Sebastian Rushworth MD: Are regular health checks good for you?
re: Overdiagnosis is Damaging Health and Happiness America
For some time now I’ve been dubious on the value of an annual physical exam.
Are regular health checks good for you?
by Sebastian Rushworth M.D., 30 June 2021. Emphasis added.
Regular health checks (a.k.a routine visits) are probably the bane of many a primary care physician’s existence. I can’t imagine many things more boring than running through a standardized list of questions with a patient who feels absolutely fine, then going through a list of lab values that are almost invariably within the normal reference range, and finally topping it off with a perfunctory physical examination. Nothing converts a highly trained professional in to an unthinking automaton more than the regular health check.
Of course, the physician’s feelings about regular health checks aren’t really what matters (except in so far as they cause physicians to choose not to work in primary care, and thereby cause a shortage of primary care physicians). What matters is whether the regular health check results in objective benefits for the patient. Well, do they?
A review was recently published in JAMA (the Journal of the American Medical Association) that sought to answer that question. Regular health checks are a big part of what primary care physicians do in many countries. In the US for example, 8% of doctor’s appointments are for a regular health check. This means that a lot of money is poured in to them... review included both randomized trials and observational studies....
...So, what were the results?
13 randomized trials studied the effect of health checks on mortality, and eleven of these failed to show any benefit. This includes the study that ran the longest, a Danish trial with almost 18,000 people that provided health checks at baseline and then after five years and again after ten years. It failed to show any difference in mortality after thirty years. It also includes the largest study, another Danish trial with almost 60,000 people that provided health checks at baseline and again five years out (and also at the one year and three year marks for those deemed to be at high risk). It failed to show any mortality benefit after ten years of follow-up.
...Overall, though, I think it’s safe to conclude that the totality of studies that have so far been done of regular health checks fail to show that they result in any reduction in mortality. Of course, whether you’re dead or alive isn’t the only thing that matters. So let’s look at other outcomes too.
Five randomized trials looked at whether regular health checks helped prevent cardiovascular disease and cardiovascular events (a.k.a. heart attacks and strokes). All five failed to find any benefit...
So the totality of evidence suggests that regular health checks do result in an increase in the number of people being given diagnoses and thus the number of people being put on medical treatment...
Firstly, some of these diagnoses don’t actually result in any treatment
[WIND: emotional harm to the patient of overdiagnosis?]
Secondly, there are many diagnoses that are treated, but where the benefits of treatment are so marginal that it isn’t clear whether treatment actually improves overall outcomes. This applies to mildly elevated blood pressure and blood sugar... but when they are only marginally raised, then treatment is much more questionable, and it’s not clear that the benefits outweigh the harms. The reason this is relevant is that most of the people identified with these conditions through health checks are at the milder end of the spectrum, and thus statistically unlikely to benefit from medical interventions.
[WIND: overdiagnosis with emotional, phsysical, financial harms]
Another condition that falls in to this category is the aforementioned hypercholesterolemia. Reducing cholesterol levels in the blood results in a reduction in deaths from heart disease (at least, that’s what the trials produced by the corporations that own the cholesterol lowering drugs say), but it doesn’t result in a reduction in overall mortality. Which does rather beg the question why we even bother to treat high cholesterol.
Thirdly, if regular health checks increase diagnoses and thus increase drug prescriptions, then they also increase the problem of polypharmacy, which is now a leading cause of death.
Regular health checks result in an increased probability of receiving a diagnosis and an increased probability of being put on drugs. They do not however improve longevity. With that being the case, the increase in diagnoses and drug prescriptions is of questionable value, and might even be a net negative, when side effects of the drugs and the negative psychological consequences of thinking of yourself as someone with a “chronic disease” are considered.
WIND: my most recent annual physical exam this year was completely useless as usual—all of the tests were normal, yet here I am still suffering severe fatigue for a year now. The doctors have no clue. They are useless for this kind of thing.
Instead, my regular doctor wanted to talk about the overdiagnosis of calcium in my heart, an incidental finding of a CT scan after my late 2018 bike crash. For which zero clinical symptoms exist. He has latched on to this for the past 3 years now, every visit. He wanted yet more overdiagnosis (a cardiac stress test at a cardiologist). The ECG last month showed perfect heart function at a resting heart rate of 42 (my lifelong low heart rate). And I have stress tested my heart about 2000 times in the past decade (hard-core cycling), and did so as recently as last June including up to 14500' elevation. And even in my weakened condition now, I hiked carrying an extra 40 pounds at up to 12000' elevation just this month—quite slowly due to fatigue, but no heart issues whatsoever.