CW: How valuable are regular medical check-ups?

Millions of Americans believe in the practice.

Government reformers believe in it.

Doctors too.

Heck, even I, an accused therapeutic nihilist, tracked down a poor soul who agreed to be my primary care doctor. Call it old-fashioned, but I wanted my own doc, and I wanted yearly “checkups.”

No procedure—not even AF ablation–is as good as prevention. Taking your body in for routine checks and scheduled maintenance makes perfect sense. Call such a notion–obvious.

But a new analysis of more than 180,000 patients followed for decades suggests that patients without symptoms get no benefit from routine checkups with a doctor. (WSJ story here.) Routine health checks had zero effect on overall death rates, death from heart disease or death from cancer. Outcome measures like hospital admissions, disability, worry and absence from work were also not reduced.

The study comes from the Cochrane Collaboration, an international group of researchers who perform systematic reviews of the evidence behind medical treatments. By culling all the published science on a matter, such unbiased reviews provide both patients and doctors with potent and actionable information. These folks ask what the science says, not what dogma holds.

This is big news. Publishing science that downplays a doctor’s role in influencing wellness stings. The lancing of dogma always hurts. Influential cardiologist, author and chief medical editor of theHeart.org, Eric Topol, captured the essence of this provocative study in this tweet:

Another sacred cow in medicine going down “the annual checkup” But will patients get wise?

As far as health topics on which to muse, this one is a 10. It’s a two-sided canvas.

First, let’s be clear: Good health cometh not from the doctor. We don’t make people healthy; people make themselves healthy. In this way, I believe everything that the study purports. Apologies to those who see trees not forests: Good health sprouts from consistently stacking together good choices. The four legs of the wellness table are good food, good movement, good sleep and good attitude. Doctors can’t do this for people; neither can screening tests or pills.

The more we learn about medical practice, the more obvious it becomes that less is more. High blood pressure and Type II diabetes are best treated with diet and exercise. Many heart rhythm disorders, including AF, can often be prevented or quieted with good sleep and stress reduction. Heart attacks and strokes drop (like a masters bike racer in an elite race) when smokers stop smoking. What’s more, emerging science increasingly calls into question the entire notion of mass screening for diseases. Think prostate cancer, mammograms, pap smears and stress tests.

It’s ironic to believe so strongly in less is more. My livelihood and in good part, my self-esteem, turn on performing successful procedures, which in many cases could have been avoided.

Okay, enough with the nihilism. Let’s flip to the other side of the canvas.

I’ll offer two lines of reasoning on why it’s not time to jettison the idea of having a regular doctor do regular check-ups. The first is that this report, though statistically robust, has limitations. Many of the studies that were analyzed were from decades ago. Medicine is much better now. Also, it’s awfully hard to compare groups of patients that either had or did not have regular check ups. As we say, there are confounding variables. Things like healthy people tend to get regular check-ups and those that did not get regular checks still may have seen their doctor often enough for various problems. So be cautious in rushing to conclusions.

The second reason to find a good doctor is the intangibles.

A personal vignette: I’m now in my third year of having a primary care doctor. I love the experience. Of course, I could do my own care. I’m a doc; my wife is a doc and we have a hotline to an array of specialists. As a family of bike racers, we have mostly needed orthopedists.

But now I’m solidly middle-aged. Creaks and chinks have emerged. I wanted my own doctor. Indulgent? Perhaps. And yes, you guessed it; I picked a doctor who is equally obsessed with endurance sports. He properly inflames himself every chance he gets.

His office is a throw back. The staff are welcoming and warm. When you call a human answers the phone. They take blood pressure readings with a stethoscope—not a digital machine. My doctor still wears a tie and a white coat. He listens to my horse-hockey and then he pokes on my aging body. Somehow the exam feels reassuring, though I know it’s probably a placebo effect. We go over labs and chat about things. Invariably he teaches me something about primary care—or life.

The bottom line:

When a ninety-year old patient gets admitted to the hospital for the first time never having seen a doctor and on no medicines, I am not surprised. I like to say that’s why she made it to ninety.

But what’s right for one person may not be so for another.

I’m for having a good doctor—one who listens, examines and teaches; not one who tests, screens and blindly follows guidelines. (Put this on Evernote: Many of today’s guidelines will be laughed at in the future.)

JMM

P.S. My highly traditional doctor has EMR. The computer screen that he’s tethered to adds nothing to the experience. In fact, it’s dreadful.

