Annual Physicals -- Futile or Not
A peer reviewed study recently published in the Cochrane Library concludes that the annual physical exam, a foundational component of modern medical practice, may be pretty much useless in terms of benefitting health.1 If true, it means that several billion dollars a year are being wasted to little or no effect. The idea behind the annual physical exam is simple: in order to prevent more costly future problems, you religiously go to your doctor each and every year, even when healthy, for a general checkup, which is covered by your health insurance, in order to catch any disease at its earliest treatable stage. And we're not just talking about cancer. Theoretically, this should help catch early diabetes, hypertension, neurological disorders, etc.
But a new study from Danish researchers has determined that there's little benefit to such routine exams for healthy people. They say that any diseases can be picked up in their early stages as a byproduct of testing when you visit your doctor for specific conditions.
Needless to say, many in the alternative health community are all over this, essentially saying, "I told you so." Even many in the medical community endorse the conclusions --if somewhat tepidly -- especially since it's hardly the first such study to come to the same conclusion. Curiously, I'm not sure I agree with them. I actually see benefit in the annual physical exam. I think the problem lies not with the exam but with what doctors do with the information they garner from the exam, and that same problem exists no matter when tests are done. But before we explore this issue further, let's look at the study.
The Danish Study on Annual Physical Exams
The researchers analyzed data from 183,000 people who took part in 14 trials carried out over a number of years in Europe and the United States. Of the 14 studies, six started in the 1960s, three in the 1970s, two in the 1980s, and three in the 1990s. In all the trials, participants were randomly assigned to either receive a routine health check -- involving screening tests, a physical exam, or advice about lifestyle changes -- or not receive one. After examining the data, the researchers concluded that the patients who received routine health checks were just as likely to die over a nine-year period compared with those who did not receive health checks. Even worse (or more curious, depending on how you look at it) routine health checks also seemed to have no effect on hospital admission rates, patient anxiety, referrals to specialists, or time lost at work. Or to quote from the researchers as they wrote in the October issue of the Cochrane Library, "General health checks are unlikely to be beneficial…A physical exam is a pretty meaningless thing to have done." To translate, the researchers concluded that the potential for harm is likely to exceed the potential for benefit when screening is implemented in a population where the overall risk of an unfavorable outcome is low. Given the lack of overall benefit, they felt this may indicate that general health checks promote over-diagnosis rather than detecting clinically relevant abnormalities. In summary: according to the researchers, general health checks do not appear to be a wise use of scarce healthcare resources.
To clarify: what we're talking about here is the annual physical (aka the general checkup) as well as routine screenings for the general population. The researchers noted that going to your doctor for specific testing such as colonoscopies and mammograms was beneficial -- they just probably don't need to be done annually. According to the researchers, every 4-5 years would be enough. It should be noted that the results from the study did not include people who had existing medical conditions, such as high blood pressure or diabetes who visited their doctor on a regular basis to monitor and control their pre-existing condition. Again, we're talking only about healthy people who followed generally accepted protocol and had an annual general physical. As the researchers said, "Eliminating annual physicals would save money partly because it would reduce unnecessary testing."
What the Medical Community Says
As I mentioned earlier, the study's overall conclusions are in line with those of previous research, which has come to a similar conclusion--that there is little evidence that annual physical exams have any value. What studies seem to be finding is that 80% of preventive services (or at least what the medical community calls preventive services) are provided at other types of visits. In the 1960s and 70s, two large randomized controlled trials were conducted and came to similar conclusions. Both studies showed little positive impact from annual physicals -- people who had physicals did not seem to live longer or have less illness than those who did not have physicals. In 1979, The Canadian Task Force on the Periodic Health Examination recommended against the annual general health check.2 And in 1989, the United States Preventative Service Task Force issued similar guidelines.3 Instead, both bodies recommended focused health checks guided by patient-specific risk factors.
