Family physicians may concentrate only on the recommendations of guidelines during periodic health examinations of healthy adults however individuals’ / patients' expectations may require a different approach. This study was conducted to reveal the hidden agendas of individuals/patients visiting a family physician for screening. A questionnaire was used in 100 healthy individuals undergoing screening at a family medicine center between February 2017 to May 2017 in Rize, Turkey. The qestionnaire included sociodemographic data, reasons for requesting screening, individuals’ health concerns, symptoms and complaints. Data was analyzed using the SPSS 21 statistical analysis program. The mean age was 38.9±11.5 years. Of the participants, 64.0% (n=64) were female, 60.0% (n=60) described themselves as moderate socioeconomic status, 44.0% (44) were smokers. The rate of alcohol consumption was 34.0% (n=34). Of the participants, 8.0% (n=8) were doing regular physical exercise, 38.0% (n=38) having healthy nutritional habits, 63% (n=63)  had complaints and symptoms, %21 (n=21) thought their symptoms might be related with a disease and %42 (n=42) were not sure about it so they wanted to have relief by undergoing screening. Of the participants with health concerns, 29% (n=29) thought that their symptoms might be related to  cancer and 19% (n=19) thought that they might be related to a chronic disease. Participants with health concerns were significantly in favor of undergoing screening tests compared to the ones without any health concerns. Even healthy individuals visiting a family physician for screening may have an underlying health concern. Therefore, family physicians should be cautious about behavioural and verbal cues to recognise and identify hidden agendas of individuals.

Keywords: family physician, health concern, hidden agenda, screening

Screening is defined as the presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures which can be applied rapidly.¹ Screening is also an indispensable part of secondary care. It aims to identify asymptomatic persons who have not yet developed symptoms and signs of illness and to reduce prevalence of diseases. Screening tests can only be performed for curable diseases with an early and easy diagnostic stage.² In 1968 World Health Organization described 10 principles of a screening test.³ A screening test should have high specificity to ensure acceptable positive predictive value and high sensitivity for diagnosis of diseases during asymptomatic period. In addition, screening tests should be feasible, cost-effective and acceptable by the patients/individuals.⁴ Family medicine is a discipline with a focus on preventive care and health promotion by continuity of patient-physician relationship. Screening tests are important components of periodic health examinations.⁴ However, decision to screen or not to screen and choosing the most appropriate screening method can be challenging for family physicians.⁵ When a patient request periodic health examination or a screening test, physicians may assume it is for detection of an asymptomatic disease. In this context, most recommendations for periodic health examinations are based largely on the prevalence of preventable disease in asymptomatic individuals.⁶ However, a prospective study has shown that the majority of patients with demand of a check-up were motivated by some specific symptoms and health concerns and were not “asymptomatic”.⁷ These aspects may be systematically ignored or overlooked in check-up consultations while the physicians tend to focus on delivering recommended screenings. Physicians may also assume that patients disclose their symptoms and talk their concerns directly with the physician. However, one in three patients had one or more hidden agendas leading to periodic health examination/check-up.⁸ Therefore, family physicians need to be aware of possible cues to reveal hidden reasons for the consultation. Furthermore, physicians need to be aware of “hidden agendas”, as patients often use periodic health examination as a reason for consultation to raise the issue of a specific problem that troubles them, to use the family physician as a counsellor to discuss problems, to seek reassurance regarding undeclared symptoms or to feel relief.^5–8 Patients who request a screening test/check-up examination may expect more than just routine screening in accordance with the current clinical guidelines.^9–11 When patients’ expectations are not met, patient satisfaction is likely to be decreased leading to reduced adherence to therapy, increased health care utilisation, more frequent malpractice litigation, and switching doctors or health plans.^12–16 The purpose of this study is to reveal the hidden agendas of individuals/patients visiting a family physician for screening.

Research design and setting

Our sample was 100 healthy individuals visiting a family physician for screening in Rize, a city in the Black Sea (Northern part) Region of Turkey. Participants with a known disease were not included. Research was completed between February 2017 to May 2017 with 100 participants. All participants gave informed verbal consent. Participants completed questionnaire including sociodemographic data, reasons for requesting a screening test, health concerns, symptoms and complaints. The questionnaires were completed face-to-face.

