Tuesday, 25 October 2016

Annual physical

It's that time of year again - time for my annual physical.  Or I should say, time for me to be a hypocrite and ignore slash skip my annual physical.  I had one about 6 or 7 years ago, and my health was essentially perfect other than a touch of chronic back pain (I love you, ibuprofen).  I don't have a family history of serious diseases, I don't smoke, I drink alcohol occasionally, and I eat balanced meals (thank you, Mrs. Bastard).  Since that time I have advised countless people, including family, friends, and patients, to get their annual physical because it was the right thing to do, despite knowing that I wasn't following my own advice.

Recently the health insurance company Cigna teamed up with a bunch of actors from several medical TV shows (including M*A*S*H, House, Grey's Anatomy, and Scrubs) to create a rather brilliantly funny advertisement reminding people to get their annual checkups.  In case you haven't seen it, here is one of them:



Ha ha!  Classic.  I love self-deprecation from actors.  And this is a great cause with solid advice.  After all, what could be wrong with reminding people to get a checkup if is going to save lives?

Well, here is the problem: there is no evidence that annual physicals actually save lives.  Yes, you heard me right.  Seriously.  A Cochrane review of 14 randomised trials involving over 180,000 subjects showed that people who had general health exams were more likely to have new diagnoses and they were more likely to start on medication for high blood pressure or high cholesterol.  While that may sound good, there was unfortunately no improvement in deaths or overall health in patients who had annual physicals versus those who did not.  Cochrane's conclusion was,

Ouch.

So have I been wrong this whole time?  How can this be?  Sure I've been wrong before, but about this?  Are McDreamy and Turk and Dr. Hawkeye Pierce wrong?  Are annual physicals really unnecessary and potentially harmful?  Well, yes.  And no.  Sort of.  In a way.  Don't worry, by the end this will all be as clear as mud.

I'll explain.

It may seem on the surface that getting people treated for untreated diseases would help.  After all, you can't regulate your blood pressure if you don't know know you even have high blood pressure, right?  And you can't get a biopsy on that enlarged prostate which could possibly be prostate cancer if you don't know it's enlarged.

That was exactly the point of the studies that Cochrane compiled, and the data are fairly clear (if counterintuitive) - it doesn't make a difference if you know you have high blood pressure or high cholesterol or not.  It doesn't make a difference if you don't know you have an enlarged prostate or a breast mass or not.  Getting them treated will not make you live longer.

Make sense?  Yeah, not to me either at first.

The bottom line is this: too many diseases are being over-diagnosed, and thus they are being over-treated.  Many people don't need to have their high cholesterol treated because it won't kill them.  Think of it this way - if you have diabetes, you're going to know it one way or another, so it will be appropriately treated.  You'll go into a diabetic coma or ketoacidosis eventually if you don't, so it shouldn't take an annual physical to find it.  And if your prostate is large enough to cause symptoms of urinary retention, you'll seek care for it, so an annual physical should not be necessary.  The large prostate and breast cancers are the cancers that can kill.

But if you have a relatively small prostate or breast cancer that is found on a routine annual physical examination, this may well lead to the cancer being removed, and while that sounds like a good thing, cancers like this tend to be relatively slow-growing.  So chances are very high that you'd die of something else before the cancer kills you (unless you're very young).  That makes these cancers over-diagnoses and over-treatments.

Make sense yet?  Sort of?

Keep in mind the Cochrane review only looked at cancer and cardiovascular health because they are two of the biggest killers worldwide.  It did not look at diabetes or autoimmune disorders, for example.  

The bigger question here is will this make any difference to how I practice?  I espouse evidence-based medicine whenever possible, so the intellectual answer should be an immediate "Yes".  Unfortunately the real answer is a rather tepid "Probably", at least for my elderly patients.  I try to limit my hypocrisy to a bare minimum, so I can't extol the virtues of evidence-based medicine one second and then cherry pick which parts of EBM I plan to follow the next.  So while I will certainly curtail advising my elderly patients to get their annual checkups, I will most assuredly not actively advise them not to.  I think that still counts.  Right?

Now a breast cancer in a 30-year old is very different than a breast cancer in an 80-year old, so I still believe that annual checkups are important for children and young people because chronic diseases caught early can be managed, and damage can be limited.  My practice there will not change one iota.

EDIT: Thanks to an anonymous reader (is that you, Dr. Franklin?), we now have more information about the Cochrane review, and it sort of affirms what I was saying, and sort of doesn't.  Clear as mud, right?

Occasional SftTB commenter Dr. Cory Franklin coincidentally wrote an editorial at the beginning of 2015 about exactly this subject, and he cited this same Cochrane review and its series of limitations.  Several of the studies in the review are from the 1960s, none of them looked at the elderly or children, and some of them didn't look at women.  One of the main problems he (correctly) saw is that medicine has advanced significantly since many of these studies were performed - statins, better blood pressure medications, advances in minimally invasive interventional cardiology, etc.  Treating high blood pressure and high cholesterol is vastly different in 2016 than it was in 1975, so one would expect morbidity and mortality to vary accordingly.  Does it?  We don't know.

