This article was originally published in Maclean's Magazine on January 14, 2008
Annual Physical May Be More Costly than Helpful
Most people think that, like going to the dentist every six months, getting your knees knocked, heart checked and blood drawn once a year by their family doctor is a smart and responsible thing to do. After all, shouldn't you treat the rest of your body as well as your teeth? In fact, missing an annual checkup, or five, triggers a sense of guilt in people - a feeling that often materializes as an annoying little voice in the back of your head (or from the pillow beside you) that keeps telling you to book that appointment. For a lot of people, especially the young and the symptomless, that voice may be wrong.
It may come as a surprise, but most family physicians no longer feel it necessary to conduct a full physical every year on each of their patients. Some medical experts even argue that it's a drain on the system, a waste of a doctor's time and resources, and responsible for millions' worth of unnecessary tests. The author of a recently published U.S. study estimates that the cost of potentially unnecessary lab work resulting from physical exams in that country exceeds US$350 million a year.
Nonetheless, millions of Canadians in search of a clean bill of health - or just a birth control or massage-therapy prescription - book an annual checkup. In fact, between the summers of '06 and '07, more than 310,000 in Alberta, 575,000 in British Columbia and an estimated 3.4 million in Ontario went for a routine health exam.
There is no question that for those with health issues, or of a certain vintage, an annual visit is a necessary ritual. But since health is near the top of nearly everyone's list of concerns, the worried will use it as an antidote for anxiety. According to a StatsCan survey, 63 per cent of those who regularly go for physical exams do it for the reassurance it provides. Prevention (15 per cent) and an existing health condition (14 per cent) lagged far behind. Tests (e.g. Pap smear) were cited by about one in 10, family history concerns by just five per cent.
In Canada, the debate over the value of an annual checkup dates back to 1979. That's when the Canadian Task Force on the Periodic Health Examination found the standard head-to-toe physical to be "non-specific," "inefficient" and "potentially harmful." Instead of the cookie-cutter checkup, family doctors were encouraged to follow an evidence-based model of medicine, focusing on a patient's age, sex and risk factors when determining how frequently to schedule a physical and what testing to include. Under this model, which prevails today, screening tests are meant as a tool to reduce mortality, not a means of providing a sense of security. MDs have even given the checkup a new name: the periodic health exam. "It's a philosophical difference," says William Hogg, a professor of family medicine at the University of Ottawa. "It's not just a physical. It's an opportunity to speak about all sorts of things."
Still, while a health exam gives many a sense of confidence, some argue the benefits may not justify the costs. Ateev Mehrotra, an assistant professor at the University of Pittsburgh's School of Medicine, who published the U.S. paper mentioned above, estimated that more than a third of physicals in the U.S. include potentially unnecessary tests. Patients, Mehrotra says, think "it's just a blood test. It's just a urine test. What we don't recognize is that a lot of time we're causing potential harm." Mehrotra says a false positive urine test, for instance, can lead to a batch of follow-up tests that do little more than prove the first one was wrong. "The risk is really small so the patient says 'what the heck,' but from a public health level those costs add up."
Nobody, it seems, has tracked similar stats in Canada, but a 2005 study from the University of Sherbrooke found that of 351 Canadian family doctors surveyed, 87 per cent said they'd order a cancer-screening test if a patient was anxious about having the disease even if they wouldn't otherwise recommend it. "For busy family doctors," says Vivek Goel, a professor of health policy, management and evaluation at the University of Toronto, "it's easier just to fill out the requisition and get the urine and blood tests done than to sit and explain to [a patient], 'at your age, with your risk-factor profile, you don't need anything done.' " Goel also claims some older Canadian doctors are "still doing a very detailed physical examination every year and ordering lots of tests to go along with them." Andries Muller, who runs the teaching clinic at the University of Saskatchewan, says many continue to order a complete blood count once a year for their patients. "There is no need for that," he says. "The only things you would pick up are severe anemia and maybe some blood cancers. Once you've tested it you don't have to do it every year." Same thing, he says, with cholesterol and thyroid tests, depending, of course, on a patient's history and risk factors.
Nobody is advocating against seeing your doctor on a regular basis. The consensus is, this is key to good preventive care. What doctors say, however, is that many healthy young people - especially men - don't need a physical every year. Blythe Brown, a family doctor in Calgary, tells his healthy male patients to come for a physical "twice in your 20s, three times in your 30s, four times in your 40s, five times in your 50s." Only after 60, he says, does it need to become annual.
Most women, due to gynecological health, should see their doctor annually. But even here there are circumstances when a full exam isn't necessary. "If I've got women who've had three normal Paps in a row, are in stable relationships and understand risk-taking behaviour," says Marla Shapiro, a family doctor in Toronto, "we may elect to do a Pap every other year so long as they are coming in for a blood-pressure check, which takes less time than a complete physical."
That said, doctors aren't turning patients away if they show up asking for a full head-to-toe checkup. Most see it as an opportunity, at the very least, to talk to patients about a range of health issues, including smoking, dieting and exercise. "It's tough to fit those kind of conversations into short visits when people come in because they're sick," says Hogg. Ruth Wilson, president of the College of Family Physicians of Canada, sees the checkup as helping foster a relationship between a patient and their family doctor. "It's kind of money in the bank," she says. "So when something bad does happen, we know each other. It's hard to quantify that." But even she doesn't think face time with their doctor every 365 days is necessary for everyone. "It uses lots of doctor time and patient time that is better directed to periodic screening at intervals depending on age and sex."
