Since the 1940s, the venerable annual physical has been regarded as one of the cornerstones of good health. Each year, many primary care physicians across the country still send out a boilerplate reminder: It’s time for your checkup. But privately, if not publicly, most doctors regard the annual physical as a medical emperor with no clothes, not even a hospital gown. (Ask your doctor how often he or she gets a checkup.) And as University of Pennsylvania bioethicist Dr. Ezekiel Emanuel says, “Spending billions on something that we have pretty good evidence is not working is not the way to go.”
After tracking nearly 60,000 people for a decade, researchers in Denmark reported last year that regular checkups had no effect on preventing cardiovascular disease or death. That study followed a 2012 meta-analysis that included 182,000 people and arrived at a similar conclusion: Regular checkups are unlikely to save lives or prevent disease. Meanwhile, the U.S. Preventive Health Services Task Force, an independent panel of health experts, explicitly recommends that people skip a number of the usual procedures of the annual checkup (for instance, the heart EKG and the prostate-cancer PSA test); its Canadian counterpart recommends against annual visits altogether.
And yet more than 45 million otherwise healthy Americans will undergo a physical this year, gobbling precious health care resources and driving up insurance premiums. All of this raises the question: Why do we get annual physicals?
You have to look back to the early 1900s, when a doctor named Eugene Lyman Fisk convinced the life insurance industry that people who saw their physicians regularly enjoyed better health and were better insurance risks, says Nortin Hadler, emeritus professor of medicine at the University of North Carolina and the author of Worried Sick. Fisk’s research methods were crude, and his positive results were never replicated elsewhere. Regardless, the checkup soon became public-health dogma. By the 1960s, medical labs had developed automated, high-speed methods to test blood for all sorts of things. The annual physical as we know it took shape. Today we’re likely to chat briefly with the doctor, step on a scale, put on a blood pressure cuff, maybe get an EKG, and then have blood drawn to be sent to a lab to get back numbers on everything from cholesterol and kidney and liver function to prostate-cancer risk.
This brisk conveyor-belt system has its advantages. Primary care doctors labor under an insurance-reimbursement system that rewards “doing” (say, performing a CT scan or colonoscopy) more than advising, so the streamlined checkup lets them cram in enough patients to make a living (if not a fortune). Patients seem satisfied that their medical information is being collected and marshaled to safeguard their health. “Going to the doctor becomes like taking your car to the garage to have the oil checked and the tires rotated,” Hadler says. “The more the tires are rotated, the better everyone thinks the annual exam was.”
But human bodies, unlike cars, can heal themselves. And when doctors attempt to discover and treat the early signs of disease, they often do more harm than good. “We all harbor abnormalities, so our diagnostic technologies find all sorts of things,” says Gilbert Welch, a professor at the Dartmouth Institute for Health Policy and Clinical Practice and the author of Less Medicine, More Health. “That leads to more testing and more prescriptions and procedures, and that’s a recipe for making people sick.”
How does that happen? New York cardiologist Sandeep Jauhar, the author of Doctored: The Disillusionment of an American Physician, says, “Doctors are trained to be uncomfortable with uncertainty.” An example Jauhar sees frequently are patients who have no history of heart problems yet fail a basic stress test; this could be a false positive, but doctors often order cardiac catheterization, just in case — an invasive procedure that can result in infection. “Every doctor I know would tell you stories about minor problems getting worked up and leading to all sorts of downstream complication,” he says. “And that’s the aspect of the annual physical that I worry about the most, the unnecessary testing.”
The problem is, when you take a closer look at what happens during a checkup, much of it begins to look unnecessary. Screening for cancer is a classic example; it’s a big reason many people believe they should see a doctor, even if they’re feeling fine. But there is less here than meets the eye. Screening for colon cancer once a decade is generally considered a good idea, but screening more often than that yields no additional benefit. And the PSA test, still a common feature of the annual physical, is a mixed blessing at best, considering the risk of false positives and unnecessary overtreatment. Welch estimates that for every prostate- cancer death prevented by early detection and treatment, 50 men are needlessly treated and about a third of them are harmed. Hunting for early-stage testicular cancer, meanwhile, is no longer recommended, because treatment success in its obvious, later stages is so great; you risk a potentially damaging biopsy of a testicle that otherwise would have caused no harm. In fact, there is only one regular cancer screen that we can definitively say saves lives, a CT scan of the lungs of smokers.
Even less-serious screens pose problems. Take blood pressure. Sure, it may be good to know whether you fall into the mild-hypertension range, between 140 and 159. But if that’s the case, your doctor will probably recommend blood pressure meds — pills that can cause fatigue, fainting, chest pain, and other side effects — though recent research suggests they do nothing to reduce the odds of a stroke or heart attack. Cholesterol is a similar story. High LDL cholesterol is a risk factor for heart attacks, but one that’s not as strong as we once thought. Doctors, however, tend to be very quick to prescribe statin drugs, even though, as University of California, San Francisco, preventive cardiologist Rita Redberg says, “they’ll prevent only a few nonfatal heart attacks, with a much higher chance of causing adverse events like muscle aches, memory loss, and diabetes.”
Doctors have a better shot at promoting health, Redberg says, “by asking the kind of unglamorous, unsexy questions your mother might ask.” What is your diet like? How often do you exercise? Do you have trouble sleeping? As for higher-tech tests of heart function for people at low risk of heart disease, such as the common EKG, they are more likely to lead to unnecessary treatment than to uncover some hidden defect that needs to be fixed. Studies show that patients with abnormal EKG results can wind up getting stents or a full-on coronary bypass, even though these risky procedures don’t reduce the chance of a heart attack in patients without symptoms.
Last, we have the metabolic screens that measure liver and kidney function. If you’re healthy and not on regular medication, these lab results are mostly as useless as they are indecipherable. “You’ll get a panel that tests for about 20 things,” says Mark Ebell, a University of Georgia epidemiologist and a primary care physician who serves on the U.S. Preventive Health Services Task Force. “Just by chance alone, one of those values is going to be abnormal.” A metabolic screen might pick up liver damage that suggests alcohol abuse, he says, but an honest conversation about lifestyle could yield the same information. And good numbers can give the heavy drinker a false sense of security, the same way a good LDL reading can be an excuse to ignore a diet and exercise routine in need of an upgrade.
So should you drop the physical altogether and see a doctor only when you’re sick? That is Ezekiel Emanuel’s personal approach, championed in a controversial New York Times article, but he’s not prepared to recommend it to everyone. He does suggest that otherwise-healthy men postpone regular checkups until they hit their late forties, when there is more to be concerned about. “That would save two or three decades’ worth of annual physicals,” he says. Of course, a pragmatist might also say that it’s a good idea to see a physician often enough so that if you do get sick or develop some unusual symptom, the first person you call will know your name and medical history. “Visits should be more of a check-in than a checkup,” explains Welch. The choice is yours. Even if that choice means not at all.