So does this additional information change my view?  Not really.  I still think it's a good idea for children to have an annual checkup, and I still don't think the elderly do.  As for all the cranky curmudgeonly middle-aged people in between (like yours truly), it remains a big muddy grey area with no good answer.  The good thing about grey areas in medicine is that there is no wrong answer.  Huzzah!  We can't be wrong!  But that's also the bad news - it's just as difficult to be right.  We just don't know enough to give fully informed advice.

But despite the distinct muddy lack-of-clarity of the issue, I still have to admit - those are some damned funny advertisements.

12 comments:

  1. It's part of the health requirement if you have a life insurance policy. They actually started it.

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  2. What did you do with the idiot post? I wondered if she survived her stupidity or won the Darwin award.

    ReplyDelete
  3. That was published by accident before it was completed. I'll put it back when it's done.

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  4. last time I went in for a physical, my doctor told me "you should probably come back for another one in ten years"

    meanwhile, I've got my annual fitness evaluation for the fire department to make sure I still have the strength and flexibility to do the job.
    problem is the health center works the same hours as my day job, and I'm too busy doing exactly what the evaluation would have me doing to go do it with them watching.

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  5. http://www.chicagotribune.com/news/opinion/commentary/ct-annual-physical-emanuel-perspec-0125-20150123-story.html

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    Replies
    1. Thanks for sharing this. Dr. Franklin makes some good points about the *current* relevancy of this data, related to the age of the various trials reviewed, in relation to various treatments and medications developed *since* those observations. Point being, medical checkups at fairly regular intervals (though he doesn't categorically suggest a complete annual physical for everyone) *might* now indeed save some lives, or at least allow patient and doctor to more proactively manage a discovered health condition, more than they might have 40 years ago.

      Doc B., I see your point also. Patients who *have* learned of a chronic health condition are likely to be already under doctor's care, which will establish the appropriate schedule for checkups and testing. My mother, a senior, hasn't had, or needed, a routine "annual physical" for, I think, almost 14 years now. She's a cancer survivor, who also has very late-onset Type 2 diabetes, and had a pacemaker implanted two years ago to help compensate for a relatively minor arrythmia that was causing general fatigue. So, there are enough routine appointments with her PCP and specialists to enable her to successfully manage everything and lead a reasonably active lifestyle. There's no reason for an additional "complete physical" when we already *know* what conditions need regular monitoring.

      Delete
  6. I have never had an annual physical, but see my primary care doctor off and on for various aches and pains. These aches and pains he totally ignores, but zones in on my cholesterol and blood pressure. Put me on pills, now my B/ P is 92/57 (just took it) hope it doesn't go any lower.

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  7. My problem was that I rarely get ill and mostly feel great so I very rarely bothered to see my PCP and the breast cancer snuck up on me. Plus the recommendations for mammograms just kept changing (and the first one I had was performed by a sadist - I swear that woman ENJOYED the fact that I broke out in a sweat with pain and I have a HIGH pain threshold!). Maybe if I had gone for an "annual" examination every two or three years it wouldn't have gotten as far as it did. Still, I'm here to share several happy observations: the neuralgia is abating, I've lost 12 pounds (thank you again, steroids! for making me a fat middle-aged woman) and I'm really enjoying having my temporarily curly hair. It's cute.

    Now they want me to consider having yet another surgery. I wasn't young enough where they would have said, "Wednesday, the ovaries gotta go too" nor old enough to say, "Aromatase inhibitors - all the way!" So I'm doing lots of homework and gathering still more family history so my oncologist and I can decide what to do next. I really don't want another surgery. Even laprascopic. Holes are holes and an opportunity for something to set up shop or go very wrong.

    Anyway, I agree that an annual physical is probably overkill for many people. I still dragged my kids in though. I certainly get seen by enough doctors throughout the year that we have a fair notion of what is going on.

    Sorry Doc, I can't find my password so you'll have to go through the hassle of approving this. It's around here. Somewhere. I know I wrote it down!

    Wednesday

    ReplyDelete
    Replies
    1. check in the refrigerator behing the condiment packets.

      and consider yourself lucky. they could have found the cancer while doing a "we don't know what's wrong, so we'll take a random part out and see if that fixes it" surgery. good news is I still have both parents.

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  8. so I'm 65. can i stop taking my blood pressure medicine? and my blood thinner for the blood clot i got after surgery? it's expensive and I'd love to stop. thanks

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    1. You seemed to have misunderstood the study. It concludes that annual physicals aren't necessarily helpful, not that medication isn't helpful.

      So while I appreciate the sarcasm, no.

      Delete
  9. yes, that was me
    don't know the answer but I know the Cochrane reviews are out of date on the topic.
    Cory F.

    ReplyDelete

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