year-old pediatric specialist
A medical professor’s wife (a nurse) who died with Alzheimer’s at age 86
Sequential, bilateral breast cancer in a registered nurse with an IQ of 160
Two deaths from pancreatic cancer
Five Doctors with prostate cancer
My favourite uncle dying of lung cancer at 55
Two prime ministers (and another uncle) dying of prostate cancer
A lethal heart attack sustained by a family doctor at 59,
A doctor, going from extra heartbeats at 65, to a bypass and pacemaker at 80
Plus many more.
Our risk Is rising
All of my friends’ conditions, excepting the two brain tumors, could have been anticipated, prevented, diagnosed and cured, or at least postponed, with suitable preventive care surveillance and timely intervention.
But the incidence of all of these conditions, in fact, all noncommunicable diseases, has been rising rapidly since the 1960s, so that now in the “2020s”, we are more and more at risk of all those missed diagnoses, which necessitate modern treatments at astronomical cost.
This thought process brought me to a consideration of preventive-care surveillance (PCS), a subject of much discussion in the medical community, which, if properly applied, would permit early diagnosis, with prevention, cure or postponement of debilitating disease.
Caveat: this treatise is not a consideration of surveillance from the public health point of view (3)
Therefore, Posit:
All citizens should be enrolled in a proactive, preventive care system at conception and followed, through birth and lifelong, so as to facilitate early diagnosis and management and so as to avoid the social and financial costs of severe, preventable illness.
Preventive care curveillance
In the words of Dr. Robert J. McCunney (1), “Prevention in medical surveillance is based on the fundamental principle of screening: that is, the administration of a test or tests at an interval such that an asymptomatic condition is recognized early in the disease process, so that intervention slows, halts or reverses the ailment.”
Applying this principle generally would guarantee ideal medical practice (2).
From the point of view of society, the overall reduction in the long-term financial and sociological costs would be a blessing (the resulting saving of fees to medico-legal lawyers, an obvious cost reduction, will not be considered here).
However from the point of view of employers, absence from work for preventive care investigations would be a short-term nuisance.
Further, from the standpoint of the “system” which would have to underwrite it, in-depth, all-encompassing, prevention-oriented surveillance for all diseases would be expensive.
Canadian healthcare thinks we can’t afford surveillance.
With these considerations in mind, Canadian politicians and medical planners have “shelved” the idea of ongoing preventive care surveillance, on the basis that doctors often order tests to increase their income, or so as not to be accused of “missing something”.
In my opinion, this is not correct. Doctors do order tests on the basis of not wanting to miss a diagnosis, but this is done in the patient’s interest, not for “CYA”, or the doctor’s financial gain.
Therefore it is reasonable to advise physicians not to order tests which are obviously unnecessary, but the decision to leave a test out of the patient’s assessment is to risk missing a diagnosis.
Anyway, surveillance has not been simply “shelved”: the ministry of health and the College of family physicians have established a protocol, by which the costs of preventive care surveillance can be avoided altogether – see the very specific directive, dubbed “choosing wisely”, which can be “googled” at: https://choosingwiselycanada.org/recommendation/family-medicine/ .
The purpose of the “choosing wisely” effort is saving costs, on healthcare.
The movement has developed into a major online campaign, a study of which entails considerable research on the Internet.
So to save you time, please see the list of instructions to family doctors, from the College of family physicians of Canada, copied verbatim from the www, below.
“Choosing wisely: 13 tests and treatments to question”, by the College of Family Physicians of Canada, last updated: July 2022
https://choosingwiselycanada.org/recommendation/family-medicine/
1 Don’t do imaging for lower-back pain unless red flags are present.
Don’t use antibiotics for upper respiratory infections that are likely viral in origin, such as influenza-like illness, or self-limiting, such as sinus infections of less than seven days of duration.
2 Don’t order screening chest X-rays and ECGs for asymptomatic or low risk outpatients.
3 Don’t screen with Pap smears if under 25 years of age or over 69 years of age.
4 Don’t do annual screening blood tests unless directly indicated by the risk profile of the patient.
5 Don’t routinely measure Vitamin D in low risk adults.
6 Don’t routinely do screening mammography for average risk women aged 40 – 49. Individual assessment of each woman’s preferences and risk should guide the discussion and decision regarding mammography screening in this age group.
