I’m somewhat reluctant to post this as the vast majority of the worlds physicians are at this very time working their fingers to the bone dealing with the coronavirus pandemic, however it’s been some time and it’s clear that like an apple Covid-19 has kept the doctor away, or rather the patient from the doctor. Healthcare staff are not all at the sharp end but for many any spare capacity has been utilised to vaccinate and provide not only healthcare but advice on both physical and mental wellbeing. Some say the next pandemic will be a mental health one so we should all try and mitigate this and not be overly scared to leave home etc.
(My very good friends Ana and Marcantonio!)
The concept of “Covid anxiety syndrome” was first theorised by professors last year, when Ana Nikčević, of Kingston University, and Marcantonio Spada, at London South Bank University, noticed people were developing a particular set of traits in response to Covid. The anxiety syndrome is characterised by compulsively checking for symptoms of Covid, avoidance of public places, and obsessive cleaning, a pattern of “maladaptive behaviours” adopted when the pandemic started. Now researchers have raised the alarm that the obsessive worrying and threat avoidance, including being unwilling to take public transport or bleaching your home for hours, will not subside easily, even as Covid is controlled.
The balance is difficult, more for some than others, however being vaccinated does give good protection and although the rules are being relaxed in many countries we all have the choice and can wear a face mask and social distance, tap elbows rather than shake hands and sanitise thus reducing the risk to ourselves and others.
HOWEVER despite my concerns that already overstretched healthcare systems can do without extra workload, it is clear that some serious illness is being missed or treatments delayed. Cancer referrals from primary care are down but there is no evidence that Covid-19 could in any way protect us, so where are these cases going? When they are eventually referred with the specialist find that it’s too late or that treatment will have to be more radical and what of those who were already diagnosed and waiting for treatment? They too have had treatment delayed and may well suffer because of this be it a painful hip for another year or worse a cancer that has spread further.
So what’s the advice from the inside? I would suggest that patients treat simple illnesses such as coughs and colds at home, seek advice from pharmacists or recognised healthcare sites on the internet. BUT don’t delay seeking help for more worrying or serious conditions. I know we’re back to balance again but flooding an overstretched healthcare system with self limiting illnesses helps no one and will likely push more worthy cases down the line.
So, back to the subject! Seldom do simple health checks throw up any great surprises and although prevention is better than cure it’s unlikely although not impossible you will pick up something absolutely unexpected, hidden and lifesaving. However, there are exceptions. Most countries will have screening programs which follow the Wilson criteria for screening which emphasise the important features of any screening program, as follows:
The Wilson criteria for screening.
- the condition should be an important health problem
- the natural history of the condition should be understood
- there should be a recognisable latent or early symptomatic stage
- there should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific
- there should be an accepted treatment recognised for the disease
- treatment should be more effective if started early
- there should be a policy on who should be treated
- diagnosis and treatment should be cost-effective
- case-finding should be a continuous process
As a health care system we must be able to afford the screening test which must be simple and acceptable to the patient and accurately pick up the condition with a known course if left untreated at a treatable stage with a recognised and effective treatment if started earlier than if it were left to present otherwise. In the UK there are several screening programs that fit these criteria from birth onward with heel prick blood tests and baby checks for physical and development as well as hearing etc.
Those most pertinent to the older age group in the UK are:-
For Men & Women:-
Bowel cancer screening
Abdominal aortic aneurysm (AAA) screening
When certain conditions such as diabetes are diagnosed patients will be followed up and screened for conditions that are more likely to occur and so Diabetic eye screening and blood tests will be performed not just to monitor the condition (HbA1c) itself but the consequences (Renal Function etc.) and conditions that we find more commonly in the diabetic group (Hypothyroidism) etc.)
Some men may ask why we don’t currently have a prostate cancer screening program in the UK. The simple answer is that PSA – the least worst screening test we have doesn’t fulfil the 4th of Wilson’s Criteria – (accurate, reliable, sensitive and specific.) In the case of Prostate Cancer, Symptoms Scores (IPSS) and Digital Rectal Examination (DRE) may prompt further examination but even MRI is not yet good enough to be a screening tool and Prostate Biopsy is invasive and not without risk. So for now at least Prostate Screening is not on the cards. If you want to find out more please visit https://prostatecanceruk.org/
In medicine we talk of symptoms and signs.
