Monday, March 7, 2011

Guest Blog: Thoughts on annual physicals and God

Richard Young, MD is a family physician educator and director of research at the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Texas. The following post was originally published on his blog, American Health Scare.

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A local reporter pulled another fast and loose assumption on unsuspecting readers recently, though this time I’ll cut her some slack. She was merely conveying a conventional belief shared by many other Americans.

The story was very sad. A well-loved, perfectly healthy minister, the Rev. Ken Diehm, became suddenly ill and developed a severe headache. Best I can piece together, he had bleeding in his brain causing the headache that was difficult to control. Somewhere along the way they discovered he had acute leukemia causing the bleeding. In spite of aggressive treatment, he died within a day.

The reporter wrote in her story that “[t]he disease had not been detected during his annual physical two weeks earlier.”

This could be dismissed as a throw-away filler line, but it speaks of an erroneous assumption that adds to our exorbitantly expensive healthcare system. If her point was to increase the emotional impact of the story, her description that he was an “. . . avid bicyclist and sports enthusiast [who] was ‘young and physically fit” sufficed. Mentioning the annual physical didn’t make him any healthier.

It has long been recognized in the U.S. and Canada that an annual physical is useless. Specifically, I’m talking about the actual physical examination. For me to spend time with a patient who has no significant symptoms probing her ears, throat, and other more personal orifices is a colossal waste of both of our time and resources (except for occasional Pap smears). I’m sure a few doctors and patients can tell stories about an abnormality that was detected in an annual physical that turned out to be something serious. This anecdote assumes early detection changes the final outcome, which is often an erroneous assumption. These anecdotes also discount the impact and harm of false positive findings that occur much more often.

My deeper concern is the false hope of control implied in the statement. The reporter assumed that if acute leukemia was detected two weeks earlier, the minister could have been cured even before his symptoms started. There of course is no evidence that any physical examination or blood test saves lives in asymptomatic people with leukemia.

I am not suggesting a periodic visit to a physician isn’t worthwhile. I am suggesting that much more is gained focusing the clinic visit time on talking with your doctor and targeting tests and interventions based on clear risk factors. If I were king of the medical universe, I would rid the lexicon of “annual physical” and replace it with “periodic conversation.” The latter phrase is a much more accurate description of the useful part of a wellness visit. Some patients such as healthy young men have little reason to see doctors unless they have issues to discuss.

The irony of the annual physical statement is its placement in the story of the death of a Christian minister. The obituary told many stories of his inspiring works and how his faith touched others, but nothing of how his faith informed an understanding of the meaning and greater hope inherent in his death. If I may take off my secular physician hat for a moment and offer a thought from his (and my) faith:

For I am already being poured out like a drink offering, and the time has come for my departure. I have fought the good fight, I have finished the race, I have kept the faith. Now there is in store for me the crown of righteousness, which the Lord, the righteous Judge, will award to me on that day–and not only to me, but also to all who have longed for his appearing. 2 Timothy 4:6-8

I have no idea why Rev. Diehm’s race ended a few days ago. But I do know God promises a long and healthy life to no one.

The U.S. spends 2.6 trillion dollars a year on healthcare and hundreds of billions of this total is spent trying to delay our inevitable passing from this existence to the next. We fear death as a society and spend lots of other people’s money attempting to postpone our mortality. Those resources could go to other uses.

We wish we could control when and under what circumstances we die, but we can’t, and annual physicals – and many other tests and interventions that are commonly provided — change this reality extremely little, and in many cases not at all.

- Richard Young, MD

2 comments:

  1. Very impressive, Rich. Great piece.

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  2. Why mention the occasional Pap smear? They are basically useless like the PSA test. Having one person look at a slide of 100,000+ cells for 5a minutes, please. Cervical cancer is and always has been rare and informed consent is never mentioned. Don't assume women "have to have" these barbaric tests. There is about a 1% chance of getting this cancer and a 77-95% risk of having unnecessary treatment due to the false positive rate. And don't say the falling rates are due to Paps. The rates were dropping before and there has never been randomized trials for Pap smears. Just admit this is all about scamming money out of women. God, I hate doctors.

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