Sunday, January 11, 2015

Today's 5¢ Health Tip — Turn Your Head & -Cough- Say "Bah!"

Uh, oh. The Zekester speaks with a forked tongue. In today's (January 2015) diatribe in the NY Fishwrap, The Zekester proclaims his willingness to undergo flu shots and colonoscopies. However, in this very blog (October 20, 2014), The Zekester proclaimed that he would eschew flu shots and colonoscopies. The Zekester tells readers of The Atlantic one thing and a few months later — reverses field like a white-coated scatback. The Zekester did not mention annual physicals in October 2014, but he did sneer at flu shots and invasive examination of the colon. Then, a few months later, The Zekester frowns on annual physicals, but forgets his dislike of flu shots and colonoscopies. This blogger scanned a reasonable sample of the comments that Fishwrap readers offered in reaction to The Zekester's polemic. Few, if any, commenters took note of The Zekester's October essay in The Atlantic. If this is a (fair & balanced) critique of talking out of both sides of the mouth, so be it.

[x NY Fishwrap]
Skip Your Annual Physical
By Ezekiel Emanuel

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We all make resolutions and promises to live healthier and better lives, to make the world a better place. Not having my annual physical is one small way I can help reduce health care costs — and save myself time, worry and a worthless exam.

Around 45 million Americans are likely to have a routine physical this year — just as they have for many years running. A poke here, a listen there, a few tubes of blood, maybe an X-ray, a few reassuring words about diet, exercise and not smoking from the doctor, all just to be sure everything is in good working order. Most think of it as the human equivalent of a 15,000-mile checkup and fluid change, which can uncover hidden problems and ensure longer engine life.

There is only one problem: From a health perspective, the annual physical exam is basically worthless.

In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world’s biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years that sought to evaluate the benefits of routine, general health checkups — that is, visits to the physician for general health and not prompted by any particular symptom or complaint.

The unequivocal conclusion: the appointments are unlikely to be beneficial. Regardless of which screenings and tests were administered, studies of annual health exams dating from 1963 to 1999 show that the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease. And the checkups consume billions, although no one is sure exactly how many billions because of the challenge of measuring the additional screenings and follow-up tests.

This lack of evidence is the main reason the United States Preventive Services Task Force — an independent group of experts making evidence-based recommendations about the use of preventive services — does not have a recommendation on routine annual health checkups. The Canadian guidelines have recommended against these exams since 1979.

How can this be? There have been stories and studies in the past few years questioning the value of the physical, but neither patients nor doctors seem to want to hear the message. Part of the reason is psychological; the exam provides an opportunity to talk and reaffirm the physician-patient relationship even if there is no specific complaint. There is also habit. It’s hard to change something that’s been recommended by physicians and medical organizations for more than 100 years. And then there is skepticism about the research. Almost everyone thinks they know someone whose annual exam detected a minor symptom that led to the early diagnosis and treatment of cancer, or some similar lifesaving story.

One explanation for the ineffectiveness of the annual exam in reducing the death rate is that it does little to avert death or disability from acute problems. Unintentional injuries and suicides are, respectively, the fourth and 10th leading causes of death among Americans. And it does little for chronic conditions without significantly useful interventions such as Alzheimer’s, the fifth leading cause of death among older people.

Further, researchers have long noted that screening healthy people who have no complaints is a pretty ineffective way to improve people’s health. If you screen thousands of people, maybe you’ll find tens whose exams suggest they might have a disease. And then upon further tests, you’ll find it is really only a few individuals who truly have something. And of those individuals, maybe one or two actually gain a health benefit from an early diagnosis.

The others may have discovered a disease, but one that either would never have become clinically evident and dangerous, or one that is already too advanced to treat effectively. For instance, early detection of most thyroid cancers leads to surgery, but in many cases those cancers would not have caused serious problems, much less death. Conversely, for individuals whose annual exams lead to the diagnosis of esophageal or pancreatic cancer, the early diagnosis might extend the time they know they have cancer but is unlikely to extend their lives.

Some are actually hurt by physicals, because healthy patients who undergo an exam sometimes end up with complications and pain from further screening or confirmatory tests.

My New Year’s resolution does not mean I won’t get my annual flu shot or a colonoscopy every 10 years — or eat a balanced diet and get regular exercise. These are proven to reduce morbidity and mortality. Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial. If they cannot, join me and make a new resolution: My medical routine won’t include an annual exam. That will free up countless hours of doctors’ time for patients who really do have a medical problem, helping to ensure there is no doctor shortage as more Americans get health insurance. Ω

[Ezekiel J. Emanuel (b. 1957) is the Vice Provost for Global Initiatives, a Levy University Professor, and Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. From 1997 to 2011, he was chair of the Department of Bioethics at the National Institutes of Health. Emanuel received a B.A. from Amherst College and subsequently received his M.Sc. (biochemistry) from Oxford University. He simultaneously studied for an M.D. and a Ph.D. (political philosophy) from Harvard University and received both degrees in the late 1980s. Emanuel also received the Toppan Dissertation Prize for the best Harvard political science dissertation of 1988.]

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