At its root is the doctor-patient relationship
After reading in the New York Times Week in Review that the annual physical exam may have outlived its usefulness, I pondered whether this is actually true. Is it a reflex, or does it have an important role? The answer, I think, depends on how you perceive and utilize this yearly ritual.
If annual medical exams mean lots of expensive diagnostic tests and invasive procedures, it may be time to put it to pasture. However, if it fosters a physician-patient relationship and allows for a partnership in prevention and treatment of diseases, then this alone may be a good reason to keep it. Doctors and patients alike complain there is not enough time spent getting to know or understand each other’s approaches. Eliminating the annual physical would only worsen the situation.
So what are the pros and cons of this time-tested ritual?
One of the downsides may be that the yearly ritual does not save lives. According to a Cochrane meta-analysis (a group of 16 studies), an annual physical exam had no benefit of on mortality risk and morbidity (disease) risk (Cochrane Database Syst Rev. 2012 Oct. 17). The report went on to say that it did not have an effect on overall mortality, nor on cancer survival and/or cardiovascular mortality. Nine trials were utilized for mortality data. The study weakness could be that the trials included were old and may not be applicable to more modern approaches. The authors also suggested that primary care physicians may already be treating patients at high risk for diseases.
Another potential negative to annual exams is that certain diagnostics, such as prostate-specific antigen screenings to test for prostate cancer, could be harmful. In a recently presented abstract (European Cancer Conference 2013; Abstract 1481), the results of a meta-analysis show that routine screening for prostate cancer in the general, symptom-free male population may have more detrimental effects than benefits — a high PSA may lead to unnecessary invasive procedures, such as biopsies and prostatectomies (removal of the prostate). Side effects could be impotence and infection, and could result in hospitalization. The author acknowledged that there have been two large studies on PSAs, one touting the benefits and the other showing increased harm. This latest assessment may be the tiebreaker. Some urologists may disagree with these newest findings.
What are the upsides of an annual medical checkup? Not all diseases show symptoms, especially in the earlier stages. Examples include hypertension (high blood pressure) and chronic kidney disease. This is also an opportunity to discuss mental health — stress levels, depression and anxiety. And, of course, there is the importance of lifestyle discussions, including weight, exercise and diet.
Chronic kidney disease
Though chronic kidney disease does not have an awareness month, it is no less significant than breast cancer or prostate cancer, causing upwards of 90,000 deaths per year. According to the Centers for Disease Control and Prevention, one in five patients with high blood pressure has chronic kidney disease (CDC.gov). Early to moderate stages of the disease may go undetected, since the only way to detect it when it has no symptoms is through blood tests and urinalysis.
If there is protein in the urine and/or reduction in the estimated glomerular filtration rate and creatinine in the blood, this may be a sign of CKD. To learn more about the treatment and prevention of CKD, I encourage you to read my Aug. 13 article. Detecting CKD early may be the key to halting its progress and preventing end-stage kidney disease resulting in dialysis. Without the annual medical exam, we may miss the opportunity to detect this disease in its early stages.
High blood pressure
High blood pressure is known as the “silent killer,” because there are frequently no symptoms until it is too late. According to a study, high blood pressure may be responsible for almost half of all heart attacks and a quarter of premature deaths in the U.S. (BMJ. 2001;322:977-980).
To reduce the risk of this “silent killer,” lifestyle modifications are in order. In a meta-analysis, involving 54 small, randomized controlled trials, aerobic exercise had significant benefits in reducing blood pressure. This was true of patients with elevated and with normal blood pressure, as well as those who were obese and those of normal weight (Ann Intern Med. 2002;136:493-503). Very few lifestyle changes alter blood pressure in “healthy” patients, but ones that do may reduce risk of ever developing the disease. In this trial, the systolic blood pressure (top number) was significantly reduced by a mean of 3.4 mmHg.
Body mass index
The first step toward obesity prevention and treatment is an awareness of the problem. According to a new report by the Institute of Medicine, physicians should regularly monitor patients’ body mass index (Evaluating Obesity Prevention Efforts, National Academies Press, online Aug. 2). This may give patients a sense urgency to lose weight. In my practice, I also assess body composition, which includes fat percent and fat mass. Though someone may not be obese, their fat mass may be higher than normal.
One of the most effective ways to get to know a patient and recommend effective prevention and treatment is with a thorough discussion of history. This is the art of medicine, and it involves the intangibles that may not show up in numbers, including mental health issues.
A recent abstract showed it is not what patients say, but how they say it that may be most important. Short essays were used to help determine whether patients were sad or actually mildly depressed (26th European College of Neuropsychopharmacology Congress; Abstract P.2.b.060). Those who were mildly depressed used significantly more verbs in the past tense than the present (100% versus 2.6%) and used less complex sentences, compared to the healthy control patients.
Ultimately, I think the success of an annual medical checkup has to do with the approach. If there is a strong focus on a thorough history, rather than a predominance of diagnostic testing leading to invasive procedures, there is very little downside. The yearly medical exam is an opportunity to discuss preventive measures, including lifestyle changes, whether the patients are healthy or have disorders that may be prevented from worsening.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.