Health screening is big business. I periodically receive post cards inviting me to take part in a local screening program. I hear ads on the radio in which people testify that having a particular screening test saved their lives.

It is not uncommon for me to be asked to review the results of screening tests that individuals have undergone. While the findings are helpful at times, often the results raise more questions than they answer.

The first time I became aware of the importance placed on periodic health screening was in the 1950s when the American Cancer Society decided to embrace the new medium of television by airing public service announcements urging viewers to “fight cancer with a check-up and a check”. The campaign was an enormous success; the tradition of submitting to an annual “check-up” or “physical” became firmly rooted in American society.

As a young physician I soon learned that the physical examination I had been taught in medical school had little in common with an “annual physical” in the eyes of my patients. To me a “physical” meant taking a comprehensive medical history and performing a hands-on physical examination. To my patients, however, an “annual physical” meant blood work, a chest x-ray, an electrocardiogram, and an assortment of other tests depending upon what they had recently read or heard.

The number of available screening tests grew tremendously over the last half of the twentieth century. The twenty-first century has seen the rise of a wide variety of genetic screening tests. Today it is possible to spend a week and tens of thousands of dollars going through a comprehensive health screening process.

Many entities have developed recommended schedules for health screening. Nearly every medical specialty organization has its list of “preventive health services”. Organizations such as the American Cancer Society and the American Heart Association promote tests they believe to be of benefit. The most widely accepted screening recommendations are those of the United States Preventive Services Task Force.

It is my firm belief however, that health screening should not be a “one-size-fits-all” program. Individual variations in risk of disease development should be taken into account when considering which tests should be performed. It is also important to recognize that more aggressive screening is not necessarily better.

Many years ago a young attorney came to me because he had noted that his physical endurance had fallen off significantly. He related that since his law practice was doing well and he could afford the best health care money could buy he had arranged to have an annual physical performed by a cardiologist. The cardiologist had elected to perform a treadmill stress test as part of his health evaluation.

The stress test results had been inconclusive, so the physician had performed a coronary arteriogram to clarify the situation. The vessels supplying blood to the heart were found to be clear of plaque, but based upon the suspicious nature of the stress test a medication in the beta blocker class had been prescribed.

The young man came to me because he was no longer able to perform his favorite activity, which was long-distance cycling. Prior to his physical he had been cycling between 50 and 70 miles a week. Following the physical he had difficulty completing even short rides and he was about to abandon cycling altogether.

The solution to the young man’s physical challenge was obvious. Beta blockers prevent the heart rate from increasing in response to exercise. With the beta blocker on board his heart could not respond to the body’s increased demand for oxygen when he exerted himself and he would quickly become too short of breath to continue his ride.

I urged him to stop the beta blocker and get back on his bicycle. He had been giving himself a “stress test” every time he went for a ride. There had been no indication for the stress test, and there was even less reason for him to be taking a beta blocker. He happily returned to his extended rides and remained in top physical condition.

The experience of the cycler is not unique. It is, in fact, quite common. I see many perfectly healthy individuals who have been advised to alter their lifestyle, undergo risky procedures, or start medication solely on the basis of borderline test results. Health screening has a role, but it should be used appropriately and the results must be reviewed in the light of the individual’s total health picture.

Although health screening is a foundation stone of a successful medical practice, I have never been convinced that an annual medical evaluation is necessary, or even a good idea, for the average individual. It is rare that a condition that is causing no symptoms will be apparent at the time of a routine screening examination. I would much rather individuals be checked occasionally for conditions that tend to be asymptomatic (silent) and seek an evaluation immediately for any new symptoms that emerge throughout the year.

Symptoms are the body’s warning signals, like the oil and temperature lights on the dashboard of an automobile. When they appear the cause should be sought immediately. Having had the vehicle’s oil recently changed does not mean that an oil leak cannot occur and having had a recent physical does not mean that a heart attack cannot happen or that a cancer cannot become evident.

How then can a person determine which screening measures are worthwhile and which are not? The following is a list of tests and procedures that are currently promoted for health screening purposes. Each may have a legitimate role in the management of specific disease states that is separate and distinct from its use as a screening tool. My comments relate to their use in asymptomatic individuals, and may not apply to someone who is experiencing a health challenge.