7 Don’t do annual physical exams on asymptomatic adults with no significant risk factors.
8 Don’t order DEXA (Dual-Energy X-ray Absorptiometry) screening for osteoporosis on low risk patients.
9 Don’t advise non-insulin requiring diabetics to routinely self-monitor blood sugars between office visits.
10 Don’t order thyroid function tests in asymptomatic patients.
11 Don’t continue opioid analgesia beyond the immediate postoperative period or other episode of acute, severe pain.
12 Don’t initiate opioids long-term for chronic pain until there has been a trial of available non-pharmacological treatments and adequate trials of non-opioid medications.
This directive, some sections of which are not unreasonable, has had a predictable effect on many family doctors, who now avoid doing any and all investigations unless the patient’s complaints and/or physical findings render the tests “defensible in the eyes of the ministry of health”.
This attitude, in my opinion as a retired physician and surgeon, runs contrary to the basic tenets and traditions of medicine and will lead to tremendous costs for medication, surgery and legal challenges in the long run.
The situation is unfortunate. However, here is a reasonable compromise, by which the scope (thus, the cost) of preventive care testing can be reduced, to allow lifesaving early diagnosis and treatment.
A limited number of factors underlie humans’ liability to noncommunicable diseases; these can be categorized as either
(1) age-related conditions (considered to be hormone deficiency effects), or
(2) stress-related effects, including those attributable to climate, income, social status, diet and social/recreational/occupational habit, or
(3) conditions, such as inherited gene aberrations or physical disabilities, unrelated to (1&2) (some of these, such as cardiomyopathy, can be shown to be related to (1&2).
Viewed from this standpoint, the problem of preventive care and disease avoidance becomes easier to consider, simpler to calculate and solvable In terms of cost.
I would propose the following protocol, which will avoid unnecessary office visits and “baseline” tests of questionable value (5):
Before conception and during pregnancy
Any maternal condition threatening to the fetus must be diagnosed and corrected before conception, or upon diagnosis of pregnancy.
Therefore the prospective mother and father, who have been educated in the principles of proactive health surveillance, request a pregnancy-planning interview (or an urgent appointment, if the pregnancy is unplanned), with their family physician.
At this visit the doctor evaluates both parents’ health history, physical condition and biochemical/hormonal status. Their occupation, income, ethnicity, physical condition and family history of conditions such as colon and prostate cancer, breast cancer and other diseases with high familial penetrance, are taken into account.
Once fully informed, the doctor decides what tests should be done.
- The mother’s assessment Includes checking her DHEA, testosterone, estradiol, progesterone, “thyroid profile” (T3, T4, TSH and rT3), inflammatory markers and vitamin D level, along with throat, urine and vaginal tests for infection, stool tests for parasites and microbiome analysis.
- The father’s assessment cannot include the general tests, but is otherwise similar.
He is booked for such additional investigations as the physician may consider important. - A second appointment for explanation of aberrant test results is arranged, with both parents attending, if possible. Even if all results are normal, They should not be advised by telephone, so as to avoid missing important questions.
The beginning of pregnancy:
Beginning pregnancy under stressful conditions or becoming stressed in the first three months of a pregnancy may may result in intracellular hypothyroidism in the mother. (7)
Intracellular hypothyroidism within the first 20 weeks of pregnancy is not just a problem for the mother: the fetus will also be hypothyroid, because it does not begin making Its own thyroid hormone until the 20th week of gestation.
Thyroid 3 hormone is essential and fetal hypothyroidism is terrible.
Although it has been said that the human brain is not fully developed until age 25 years, major brain connections are made between the 8th and 16th (? 8th – 20th) week of pregnancy.
So if the T3 supply to the fetal brain is insufficient, essential brain areas may be connected incorrectly.
A significant increase in the rate of ADD/HD, dyslexia, autism, schizophrenia and gender dysphoria has been observed in children whose mothers were hypothyroid during the first 3 months of pregnancy.
Therefore it is imperative that the mother’s thyroid function be checked and signs of intracellular hypothyroidism be corrected, preferably before starting the pregnancy, but otherwise as soon as pregnancy has been diagnosed.
For the same reason, even if the mother is not conscious of stress,
her thyroid profile should be repeated at 8, 12 and 16 weeks of gestation.
Then if she develops intracellular hypothyroidism, treatment with Triiodothyronine can start immediately, to ensure that normal “nerve wiring” in the baby’s brain.
Other than thyroid surveillance, uterine ultrasounds and intrapartum observations and protocols are carried out as traditionally recommended.
