What are the risks and benefits of getting a comprehensive annual physical exam and routine blood testing?
The model of getting an annual physical exam dates back nearly a century in American medicine, but recently, many health authorities “have all agreed that routine annual checkups for healthy adults should be abandoned”—yet, the majority of the public still expects not only a comprehensive annual physical exam, but also extensive routine blood testing. “Given the gap between patients’ enthusiasm for and [the new] guidelines’ skepticism about annual head-to-toe examinations, what are physicians to do?” As I discuss in my video Is It Worth Getting an Annual Physical Exam?, “first, we must educate patients about preventive practices of proven and unproven benefit.” For example, the only routine blood test currently recommended by the USPSTF, the official preventive medicine guidelines setting body, is cholesterol.
The reason “why many physicians continue to perform annual examinations of patients’ hearts, lungs, abdomens and even reflexes and continue to order some of the tests that have been proven ineffectual or even harmful” is because, otherwise, the patient might leave unsatisfied with the visit. “Evidence suggests that the more thorough physicians are (that is, the more physical and laboratory examinations they perform), the better patients feel about their health and their physicians.” So, they are like “placebo clinical manoeuvers…But rather than performing unnecessary (and sometimes contraindicated) physical exams and laboratory tests during an annual visit, perhaps physicians should spend some of the time saved by telling their patients why they are not examining their abdomens, hearts and lungs”—that is, why they’re not just going to go through the motions like some witch doctor.
“Most important, we need to educate ourselves about the dangers of overdiagnosis….There will always remain a small possibility that our examination might detect some silent, potentially deadly cancer or aneurysm. Unfortunately for our patients, these serendipitous, life-saving events are much less common than the false-positive findings that lead to invasive and potentially life-threatening tests,” wrote a doctor from the Cleveland Clinic. He went on to share a story about his own father who went in for a checkup. Can’t hurt, right? His dad’s physician thought he felt what might have been an aortic aneurism, so he ordered an abdominal ultrasound. Can’t hurt, right? His aorta was fine, but something looked suspicious on his pancreas, so a CT scan was ordered. Well, that can hurt—it’s a lot of radiation—but thankfully, his pancreas looked fine. But…what’s that on his liver? It looked like cancer, which made a certain amount of sense since his dad had worked in the chemical industry. Realizing how ineffective the treatments were for liver cancer, he realized he was going to die.
His daughter was not ready to give up on him, though, and convinced him to see a specialist. Maybe if they cut it out, he could live a few more years. But first, they had to do a biopsy. The good news was he didn’t have cancer. The bad news, though, was that it was a benign mass of blood vessels, so when they stuck a needle in it to biopsy, he almost bled to death. He required ten units of blood—and ten units is about all you have! This resulted in pain, thus morphine, thus urinary retention, and thus a catheter, yet, thankfully, no infection. Just a bill for $50,000.
The frustrating thing is that there wasn’t any malpractice or anything in the whole horrible sequence. Every step logically led to the next. “The only way to have prevented this [life-threatening] outcome would have been to dispense with the initial physical examination”—the “checkup” that couldn’t hurt, right?
“Why, then, do we continue to examine healthy patients? First of all, we get paid to do it.” His dad’s initial doctor only received a hundred bucks or so, but just think about all that “downstream revenue” for the hospital and all the specialists. Overdiagnosis is big business.
“Too many patients bear the costs and harms of unneeded tests and procedures,” but without annual check-ups, we doctors would miss out on all those opportunities for “open communication and interpersonal continuity…” Is that so? In that case, replied one physician, if you want communication, why not just take your patients out to lunch?
“Of course, such lunches should fairly and ethically be preceded by an informed consent discussion that allows prospective diners to understand the risk that they will be infantilized, made dependent, and may well receive unnecessary and injurious diagnostic and therapeutic interventions as a consequence of that grilled cheese and soup”—particularly, I would add, if you’re feeding your patients grilled cheese, having already chalked up your first such “unnecessary and injurious” act!
So, if you don’t have any symptoms or issues, should you even have an annual check-up? That was the subject of my last video, Is It Worth Getting Annual Health Check-Ups?.
Check out this video to Find Out If Your Doctor Takes Drug Company Money.
I sometimes stumble across these peripheral issues and fall down various rabbit holes. For example, I’ve got a whole series of videos on various diagnostic tests such as mammograms. I don’t want to get too far away from nutrition, but whenever I learn something new and interesting—particularly if there are conflicts of interest trying to muddy the waters—I feel compelled to try to share to help set the record straight.
Michael Greger, M.D.
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