A Comprehensive Medical History

The most valuable tool in screening for potential health problems is the most neglected today. It is the recording of a comprehensive medical history. I attended medical school in an era when few screening tests were available. Physicians back then valued bedside diagnostic skills. I was taught that the most important part of any evaluation was the medical history – what the individual seeking my assistance was able to tell me. A good history, I was told, provides between 85 and 90 percent of all of the information available about a person’s medical condition.

I have found that to be true over the course of my medical career, which is now in its fourth decade. Whenever I schedule a consultation with an individual who is seeing me for the first time, or whom I have not seen for several years I ask that a medical history form be completed prior to the visit. I do this for several reasons, the most important of which is that the person is much more likely to include all pertinent information if he or she is able to complete the form free of time constraints.

The second is that having an outline of the individual’s current situation already on paper allows me to listen more intently when I ask the person to relate their concerns to me. If I am furiously taking notes while the person is speaking it is much more likely that I will fail to hear an important piece of information. Finally, the completed history form tells me where to spend time clarifying concerns or drawing out more details about the person’s current condition.

A medical history begins with what is called the chief complaint. In the case of a screening evaluation this will simply be, “I want to be sure I’m in good health.”

The individual’s past medical history is then explored. What illnesses have occurred in the past? What operations have been performed? Does the person have any allergies? Is he or she on any medications? Are any nutritional supplements being taken?

A family medical history is also important. What diseases tend to run in the family? At what ages have family members died? Has anyone in the family had a problem similar to the one the individual is currently experiencing?

The personal and social history is reviewed. What is the typical diet? How much physical activity is performed? What is one’s educational background and what occupations have been performed? What is the current living situation? What are the person’s religious beliefs and practices?

This is followed by a complete review of symptoms. Each body system is explored. Common symptoms are suggested to jog the person’s memory. The importance of noting any and all symptoms that are present cannot be overstated. I shall always remember individual who was seeing me for her routine annual check-up informed me that she had undergone surgery to remove a brain tumor since she had last been seen.

The tumor was of a type that is slow-growing. It is almost always signaled by a loss of the sense of smell early in its development. The loss of smell may precede the onset of other symptoms such as headaches by several years.

I couldn’t believe that I hadn’t picked up on that clue and scheduled a CT scan of her brain at one of her previous visits. I checked her record. Although I had asked each year if she had been experiencing any problems with her ears, nose, and throat nothing was recorded.

I then asked, “When did you notice that you had lost your sense of smell?”

“About five years ago,” she replied.

“Did you tell me you had lost your sense of smell?” I questioned.

“No,” she said, “I didn’t think it was worth mentioning.”

The medical history is instrumental in determining what additional tests, if any, should be performed. When tests and procedures are pursued outside of the context of a comprehensive personal health history, adverse consequences are far more likely to result.

A Comprehensive Physical Examination

While the medical history supplies 85 or 90 percent of the available information, the physical examination provides an additional 7 to 10 percent. Height and weight measurements are taken along with vital signs such as the blood pressure and pulse rate. A careful head to toe examination using the skills of visual inspection, auscultation (listening), percussion (tapping for areas of brightness or dullness), and palpation (feeling and probing) follows. The amount of information that can be successfully gleaned from a skillful physical examination is reflected by the fact that Degowin & Degowin’s classical book on the subject encompasses nearly 1100 pages.

I have come to recognize that the physical examination I was taught in medical school and which is covered in textbooks only scratches the surface in obtaining information about the health status of the human body. The body is more than muscle and bone; it is more that tissues and organs. The body contains hundreds of chemicals that can be measured by blood tests, but it is also filled with electromagnetic programs the function of which can only be determined by a “hands on” examination. Detecting energetic disturbances and correcting “glitches” in the body’s computer programs may be the ultimate in early detection of disease. Evidence is mounting that disease begins with disruptions of the body’s energy flow and subsequently progresses to involvement of its biochemistry and anatomy.