Postpartum
Immediately after birth, the newborn and the mother are checked as usual, but in addition, the mother’s hormonal and thyroid profiles, including T3/rT3 ratio, are repeated.
Special attention is given to levels of DHEA, testosterone, progesterone and Allopregnanolone and any abnormalities which may be found are corrected ASAP.
(A normal balance between these particular hormones will prevent maternal postpartum depression, which may adversely affect the newborn child).
The “Pediatric Years”
Thus, the newborn enters the world with the advantage of a carefully managed pregnancy in a fit and healthy, happy mother and presumably, in the best of health.
The pediatrician observes the child’s progress and administers immunizations and other care as recommended.
The pediatrician should ensure that each child has acceptable vitamin D levels, but otherwise need not check for hormonal aberrations.
It must be remembered however, that children who are abused, or otherwise “psycho-shocked”, may develop PTSD.
PTSD results in “up regulation” (increase)of cortisol and “down-regulation” (reduction) of thyroid 3: in other words, intracellular hypothyroidism.
Further, under these circumstances, aberration of other hormone levels is inevitable.
Frequently, stressed children begin their teen years with severe hormone imbalances, which may result in a cognitive deficit or aberration.
Therefore it is important to make sure that every shocked child Is checked for intracellular hypothyroidism (easily diagnosed with T3/rT3 Calculation) (7).
If the tests show a low T3/rT3 ratio, the child should be referred to a metabolic medicine professional, for careful management.
Special attention should be paid to that child’s hormone balance in the teen years.
The pubertal and early “Teen” years: baseline adult assessment at age 15.
In the female, Hormonal balance is assessed at menarche, to establish a baseline: ongoing testing is scheduled if abnormalities are found.
In particular, Progesterone deficiency (tested on the 21st day of a female’s menstrual cycle) and DHEA deficiency should be noted, reassessed on an ongoing basis and treated (or referred to an appropriate specialist), if necessary.
The first adult “baseline” test panel is done at age 15.
In the male, hormonal aberrations found at puberty are corrected if necessary, pending adult baseline testing at age 15.
For both males and females, vitamin D, DHEA, Testosterone, Estradiol, Progesterone and Thyroid balance should be assessed at age 15 and as necessary, especially if there has been abuse, psychological upset, excessive weight gain, anorexia or poor performance at school.
However, in the absence of symptoms, abnormal results or “troubled teen” events, hormonal assessment at 15 years of age can be done virtually: a doctor’s visit can be arranged if aberrant results are flagged.
If all test results are normal and no ominous “events” ensue, they need not be repeated until age 20.
The young adult: 3rd – 4th decade
(1) Neurosteroid (DHEA, Testosterone, Estradiol, Progesterone), thyroid hormone balance with T3/rT 3 ratio, vitamin D levels* and general “checkup” testing should be done at age 20 and if all is well, repeated at age 25 and 30.
“Virtual” reporting is fine: if no abnormality is found, there is no need for a doctor’s visit. However if aberrant results are “flagged”, a face-to-face visit with the doctor should be arranged so as to sort the question out.
* Vitamin D, a hormone of cutaneous origin, is chronically deficient in a majority of the population, resulting in increased susceptibility to viral, and other, infections, osteoporosis and many metabolic aberrations.
(2) A machine-readable, preventive care questionnaire regarding symptomatology (with particular reference to hypothyroid symptoms), subjective assessment of health status including changes in appetite, weight, sleep, bowel and urinary habits, libido and mood, is filled out yearly by the patient and a doctor’s appointment is arranged to discuss any flagged items.
(3) Routine surveillance, usual in family medicine practices, might be automated, with a doctor’s visit for flagged items: for example,
– fecal PCR tests for colon cancer,
– a self-administered PCR “Pap” test,
– hepatitis and other routine blood tests,
– microbiome assessments,
– breast thermography,
– PSA,
– urinalysis
– hormone balance testing.
(4) In-depth reassessment, with questionnaire, EKG, chest x-ray, hormone balance and abdominal ultrasound, is done every 5 years to age 40.
The patient is seen for reevaluation, at a formal “doctors appointment” at age 30 and 40.
The established adult (5th – 6th decade)
(1) In-depth reassessment, including the questionnaire and a doctor’s visit, plus PSA for men, hormone balance for women and tests appropriate to any family history of colonic, breast or prostate cancer (etc.), should be repeated every 2 years from age 40 to age 66 and ad hoc: if all tests remain normal and there are no symptoms, the patient should visit with the doctor at age 45, 50, 55, 60 and 65.
