Thursday, February 5, 2015
Examining the annual exam
In last week's New York Times, Dr. Ezekiel Emanuel suggested that this year's resolution might be to abandon the ritual of your annual physical. The title of his column, perhaps chosen by an editor to maximize glibness and thus provocation, was: “Skip Your Annual Physical.”
But permit me to suggest you don't commit to that just yet. The annual physical exam warrants some more examination, a defense to follow its prosecution.
Dr. Emanuel is a knowledgeable and thoughtful source, and reliably on the side of the patient even while representing public health. He thus represents both an able and reasonable prosecutor. His case is built on rather prodigious precedent, namely opinions rendered (or not) by the Cochrane Collaboration, and the U.S. Preventive Services Task Force. The former is a non-profit research group devoted to generating and disseminating systematic reviews of important biomedical topics. The latter is a government commissioned group of experts empaneled to offer stringently evidence-based guidelines for all matters in the area of disease prevention.
As Dr. Emanuel damningly propounds, the first of these august bodies has inveighed against the annual physical. Specifically, the Cochrane Collaboration found, as Dr. Emanuel notes, no benefit of the annual check-up in randomized trials. The matter of who, exactly, would be willing to be randomized to either receive or avoid a check-up for years is not clear, but cause for rumination; as are the practices in general of participants in a randomized trial as compared to the population at large. Be that as it may, there was no benefit of the annual check-up related to morbidity or mortality, and the possibility of harm from over-diagnosis and over-treatment.
The second of these authoritative bodies, the USPSTF, may, I suppose, be cited for passive opposition. They have thus far failed to evaluate the annual check-up at all, and thus offer no recommendation in its defense. Their Canadian counterpart has, like Cochrane, opined against.
There the prosecution rests, leaving things looking admittedly bleak for the defendant.
The case against the annual check-up is based on data-driven scrutiny of what, exactly, it yields. The case is sound. The routine, annual exam is very unlikely to find some otherwise occult pathology. Consider the probability of finding some otherwise unsuspected disease in an apparently healthy person with a battery of routine lab tests at the time of a routine check-up. The enterprise makes playing the lottery look like responsible investing.
Further, I rather doubt medical training is required to know that the chances of detecting a lurking neurological disease by tapping on the patellar tendons of a person neurologically intact enough to run a household and a career, and stride with a normal gait into an exam room makes zero look like a big number. These are the glaring fallibilities of the routine check-up. There is no refuting them.
But there is a defense just the same. It has nothing to do with refuting the answers, and everything to do with questioning the questions.
What is the benefit, when we do get acutely ill, of having a doctor we know and who knows us be the one to get that 3 a.m. call and either turn up in the ER, or at least guide the decisions made? That's hard to measure, and to my knowledge has not been measured, but surely is not zero.
What is the value of the information exchange for which the annual check-up serves as an excuse, and perhaps in an apparently, thus far healthy person, the only excuse?
Those same authorities, Cochrane and Task Force, have found clearly in favor of smoking cessation advice by a clinician. When will a smoker who never goes to see their doctor get that counseling? They have found in favor of dietary and weight management counseling as well, at least in select circumstances; the same question pertains.
More robust evidence and stronger expert opinion favor blood pressure monitoring, cholesterol monitoring, various cancer screening, and certain immunizations. The immediate question is again: when will these be addressed in a healthy person if healthy people all skip their check-ups? The related and perhaps more important question is: will people do these things if never advised by a clinician they actually know and trust? The extent to which trust, or the unmeasurable elements of a doctor/patient relationship figure in the uptake of those preventive services which are highly recommended and irrefutably evidence-based is, to my knowledge, unassessed and unknown.
If, for instance, an annual reminder from a physician is part of the reason someone quits smoking, that won't show up on any spreadsheet as pathology discerned thanks to that encounter. Rather, there will be a blank space on some spreadsheet where a diagnosis of emphysema, or lung cancer might have gone. Sometimes it's what you don't find that matters most. In fact, in my field, preventive medicine, that's always true. Our successes are measured in things that don't happen.
The annual exam may be the only real opportunity for lifestyle counseling in a healthy person. It may, at least occasionally, be part or even much of the reason that person remains healthy over the years. But again, that won't show up as data in favor of the annual exam. It will only add to the tally of absent data. A bad outcome that doesn't occur for reasons that are hard to discern.
If the case against the annual check-up is that it performs poorly as a hunt for occult and unlikely pathology at any given time, it is guilty as charged. But if the case is that it contributes nothing to the prevention of pathology over time by a variety of indirect causal pathways, the case falls apart for want of evidence. We know the ways in which the annual check-up is not helpful and inefficient. We do not know what the harms would be of abandoning it.
I would argue, then, that glib dismissal is misguided. Rather, the safest and most promising option in the absence of answers to all relevant questions, is to optimize the annual exam, not discard it. There is no need for a battery of perfunctory procedures or ridiculously low-yield lab tests. But these could be replaced with a review of lifestyle practices and use of relevant preventive services; with time for pertinent, customized lifestyle counseling; and with attention to whatever happens to be on a patient's mind, building that very thing to which modern, evidence-based medicine may pay all too little attention: a relationship. A fundamental human connection.
As others have before him, Dr. Emanuel indicts the annual exam for the pathology it unnecessarily seeks, and predictably fails to find at a given time. But they in turn may be failing to consider that the annual reaffirmation of the doctor/patient connection may itself be a defense, and part of the reason some pathology isn't found in the fullness of time.
We can't say for sure, but that's my point. The case is not closed because, at best, we only have answers to the questions we have thus far posed.
See you next year?
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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