The Case FOR the Annual Check-Up

Blink and it will be gone. Make no mistake about it: the “Annual Check-up,“ once the pillar of our preventative health care system, is on the verge of becoming obsolete – or `medically “insignificant“.

Already, the Annual Health Exam has been de-listed in several provinces:
British Columbia, Nova Scotia, New Brunswick, and Newfoundland and Labrador no longer cover annual physicals in patients without symptoms of illness. Ontario offers “personalized health reviews” in which the doctor focuses on the health risks specific to the patient and the patient’s age.
If you live in Alberta, Manitoba, Saskatchewan, Quebec, Prince Edward Island, and the Northwest Territories – appreciate the Check-up while it lasts.
Calls to eliminate the annual physical examination are not new. In 1979, the Canadian Task Force on the Periodic Health Examination recommended “that the annual checkup, as practiced almost ritualistically for several decades in North America, be abandoned.”
In 2013, the Choosing Wisely campaign (see poster below) recommended against annual preventive examinations in asymptomatic patients.
Despite these calls, many people still want an annual physical. Not surprisingly, surveys show that the majority of both patients and physicians remain strong proponents of the annual check-up.
Ironically, while experts are divided on whether there is a benefit to getting an annual exam, the federal Affordable Care Act (ie. Obamacare in the United States) requires insurers to cover annual physicals free of charge.
So, what exactly is the controversy? Simply, some research has demonstrated that regular physicals do not reduce rates of illness or mortality. At best, the researchers suggest that these exams are an egregious waste of health-care resources, and at worse, they are dangerous by promoting “superfluous,“ expensive testing.
The research most frequently cited against the annual physical is a 2012 analysis of 16 trials by the Cochrane Collaboration. This study concluded that “physicals“ do not reduce mortality or illness. Critics point out that the trials excluded elderly patients and were predominantly performed in Europe, where most patients were already regularly seeing doctors. In other words, do these results really reflect our reality in Canada?
In more detail, the Cochrane review included 16 trials and 182,880 participants. While the authors concluded that they did not find an effect on clinical events or other measures of morbidity, one trial found an increased occurrence of hypertension and hypercholesterolemia with screening and another trial found an increased occurrence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. Two trials found an increased number of people using antihypertensive drugs, and another two trials found small beneficial effects on self-reported health. The authors also comment, “we did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied.“ Of note, two additional studies were excluded from the analysis.
In the end, the author`s concluded, “General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.“
Why did the author`s conclude that the General Health Check, or Annual Check-up, were “unlikely to be beneficial?“
The authors suggest:
1. “One reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.
2. Also, those at high risk of developing disease may not attend general health checks when invited.
3. Most of the trials were old, which makes the results less applicable to today’s settings because the treatments used for conditions and risk factors have changed.“

I have included a few clippings from news organizations on this heated topic (see below). But I was amused by the “observations“ of the following physician to the Wall Street Journal article:
Observations as a physician:
1. Nothing ultimately improves mortality since everybody dies. Unfortunate fact overlooked in medical trials.
2. Ironic that presumed liberals (Ivy League affiliated) want universal healthcare but don’t want patients to be seen.
3. If they don’t come in yearly, how else will I be able to nag them every year to quit smoking and tell them that they’re too fat?
4. Hypertension: the “silent” killer because often there are no symptoms until a stroke or heart attack. But don’t see me unless you have symptoms.

In the end, I am reminded of Malcolm Gladwell`s brilliant bestseller “Blink.“ Sometimes we simply overthink the obvious. We become all-consumed with the analysis that we ignore the simplicity in front of us. Annual check-ups, like everything, need to evolve. Preventative medicine should be personalized – but it needs to be planned. Air Canada (hopefully) does not wait for the airplane to make funny noises before checking it out. Routine maintenance is neither a luxury nor superfluous – it is common sense.
We cannot and should not base care or conclusions on old studies that are “less applicable to today`s settings.“ We should make recommendations on well-designed, up-to-date studies that reflect our current health care needs.
Why do the majority of patients and physicians remain strong proponents of the annual check-up? Because it feels right. All the analysis to devalue the annual check-up simply cannot compete with the primal benefit of nurturing a meaningful, trusting, patient-physician relationship. For my part, I certainly hope the annual check-up lives on.