By the time medical school begins, most physicians-to-be already know a great deal about screening. We have all learned from watching television that mammograms and prostate-specific antigen tests should occur once a year beginning at a certain age. Most of us have had our cholesterol levels checked and the majority of women have had several Pap smears long before their medical careers begin. This issue of Virtual Mentor explores some of the attitudes physicians develop regarding screening and why many of us feel obligated to perform these tests, despite a frequent lack of evidence supporting their benefits.
As a urology resident, I have seen many patients whose lives I think were saved by screening. I’ve been in situations where both the patient and I wished he had undergone screening before the disease progressed. But I’ve also seen many patients who’ve had abnormalities detected on screening and had their lives disrupted as they underwent further work-ups and tests, often for what ultimately proved to be a negative result or, sometimes worse, an ambiguous one. Few tasks are as difficult as counseling a patient about a disease that could be fatal or could, in fact, not even become a matter of clinical concern during his lifetime. There have been many days when I’ve gone home grateful that a patient had undergone a screening, but probably just as many when I’ve wondered how much we have really helped someone.
In the January 2006 Virtual Mentor, we highlight the spectrum of difficulties encountered with screening. We are fortunate to have contributions from many passionate authors who examine important questions about screening. How informed are patients about tests to which they consent and how informed should they be? How much do physicians know about the sensitivity and specificity of tests they recommend and the number of screenings it takes to save 1 life? What are the implications of prenatal genetic screening on the diversity of the population and on society’s view of disability? How should physicians respond when patients request CT scans in the absence of symptoms, family history, and risk factors for disease? What must we do to ensure that our health care system provides follow-up treatment to all who have positive test results? In addition, the authors provide some basic information about what makes a good screening exam and offer an interpretation of the literature regarding the cost-effectiveness of CT screening for lung cancer.
Screening patients carries tremendous responsibility. I hope this issue gives us all insight into the pitfalls of screening and the necessary preparation a physician must make before ordering a screening test. Understanding these ethical issues should allow us to more effectively use screening for its intended goals—to provide a benefit to our patients while remembering: first, do no harm.