I’m skeptical about … annual checkups.

The concept of the annual checkup, now referred to as a “periodic health assessment,” dates back to 1861. Although the tools, tests, and screenings available today are far more sophisticated than those available to the antebellum physician, the purpose of the assessment has changed little—to provide an overview of health and the opportunity to screen for acute and chronic disease. The concept of seeing a physician for health maintenance was popularized  in the 1930s and 40s by insurance companies that realized an ounce of prevention might be worth more than a pound of cure when it came to keeping business executives humming and productive. By the 1960s, the annual physical was an entrenched component of American healthcare, widely accepted by both patients and physicians.

But a funny thing happened on the way to the doctor’s office; there wasn’t much data supporting the notion that such visits improved health outcomes. Now I’m the first to admit that an absence of evidence is not the same as evidence of absence. On the surface, the idea of periodic visits to the doctor certainly makes sense. The stated goals of the periodic health assessment are the following:

  • Primary prevention of disease through the identification and modification of disease risk factors.
  • Secondary prevention of health complications through early detection of asymptomatic or minimally symptomatic disease.
  • To enhance the patient-physician relationship by providing an opportunity for discussion and anticipatory guidance.
  • To update clinical data and promote healthy behaviors.

There is a big difference, however, between treating symptomatic disease in a selected population and screening for asymptomatic disease in a general one. For example, when the prevalence of a disease like tuberculosis in the community is low, then it’s a mathematical certainty that even highly specific screening tests will yield more false positive results than true positive ones, meaning that many people without disease will be faced with the added expense, anxiety, inconvenience, and discomfort, that is sure to accompany the follow up testing and treatment.

On the flip side, patients also have to contend with false negative test results providing false reassurance that a disease isn’t present when it’s actually lurking in the shadows undetected. There is even data supporting the idea that when patients are advised they are in “perfect health,” they are less likely to discontinue unhealthy behaviors like smoking (“Thank God I don’t have cancer. Guess I’ll keep smoking a while longer.”), drinking (“The doc says my liver studies are fine, so maybe I’m not drinking too much.”), or unsafe sex (“Whew, no HIV, gonorrhea, or chlamydia. Guess I can get away with not wearing a condom now and then.”).

Finally, there’s the growing problem of over-diagnosis, where asymptomatic disease never destined to become symptomatic is discovered through a screening test. PSA testing for prostate cancer remains the poster child here. When 80% of men older than age 80 who die from other causes are found to have occult prostate cancer on autopsy, then it’s clear that prostate cancer is the normal finding in men who live to this age. Over-diagnosis here leads to harm in the form of incontinence, impotency, and anxiety, which is why routine PSA screening is no longer recommended.

Widespread screening guarantees over-diagnoses. The authors of a 2012 Cochrane Collaborative review on the benefits and harms associated with periodic health exams concluded that: “While we cannot be certain that general health checks lead to benefit, we know that all medical intervention can lead to harm.” True.

 

(Reference 6)

(Reference 6)

 

But tradition dies hard, particularly in the profit-motivated US healthcare system where doctors are paid for doing things. As far back as 1979, the Canadian Task Force on Preventative Health Care stopped recommending routine annual exams. Meanwhile, in the US, despite contrary recommendations from the AMA (American Medical Association), the USPSTF (US Preventative Services Task Force), and the ACP (American College of Physicians), many doctors continue to advocate for annual checkups. In a 2005 poll of primary care physicians, 88% of respondents reported that they continue to perform annual checkups on their patients. Nearly half believed that a battery of routine lab tests and screening diagnostics were also necessary, despite strong evidence that this does nothing to improve patient health outcomes. More than half of the doctors erroneously believed that annual exams are recommended by national organizations like the AMA. Not surprisingly, when physicians don’t know or ignore the recommendations of such organizations, patients continue showing up as instructed. In general, the public believes in the value of annual exams accompanied by testing, testing, and more testing. The question remains, could this money, which amounts to more than $5 billion annually, be better spent? And would the 50 million patients spending it be better served by a walk in the park, instead?