Data analysis

Data was analyzed using the SPSS 21 statistical analysis program. Demographic data was analyzed as numbers and percentages. Cross tables were used and analyzed using chi square and ANOVA tests. The level of significance was set as p<0.05. We used the Shapiro–Wilk test to check distribution of variables. There were variables with normal distribution such as age, smoking, exercise, education status, household income per month. There were also variables without normal distribution such as socioeconomic status, marital status, alcohol consumption.

The mean age was 38.9±11.5 years. Of the participants, 64.0% (n=64) were female, 60.0% (n=60) were married, 60.0% (n=60) described their socioeconomic status as moderate, 39% (n=39) were university  graduates (Table 1). Of the participants, 44.0% (n=44) were smokers. The rate of alcohol consumption was 34.0% (n=34). Of the participants, 8.0% (n=8) were doing regular exercise more than 150 minutes per week, with only 38.0% (n=38) having healthy nutritional habits (Table 1). Of the participants 41% (n=41) had positive family history for cancer (Table 1). Motivations of participants who visited for screening are shown in Table 2. Of the participants, 37% (n=37) had no complaints or health concerns, 21% (n=21) thought their complaints might be related with a serious disease and %42 (n=42) were not sure so they wanted to consult the family physician for relief (Table 2). We asked participants ‘’Which disease do you think can be related with your complaints or health concerns?’’, 29% (n=29) stated cancer, 19% (n=19) a chronic disease such as diabetes mellitus, hypertension, hypothyroidism, asthma, coronary heart disease, and 7% (n=7) a psychological problem (Table 3). There was a significant relationship between having any complaints/symptoms and increased health concerns (p=0.003) and participants with complaints/health concerns were significantly in favor of undergoing screening tests (p=0.003) (Table 4). Participants with a positive family history for cancer were in favor of undergoing screening tests even if they did not have any complaints or health concerns however it was not statistically significant (p>0.05) (Table 4). As the age of participants increased, the frequency of visiting for periodic health examination/screening increased (p=0.01) and increased age was significantly related with being in favor of undergoing screening tests (p=0.01) (Table 4).

In a study, hidden agendas, such as health concerns and psychosocial problems, were found in one third of the patients. They might actually be the primary reason for patient’s request for a screening test.⁷ Periodic health examination is an important opportunity for early detection of an asymptomatic disease.¹⁷ However, our study showed that less than half of the individuals/patients were asymptomatic and most of them requested to undergo a screening test not for disease prevention. The ones with complaints/symptoms were more likely in need of relief for their complaints/symptoms. Some of these symptoms resulted in several diagnostic tests. Hidden agendas (complaints/symptoms/health concerns) may be the main motivation for individuals requesting a periodic health examination/check-up/screening. Our finding was consistent with literature stating that symptoms and health concerns are important stimulus for requesting a check-up/periodic health examination.⁹

A systematic review has demonstrated that periodic health examination has a beneficial effect on the delivery of some clinical preventive services and may have a beneficial effect on patient worry, providing justification for its continuing implementation in clinical practice.¹⁸ Therefore, recognizing a patient's true concerns and worries is important. It was also interesting that nearly half of the participants were not in favor of undergoing a screening test if they had no complaints or health concerns. This indicates that there is not low number of the individuals who have the opinion 'screening tests should be requested when complaints occur'.

Limitations of the study

Participants were at younger age so we could not find a significant relationship between age and symptoms/health concerns.  We did not examine participants’ complaints and symptoms in detail. So we could not explain which complaint or symptom was more effective in motivation for requesting a screening test/periodic health examination.

As we expected, health concerns of individuals/patients was their main motivation for requesting to undergo a screening test. We also found that health concerns and motivation for screening were affected by some sociodemographic data. Hidden agenda of individuals/patients visiting family physician for screening should be revealed. Being alert to behavioural and verbal cues is important for family physicians to recognise and identify hidden agendas and to improve the physician-patient relationship.

None.

The author declares there is no conflcit of interest.

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