The older adult
Healthy persons over 65 years of age should plan for an in-depth preventive care reassessment yearly, including a questionnaire, repeat laboratory tests and a doctor’s visit, “In person”, from age 66, onwards.
Specific investigation, with a doctor’s visit, should follow discovery of hormonal, symptomatic or test result aberrations observed at any age.
The system, our citizens and the ministry of health
The above suggestions are intended as a guideline for the granular management of the individual citizen’s healthcare, not as a criticism of, instruction to, or proposed management of our central, supervisory institutions.
Proactive healthcare monitoring would not survive without central surveillance (6): therefore this treatise, its principles and its propositions is intended to apply the basic principles of good medicine and the tenets of our central colleges and associations, and not as a substitute for central, overall surveillance of the health system.
Summary: proactive, preventive medical care includes
Routine assessment of the mother and father, for conditions which might adversely affect the fetus and later, the child.
Postnatal blood testing of both mother and baby, to exclude threatening abnormalities.
The child is followed as usual by a pediatrician, but special attention is paid to thyroid hormone balance and vitamin D.
The teenager is observed for aberrations of socialization, plus neurosteroid and thyroid hormone balance.
Preventive care surveillance in the 3rd, 4th and 5th decades is minimized by concentration on neurosteroid and thyroid balance: additional investigations are done remotely and visits to the doctor are arranged as necessary, based on a 5-yearly reassessment to age 40, a 2-yearly preventive care reassessment to age 66 and thereafter, yearly follow-up.
References
(1) Medical Surveillance: The Role of the Family Physician, by ROBERT J. MCCUNNEY, M.D., Massachusetts Institute of Technology Medical Department Cambridge, Massachusetts, Am Fam Physician. 2001;63(12):2339-2340, https://www.aafp.org/pubs/afp/issues/2001/0615/p2339.html
(2) “Quality in primary care./System performance.”, Editorial in Can Fam Physician. 2011 Oct; 57(10): 1219–1220.
PMCID: PMC3192094. PMID: 21998241,
https://www.hqontario.ca/System-Performance/Specialized-Reports/Primary-Care-Report
(3) “Canadian Primary Care Sentinel Surveillance Network, a developing resource for family medicine and public health.”, by
Richard V. Birtwhistle, MD MSc CCFP FCFP, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3192094/
The Canadian Primary Care Sentinel Surveillance Network (CPCSSN—pronounced sipsin) started in 2008, with a grant from the Public Health Agency of Canada (PHAC), to study the feasibility of developing a network to collect health information on patients with chronic diseases across the country. This information is intended to be a resource for monitoring chronic disease in Canada, as well as for primary care research. The Canadian Primary Care Sentinel Surveillance Network has been organized as a network of networks, and its board is made up of network directors. As a sub-entity of the College of Family Physicians of Canada (CFPC), CPCSSN is partnering with the PHAC and the Canadian Institute for Health Information. The CFPC has been instrumental in both the support and the development of this network. The central office for CPCSSN is at the CFPC’s national office, where its project management, financial oversight, and privacy and knowledge transfer take place.
(4) Governments in several European countries equip all primary care practices with interoperable, ambulatory care-focused electronic health records (EHRs) ………. From “A new vision for Canada: Family Practice—The Patient’s Medical Home 2019” (4), a vision of a high quality, coordinated pan- Canadian health care system, by the College of Family Physicians of Canada.
Mississauga, ON: College of Family Physicians of Canada; 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf
(5) How Medical Practices Can Succeed At Remote Patient Monitoring: sponsored by by Accuhealth – “Once mastered, the remote patient monitoring platform gives the practice a pathway to establishing meaningful care management.”
https://mhealthintelligence.com/news/how-medical-practices-can-succeed-at-remote-patient-monitoring
(6) European primary care surveillance networks: their structure and operation, by Joan GM Deckers, W John Paget, François G Schellevis, Douglas M Fleming, in Family Practice, Volume 23, Issue 2, April 2006, Pages 151–158, Published 07 February 2006, https://doi.org/10.1093/fampra/cmi118
(7) Intracellular Hypothyroidism & Thyroid Hormone, by GA Harry, https://wordpress.com/page/cbhrt.ca/91
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