The Dark Side Of Regular Physicals
LET’S (NOT) GET PHYSICALS
The Dark Side Of Regular PhysicalsJun 05
LET’S (NOT) GET PHYSICALS
By Elisabeth Rosenthal
New York Times
June 2, 2012
For decades, scientific research has shown that annual physical exams — and many of the screening tests that routinely accompany them — are in many ways pointless or (worse) dangerous, because they can lead to unneeded procedures. The last few years have produced a steady stream of new evidence against the utility of popular tests:
Prostate specific antigen blood tests to detect prostate cancer? No longer recommended by the United States Preventive Services Task Force.
Routine EKGs? No use.
Yearly Pap smears? Nope. (Every three years.)
So why do Americans, nearly alone on the planet, remain so devoted to the ritual physical exam and to all of these tests, and why do so many doctors continue to provide them? Indeed, the last decade has seen a boom in what hospitals and health care companies call “executive physicals” — batteries of screening exams for apparently healthy people, purporting to ferret out hidden disease with the zeal of Homeland Security officers searching for terrorists.
In 1979, a Canadian government task force officially recommended giving up the standard head-to-toe annual physical based on studies showing it to be “nonspecific,” “inefficient” and “potentially harmful,” replacing it instead with a small number of periodic screening tests, which depend in part on a patient’s risk factors for illness. Faced with such evidence, I have not gotten an annual physical since around the time I finished my medical training in 1989. I respect my doctors, but I see them only when I’m sick. I religiously follow schedules for the limited number of screening tests recommended for women my age — like mammograms every two years and blood pressure checks — but most of those do not require a special office visit.
“There’s a lot of inertia and unwillingness to let things go — it’s hard for doctors and patients,” said Allan S. Brett, professor of clinical internal medicine at the University of South Carolina, who tells well patients there is no need to see him annually. “I’ve rolled back the frequency and intensity of screening over the years, absolutely. I’m not doing lots of things now, because there’s no evidence that they help.”
There is, of course, economic impetus for American medicine’s “more is better” mode — at least when patients have insurance. In the United States, most doctors and hospitals profit more by doing more, and prices are particularly high for tests and scans. Also, we are one of the few countries where drug makers and hospitals advertise products and treatments directly to patients, creating demand from consumers who don’t actually pay their full costs.
But there are sociological reasons for America’s enthusiasm as well: an abundance of specialists, who are more likely to deploy tests and procedures, as well as malpractice fears, which leave hurried doctors inclined to order a test rather than explain why it is not necessary. And then there’s habit, said Dr. Brett, who writes extensively on the scientific basis of medical practice, adding: “If you ask gynecologists why they still do yearly Pap smears they’ll say things like: Patients expect it; It keeps patients coming back; It’s what we do in an OB-GYN visit.”
With health care costs spiraling out of control and insurance companies asking patients to pay a greater portion of bills, America may be poised to rethink its rituals. This year the American Board of Internal Medicine Foundation joined forces with Consumer Reports to compile a list of basic medical tests and procedures that are often performed but that don’t add value. The project — called Choosing Wisely — already has a list with dozens of entries, and more will be added in the fall.
“This is the right message from the right messengers — not insurance companies and government, but doctors and patients,” said Dr. Christine Cassel, president of the foundation. “The issue of confronting waste in the American health care system has grown increasingly important. But when this issue comes up in the political arena it becomes about rationing and death panels.”
The United States spends about twice as much per person as other developed countries on health care, generally without better results. A 2009 study of waste in the United States health care system pointed to “unwarranted use of medical care” — unneeded, unproven or redundant diagnosis or treatment — as the biggest single component, accounting for $250 billion to $325 billion a year.
Ateev Mehrotra, an assistant professor at the University of Pittsburgh School of Medicine, has estimated that unneeded blood tests during physical exams alone cost $325 million annually. The only routine blood test currently recommended by the United States Preventive Services Task Force is a cholesterol check every five years.
