Screening for disease is big business. When one needs screening? Does one go and screen the general population? And if so what ailments you screen them for?
These are important questions not only from the point of people’s health but also from the larger issue of economics of health.
Let me illustrate this by a case story which motivated me to write this piece.
He was a 34 year old man whom I will call Mr S, who came to see me two days ago.
Mr S said without any preamble. ‘Your friend, Mr Y asked me to see you,’ he said. This friend of mine is an unavoidable evil [wrong metaphor to use, matter of fact he is very good human being]. He continued without interruption,’ I have liver disease and also high fat in my blood and doctor wants to put a tube down my throat’
I could see he was very agitated and very anxious. Just to put him at ease I asked him who is the doctor who has said so and asked him for some details.
‘Sir, I went Hospital M for my annual medical examination and they found out I have these problems. And they want to admit me. I know Mr Y, your friend and he asked me to see you before getting admitted’.
I went through the annual medical examination reports.
The following tests were conducted. The reports were all in an eye catching folder with all the details of the hospital’s virtues prominently displayed on the envelope.
Complete blood study, ESR, CRP, Chest X-Ray, Abdominal ultrasound scan, Urine analysis, Liver function tests, Blood urea and Creatinine, Blood lipids, Sugar both fasting and after food, EKG, Echo cardiogram, Lung function tests, Audiometry, Eye examination, A physician’s sport and a dieticians consult.
The liver function test showed a marginal rise in blood bilirubin [1.6 instead of 1.4] and his cholesterol levels were marginally high. I found no need for him to undergo and endoscopic procedure, neither a need to take any cholesterol reducing medication as advised by the physician. What he need was a regulated diet with an hour’s exercise and a redo of liver function after 4 to six weeks. Most of the tests that were done on him were unnecessary to say the least. What was the hospital’s screening programme was trying to do?
The answer is very simple.
It was designed to create patients and also is easy pickings. The patient had spent a packet on these tests.
Then was there nothing wrong with the patient? There was something wrong. He had bilateral Hydrocele [collection of fluid around his testicles].This might need surgery at a later date. How was it that it was missed in all this gamut of tests?
Again the answer is simple. None bothered to pull his trousers down to check his genitals!
So what is the lesson to be learnt? Is screening for disease absolutely unnecessary? I would not say so. It is unnecessary in the sense it is not cost effective and detects very few treatable illnesses. Instead there should be what is called selective screening. Let me elaborate. Cancer breast has a strong hereditary bias. If there is a strong family history then the screening for breast cancer in the siblings is worth the effort. Doing mammography for all women is astronomically expensive. Other examples are Heart disease and diabetes. If there is a positive family history then the children should be screened periodically. Probably the most cost effective tests are a blood pressure check and a blood check for diabetes. All others are waste of good money. A normal lipid profile [blood fat study], liver, kidney, lung, eye, ear function will remain so for many years. Then what is the rationale of doing all this, year after year?
The answer is again simple. Keep this farce of a programme gong and create patients whenever it is possible.
What is the final line?
Screen for disease in the susceptible and leave the rest alone. They will be better off without our interfering.