"Worth Getting an Annual Health Check-Up and Physical Exam?"
Physicians and patients have come to expect
the annual check-up as a routine part of care.
However, considerable research has not demonstrated
it has any substantial benefits.
And so a revolt is brewing against the tradition of periodic check-ups.
Even the Society for General Internal Medicine
has advised primary care physicians
to avoid such "routine general health checks for asymptomatic adults."
Check-ups seem to make sense, but historically medical practice
has included all sorts of things that seemed to make sense,
such as hormone replacement therapy for menopause,
until it was put to the test and found to increase
the risk of breast cancer, blood clots, heart disease, and stroke.
Or like when doctors killed babies by making the so-called
"common sense" recommendation that infants sleep on their tummies,
whereas we all know now "Face Up to Wake Up."
We should always demand evidence.
We check our cars regularly though.
So why shouldn't we also check our bodies?
Well, unlike cars, our bodies have self-healing properties.
To see if the benefits outweigh the harms,
researchers decided to put it to the test.
So what are the benefits and harms
of general health checks for adult populations?
The bottom line is that check-ups were not associated
with lower rates of mortality, meaning not associated with
living longer or a lower risk of dying from heart disease, stroke, or cancer.
So general check-ups may
not reduce disease rates or death rates,
but they do increase the number of new diagnoses.
And the harmful effects of the tests and subsequent
treatments could have balanced out any benefits.
Possible harms from check-ups include overdiagnosis,
overtreatment, distress or injury from invasive follow-up tests,
distress due to false positive test results,
false reassurance due to false negative test results,
possible continuation of adverse health behaviors
due to negative test results, adverse psychosocial effects
due to labeling, and difficulties with getting insurance
now that you have a pre-existing condition,
not to mention all the associated cost.
For example, diabetes.
Wouldn't it be great if we picked up a case of diabetes earlier?
Perhaps not, if they were given the #1 diabetes drug at the time,
Avandia, which was pulled off the market because
instead of helping people, it appeared to be killing people.
Adverse drug events are now one of our leading causes of death.
When it comes to lifestyle diseases, like type 2 diabetes,
maybe we should instead focus on
creating healthier food environments,
like my new favorite organization, Balanced,
to help prevent the diabetes epidemic in the first place.
How many times have you tried to inform someone
about healthy eating, about evidence-based nutrition,
only to have them come back and say,
"No, I don't have to worry; my doctor says I'm OK.
Just had a check-up, everything's normal."
As if like having a normal cholesterol is OK
in a society where it's normal to drop dead of a heart attack,
the number one killer of men and women.
I mean, if you went to see a lifestyle medicine doctor
who spent the check-up giving you the tools
to prevent 80% of chronic disease, that's one thing,
but given the way medicine is currently practiced,
it's no wonder, perhaps, why the history of routine check-ups
"has been one of glorious failure."
But generations of well-meaning clinicians
just don't want to believe it.
Policy should be based on evidence though.
Poor diet is on par with cigarette smoking
as the most common actual cause of death;
yet, the medical profession is inadequately trained in nutrition.
Worse, nutrition education in medical school appears
to be in decline, if you can believe it.
A shrinking of nutrition education among health professionals.
So the advice you get in your annual check-up may just be
from whatever last tabloid your doctor
skimmed in the check-out line.
Screening opportunities should not be regarded as
a form of "health education," one medical journal editorial read.
"People who are obese know very well that they are,
and if we have no means of helping them,
we should just shut up."
Well, if you really have nothing to say that will help them,
maybe you should shut up, especially doctors who say
they have no idea what constitutes a "healthy" diet,
though veggies and nuts are a good start.
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.