- Margaret McCartney, general practitioner, Glasgow
The internet is brimming with health advice—and now online health “checks.” NHS Choices (www.nhs.uk) offers much straightforward information but also “health check tools,” such as a depression self assessment that offers people the opportunity to “take this short test to find out if you’re suffering from depression.”1 This test is the PHQ-9 patient health questionnaire, which, we are warned in the preamble, is “not intended to replace a consultation with a GP.” NHS Choices also provides a wellbeing self assessment, which uses the WEMWBS (Warwick-Edinburgh mental wellbeing scale), and home hygiene, mole, and asthma self assessments.
Having done NHS Choices’ asthma check (“use this self-assessment to find out if you might have asthma”) and offering symptoms of exertional chest pain and breathlessness, I found that I was “unlikely” to have asthma but that I should seek advice if symptoms changed or got worse. Is this helpful? The kidney disease check will, if your urine has ever tested positive for blood or protein, recommend that you see your general practitioner for further tests. It does not put such previous test results in the context of information such as concurrent urine infection or menstruation.
The NHS is not the only organisation that offers online self checking and advice. Chris Steele, a general practitioner and resident doctor on ITV’s This Morning, has videos that demonstrate how to examine your own breasts or testicles.2 In the breast examination video, he recommends various poses, including a superclavicular examination. However, teaching breast self examination is known to be unhelpful and potentially harmful.3 Channel 4’s Embarrassing Bodies programme has extensive “my health checker” features on its website, which “check everything from BMI to OCD.” It says, on the opening page, that “a urine test is a very simple and easy way to check for potential problems such as dehydration, sexually transmitted infections and even kidney or bladder cancer.” But the test the site offers is self assessment of urine colour alone, which is not capable of excluding any of these conditions. The site also has tests to “find out whether you display the kinds of attention or hyperactivity problems that are known to be associated with ADHD.” It includes videos that say that “self examination saves lives,” recommending monthly breast examination to men and women, and a different routine, including squeezing the breast to check for discharge. It also offers routines for doing a monthly vulvar or testicular examination.4 Embarrassing Bodies takes some of its information from NHS Choices.
How much of these self check tests is based on evidence of usefulness in real life settings? The PHQ-9 questionnaire, for example, has been found useful for screening but not as a diagnostic instrument in people at high risk of depression. It is not useful for people at normal or low risk.5 The WEMWBS was designed for monitoring mental wellbeing at a population level,6 yet NHS Choices says that you can use it to find out “how happy you are.”7 It says that the checks “are in no way designed to be used for diagnosis or to suggest treatment. They are designed to help people reflect on and better understand their health, providing links to useful web content.” Each online self assessment, it adds, was “signed off separately by a clinician and a Department of Health policy as per our standard editorial process.”8 One NHS Choices web page recommends “men to examine their testicles regularly, about once a month,”9 but a sidebar on another page notes “disagreement among the medical community about who should check for testicular cancer and how often” and repeats the American Cancer Society’s advice against regular self examination for men at normal risk.10
Over at Channel 4 Embarrassing Bodies supplies no information about evidence on the lack of effectiveness or the harms of teaching breast self examination or about the lack of trial evidence supporting routines for testicular or vulvar self examinations. One self assessment encourages people to match the colour of their urine to a chart, which states that yellow urine means “your hydration risk level is very high” and if the urine is “consistently this colour, it would be advisable to get a check-up from your GP.” Yet dehydration cannot be diagnosed from one urine sample,11 and there are no questions about thirst or food and fluid intake.
The site’s ADHD questionnaire is designed by Dore, a company that previously offered unconventional treatment for ADHD and dyslexia and has been criticised by the professor of developmental neuropsychology Dorothy Bishop for publication of “seriously flawed” studies and misleading claims of treatments.12 There is a link to the Dore website on the opening page of the Channel 4 questionnaire.13 Channel 4 said in a statement that it is “immensely proud of the Embarrassing Bodies series and its website, which have been a huge success with viewers, with the self check videos receiving about two million views to date, and MyHealthChecker totalling one million uses.”
It added: “Both the programme and the website are guided by the highest editorial standards and we have worked closely with recognised medical organisations, including NHS Direct, to ensure the advice and information given are appropriate. We regularly receive positive feedback with viewers telling us how helpful they’ve found the service.”
Easy access to accurate health information is to be applauded, and it is right that people can see the types of evaluations that have been used in healthcare. However, the proliferation of online health checkers has not been accompanied by full explanation of the limitations of the tests in real life and the potential for misdiagnosis, delayed presentations, and unhelpful information. Indeed, the multitude of checks lacking proof of benefit risks sidelining useful information, such as that on smoking cessation. As medicine moves online, it is essential that people get fair information that is based on hard evidence of effectiveness.
Cite this as: BMJ 2012;345:e6745
Provenance and peer review: Commissioned; not externally peer reviewed.
Competing interests: None declared.