Comments

  1. Thomas Runyan says

    You forgot to mention the reason many people go to the doctor for yearly check ups even though they feel fine is to get medical reimbursement from their company on insurance. My company gives us $400 a year towards our health insurance if we get an annual check up. Although I understand the concepts of the findings I still feel people will discuss issues that they have disregarded as non-issues once they are with their doctor who is a much better person to decide what is a non-issue.

  2. says

    Having jumped into the whack side of the gene pool, I in no wat fall into the demographics these studies measure. However, because I had a six month old clean mammogram, my doctors knew the agressiveness of my cancer. And because I have a primary care doctor who knows what my blood pressure normally runs, when I showed up with a reading of 196/102 he knew that something had suddenly gone wrong. I will be keeping my annual physicals.

  3. says

    John – Are you sure you are not a primary care doctor in disguise ??? Your posts always have the most pleasant primary care perspective that I’m continually amazed that you deal with AFib all day when you’re not out biking.

    Seriously – This column is RIGHT ON TARGET with my primary care perspective. It is the intangibles that count! It is truly comforting to have a well rounded primary care clinician who listens, synthesizes, is not stuck on ‘rules’ or ‘protocols’ – and who is able to facilitate informed patient decision-making.

    I attribute results of the Cochrane study you mention to the sobering reality that in the whole scheme of things – many individuals need to be “screened” for a medical condition in order to pick up the one who has the disease at an early enough stage that treatment can be effective. If for example, NNTS (Number-Needed-To-Screen) is 1/250 – that means that only 1 patient benefits (perhaps a huge life-saving benefit for that one person!) – but the other 249 individuals do not get any benefit -yet pay the cost and are subject to potential for adverse effect (ie, screening procedures like colonoscopy are not completely benign – and procedures like stress testing are subject to false positives with further testing that isn’t necessarily benign).

    BOTTOM LINE: Nothing beats a healthy lifestyle for minimizing one’s risk. Nothing beats good genes and “luck” that one doesn’t come down with a bad disease. Having a well-rounded primary care clinician to go to for discussion and perspective is invaluable – but regular yearly check-ups may not necessarily lower overall mortality among persons who are highly health-conscious and who remain asymptomatic.

  4. says

    I’m not arguing with the data, but it doesn’t make sense to me. Once a year, the baseline of blood pressure, fasting cholesterol and blood sugar is recorded. Changes for the worse are noted. If not done by the PCP, then who? Shall we go in to the local testing facility an interpret our own results?

    • Joulest says

      My PCP found both my anemia and vitamin D deficiency when I went to him with complaints. The bloodwork done in my annual physicals have yet to find anything I wasn’t already aware of.

  5. Joulest says

    I feel that regular check-ups, like consumption of a general multi-vitamin, is a symptom of a good health mindset and not the cause. It’s been proven in multiple studies that general multi-vitamins do very little to improve health but the people that take them are healthier due to the lifestyle changes that cause one to consider multi-vitamin use. The sort of person that goes to their regular check-up is likely the same sort of person that attempts to eat a decent diet, exercise when they can, and make various minor life changes to ensure they stay healthy. The person that believes an ounce of prevention is worth a pound of cure is also the person who pauses at the vitamin shelf while examining their nutritional needs and goes to their physician when they first start feeling “off” instead of waiting for it to become an emergent condition. Those thoughts lead to actions that lead to good health. Doctors and vitamins are superfluous until needed.

    I’m not bashing vitamins, mind you, I have anemia and horrific vitamin D deficiency, all of which was found by my doctor when I went to see him due to a strange array of symptoms so I take a multi-vitamin now because the symptom specific ones are no longer necessary but everything else in the multi? Not nearly as necessary as a good diet.

  6. Bill H says

    EMR rant

    Saw PCP last month for a medicare wellness visit.
    (I only did it because Humana has a rewards program. I figured everything had been covered in my annual 4 months earlier.)

    He also gave me lab orders for blood work. And that I did not need to see him again to renew my BP/statin meds.

    Called to day for the renewals. Nurse called back and said that the doctor needed to see me because they did not have a record of any visit this year.

    Besides the AWV and annual I had 4 other visits this year.

  7. Don L says

    I used to only visit my PCP when I was acutely ill (rare) or suffering from a sports-related injury (not so rare). My PCP would use those opportunities to monitor my BP and send me out for routine blood work etc. He often told me that he was quite happy to keep on patching up my sports injuries because he took it as a good sign that I was being active.

    I am pretty sure that I cost the Canadian health care system less in my first 51 years than I have in the past 4 dealing with afib.