Is it Time To Cancel Your Annual Check-Up?
It sounds like heresy, but recent evidence challenges the long-held belief that the annual physical is beneficial for healthy adults. Researchers at the Nordic Cochrane Center in Copenhagen wrote last week that although a regular check-up with multiple screening tests might seem to offer the advantage of catching problems like heart disease and cancer early, their review of studies involving some 180,000 adults actually found no benefit. People who had annual check-ups were no less likely to be admitted to the hospital, become disabled or miss work than those who did not have regular physicals. Even more surprising, they were no less likely to die from heart disease, cancer or any other illness.
In fact, subjecting healthy adults to this yearly battery of tests may do more harm than good. The authors write, “One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.”
The underlying message in this new analysis is that if we go looking for something slightly out of whack, we are likely to find it. That leads to further testing—some of which may be invasive—and possible diagnosis and treatment of disease that might never progress. Finally, wholesale testing for a range of conditions without determining if a patient’s age, medical or family history puts him at risk, raises the likelihood of over-treatment and even harm from unnecessary interventions. Oh, and it also increases health care costs. According to the Centers for Disease Control, in 2009, the routine general health check was the most common reason patients visited their doctor in the United States.
While the Cochrane findings support the view that the traditional annual check-up with its battery of testing is of limited benefit, we must be careful not to diminish the important role of primary care in both improving health outcomes and lowering costs. In fact, having a regular source of primary care—the internist, family doctor, nurse practitioner or clinic—is often our first and clearly most effective link to the health care system.
Studies have shown that adults with a primary care physician had 33 percent lower costs of care and were 19 percent less likely to die than those who saw only specialists.The benefits of having a regular primary care provider also include reduced hospitalization, fewer visits to the emergency room and a higher level of patient satisfaction. These effects are, of course, more pronounced for people with a chronic illness who are better able to control their diabetes, asthma or other long-term health problems when they are enrolled in a patient-centered medical home; a more comprehensive model of primary care.
So where is the line drawn? The Cochrane researchers, along with other critics, believe that the negatives associated with performing a battery of yearly screening tests like mammograms, cholesterol and lipid work-ups, prostate cancer screening and EKGs (to name some common procedures) on all healthy adults outweigh the benefits. The American Academy of Family Physicians, for one, recommends few components of the traditional physical exam: For both men and women just a blood pressure measurement, and for women (depending on age and sexual activity), a periodic Pap smear.
As H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice points out in the book, “Overdiagnosed: Making People Sick in the Pursuit of Health,” we have been oversold on the benefits of screening for early cancers and tend to overlook the risk of over-diagnosis of diseases that would never have progressed or caused ill effects. This, of course, leads to potentially harmful over-treatment. An editorial accompanying the Cochrane study points out other ill-effects from wholesale testing in annual check-ups; “Abnormal screening results can also lead to further investigations and accompanying risks: anxiety or psychological distress; lost income due to work absences; difficulties securing insurance; and increased healthcare costs.”
The better approach, according to the Cochrane authors, is to consider patient-specific risk factors like family history of illness, obesity, previous health problems, etc., and to offer more focused check-ups. In fact, the Cochrane researchers say that one reason that annual physicals seem to provide little benefit is that “primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.”
They continue; “What we’re not saying is that doctors should stop carrying out tests or offering treatment when they suspect there may be a problem. But we do think that public healthcare initiatives that are systematically offering general health checks should be resisted.”
Other primary care experts agree. Welch says that as a primary care physician himself, he is not suggesting that patients skip annual visits. It’s just that he views these as “check-ins” not “check-ups.” The difference is that instead of running a battery of screening tests on every healthy patient, doctors would do better to assess a baseline of where patients are in their lives. Welch sees more benefit in asking patients questions that include; Are you working? How is your family situation? How do you feel? What are your goals for the future? The answers to these and other insights into family history of illness and other risk factors can help guide the physical exam. `
The Cochrane editorial concurs; “Practitioners should continue to investigate and treat patients with symptoms or clinical clues to underlying disease or its risk factors.” When it comes to the annual check-up, “ practitioners should focus on tests that are targeted to the patient’s age, sex, and specific risk factors, and that are supported by high-quality evidence.”
On the blog Dr. John M, cardiac electrophysiologist John Mandrola writes that he recently began seeing a primary care doctor himself and finds value in an annual check-up much like the one described by Welch; “I’m for having a good doctor—one who listens, examines and teaches; not one who tests, screens and blindly follows guidelines.”
This is an important distinction but sadly, an approach not currently supported by our dominant fee-for-service payment system. Blood screens, X-rays, stool sample testing and other screening tests are reimbursed by insurers. In the New York Times, doctor and reporter Elisabeth Rosenthal writes that “Ateev Mehrotra, an assistant professor at the University of Pittsburgh School of Medicine, has estimated that unneeded blood tests during physical exams alone cost $325 million annually.” Meanwhile, “[t]he only routine blood test currently recommended by the United States Preventive Services Task Force is a cholesterol check every five years.”
The final point: Only when doctors get fairly compensated for the value of their time spent with patients on “check-ins,” rather than the test-driven “check-ups” will we begin to see significant change.