Do most of us need an annual health check at the doctor’s office? You may think this to be a very silly question, especially coming from me a family doctor who constantly discusses preventive medicine in my articles. I love to see my patients every year just to check in and make sure they are living a healthy lifestyle, as well as to offer a “medical tune up.” Most of my colleagues as well as patients also seem to feel that their annual health checks are helpful. But a growing body of evidence shows that much of what doctors order in these annual exams doesn’t actually help most of us live longer or better. In fact, a 2012 Cochrane meta-analysis of the best research reviewed over 180,000 persons followed for about 10 years after health checks, and found no major decrease in death rates, cancers or heart disease. The Society of General Internal Medicine, in the US, officially tells doctors, “don’t perform routine general health checks for asymptomatic adults…regularly scheduled general health checks without a specific cause including the “health maintenance” annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.”
So if the evidence just isn’t there, then how on earth did we get addicted to our annual health checks – especially here in China? Many Chinese seem quite addicted to their annual health check packages, and I get the impression that most believe that the more testing they get, the healthier they are. I’ve also had three health checks at these famous private health check centers, and while I was impressed at their efficiency, I was very disturbed that a great number of tests I did were completely non-evidence based. I literally felt like a cow being herded through a slaughterhouse, being moved in an assembly line from room to room, poked and prodded in all sorts of embarrassing places.And yet everyone around me seemed completely happy and reassured that they were getting “checked out”.
Here’s the major problem for me, besides the unhelpful tests: not one doctor sat down first with me to ask my risk factors and decided which tests I needed. No panel of tests, no matter how much money you spend, are a superior substitute for one good primary care doctor who knows you well and simply asks you a few questions. Every good doctor knows that 80-90% of all diagnosis is from the history and physical only. Doctor William Osler, considered the father of modern medicine, famously said, “Listen to your patient, he is telling you the diagnosis.”
If we doctors must order a test to screen for a disease, it should have strong evidence from multiple studies that it is accurate and sensitive, not missing any true disease as well as not falsely diagnosing. It also needs to be cost effective for society to test on a large scale. A good screening test also should be looking for diseases we can easily cure and treat. Many screening tests do work well and save many lives, such as blood pressure checks, glucose checks for sugar, and colon cancer screening for anyone over 50. Those tests have strong evidence from multiple studies that they can save many lives.
But many other tests do not have strong evidence. Take cancer screening for example; there’s great evidence that pap smears, mammograms, and colonoscopies can especially save lives for people of specific age groups. But very few other cancer screening tests are effective, including chest x-rays and the PSA test — especially blood tests for tumor markers. Chinese patients, much more than in my home country of America, seem very keen on getting as many blood tests as possible for tumor markers at their health checks — but very few of these have serious data that they are accurate or helpful as screening tests. The American Cancer Society has written a good review of these tumor markers, noting that “tumor markers are used mainly in patients who have already been diagnosed with cancer to watch their response to treatment or look for the return of cancer after treatment.” And yet most of my Chinese patients walk out of these health checks, and they show me their tumor panel with a dozen “normal” results — but they seem to have no idea that the great majority of these tests aren’t very accurate. They feel reassured that they are cancer-free, but it just isn’t true — not from these tests. Hopefully in a few years, such tests will become more accurate, but right now most are not.
Of course, many times a test result is abnormal, and follow-up may indeed discover something dangerous which can be fixed, thus saving a life. But a large percentage of abnormal results found from tumor markers, CT x-rays and other screening tests find incidentalomas – benign lumps that will scare the patient into costly and invasive exploratory tests which usually find nothing serious. Also, screening tests themselves can cause problems — a young woman getting an annual CT scan to screen for cancer is not only falsely reassured by a normal test, but also dramatically increases her risk of getting a cancer due to the high radiation in an annual CT.
This issue of over-testing patients with potentially dangerous screening tests is actually quite a big deal, and wastes billions of dollars across the world. In the USA, a collection of the most prestigious medical societies now creates an annual list, named Choosing Wisely, of common tests which probably should be done much less often. For example, my American Academy of Family Practice recommends no routine ECG during any annual physical for a healthy person; no DEXA bone scan in healthy women under 65; and no Pap smears for women under 21.
So what’s the best option for patients? Instead of pre-packaged health checks, the best solution is to have a tailored health check, where the patient and doctor first sit down together, review their medical history and perform a physical exam. After these crucial first steps, the doctor should decide which tests are appropriate to order. A 35 year old slim male needs a lot less screening tests than a 35 year old man who has a big belly, has smoked since age 12, and gets less than six hours of sleep. Actually, this second man would benefit a lot more from their doctor’s health advice than from tests!
I hope I haven’t just put myself out of business with this article! I always love to see my patients and will continue to enjoy their visits. I just hope that a few more of them no longer feel the urge to buy a fancy health screening package first. I hope after reading this, they understand that they should always first just visit their primary care doctor, hopefully the same doctor every year. We need to chat first, get to know each other, see how you’ve been since a year ago, and then do an exam. After that, we decide which tests you need — if any. Hopefully, you will leave my clinic feeling not only healthier, but more reassured that the personal touch was much more effective for you than the shotgun-approach of a package of tests. Never forget Doctor Osler: “Listen to your patient, he is telling you the diagnosis.”
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