Doubts on the periodic health examination.

THE LOGIC behind the concept of periodic health examinations as a health maintenance procedure is impeccable. Yet many of us have feelings of doubt about their real value which are in conflict with this logic. Since logic has played only a small part in many of the successes of the scientific method, our doubts are at least respectable. It has however strongly appealed to many medical and lay minds and has by now produced in its support an enthusiasm, almost a faith. Perhaps the very level of enthusiasm is enough to stimulate the sceptics. There are several reasons behind this scepticism, and these are perhaps felt rather than expressed, but it is the purpose of this contribution to examine some of them. The whole topic is bedevilled with problems of definition and semantics. The main question of when an abnormality is sufficiently severe or established to be called a disease has never been squarely faced. There are many examples in the literature where this problem is completely ignored and authors are content to list a series of abnormalities discovered. Yet it is a fundamental problem in this broad borderland between health and disease, and until commonly accepted criteria are developed and used, the results of separate investigations often cannot be validly compared. Many of the articles in a voluminous, and American-dominated, literature describe a method of investigation and presentation of results which leave much to be desired. Quite frequently the age and sex breakdown of the patients is ignored, and very frequently the time-base of the investigation is not stated. Again, details of successive years' work upon the same series of patients sometimes cannot be extracted from the grouped data, and it is thus impossible to discover what proportion of total findings were discovered at examinations following upon the initial one. In other papers it is not clearly stated whether the findings reported were already known to the patient as a result of previous procedures; where this was so, little can have been achieved by the examinations. Some reports show that the people entering were often highly selected and in some instances were volunteers. It is very difficult to find from the published literature much objective evidence to support the present enthusiasm. The existence and discovery of large numbers of abnormalities proves nothing. Any regular examination of an ageing biological organism, if thoroughly and carefully performed, must reveal the stigmata of decay. It can be argued that the aim of periodic examinations must be essentially curative—the object being the early detection of disease and its subsequent treatment in the hope that the course of the illness can be favourably influenced. But, if the procedure is viewed as therapeutic, the same modern criteria of validity must be applied to this as to other recently introduced therapeutic weapons. Yet there is an almost total absence of reports of controlled trials in matched populations of adequate size. (A small trial is reported by Wade, 1958.) There are difficulties in the definition, planning and organization of a controlled trial, some of which have already been mentioned, but perhaps the biggest is the length of the human life span. Such an investigation will yield results but slowly, and so we are in the classical dilemma of being pressed to allow the empirical impressions of limited individual experiences to become the justification for a new procedure.