Diagnosis: Annual checkups overrated
By Judith Graham | Tribune staff reporter
Your doctor probably knows it. Medical organizations certainly do. But most patients have no idea.
The annual physical examination — that encounter when a physician looks in your throat, listens to your heart, pokes your abdomen, checks your reflexes and tests your blood — is no longer a generally recommended medical practice.
That’s because there is scant scientific evidence showing that yearly checkups help prevent disease, death or disability for adults with no symptoms. Many tests and procedures performed during the visits have questionable value, experts say.
Instead of an annual physical, healthy adults should undergo a much-streamlined exam that’s focused on prevention every one to five years depending on a person’s age, sex and medical profile, the American College of Physicians and other professional groups suggest.
Men and women see physicians more frequently for yearly medical checkups than for any other reason, at a cost of $7.8 billion a year in the U.S., close to the $8.1 billion spent on breast cancer care, according to a recent report in the Archives of Internal Medicine. The figure reflects the strong attachment to this entrenched medical tradition felt by patients and doctors.
“There’s a feeling of well-being you get from having your doctor look you over and pronounce you in good health,” said Andrew Griffo, 48, a financial adviser who lives in Park Ridge and schedules a physical every year.
Largely out of public sight, however, the medical orthodoxy that all adults should undergo a comprehensive annual medical review to detect potentially significant clinical abnormalities has been under scrutiny since the 1970s.
Experts’ concerns revolve around two components of the traditional checkup: the comprehensive physical exam and an extensive battery of tests checking a person’s blood, urine, thyroid and heart. (A third component, an updated patient history, hasn’t prompted the same scrutiny.)
“There is very little evidence, if any, that doing [comprehensive] exams yearly on patients without symptoms is good for anything,” said Dr. Ned Calonge, chairman of the U.S. Preventive Services Task Force, which does not endorse yearly physicals.
Experts question many of the tests traditionally performed during these visits. Chest X-rays, for example, can detect lung cancer but have not been shown to prevent deaths from the disease. Nor are rectal exams useful as screening tools for rectal or prostate cancer.
Similarly, there is little evidence supporting a broad range of tests still routinely conducted on patients who get yearly checkups — complete blood counts, blood chemistry panels, thyroid-function checks, urinalyses and electrocardiograms, Calonge noted.
What does make a difference, the task force has found, are interventions that help patients change health-impairing habits or that spotlight emerging illnesses for which reliable and effective treatments exist. Examples include Pap smears, mammograms, cholesterol tests, blood-pressure checks, and counseling to stop smoking, lose weight, get more exercise and eat a healthier diet.
Instead of asking patients to come in every year for a checkup, physicians should be figuring out which patients need what types of preventive care and making sure they get those services, experts suggest.
“The issue is [doing] the types of preventive care that make a difference,” said Dr. Carol Wilhoit, medical director of Blue Cross and Blue Shield of Illinois, the state’s largest insurer. That can be done “at a checkup, or it can be done if I come in to see my doctor about a cold,” she said.
Some believe that for many patients an annual checkup may not be needed at all. In fact, the new Archives of Internal Medicine study found most patients receive the bulk of recommended preventive care — such as counseling about weight or blood-pressure checks — not during physicals but on other occasions, such as when they see doctors about a cold or a chronic condition like diabetes.
The report also estimates that, a third of the time, routine physicals become an occasion for unnecessary tests such as electrocardiograms, boosting medical bills by more than $350 million and contributing to soaring medical expenses.
There’s good reason to ask “whether the time and resources being spent are worth it,” said Dr. Ateev Mehrotra, the study’s lead author and assistant professor at the University of Pittsburgh School of Medicine.
Many patients, however, wouldn’t consider doing without a traditional physical, said Dr. Kathleen Miller, a Decatur family physician who said she often schedules yearly checkups because patients insist.
“Frankly, there are people who would feel I wasn’t doing my job if I didn’t lay hands on them and look them over. They have the expectation this is something doctors are supposed to do,” Miller said.
As for physicians, many remain attached to the practice as well. A 2005 report in the Archives of Internal Medicine found that two-thirds of primary-care doctors believe yearly physicals were necessary and nearly nine in 10 perform them.
“The exams allow a physician to step back, pause, refresh their perspective on a patient, and have that conversation about issues that may not be addressed in an urgent visit,” said Dr. Bill Corwin, medical director of Harvard Pilgrim Health Care, a health plan serving more than 1 million members in New England.
Several recent reviews suggest this “timeout to talk” has a positive impact on prevention. In March, for instance, a separate review in the Archives of Internal Medicine discovered that patients who go in for routine visits get more frequent screenings for breast, prostate and colon cancer.
Dr. William Werner, chief medical officer at Advocate Illinois Masonic Medical Center, knows the evidence doesn’t support routine comprehensive physical exams but is inclined to recommend them anyway.
“You don’t do this in a silent environment: You’re talking to the patient the entire time, you’re learning more about the patient, and over time they may open up to you” about issues important to their health, he said.
When Dr. John Sage of Mt. Prospect, 60, was a young doctor “a checkup every year was the standard,” he said. Now, even though he’s fully aware of the latest research, the family physician still recommends annual exams to patients 50 or older, the age group most likely to develop medical concerns.
There just isn’t enough time during regular hurried office visits to really talk to patients and accomplish all recommended preventive measures, the doctor said.
His routine is to schedule a yearly half-hour appointment. In the first 15 minutes Sage does pretty much the same comprehensive physical exam he learned as a medical resident.
“I’ve been doing this for over 30 years, and it’s hard for me to stop,” he admitted. “I feel I know my patients better, and I think they feel ‘at least I know this doctor is thorough and when I’m not feeling well he’ll give me his full attention.'”
During the second half of the exam, Sage talks with the patient about health habits and prevention. Often, the hardest part is convincing patients they don’t need a medical test they’ve heard about from friends or another physician.
“If you’re 52 and you think you need a bone-density test, I’ll tell you the guidelines say you don’t need that until you’re 60. Or if you want to go on diet pills or have a MRI that’s not yet indicated, I’ll try to dissuade you,” Sage said. “Much of this testing just isn’t necessary.”