Unsettled, to say the least. A recent analysis from The Cochrane Collaboration, an international group that reviews scientific evidence, concluded that general health checkups for adults did not help patients live longer or healthier lives.
I thought about that the other day as I worked my way through the morning appointments. Some patients were there for management of their ongoing diseases, like diabetes and hypertension. But many were there for a general checkup, often prompted by minor symptoms.
One 43-year-old man came because of shoulder pain. It took just a few minutes of questions and physical exam to attribute the pain to muscle strain from lifting weights, with the simple prescription to lay off the weights for a few weeks.
For an internist, though, this is a golden opportunity — a minor symptom gets a patient into my office, which becomes a prime opportunity to address general health. Like many healthy people, he hadn't been to a doctor in years, so there was lots to do.
I checked his blood pressure to screen for the "silent killer" of hypertension. I noticed that he hadn't had a tetanus booster in 10 years, not to mention an annual flu shot. I ordered a blood test for cholesterol. I went through his family medical history in case there were any particular diseases we should be on the lookout for.
We discussed a healthy diet and exercise. I screened for H.I.V., depression, domestic violence, smoking, and drug and alcohol abuse.
It was a lot to pack in for a visit about shoulder pain, but screening is where we get the most bang for the buck, or so we've been told. If our detailed interview uncovered one serious illness in the making, we'd be poised to treat it earlier, not later. This is the essence of primary care medicine.
So to read the new report suggesting that these exhaustive (and exhausting!) general checkups may not impact morbidity and mortality was dispiriting.
The study was a meta-analysis, in which the authors scoured the literature and came up with 16 randomized trials in which one group of patients had general checkups and the other group did not. Two-thirds of the trials, covering more than 150,000 patients, followed the patients long enough — nearly a decade — to track actual death rates.
Patients in the checkup group received many more new diagnoses; one trial found a 20 percent increase. But they did not live longer. They died from cancer and heart disease at the same rates as their peers who did not have checkups.
The visit with my patient ran well over our allotted time. The next several patients were delayed because I'd scrambled to cover all the bases that constitute general health. (The same bases, incidentally, that are being tabulated as a measure of my "quality.") But are we — as the study might suggest — wasting our collective breath here?
Certainly the study had drawbacks. By the time a trial is planned, executed, published and then later reviewed in a meta-analysis, it is of course outdated to some degree. So in some of the trials, the medical practices may not reflect what we are actually doing today. And the group that did not have checkups may have actually received a fair bit of general health screening along the way if they, like my patient, saw a doctor for a sore shoulder and walked out with a cholesterol analysis and a flu shot. Additionally, not enough data were collected to permit conclusions about the potential harms of general checkups — excess medications, harmful tests, false-positive diagnoses.
Still, it would have been nice to see a hint of a benefit for checkups in this analysis, given how much effort and time is invested in screening. We strive to practice evidence-based medicine, and if general checkups don't help our patients live healthier and longer lives, then maybe we should be focusing our resources elsewhere.
Of course it can also be argued that this analysis, like most studies, offers us only averaged data for a population of people. It does not give us specifics for an individual person. There may be certain types of patients who do benefit from check-ups, and others who may be harmed.
So I'm not – yet — telling my patients to skip checkups altogether. Certainly those in robust health need not slavishly adhere to the annual physical. In any case, it's not so much the annual "physical," but rather the "history-taking," that is critical. It's the detailed conversation that is much more likely to uncover lurking medical issues than the physical exam or blood tests.
What the meta-analysis can't quantify, of course, is the value of establishing a doctor-patient relationship before one gets sick. I feel fortunate to have been with many of my patients for years, a few for a decade or two. If you stick together long enough, you'll be there when something comes up. Treatment is immeasurably easier when it's not taking place between strangers. It's hard to place a numerical value on that.
Danielle Ofri is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is "Medicine in Translation: Journeys With My Patients."
http://well.blogs.nytimes.com/2013/01/03/making-a-case-for-the-medical-check-up/
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Thursday, January 3, 2013
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