Keep in mind, the studies did not find that annual physical exams produced worse results -- just that they didn't improve outcomes and were thus a "costly redundancy." But as we'll discuss later, perhaps the problem doesn't lie with the checkups but with the procedures implemented after the checkups. For now though, back to the medical community.
Newton's First Law (also known as the Law of Inertia) states that an object at rest tends to stay at rest and that an object in motion tends to stay in motion. I mention this because if any group is ruled by Newton's First Law, it is the medical community. Comments on the recent study are indicative.
An editorial in the Cochrane Database, commenting on the recent study noted, "Concerns about over-diagnosis notwithstanding (and despite the national guidelines), general health checks are considered by physicians and the public as both necessary and recommended." 4
As it turns out, when surveyed, physicians say they keep promoting annual physicals because they help build relationships with their patients, and they believe that they potentially offer preventive care benefits -- despite all studies to the contrary. Or to quote from a recent article in The Clinical Advisor, "One of the greatest causes for celebration is when a patient that routinely visits our clinic for acute illness or medication refills makes an appointment for a physical exam...As health-care providers, it is essential that we take an active role in reminding the public about the importance of annual physical exams. We must encourage our patients to make these appointments, and ensure that we take this time to ensure that appropriate screening exams are complete, health promotion education is delivered, and immunizations are up to date."5 Of course, the more cynical might say that physicians are holding onto annual physicals merely because they offer lucrative billing opportunities -- to the tune of some $8 billion a year in the U.S. alone. There might be a grain of truth to that assumption, but mostly, I think, it's inertia. Once an idea gets established in the medical community, it takes many years to change it regardless of the studies that line up against it. Needless to say, since physicians are still so keen on annual physical exams and routine screenings, their patients are too.6
A Fly in the Ointment
On the other hand, there might be a different way to look at this data. Perhaps the lack of apparent benefits lies not in the annual physical itself but in what happens after the physical. Keep in mind, as noted earlier, the studies are not saying that the annual physical produces worse results than visits with specific tests -- merely the same results. And if the results are the same, one needs to ask what they share in common -- and that happens to be the medical intervention that follows the exam. If your blood pressure reads high, it doesn't matter whether that reading came in an annual physical or a visit for something else. You're going to get the same blood pressure medication. Likewise, high cholesterol readings are getting you a prescription for statin drugs regardless of when the test was taken. No wonder there's no difference in outcomes between getting an annual physical or getting a problem specific checkup -- you end up getting the same treatment.
At this point in the discussion, we need to ask ourselves how effective is the combination of testing and medical intervention? And the answer is: it depends. Getting a colonoscopy and having polyps removed can reduce your chances of getting colon cancer. Or discovering a cancerous lesion in your bowel and having it removed when it's very small significantly increases your chances of survival.
On the other hand, having a mammogram maybe doesn't help so much. According to some studies (and contrary to the recommendation of the study that triggered this newsletter), getting a regular mammogram is not especially effective…regardless of when you get it. These studies concluded that breast cancer screening has not been shown to have a major impact on the reduction of breast cancer mortality. Even worse, of course, because of the exposure to radiation, each mammogram that a woman gets increases her risk of getting breast cancer by two percent. Two percent may not seem like a lot until you add up ten to fifteen years worth of regular two percent increases. It pretty much nullifies any advantage early detection gives you, which would help explain why increased mammogram screening does not improve mortality statistics. And then, on top of everything else, there's the fact that false positive readings from mammograms may run as high as 90%!
For men, a PSA test for prostate cancer fares no better. In 2010, Dr. Richard Ablin, the man who actually discovered PSA (prostate-specific antigen), said that the PSA test "is hardly more effective than a coin toss." According to Ablin, the test does not detect the presence of prostate cancer. It merely shows how much prostate antigen a man has in his blood. "Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can all elevate a man's P.S.A. levels, but none of these factors signals cancer. Men with low readings might still harbor dangerous cancers, while those with high readings might be completely healthy." And yet, a high reading will often trigger medical intervention -- whether it's pharmaceutical or a surgical biopsy.