 

(Reference 4)

(Reference 4)

 

Currently the AMA recommends periodic health exams every 5 years for people younger than 40, then every 1 to 3 years thereafter, but even here the data is sketchy. In the absence of symptoms, the USPSTF specifically recommends against routine lab testing (e.g. blood counts, chemistries, and urine checks) and screening diagnostics like EKGs. The evidence against doing these things comes largely from a 2012 systematic review on the benefit of periodic health exams that reviewed outcome data for more than 180,000 patients. The authors found no benefit associated with them—no mortality benefit, no decrease in morbidity, no decrease in job absenteeism, no decrease in disability, no decrease in hospitalization. Zip. In fact, of all the components included in the periodic health exam, only 2 (blood pressure screening for all, and regular PAP smears for women) have high quality evidence supporting them. Currently, the only recommended screening tests for everyone at every age are blood pressure, height, and weight. For adults older than age 40, a cholesterol check and specific cancer screening are also recommended. The remainder of the exam should be tailored to the specific needs of the patient. Know that a battery of random tests is more likely to lead you and your doctor down goose chase lane than it is to uncover a dread disease.

 

(Reference 4)

(Reference 4)

 

This does not mean that periodic well-visits to the doctor are a complete waste of time. I can think of at least 3 good reasons to see a doctor in the absence of acute illness: 1) For preventative counseling and health information, 2) To update your health record and to remain current on immunizations, and 3) To foster a healthy, trusting, respectful patient-physician relationship. Your primary care physician (not Dr. Google) should be your go-to source for health and safety counseling on a variety of topics ranging from smoking cessation to advanced medical directives to safe sex practices. Based on training and inclination, physicians may or may not be a good source for diet and nutrition information. Realize that most have no more than a rudimentary knowledge of the subject. Registered dietitians are better here. Also keep in mind that, with the exception of sports medicine-trained physicians, most primary care doctors know no more about exercise than you do. Unless they happen to be active athletes themselves, most will have no training in this area.

One of the best reasons to see a doctor when you’re not sick is to prevent becoming sick by getting immunized (see vaccines.gov to locate vaccination services near you). Current recommendations include vaccines against 16 different infectious diseases. I advocate for all vaccines in everyone. They do not cause autism or any other defined illness. Period.

Viral infections prevented or mitigated through vaccination:

  • Mumps, measles and rubella (MMR)
  • Hepatitis A
  • Hepatitis B
  • Human papilloma virus (HPV)
  • Chicken pox and shingles (varicella)
  • Influenza
  • Rotavirus
  • Polio

Bacterial infections prevented or mitigated through vaccination:

  • Tetanus, diphtheria, and pertussis (TDAP)
  • Meningococcus (meningitis)
  • Pneumococcus (pneumonia)
  • Haemophilus influenza B

(Note: This is a partial list including only the illnesses where vaccines are recommended for all Americans.)

Lastly, periodic health exams help strengthen the patient-physician relationship. A calming voice, a gentle touch, an empathetic ear; these constitute the human elements of the healing arts, and it’s clear that they are more effective when delivered by someone familiar. The cold hard steel of the scalpel, the exactitude of the CT scanner, and the precision of the photon beam will never replace the human element of caring and concern. Of all the reasons to visit a physician, this is perhaps the most important one, and represents why I am reluctant to recommend abandoning the periodic health exam altogether.

As for me, I haven’t seen a primary care physician in nearly two decades. But I’m planning on seeing one soon. No, really, I am.

References:

  1. Ebony Boulware et al., “Systematic Review: The Value of the Periodic Health Evaluation,” Annals Int Med 2007: 146: 289-300.
  2. Lasse Krogsbol et al., “General Health Checks in Adults for Reducing Morbidity and Mortality from Disease: Cochrane Systematic Review and Meta-Analysis,” BMJ 2012; 345: e7191-e7204.
  3. Hanna Bloomfield et al., “Evidence Brief: Role of the Annual Comprehensive Physical Exam in the Asymptomatic Adult,” Dept. of Veteran’s Affairs / Health Services Research & Development Services, Oct. 2011.
  4. Allan Prochazka et al., “Support of Evidence-Based Guidelines for the Annual Physical Examination: A Survey of Primary Care Providers,” Arch Int Med 200; 165:1347-52.
  5. Elizabeth McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,” NEJM 2003; 348:2635-45.
  6. Ateev Mehrotra and Allan Prochazka, “Improving Value in Health Care — Against the Annual Physical,” NEJM 2015; 373 (16): 1485-87.

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