"Is it Worth Getting an Annual Physical Exam?"
The model of getting an annual physical exam dates back
nearly a century in American medicine, but recently many health authorities
have all agreed that routine annual checkups for healthy adults
should be abandoned.
Yet, the majority of the public still expects not only a comprehensive
annual physical exam, but extensive routine blood testing.
Given the gap between patients’ enthusiasm
and the new guidelines’ skepticism about annual physicals,
what are physicians to do?
Well, first we must educate patients about preventive practices
of proven versus unproven benefit.
For example, the only routine blood test currently recommended
by the USPSTF, the official preventive medicine guidelines setting body,
is cholesterol.
The reason why so many physicians continue to perform annual examinations
of patients’ hearts, lungs, abdomens, and even reflexes
and continue to order some of the tests that have been proven
ineffectual or even harmful, is because otherwise,
the patient might leave unsatisfied with the visit.
Evidence suggests that the more physical and laboratory examinations
they perform, the better patients feel.
So, they’re like placebo maneuvers.
But, rather than performing unnecessary or worse exams and tests,
perhaps physicians should spend some of the time saved
by telling their patients why they are not going
to just go through the motions like some witch doctor.
Most important, we need to educate ourselves
about the dangers of over diagnosis.
There will always remain a small possibility that our exam
might detect some silent, potentially deadly cancer or aneurysm.
Unfortunately for our patients, these serendipitous, life-saving events
are much less common than the false-positive findings
that lead to invasive and potentially life-threatening tests.
This Cleveland Clinic doc shared a story about his own father
who went in for a checkup.
Can’t hurt, right?
The doctor thought he felt what might have been an aortic aneurism;
so, he ordered an abdominal ultrasound.
Can’t hurt, right?
Aorta was fine, but hmm...
something looked suspicious on his pancreas;
so, a CT scan was ordered.
That can hurt: lots of radiation.
But thankfully, his pancreas looked fine,
but hey — what’s that on his liver?
Oh, for goodness sake.
Looked like cancer,
which made a certain amount of sense having worked in the chemical industry.
So, realizing how ineffective the treatments were for liver cancer,
he realized he was going to die.
The daughter was not ready to give up on him, though,
convinced him to see a specialist;
maybe if they cut it out, he could live at least few more years,
but first they had to do a biopsy.
And, the good news was, no cancer.
The bad news, though, it was a benign mass of blood vessels;
and so, when they stuck a needle in it, he almost bled to death.
Ten units of blood is all you have.
Pain, and so morphine, and so urinary retention, and so catheter;
yet, thankfully, no infection.
Just a bill for $50,000.
The frustrating thing is that the whole horrible sequence
wasn’t malpractice or anything;
every step logically led to the next.
The only way to have prevented this life-threatening outcome
would have been to dispense with that initial physical examination.
The one that couldn’t hurt, right?
Why, then, do we continue to examine healthy patients?
Well, first of all, it’s because we get paid to do it.
His dad’s initial doc only got a hundred bucks or so,
but just think about all that “downstream revenue”
for the hospital and all the specialists.
Over-diagnosis is big business.
Yes, too many patients bear the costs and harms
of unneeded tests and procedures,
but without annual check-ups, we doctors would miss out
on all those opportunities
for open communication and interpersonal continuity.
To which one physician replied: “Look, if you’ve deluded yourself
into thinking you’re doing more good than harm,
if you want communication, why not just take your patients
out to lunch or something?”
Of course, such lunches should fairly and ethically be preceded
by an informed consent discussion that allows prospective diners
to understand the risk that they may be patronized to,
and may well receive unnecessary and injurious interventions
as a consequence of that grilled cheese and soup—particularly,
I would add, if you’re feeding your patients grilled cheese,
having already chalked up your first
such unnecessary and injurious act.