In fact, in 2012, the U.S. Preventative Services Task Force formally recommended "against PSA-based screening for prostate cancer" -- giving it an efficacy grade of "D", its lowest ranking.7 Amazingly, the USPSTF acknowledges the power of Newton's first law within the medical community in their recommendation. And I quote, "Although the USPSTF discourages the use of screening tests for which the benefits do not outweigh the harms in the target population, it recognizes the common use of PSA screening in practice today and understands that some men will continue to request screening and some physicians will continue to offer it. The decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms and respect patients' preferences." In other words, even though this test has been shown to produce little benefit and some considerable harm, the USPSTF understands that, for the foreseeable future, it will continue to be utilized. Amazing!
And then of course, there's cholesterol testing. If you test high for cholesterol, your doctor is going to prescribe statin drugs -- after paying lip service to dietary changes. Make no mistake, this is big business. More than 255.4 million prescriptions for statins and other lipid lowering drugs were filled in 2010, making them the most prescribed class of drugs in the world. But do they work?
And the answer, as we've discussed previously, is yes and no. Yes, they lower cholesterol levels in your body -- but, no, studies have shown that they do not add a single day to your life unless you've already had a heart attack. Even worse, they can increase your risk of cancer by 50%. Quite simply, statin drugs are less scientific than you have been led to believe. And as with PSA testing and regular mammograms, Newton's law applies and large numbers of doctors still pump for not only their continued use, but their "increased" use.
And let's not forget bone density testing to determine if women should go on an HRT (hormone replacement therapy) regimen -- even though any benefits from HRT have been shown to be temporary at best, while at the same time dramatically increasing a woman's risk for several types of cancer. As with PSA testing, the USPSTF gave a "D" grade to HRT as a medical option.8 In making its recommendation, the task force considered 51 full-text articles from 9 trials published between January 2002 and November 2011. The task force concluded that estrogen plus progestin and estrogen alone decreased the risk for bone fractures but increased the risk for stroke, thromboembolic events (deep vein thrombosis and pulmonary embolism), gallbladder disease, and urinary incontinence. Estrogen plus progestin increased the risk for breast cancer and probable dementia, while estrogen alone decreased the risk for breast cancer. Amazingly, despite the clear evidence and the USPSTF recommendation against its use for the prevention of chronic medical conditions, millions of HRT prescriptions are still written every year. Isaac Newton would be proud. In summary, it's really true: you can't teach an old doctor new tricks.
Physical Exams - Yes or No
So where does that leave us? Am I recommending that you avoid all testing and all treatment? Not at all! Clearly the problem lies not in knowing that you "may" have a medical problem, it lies in what happens after you know. Understanding that, I'm more in favor of the annual checkup than the problem specific checkup because it offers you the best chance of avoiding medical intervention.
When you go to the doctor because you already sense that something is wrong, the odds are far higher that after testing you're going to end up with drugs or a surgical procedure to deal with that problem than with a general checkup. And if you went to the doctor because you thought you had a problem, the odds are pretty good that you're going to do whatever the doctor tells you.
On the other hand, with the annual checkup, assuming you haven't noticed any symptoms before going in, the odds are that if something is discovered, it will be at an earlier stage. That allows you options. You don't necessarily have to jump right in with surgery or drugs. You can try alternative options. Even better, oftentimes the numbers that come back from an annual checkup are merely suggestive so that your doctor has no definitive recommendation. Your liver enzymes might be slightly higher than normal or your blood pressure might have moved up a bit over the years. Nothing so dramatic or definitive that your doctor will be able to identify a specific problem or take action -- but you can. For example:
- If your blood sugar is moving to the high side of normal, your doctor is unlikely to recommend pharmaceuticals. But you can nevertheless modify your diet and start taking some herbs with your meals that reduce glycemic swings and rebuild your pancreas' ability to produce insulin. In other words, nip the problem in the bud.