A comprehensive physical examination together with a comprehensive medical history is the most cost-effective and safest screening procedure available. The history will expose genetic susceptibilities, uncover risky behaviors, and point to areas of one’s lifestyle that need improvement. A physical examination will determine whether an individual’s blood pressure is dangerously elevated. It can assess whether or not the person is developing insulin resistance that could lead to diabetes and heart problems. It can detect changes in the breast or prostate that may indicate that a cancer is present. If performed properly, it may even detect electromagnetic abnormalities long before a physical challenge is present.

Pap smear Screening

Few screening tests are considered as necessary as the annual pap smear. The term “pap smear” refers to a specimen that contains cells obtained by brushing or scraping the cervix that is sent to a laboratory for analysis. It is used primarily for early detection of cervical cancer or changes that are associated with the subsequent development of cervical cancer.

Although a pap smear is traditionally obtained annually, studies have shown that if a woman is in a stable, monogamous, sexual relationship and has two successive normal pap smears the likelihood of ever developing cervical cancer is nearly non-existent. This is because most cervical cancers are triggered by an infection with a strain of the wart virus that is sexually transmitted. An annual pap smear may be worthwhile for women who have multiple sexual partners, but for others there is no good argument for having a pap smear checked more often than every five years.

Since the cervix is the lowest segment of the uterus and is removed with the rest of the organ in nearly all hysterectomies it is illogical to continue to have pap smears tested following the procedure. Physicians argue that the pap smear can give an indication of the need for hormonal support, but there are more effective ways of determining the need for hormonal replacement.

Screening Mammograms

The recommendation that every woman have an annual mammogram beginning at the age of fifty is nearly as universal as the recommendation that she have an annual pap smear. Many advocate beginning screening mammograms at age forty and some argue that they should be instituted at age twenty-five for individuals who carry BRCA1, a gene that has been associated with a high risk of developing breast cancer.

Mammograms, however, are not entirely free of risks. A mammogram is an x-ray of the breast, and x-ray exposure is a known risk factor for cancer development. This risk is downplayed by nearly all who promote screening mammography. In an article published in January 2009, however, researchers from Johns Hopkins University, the National Cancer Institute, and Memorial Sloan-Kettering Cancer Center concluded that the number of breast cancers resulting from five annual mammography examinations between the ages of 25 and 29 would be 26 per 10,000 women studied. Between the ages of 30 and 34 twenty cancers per 10,000 women studied would be expected to be caused by the radiation exposure, and 13 cancers would appear per 10,000 women screened between the ages of 35 and 39. They concluded that the benefit of early cancer detection did not outweigh the risk of radiation induced breast cancer in high-risk women under the age of forty.

If the radiation risk of annual mammography screening cannot be justified in women at the highest risk for breast cancer, what can one conclude about the risk/benefit ratio in women who are at average risk? The justification for screening mammography has been based upon the assumption that early detection of breast cancer will significantly improve the survival rate.

This does not appear to be the case. Studies comparing the breast cancer death rate in unscreened women to that of women who have undergone routine mammography screening have failed to show a significant difference. The most recent review, published in April 2009 by Biomed Central, reported a survival percentage of 99.12 % in unscreened women and 99.29 % in screened women between the ages of 40 and 65. The average benefit of a single screening mammogram was determined to be 0.034 %, meaning that one life would be saved for every 2970 women screened. Even this may be overstating the benefit.

One of the longest running studies looking at the outcome of screening mammography is the Canadian National Breast Cancer Study. The study has been under attack ever since its findings were first published in 1992. The study has consistently shown that while the overall death rate from breast cancer in screened and unscreened women is identical, the death rate among women less than fifty is greater in screened women than in those who are unscreened. Proponents of mammography screening discount this, but there is a logical explanation. Many of the cancers found in young women by mammography are ductal carcinoma in situ (DCIS). Breast cancer research is now suggesting that DCIS represents a collection of latent (inactive) cancer cells that may disappear spontaneously if untreated. Some believe that surgical trauma triggers aggressive tumor growth by activating these latent cancer cells. Some enter the bloodstream at the time of surgery and become foci of distant metastases.

I am not an advocate of routine annual screening mammograms. Women who choose to have them do so at their own risk, and are unlikely to improve their chances of survival even if cancer is present.