May 19, 2015

FIRST, DO NO MORE HARM:

Skip Your Annual Checkup (Joseph Hooper, 5/15/15, Men's Journal)

Since the 1940s, the venerable annual physical has been regarded as one of the cornerstones of good health. Each year, many primary care physicians across the country still send out a boilerplate reminder: It's time for your checkup. But privately, if not publicly, most doctors regard the annual physical as a medical emperor with no clothes, not even a hospital gown. (Ask your doctor how often he or she gets a checkup.) And as University of Pennsylvania bioethicist Dr. Ezekiel Emanuel says, "Spending billions on something that we have pretty good evidence is not working is not the way to go."

After tracking nearly 60,000 people for a decade, researchers in Denmark reported last year that regular checkups had no effect on preventing cardiovascular disease or death. That study followed a 2012 meta-analysis that included 182,000 people and arrived at a similar conclusion: Regular checkups are unlikely to save lives or prevent disease. Meanwhile, the U.S. Preventive Health Services Task Force, an independent panel of health experts, explicitly recommends that people skip a number of the usual procedures of the annual checkup (for instance, the heart EKG and the prostate-cancer PSA test); its Canadian counterpart recommends against annual visits altogether.  [...]

[W]hen doctors attempt to discover and treat the early signs of disease, they often do more harm than good. "We all harbor abnormalities, so our diagnostic technologies find all sorts of things," says Gilbert Welch, a professor at the Dartmouth Institute for Health Policy and Clinical Practice and the author of Less Medicine, More Health. "That leads to more testing and more prescriptions and procedures, and that's a recipe for making people sick."

How does that happen? New York cardiologist Sandeep Jauhar, the author of Doctored: The Disillusionment of an American Physician, says, "Doctors are trained to be uncomfortable with uncertainty." An example Jauhar sees frequently are patients who have no history of heart problems yet fail a basic stress test; this could be a false positive, but doctors often order cardiac catheterization, just in case -- an invasive procedure that can result in infection. "Every doctor I know would tell you stories about minor problems getting worked up and leading to all sorts of downstream complication," he says. "And that's the aspect of the annual physical that I worry about the most, the unnecessary testing."

The problem is, when you take a closer look at what happens during a checkup, much of it begins to look unnecessary. Screening for cancer is a classic example; it's a big reason many people believe they should see a doctor, even if they're feeling fine. But there is less here than meets the eye. Screening for colon cancer once a decade is generally considered a good idea, but screening more often than that yields no additional benefit. And the PSA test, still a common feature of the annual physical, is a mixed blessing at best, considering the risk of false positives and unnecessary overtreatment. Welch estimates that for every prostate- cancer death prevented by early detection and treatment, 50 men are needlessly treated and about a third of them are harmed. Hunting for early-stage testicular cancer, meanwhile, is no longer recommended, because treatment success in its obvious, later stages is so great; you risk a potentially damaging biopsy of a testicle that otherwise would have caused no harm. In fact, there is only one regular cancer screen that we can definitively say saves lives, a CT scan of the lungs of smokers.

Posted by at May 19, 2015 7:41 PM
  

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