- If your liver enzymes are elevated or your cholesterol level has edged up, you can opt for a liver detox to improve your liver's ability to perform its designated functions.
- If your CRP (C-reactive protein) level is elevated, you can start incorporating proteolytic enzymes into your daily routine to help reduce systemic inflammation.
The bottom line is that unlike the problem specific checkup, the annual checkup gives you a better shot at allowing you to make early alternative interventions so you don't have to rely on the more drastic--and dangerous-- medical option down the road. And that's why I'm in favor of the general checkup -- because it gives you your best shot at avoiding medical treatment, which in many cases is the real problem.
Let me be perfectly clear here. I'm not saying that medical options should never be used. If your name is John Wayne Bobbit,9 you want a surgeon ASAP after your wife adjusts you, not an herbalist. If your blood sugar numbers are high and you don't have the self discipline to control your diet despite the risk, then you need the pharmaceutical option. Or if you can't lower it no matter what dietary changes you make, you need the drugs. If you have a colon cancer that has advanced so far that it has literally blocked your colon so that death is days away, you need surgery to remove the immediate problem so that you have time to deal with the longer term problem of the cancer coming back. It's not that the medical option should never be used, but rather that it should be used as the option of last resort. And the simple reason for that is that medical options rarely deal with the underlying problem. Instead, in most cases, they are designed to deal with the immediate manifestation of the problem -- the symptoms, if you will. If you break your arm, those are one and the same. But if your blood sugar is high, it's important to understand that the high blood sugar numbers and the reason they are high are two different things; and if all you do is pharmaceutically force your numbers back down, then you haven't dealt with the underlying problem, which then still lurks in the background…just waiting to take you down for the count at some point in the future.
If you have a medical doctor and your insurance pays for an annual checkup, get it. Then use the results to direct your alternative health plan -- not as an invitation for medical intervention. Used that way, the annual physical exam can be invaluable.
- 1. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD009009. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract
- 2. "Canadian Task Force on the Periodic Health Examination. The periodic health examination." Canadian Medical Association Journal 1979;121(9):1193-`1254. (Accessed 13 Nov 2012.) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1704686/pdf/canmedaj01457-0037.pdf
- 3. US Preventative Services Task Force. "Guide to clinical preventative services: an assessment of the effectiveness of 169 interventions." Baltimore: Williams & Wilkins, 1989. (Accessed 13 Nov 2012.) http://wonder.cdc.gov/wonder/prevguid/p0000109/p0000109.asp
- 4. Thompson S, Tonelli M. General health checks in adults for reducing morbidity and mortality from disease [editorial]. Cochrane Database of Systematic Reviews 2012 17 Oct;10:ED000047 (Accessed 13 Nov 2012.) http://www.thecochranelibrary.com/details/editorial/2723031/General-health-checks-in-adults-for-reducing-morbidity-and-mortality-from-diseas.html
- 5. Leigh Montejo. "Encourage annual physical exams in underserved populations." The Clinical Advisor.29 Oct 2012. (Accessed 26 Nov 2012.) http://www.clinicaladvisor.com/encourage-annual-physical-exams-in-underserved-populations/article/265874/
- 6. Schwartz LM, Woloshin S, Fowler FJ, Jr., Welch HG. "Enthusiasm for cancer screening in the United States." JAMA 2004;291(1):71-78. http://jama.jamanetwork.com/article.aspx?articleid=197942
- 7. "Screening for Prostate Cancer." USPSTF May 2012. (Accessed 26 Nov 2012.) http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm
- 8. Virginia A. Moyer. "Menopausal Hormone Therapy for the Primary Prevention of Chronic Conditions: U.S. Preventive Services Task Force Recommendation Statement." Ann Intern Med. 23 October 2012. http://annals.org/article.aspx?articleid=1384872
- 9. Wikipedia. http://en.wikipedia.org/wiki/John_and_Lorena_Bobbitt