The New York Times’ venerable health columnist Jane Brody recently wrote about the advisability of the annual physical checkup. It’s a topic we’ve covered, too, reaching mostly the same conclusion: In most cases, an annual doctor examination is a poor use of time, money and medical resources.
As Brody points out, trying to figure out if a routine checkup is a good idea is more important than ever, because next year, the Affordable Care Act (“Obamacare”) will enable about 30 million more people to be insured. Many of them will be eligible for an annual exam that insurance plans must cover. That’s a lot of potential demand on a resource stretched pretty thin.
So who should get a checkup? And how often?
According to one of Brody’s sources, about 44.4 million adults get preventive exams every year. If every U.S. adult got one, 145 million more visits would occur every year, and gobble up almost half of all the time primary care doctors spend with patients. And you think the health-care system is slow, inefficient and frustrating now?
No one within or outside of the medical community disputes the wisdom of regular checkups for babies, children and pregnant women. No one disputes the wisdom of exams that include specific screenings for certain populations, such as Pap smears for women. But, as Brody says, “Among physicians, researchers and insurers, there is an ongoing debate as to whether regular checkups really reduce the chances of becoming seriously ill or dying of an illness that would have been treatable had it been detected sooner.”
Those who vote “no” point to a growing number of studies that fail to find a benefit that outweighs the risk that they’ll do more harm by finding something abnormal that, if it had never been discovered, would never have done harm. Something can be technically “abnormal” without being threatening or even, sometimes, interesting.
But the default behavior by too many practitioners is to conduct extra tests. This causes the patient distress, expense and, sometimes, medical complication.
One of Brody’s examples was provided by a physician who told the tale of Brian Mulroney, former prime minister of Canada. He had a physical in 2005 that included a CT scan. It showed two small lumps in his lungs. He underwent surgery to find out what they were, after which he developed an inflamed pancreas that forced him into the intensive care unit. He was in the hospital six weeks, and readmitted a month later to remove a cyst caused by the inflammation of his pancreas.
Oh, and the lung lumps were benign.
Of course, the question arises: What if the lumps had been cancerous? Wouldn’t the initial scan and all the unpleasant consequences of it have been worth it in order to be able to treat the cancer?
“The question of benefits versus risks from routine exams,” Brody writes, “can be answered only by well-designed scientific research.”
One recent study cited in her story was conducted at the Nordic Cochrane Center in Copenhagen, Denmark.
Researchers analyzed 14 clinical trials of routine checkups that followed participants for as long as 22 years. The team found that healthy people who got routine checkups got no benefit in terms of the risk of death or serious illness compared with compared with people who did not.
And as we’ve said in this blog repeatedly, the researchers concluded that many routine exams involve specific screening tests whose value hasn’t been studied adequately. The possible harms of such routine tests, they said, are “overdiagnosis, overtreatment, distress or injury from invasive follow-up tests, distress due to false positive test results [a test that shows the existence of a potential problem when there isn’t one], false reassurance due to false negative test results [tests that don’t show a problem when there is one], adverse psychosocial effects due to labeling and difficulties with getting insurance.”
Among a general population-that is, the subjects weren’t chosen because they did or didn’t have certain risk factors of medical problems-the Danish team simply didn’t find that having a checkup reduced the possibility of dying any more than not having one. Nor did they find any reduction in cardiovascular problems and cancer-the causes of death most likely to be influenced by health checkups.
But a regular doctor appointment can be useful, Brody says, noting that many doctors welcome an annual visit even when their patients don’t have a medical issue because it’s good for the relationship-it helps alert them to changes in patients’ lives that can affect health. And doctors can use that time to encourage patients to get needed immunizations and other health care, such as eye and dental exams that have proven benefits with almost no risk.
So what’s a person to do if she wants to monitor her health without overdoing it?
Brody has three pieces of advice:
1. Whenever you visit the doctor for any reason, have your blood pressure checked and get blood tests if the ones in your medical record are older than a year.
2. Remain current on immunizations-flu shots, tetanus, shingles, etc. (If you don’t know which vaccinations you should have, ask. Some are recommended for certain age groups or if you have certain risk factors.) Get the screening tests specifically recommended for your profile-age, gender, risk factors, family and personal medical history.
3. Some symptoms require attention. If you develop unexplained pain, shortness of breath, digestive problems, a lump, a skin lesion that doesn’t heal, or unusual fatigue or depression, call your doctor. If the problem is diagnosed and treated, ask when you should feel relief. If that time has come, and you’re not feeling better, seek further help.