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The vogue for screening tests, driven by powerful commercial and political forces, is having an increasingly malign influence on our patients' health (as well as imposing a growing burden on our surgeries).
In recent weeks, two patients have presented me with the results of some of the latest screening initiatives in the private sector. One had paid around £3000 for the ‘ultimate check-up’.1 In addition to consultation and examination, the check-up included ‘over 40’ blood and urine tests, audiometry, ECG and spirometry, and ultrasound examinations of all internal organs. It culminated in a ‘virtual tour’ of the body using MRI images, and offered a DVD ‘to take away, including a video of your beating heart’, perhaps to enable the anxious patient to convince himself that he was still alive — or to show his significant other that the metaphoric source of romantic devotion was in good physiological order. At a special discount, MRI colonoscopy was available as an extra, although it was not clear whether the take-home DVD would include a tour up the customer's own rectum — an appropriate image of post-modern narcissism (and perhaps an entertaining addition to the family website).
Another patient had received a mail-shot from an enterprising company offering — at a mere £129 — ultrasound examinations of carotid arteries, the abdominal aorta, peripheral arteries and bones (for osteoporosis).2 The letter invited customers to a local community centre, reassuring them that ‘all four tests can be performed in less than an hour and you only have to take your shoes and socks off!’. While clients undergoing the ‘ultimate check-up’ are offered a 10% discount for bringing along a friend or relative, those at the lower end of the market are simply exhorted to ‘tell a friend or loved one — you may just save a life’.
Although all these tests, with the exception of screening for abdominal aortic aneurysms in men over 65 years, have been rejected by national screening authorities, they are being informally ‘rolled out’ in this way around the country. While turning screening into a sort of recreational activity, these tests are likely to generate high levels of anxiety (especially from false-positive results) and further morbidity (from over-investigation and over-treatment). It is not at all reassuring to learn that the promoters ‘always encourage you to discuss any findings with your GP’. The popular appeal of screening tests in an anxious age results from the inflation to mythical status of the commonsensical notion that early detection leads to a more favourable outcome. But this is only true if early treatment is effective: this has not been demonstrated, for example, in relation to prostate cancer or in the case of atheromatous carotid arteries. There is a related presumption that late presentation is a common factor resulting in a rapid demise, particularly from cancer, but again, this has to be substantiated, especially when it may be the case that delays and inadequacies in treatment are a more important problem. Although it remains contentious, the popularity of the conviction that early diagnosis of cancer means better prognosis nurtures a climate of blame: patients blame themselves, family members blame patients, and everybody blames doctors for failing to recognise or diagnose malignancy before it becomes readily apparent.
The popularity of commercial scans and tests has increased the pressure on the NHS to provide similar procedures, resulting in the introduction of the ‘MOT at 40’ promised by the minister of health.3 It is already clear that this will be considered a big disappointment. Patients whose friends and family members have had combined ultrasound scans or comprehensive Bupa medicals — never mind those who have had the ‘ultimate check-up’ — will feel grossly short-changed when they are offered meagre checks of height, weight and blood pressure and tests of blood glucose and cholesterol and sent on their way (perhaps without even seeing a doctor or nurse). The focus groups will soon relay popular dissatisfaction back to Westminster and it will be only a matter of time before extended surgery hours are devoted to providing MRI virtual body tours.