And the over-screening for some occurs in a country where 50 million people are uninsured and receive little medical attention. More than half of uninsured adults in the United States did not see a doctor in 2010. Fifty percent of Americans are not up to date with the few screening tests that are recommended — like a colonoscopy once every 10 years for those over 50 — because of high costs, said Karen Davis, president of the Commonwealth Fund.
Intensive screening can prove useless for a number of reasons, experts say: Tests can have high rates of “false positives,” signaling that there may be disease, when further tests and procedures reveal none. Likewise, they can screen for conditions where early detection does not alter the course of the disease, either because the body might heal itself or because there are no effective remedies. In either case they can lead to aggressive procedures to clarify the diagnosis or provide treatment, which themselves can be harmful.
In a report released last month, the Commonwealth Fund pointed to a heavy reliance on specialists in the United States as a central factor in driving up costs. Americans have far fewer doctor visits on average than patients in places like Japan and Denmark. But they see more specialists and get more tests.
Specialists are generally inclined to use the tools — and newest toys — of their trade. Surgeons operate. Radiologists conduct scans. Interventional cardiologists do angiograms and stent placements to hold open arteries. “When you go to Midas you get a muffler,” we said when I was in medical training.
“If you have back pain, maybe a primary care doctor says take a muscle relaxant and do these exercises,” Ms. Davis said. “But in the U.S. you might say ‘my friend went to this doctor and had surgery and it’s better.’ So you make an appointment with a back surgeon but before you see the surgeon, you must have a scan. There’s less of what doctors call ‘watchful waiting.’ ”
Many of the screening tests are developed, evaluated and then promoted by specialists and specialty societies — and some prove unhelpful when more widely studied. Specialists are often the last to give up a procedure.
Dr. Brett estimated that 80 percent of urologists still believed the prostate specific antigen tests to be beneficial or worthwhile, compared to only 20 percent of primary care doctors. That test is no longer recommended by the Preventive Services Task Force because prostate cancer is most often an extremely slow growing disease that does not kill, while prostate cancer surgery comes with frequent complications, like incontinence.
“The last patient you saw can influence you more than the study of a huge population,” said Dr. Cassel, an internist who was previously an official at several medical schools. “Urologists see the people who have serious advanced prostate cancer, which is a devastating disease. And they have a tool — surgery — that addresses it. So they want to do it.”
Doctors emphasize that in moving away from aggressive screening, they are not endorsing less care for the ill or proscribing preventive care that is helpful. “If you can afford it, there’s a tendency to say ‘why not?’ ” said Dr. Cassel. “Well, there are a lot of reasons: CT scans are very high radiation. Every test comes up with little incidental findings. So you have a cardiac stress test and that will lead to catheterization, which has risks, and it turns up just a normal variant. There’s a therapeutic cascade that follows each test.”
A recent study in the Annals of Emergency Medicine found that 10 percent of Americans get CT scans each year and that the use of CT scans in emergency departments has increased sixfold in little over a decade. The Choosing Wisely program recommends against the common practice of conducting X-rays or scans on patients with simple back pain that is less than six weeks old. Virtually all people over 50 will have abnormalities on such tests, and most back pain gets better without surgery.
Consciously or subconsciously, experts say, commercial interests foster unneeded tests. Studies show that doctors who invest in radiology machines are more likely to order X-rays, for example.
As of today, only a few screening tests are recommended as useful for healthy, asymptomatic people by the Preventive Services Task Force and some of those — like blood pressure checks — don’t require a doctor visit and could be performed in a pharmacy. “If you follow their recommendations you hardly do anything to patients,” said Dr. Brett, adding that the most important intervention doctors perform on healthy patients may be counseling about habits. For new patients, he still does the full head-to-toe medical exam — though he does not routinely order blood work — and regards some parts as more or less playacting.
Doctors have become accustomed to performing this ritual in years of training, and “patients come to expect it,” Dr. Cassel said.
“Patients say, ‘hey, why didn’t I get my CXR?’ So many docs say O.K., and order one. You don’t really need all those tests and probably most of the physical exam.”