Signs and symptoms are abnormalities that can indicate a potential medical condition. Whereas a symptom is subjective, that is, apparent only to the patient (for example back pain or fatigue), a sign is any objective evidence of a disease that can be observed by others (for example a skin rash or lump).
So having difficulty passing urine in men or getting up several times at night are symptoms of an enlarged prostate (Natural – Benign Prostatic Hypertrophy (BPH) and/or Prostate Cancer) but having a large prostate can be a sign of BPH
There are a number of conditions that are often ‘silent’ that is we need to look for them as they are often asymptomatic and are causing no symptoms. High Blood Pressure and the early changes in the Cervix that can lead to Cervical Cancer being two. Breast umps can be painful and palpable – symptom and sign – however can be ‘silent’ – in fact Breast cancer has to divide 30 times before it can be felt. Up to the 28th cell division, neither you nor your doctor can detect it by hand. With most breast cancers, each division takes one to two months, so by the time you can feel a cancerous lump, the cancer has been in your body for two to five years. This is the reason we screen because by the time the breast lump can be felt it may already need prompt treatment or even have spread. In fact so difficult is a breast lump to feel in the early stages but often so readily seen on mammogram and treatable that it fulfils Wilson’s Criteria and is screened for.
Blood Pressure (BP = Hypertension) is easily measured – and I suggest every household with adults of middle age and above has an Automatic Upper Arm Digital Blood Pressure Monitoring Machine to measure Blood Pressure and Heart Rate Pulse at home. – A high BP is most often ‘silent’ and needs to be measured – Headaches are rare and of course being tense increases BP and so arriving at the Doctors Office early and relaxing or taking several measurements at home will help avoid ‘White Coat Hypertension/Syndrome” –is a phenomenon in which people exhibit a blood pressure level above the normal range, in a clinical setting, although they do not exhibit it in other settings. (There is controversy as many would argue that there is nothing exceptional in clinical settings alone and other stressful situations will result in high BP albeit temporary – However if these episodes are prolonged or frequent it may damage the arteries just the same.) If your BP is consistently high then the ‘Gold Standard’ measurement is a 24 hour BP recording with readings taken every few minutes throughout the day and night. Averages are calculated and with this and other factors (Age, cholesterol etc.) a risk figure can be calculated (eg QRISK3 ) and treatment options discussed.
Physical Health Checks will take into account your age, sex and ethnicity and some or all of the factors below which are easily measurable and together give a validated risk score regarding Cardiovascular disease – Heart Attacks and Stoke.
- High Blood Pressure (Hypertension). High blood pressure increases your risk of heart disease, heart attack, and stroke.
- On blood pressure treatment?
- High Blood Cholesterol. One of the major risk factors for heart disease is high blood cholesterol measured on a (usually fasting) blood test.
- Obesity and Overweight. BMI = Weight (kg) / Height (m)²
- Whether you have inherited genes relating to ethnicity or if you have a family member who had a heart attack etc. at a young age. (Usually less than 60)
- Chronic Kidney Disease – measured on a blood and urine samples. (Stage 3,4 or 5)
- Physical Inactivity?Fitness is more difficult to assess and give a numeric value.
- Angina or heart attack in a 1st degree relative < 60
- Chronic kidney disease (stage 3, 4 or 5)
- Alcohol consumption
- Atrial fibrillation
- Rheumatoid arthritis?
- Systemic lupus erythematosus (SLE)?
- Severe mental illness?
(this includes schizophrenia, bipolar disorder and moderate/severe depression)
- On atypical anti-psychotic medication?
- Are you on regular steroid tablets?
- A diagnosis of or treatment for erectile dysfunction?
The most important values in terms of risk are toward the top of the list. However, other factors we know can contribute to the risk score. So as I said few will be a surprise to you. Smoking really does do what it says on the pack, being overweight and unfit isn’t something you need a doctor to diagnose. You will know about your own medical and family history, diagnoses and what medication you take, so a few simple blood tests can fill in the blanks.
Of course a physical examination of your skin and systems will give further information. In the UK we use an Americanism ‘If it aint broke don’t fix it’ – That’s to say we don’t usually do annual ‘medicals’ common in the USA etc. Essentially measuring the measurable – but hope to focus in on issues brought to the doctor by the patient and tune investigations accordingly. There is a worry some health professionals feel that having measured the standard ‘data set’ and found nothing wrong, patients will feel reassured, carry on with their unhealthy lifestyle and not report changes as they have been told ‘all is well’!
There is much, much more, but for now I think this covers the basics!