CW: How valuable are regular medical check-ups?

Millions of Americans believe in the practice.

Government reformers believe in it.

Doctors too.

Heck, even I, an accused therapeutic nihilist, tracked down a poor soul who agreed to be my primary care doctor. Call it old-fashioned, but I wanted my own doc, and I wanted yearly “checkups.”

No procedure—not even AF ablation–is as good as prevention. Taking your body in for routine checks and scheduled maintenance makes perfect sense. Call such a notion–obvious.

But a new analysis of more than 180,000 patients followed for decades suggests that patients without symptoms get no benefit from routine checkups with a doctor. (WSJ story here.) Routine health checks had zero effect on overall death rates, death from heart disease or death from cancer. Outcome measures like hospital admissions, disability, worry and absence from work were also not reduced.

The study comes from the Cochrane Collaboration, an international group of researchers who perform systematic reviews of the evidence behind medical treatments. By culling all the published science on a matter, such unbiased reviews provide both patients and doctors with potent and actionable information. These folks ask what the science says, not what dogma holds.

This is big news. Publishing science that downplays a doctor’s role in influencing wellness stings. The lancing of dogma always hurts. Influential cardiologist, author and chief medical editor of theHeart.org, Eric Topol, captured the essence of this provocative study in this tweet:

Another sacred cow in medicine going down “the annual checkup” But will patients get wise?

As far as health topics on which to muse, this one is a 10. It’s a two-sided canvas.

First, let’s be clear: Good health cometh not from the doctor. We don’t make people healthy; people make themselves healthy. In this way, I believe everything that the study purports. Apologies to those who see trees not forests: Good health sprouts from consistently stacking together good choices. The four legs of the wellness table are good food, good movement, good sleep and good attitude. Doctors can’t do this for people; neither can screening tests or pills.

The more we learn about medical practice, the more obvious it becomes that less is more. High blood pressure and Type II diabetes are best treated with diet and exercise. Many heart rhythm disorders, including AF, can often be prevented or quieted with good sleep and stress reduction. Heart attacks and strokes drop (like a masters bike racer in an elite race) when smokers stop smoking. What’s more, emerging science increasingly calls into question the entire notion of mass screening for diseases. Think prostate cancer, mammograms, pap smears and stress tests.

It’s ironic to believe so strongly in less is more. My livelihood and in good part, my self-esteem, turn on performing successful procedures, which in many cases could have been avoided.

Okay, enough with the nihilism. Let’s flip to the other side of the canvas.

I’ll offer two lines of reasoning on why it’s not time to jettison the idea of having a regular doctor do regular check-ups. The first is that this report, though statistically robust, has limitations. Many of the studies that were analyzed were from decades ago. Medicine is much better now. Also, it’s awfully hard to compare groups of patients that either had or did not have regular check ups. As we say, there are confounding variables. Things like healthy people tend to get regular check-ups and those that did not get regular checks still may have seen their doctor often enough for various problems. So be cautious in rushing to conclusions.

The second reason to find a good doctor is the intangibles.

A personal vignette: I’m now in my third year of having a primary care doctor. I love the experience. Of course, I could do my own care. I’m a doc; my wife is a doc and we have a hotline to an array of specialists. As a family of bike racers, we have mostly needed orthopedists.

But now I’m solidly middle-aged. Creaks and chinks have emerged. I wanted my own doctor. Indulgent? Perhaps. And yes, you guessed it; I picked a doctor who is equally obsessed with endurance sports. He properly inflames himself every chance he gets.

His office is a throw back. The staff are welcoming and warm. When you call a human answers the phone. They take blood pressure readings with a stethoscope—not a digital machine. My doctor still wears a tie and a white coat. He listens to my horse-hockey and then he pokes on my aging body. Somehow the exam feels reassuring, though I know it’s probably a placebo effect. We go over labs and chat about things. Invariably he teaches me something about primary care—or life.

The bottom line:

When a ninety-year old patient gets admitted to the hospital for the first time never having seen a doctor and on no medicines, I am not surprised. I like to say that’s why she made it to ninety.

But what’s right for one person may not be so for another.

I’m for having a good doctor—one who listens, examines and teaches; not one who tests, screens and blindly follows guidelines. (Put this on Evernote: Many of today’s guidelines will be laughed at in the future.)

JMM

P.S. My highly traditional doctor has EMR. The computer screen that he’s tethered to adds nothing to the experience. In fact, it’s dreadful.