The Patient Was…

The patient was a 65-year-old media mogul. He had no personal medical record of significance, but because of a family history of heart disease he deemed it wise to have himself checked out.

A thorough history revealed a complete lack of any symptoms suggesting cardiovascular disease. A careful physical examination was entirely unremarkable. Appropriate noninvasive testing confirmed the absence of any evidence or suggestion of heart or vascular abnormality.

When the good news was presented to him, he sat silently.

“Well,” he said, after a long moment, “why don’t we do this with the rest of me?”

“What do you mean?” I asked.

“I’m really happy that my heart is so good,” he said. “If I knew the rest of me was so healthy, it would be like a new lease on life. Imagine, at age 65, knowing you’re completely well. Can you do some kind of a total body scan to show that I’m healthy?”

At the time, the only advanced imaging technology readily available was a CAT scan (also called a CT scan). Positron Emission Tomography (PET scanning) and magnetic resonance imaging (MRI) had not yet been introduced into clinical medicine. CAT scans were the technique of choice for detailed looks inside the body.

But CAT scans, even now, are not 100 percent accurate. There are false positives and false negatives. A false positive is when a scan is reported to show an abnormality that isn’t there; a false negative means an abnormality is present but the scan misses it and is reported as normal. The accuracy of CAT scans depends on a number of factors, including the machines used, what is actually inside a patient’s body, and the expertise of the radiology specialist who looks at and interprets the images.

Total body scanning is becoming more popular now, with the advent of MRI technology. Unlike PET scanning, which uses radioactive materials, and CAT scans which administer considerable radiation to the body, MRI routinely uses neither. The problems of false positives and false negatives still exist, however, and the consequences of each can be serious.

A false positive often leads to further testing, which may itself be risky, and to treatments that may be dangerous and invasive. False negatives, of course, can lead to a false sense of security and neglect of real problems that exist but are missed on testing.

Another concern with what might be considered random testing in the absence of a specific medical reason is the finding of things that are normal for a patient’s age, but that may still be sources of concern, and for which there are neither  treatment nor remedy.

Despite my urgently trying to dissuade him from undergoing a total body CAT scan the patient rejected my advice. He insisted on having the test, fully aware of all the problems I related.

The report, as I feared, presented a problem. There were no abnormalities requiring further testing, and nothing abnormal to treat. In fact, the report was as favorable as one could hope for in a sixty-five year-old man. But that was the issue. He was sixty-five, and there are changes within the body that occur over time that are considered part of the process of aging. There are no treatments for some of these, and they are called normal.

He read the report, initially pleased with the headline conclusion: Normal scan of  65-year old male.

But the details of the report on his brain upset him: findings in the brain structures compatible with normal aging. Details included changes in brain volume, and the word “atrophy” was mentioned.

The patient was distraught. Nothing I could say mollified or reassured him. He left the office in a blue mood. On subsequent visits, he always referred to the report, referencing his aging brain, and he never recovered the optimism and equanimity he had previously displayed.