Do I Really Need A Check-Up?

Posted 06/24/2013

You’d never guess this would be a hotly debated topic among physicians, since an affirmative answer seems so obvious. As for patients, assuming you have insurance, a doctor, and nothing’s really wrong with you, you still might like someone to look things over and ensure nothing’s amiss, no evil lurking inside that will cause you to keel over while you’re still (relatively) young.

If you want regular check-ups, you’re in luck. Many health insurance companies now offer annual wellness checks. In fact, check-ups are already written into the Affordable Care Act (ACA), which will bring a lot of people into doctor’s offices who once stayed away, basically because they had no money.

But eventually some spoilsport was going to ask if all these check-ups people were clamoring for really paid off, especially if these people were young or middle-aged, that line being arbitrarily drawn at under 65.

Determined to discover what seemed like useful information, a group of medical researchers from Denmark reviewed a total of 14 clinical trials conducted between the late 1960s and the early 2000s, tracking over a period of years nearly 200,000 patients divided equally between the “checked-up” and the “non-checked-up.” For their review, they sought trials that measured just one outcome: death.

More harm than good?

Published this week in JAMA, their conclusion is that there wasn’t any difference in death rates between those who got check-ups and those who did not. They also discovered (to no one’s surprise) that among those who had regular check-ups, there was excessive additional testing, more referrals to specialists, more prescriptions, and more diagnostic labels (not to mention more worry) than among those who’d not seen a doctor at all.

In other words, maybe all these wellness checks and disease screenings aren’t such a hot idea since they seem to be doing people more harm than good. But an accompanying editorial disagrees, saying we do need wellness checks. We’ve just not been doing them the right way.

The editorial first points out that in all 14 clinical trials, disease screenings were performed in special outpatient units designed for efficiency. Personnel collected both biometric (weight, height, blood pressure, etc.) and lab data, and when abnormal results appeared they provided medical counseling. However, the tests and counseling were all done parallel to the patient’s primary care doctor, rather than including him or her. This immediately placed a barrier to optimal coordination of care.

In other words, in these clinical trials at least, those in the regularly checked-up group may actually have been receiving substandard care.

If we extrapolate this to the future, let’s say you’re going to a Walgreen’s or CVS clinic for your wellness check and it’s discovered you have high blood pressure. They give you a brochure on high blood pressure, tell you to cut back on salt, and recommend you see your doctor. This isn’t as effective as having your high blood pressure discovered in your doctor’s office. It simply makes no sense to have two locations for measuring blood pressure and, if necessary, receiving prescriptions for treatment.

The second point in the editorial is that when data on all these patients was reviewed, there was a real disconnect between the diseases that were being screened for and what people under 65 actually die of. This is a significant point. Of the almost 12,000 deaths that occurred in both groups, the checked and the unchecked, the most common causes of death were injury, suicide, homicide, heart disease, and cancer. Since we have yet to invent effective tools for preventing the first three, when these studies were started (and to this day) the only serious screening that happens during wellness checks is for heart disease and cancer.

And maybe this is the real problem. Maybe the failure of the check-up group to be superior to the unchecked group is that the point of screening for risk was being soundly overlooked. They were being screened for disease (heart disease and breast, colon, cervical, and prostate cancers) rather than for unhealthy lifestyles.

Given that developing cancer before age 65 is a fairly rare event, consider all the trouble they endured getting screened for it. Cancer screening, especially among healthy people, is considered low-yield, averaging about one case in 1000 screenings each for breast (mammogram) and colon (testing stools for blood). My experience with the exceptionally healthy WholeHealth Chicago patient population certainly aligns with this data. In my 13 years of screening patients under 65 for cancer, I’ve had not one mammogram, Pap smear, or colonoscopy reveal an undiscovered cancer in anyone. Cysts, dysplasias, and polyps, yes, but actual cancer under 65 discovered in a screening, no.

From the point of view of the Danish investigators, the standard wellness checks they reviewed as they were performed from the late 1960s to the early 2000s were a waste of everyone’s time and money, and probably dangerous to boot.

Looking at lifestyle

But if we changed the wellness check to a lifestyle check, we could potentially make a real difference. The more data we gather about what prevents chronic illness and premature death, the more the finger points to unhealthy lifestyle choices.

Let’s update the same-old wellness check to something effective. Let’s have you arrive for your check-up with a completed questionnaire on which you’ve answered a variety of questions on topics that might include seat belt use, number of guns in your home, and your honest diaries of a week’s worth of food eaten, alcohol consumed, physical activity performed, and stresses encountered.

Having a health counselor review this with you, and giving her both the funds and authority to initiate nutritional counseling or a fitness program, we might see real progress in wellness checks. We could limit our current fixation on disease screening to individuals at special risk, such as those with strong family histories of heart disease or cancer, or to those with unhealthy lifestyles who either cannot or will not change.

Here’s one example of how such lifestyle screening could make a real difference. In a report published recently in Internal Medicine News, of 17,000 men tracked over a period of 20 years, those who were most physically fit enjoyed not only the expected low frequency of heart disease, but also 68% less lung cancer and 38% less colon cancer than men who were deemed physically unfit. With this in mind, an effective wellness check would include an assessment of exercise habits, maybe even actually measuring physical fitness, and getting the unfit into shape with a subsidized fitness program. Instead of repeatedly measuring cholesterol or testing stools for blood, we’d be measuring improvements in weight, body fat percentage, and cardiorespiratory endurance.

To the question posed in the title of this health tip, the answer is definitely yes, provided you recognize that within the current health care system much of your check-up will be a DIY project.

Be well,
David Edelberg, MD