That kind of targeted care is the focus these days. "If a 35-year-old male was in, I'd ask 'Do you have any problems with vision or hearing?' " says Hogg. "If he said no, I wouldn't even look in his eyes or ears because there are no conditions for which early diagnosis makes a difference in treatment. There's no advantage in finding [problems] before he has symptoms." Similarly, the evidence doesn't support an annual chest X-ray on smokers every year, says Wilson. "You can pick up lung cancer if you do that, but there is no evidence that you save lives," she says.
There's one place you won't hear much about annual physicals being unnecessary, even for young, symptomless men: your average private clinic, which can run almost every test known to man, and sees the benefit in doing so on an annual basis. At Medcan in Toronto, patients spend about four hours criss-crossing between about a dozen preventive health stations. It's like a physical Olympiad. A typical first appointment includes blood and urine tests, an abdominal ultrasound, chest X-rays, cardiac stress testing, an ankle brachial index, fitness appraisal, nutrition evaluation, hearing and vision tests, pulmonary lung testing. Even a massage. Getting all these tests done in the public system would take weeks, says James Aw, the clinic's medical director. Medcan's way takes an afternoon, but sets you back $1,895.
A hefty price tag, but Medcan says it finds previously undiagnosed or misdiagnosed illnesses in about 20 per cent of clients. A third of these, it claims, could be life-threatening if not dealt with properly. Depending on how you look at it, Medcan's 2007 stats are alarming or impressive: 1,313 clients were diagnosed with cardiovascular disease, 319 with diabetes, and 139 with cancer. Some showed no symptoms. "You wouldn't recommend an abdominal ultrasound for the general masses because it would be a huge burden on taxpayers," says Aw. "But we pick up things, like renal or pancreatic cancer. Different lumps or bumps that wouldn't have been picked up unless the patients had symptoms."
Aw concedes that "sometimes we are looking for the needle in the haystack. But we all know folks that have had breast cancer before the age of 50, the screening protocol for the Canadian system." And, he says, it's better than the alternative. "If you do periodic screening every five years, you're looking at a five-year gap and are falling back into a public model, which is, 'you come see us when you have symptoms.' "
Critics question the need for so many tests. "Some of them are going to turn up a false positive," says Goel. "You're going to be labelled with something and you could wind up on medications or wind up having risky procedures done." Goel adds that many of the follow-up tests find their way back into the public system, at a cost to taxpayers. And needless to say, executive physicals are a luxury to all but a small elite. For the other 99.9 per cent, questions of frequency and effective care aren't easy to answer. If the 20-minute checkup is thought to be unnecessary for some, how do we determine exactly what the baseline is for preventive care? Family doctors can't possibly have the time or scientific skills to sift through every journal article and make the necessary critical judgments about who should be tested, for what, and when.
That's why for years, doctors, educators and, whether they know it or not, patients, have counted on the Canadian Task Force on Preventive Health Care (formerly the Task Force on the Periodic Health Examination). The task force's "red brick" - a 1,009-page doorstop published in 1994 - includes recommendations on 80 clinical actions. Regular updates were issued online in the form of Dos (e.g. screening men for colorectal cancer starting at 50) and Don'ts (e.g. routine teaching breast self-exams for women of all ages).
These guidelines help make the annual - or biannual, or triannual - checkup a more intelligent system. The trouble is, the task force was left on shaky financial footing in 2003 when the provinces, after a decade of splitting the cost with the feds, pulled their commitment. The team continued working for a couple of years, publishing their most recent update in 2006. But last year, when the time came to begin a full set of reviews, there wasn't enough money.
For many on the front lines, the disbanding of the task force leaves a serious gap. A few years ago Vinita Dubey, an associate medical officer with Toronto Public Health, compiled a gender-specific, two-page chart for doctors to use during the periodic health exam, relying heavily on the task force's recommendations. In one study, doctors using her checklist provided nearly 50 per cent more of the recommended preventive services to patients than those who didn't. Dubey recently updated the form (removing the Hormone Replacement Therapy recommendation based on new information) and plans to review it every couple years. Without the task force, that's a much tougher task.
Recently, at the request of the Public Health Agency, John Feightner, the former chair of the task force, submitted a detailed proposal on getting it running again. Feightner is optimistic the funding will be made available early in '08. The task force had been operating on a $500,000 annual budget - "an extraordinarily small percentage of the amount spent on health care," says Feightner. "And the return on the investment is quite significant." Hogg thinks it's a no-brainer: "Think of the costs saved to the system by only screening a certain part of the population instead of everyone."
Of course, patients have their own ideas and expectations. Muller says he still has some who say, "you checked my cholesterol last year, why are we not doing it this year again?" That's partly why he sets aside 45 minutes for a physical: some of it is spent explaining why he's not doing certain tests. Most GPs can't afford that kind of time. A 15-to-20-minute block is far more common. "If you look at the recommendations of what a family doctor needs to do it's virtually impossible to get it all done in 15 minutes," says Shapiro. "And one of the last things on the list is immunization, which for me is the most preventative thing we can do." There is so much more, she says, "than just your blood pressure and looking at the back of your eyes. It can be daunting."
Some day, it all may be superfluous. Genomics is expected to play a critical role in the future of family medicine. Women with specific breast cancer mutation genes are already being identified for more frequent examinations and mammographies. And Medcan, for instance, offers blood tests that determine whether someone is on the proper medication or the right dose based on their genomic profile. The true potential of genomics is at least a decade away, at least partly due to cost. "The holy grail would be to do a blood test that, based on your DNA, would tell you to watch out for heart disease and that's it," Aw says. "So you'd never need a colonoscopy."
Maclean's January 14, 2008