Are Annual Physicals Beneficial?

     I have received a number of questions about the latest Cochrane report about the purported uselessness of annual physicals, so I thought I should analyze the report for my readers. (My earlier thoughts were posted in an earlier blog, entitled The Annual Physical.) For those of you who are not familiar with the Cochrane system, it is similar in concept to the group of French mathematicians who have published articles for over 50 years under the pen name Bourbaki. The Cochrane group is an international non-profit organization. It  has a fluid makeup and a number of different participants, and devotes itself to finding the best proven treatment or diagnostic process for a given disease or symptom, based on clinical studies. They publish a book each year under the auspices of the British Medical Journal, and when you read the book you are led to realize how few of our medical methods are well-grounded in clinical fact. As I have often mentioned before, what seems "obvious" often does not stand up under clinical studies, e.g. the proper treatment to reduce the number of calcium oxalate kidney stones you  produce is to INcrease the amount of calcium in your diet, not to decrease it. I should also mention that the calcification of your coronary arteries proceeds independently of the amount of calcium in your diet.

     A good summary of the Cochrane report to which I refer was published online by Med Page Today on October 16, 2012, at http://www.medpagetoday.com/PrimaryCare/GeneralPrimaryCare/35356. The study was a meta-analysis (and see my previous blog on that subject with an analysis of the weaknesses of such a study) of 16 clinical trials involving over 180,000 patients. The endpoint they looked at in 8 studies was cardiac mortality and in 8 studies was cancer mortality.  They found that patients who had regular health checkups died from both causes at the same rate as those who did not have an annual physical, and they also did not have less disability.

     There are several logical errors in this analysis. To begin with, since the mean time of the studies  was 9 years, they could not test for total mortality, i.e. extension of one's lifespan. Secondly, many patients go for  screening studies such as a pap smear and a mammogram without having an annual physical. Thirdly many patients take themselves to cardiologists of their own accord, and periodic cardiology visits were not counted as a regular health checkup any more than was a visit to one's gynecologist. The conceptual problem with all the studies is that no attention was paid as to how a potentially fatal disease or condition was discovered. We do know that certain interventions save lives, so that people who see a doctor, even aperiodically, live longer than people who never see a doctor. Therefore the questions devolves upon when and how often a patient should be examined by a doctor, and whether the schedule of the visits should be rigidly time-ordered, or one should wait for the patient to come in. At what time interval does a periodic physical exam of a patient with no complaints begin to save lives? This is the basic unanswered question.

The Annual Physical

     There has been much written lately about the utility or non-utility of the annual physical exam and its associated tests. There have been articles in the New York Times, the Annals of Internal Medicine and the Journal of the American Medical Association, as well as statements by the National Institutes of Health, the American College of Physicians, the American Academy  for Family Practice the Canadian Medical Society, and various other organizations. Since there has never been an overall consensus, the reading public is left confused and thrown back on its own resources and preconceptions.

     Firstly, what do we mean when we say that an annual physical exam is "beneficial" to the patient? The answer to that question depends in part on who we ask, and in part on how we measure "beneficiality". Do we ask the opinion of the patient, the doctor, a medical organization, a patient organization, an insurance company, or the government? Is an annual physical exam and its associated tests beneficial if it saves the patient's life,  or if it reduces future morbidity, or if as a result  the patient functions with more physical and/or mental energy? And what of the sense of well-being that a patient feels when he/she is told that the results of the annual exam were perfectly normal? Do we discount that feeling because there is no way to measure and quantify it? Isn't there  value in reassuring a patient that his/her aches and pains are not the symptoms of a serious disease? What if the meat of the annual exam lay in one question that the physician answered for the patient, or one medical misconception that the doctor cleared up and thereby enabled the patient to avoid a future medical problem?

     In previous blogs I have listed questions that should be asked at the annual physical, and which tests I think are medically beneficial and which are not, along with my reasons for the tests. One could make a case that just making sure that the patient received an annual flu shot is enough reason for an annual physical. One could also make a case for measuring blood pressure, since there is plenty of clinical evidence that treating hypertension with a regime that includes a diuretic reduces the patient's risk of a cerebral stroke. There is also an argument for annual testing for infectious diseases that can be treated, such as tuberculosis, syphilis and AIDS. What of the benefit to society when I ask a patient if he/she has trouble reading street signs at night while driving, and then suggest seeing an ophthalmologist if the answer is "yes"? I gloss over the obvious comments a physician would make to the patient about losing weight, stopping smoking and getting more exercise (although a recent study showed that 10% of the patients who exercise damage their health by doing so, two studies  published in Lancet showed that overweight people with a BMI between 26 and 29 had better odds of surviving a heart attack, and two European studies demonstrated that smokers have a reduced incidence of Parkinson's disease). And should I encourage teetotalers to have a daily glass of wine since every study shows that this nutritional intervention improves mortality?

     One fact that is never mentioned in all the discussions of annual physicals is state law: in every state it is a violation of "good medical practice" for a doctor to renew a prescription if the patient has not been seen  within the previous 12 months (and more frequently for DEA-controlled drugs, which includes sleeping pills and tranquilizers). By age 40 almost every patient is taking at least one prescription drug, and therefore needs to be seen annually. And for those only taking over-the-counter supplements, their regime should also be reviewed annually to keep them from consuming OTC drugs that might be harmful----e.g. we now know that daily doses of Vitamin E increases your risk for having a heart attack.