“All checkups can cause harm, some can do good.”
We all know that a lot of activity in Family Practice lacks evidence to support effectiveness, but that doesn’t stop us doing those things we have always done. But why do we persist with habit activities in the face of the Primum non nocera principle? First do no harm should be central to medicine. Should be, but isn’t. The routine medical checkup is a classic violation of this oath.
Followers of the science of screening will recognise the plagiarism of the opening quote, but how many of us think of this as we listen to the heart or palpate the abdomen of that fit healthy 40 year old who has come in for their annual checkup, oft funded by his/her insurance company. What chance is there that the good family physician/general practitioner will find an abnormality of no consequence or worse still find a disease or condition for which there is no cure. That might seem to be of little harm but alas, that simple little heart murmur, ectopic beat, hepatic enlargement or left iliac fossae fullness will lead to a diagnostic pathway which is guaranteed to harm in some way, without any certainty of benefit. Even early detection of an incurable disease simply prolongs the duration of suffering.
There is a chance that the clinical examination will find a curable abnormality in an asymptomatic person but the game is a matter of balancing the odds: the odds of harm verse the odds of benefit. First do not harm suggests that harms should be of great import. Medicine, however tends to use its own value system in this balance.
The more specialized the doctor (partialists as a friend calls them) the greater will be the perception of benefit. Steel et al showed that specialist would accept a statin like treatment at an NNT of 1 in 100; family physicians 1 in 50 and patients 1 in 20. Some cultures especially USA have a more interventionalist view to health and thus the harm of screening is less appreciated.
The interesting thing about these checkups is that they arose largely from an interaction of insurance companies, corporate world and medicine. The checkup thereafter rapidly spread throughout the Western World and Asia. This legacy now needs revision and needs to focus on screening only for what can be proven to have significantly greater benefit than harm.
What of your country, your practice, dear colleague?
(GFD Medical Editor)
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