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,
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.
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.