It has long been observed that one of the challenges with the delivery of healthcare in America is that the wealthy get too much of it and the poor do not get enough.
Over the past week, I have been interviewed by several health reporters about a posting by an Instagram influencer regarding the benefits of full-body MRI scans as a preventive test, to detect diseases before they cause morbidity or mortality. This initiated a discussion about the basics of screening, without going into much detail regarding the intricacies associated with the epidemiology of screening tests — namely sensitivity, specificity, prevalence, positive predictive value, etc.
Moreover, we talked about the risks associated with screening tests. While the potential benefits of full-body MRI scans were prominently highlighted, a discussion of the possible risks was absent. Many of you know I work in the pharmacovigilance arena, where assessing the benefits AND risks associated with the use of a product is paramount, as we try to ensure patient safety.
The risks of full-body MRI scans include increased costs to patients and the healthcare system. There also needs to be a consideration of the unnecessary procedures, attendant complications with possible morbidity and mortality, mental anguish, and likely increased litigation, especially given the high rate of false positives that will be noted in screening the general population with such scans.
As preventive medicine physicians, our usual perspective is on population health, while still considering the needs of individual patients. So as this discussion about the utility of full-body MRI scans will be taking place in the offices of primary care physicians across the country in the coming days and weeks ahead, there is an obvious need for accurate, evidence-based recommendations to be disseminated as broadly as possible to prevent the potential risks associated with such tests, especially given their limited clinical value.
This is where you, as ACPM members, can help to facilitate such discussions where you work and lead — at your community health centers, hospitals and various institutions. A good starting point would be to get familiar with this article: Choosing Wisely® in Preventive Medicine: The American College of Preventive Medicine’s Top 5 List of Recommendations by Dr. Catherine J. Livingston and colleagues in the AJPM in 2016. Their recommendation for body-scans was as follows: “Don’t Use Whole-Body Scans for Early Tumor Detection in Asymptomatic Patients”.
Additionally, and without being cynical, perhaps the biggest benefits will accrue to the companies and physicians who provide such test to patients without the proven safety and efficacy that needs to be demonstrated of pharmaceutical devices, which is usually done by conducting two randomized clinical trials to show that said device is safe and effective when used as indicated. So, until the purveyors of full-body MRI scans can demonstrate the safety and efficacy in the general population of this test, other than limited anecdotal reports of benefit, why should patients get them and at what cost?
Well, that cost is likely to be in the thousands of dollars per scan, with the additional financial and medical costs associated with follow-up and possible associated complications. And, all this leading to care that is not cost-effective and will not result in better population health outcomes — given the most likely purchasers of these scans will be the “wealthy-healthy” individuals who are concerned, maybe overly so about their health and who can afford such scans.
So yes, in a free country like America, where a large healthcare gap already exists and where you can buy as much healthcare as you desire, we will continue to see the wealthy getting too much of it, while the poor will not get enough.
But we as preventive medicine physicians can each do our part to mitigate the wanton misuse of such testing!
Mirza I. Rahman
MD, MPH, FAAFP, FACPM