July 2005

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Vol. 4, No. 7


The Annual Physical Exam – A Ritual to Be Avoided

My parents believed so much in the healing powers of medicine that as a child I was subjected to annual physical examinations at the University of Michigan Medical School.  For nearly half a day several highly trained professionals examined my body looking for the slightest indication that I might have the beginnings of a potentially fatal illness, such as cancer.  An analysis of my body fluids and excrements provided the final proof that I was in excellent condition – likely to survive until next year.  

You might think this exam to be prudent action by my parents, showing their love and concern; but these expensive intrusions did nothing to prevent me from suffering a debilitating stroke at the age of 18, having a cholesterol level of 335 mg/dl at 22, gaining 50 extra pounds of fat by the time I was 24, and undergoing major abdominal surgery when I was 25 years young.  Nor is an annual physical examination likely to make a meaningful difference in your life – and that is why major health organizations worldwide recommend against this customary checkup.

In 1979, the Canadian Task Force on the Periodic Health Examination was the first organization to recommend against annual physical examinations.1   Since then, the American College of Physicians, the American Medical Association, the U.S. Preventive Services Task Force (USPSTF), and the U.S. Public Health Service have all agreed that routine annual physical exams for healthy adults should be abandoned and instead doctors should focus their attentions, during the time spent with their patients, on the few problems that they can really help.2-5 

 

Popularity of a Thorough Physical

The idea that an annual physical examination can serve as an important tool to ward off disease and prolong life was first proposed in 1861.  The comprehensive annual physical was advocated by the American Medical Association in the 1920s and was the standard of care until the 1970s.  As recently as 1993, family practitioners in New England (USA) reported spending 35% of their office time on annual physical examinations of adults.  This translates into as many as 11 million visits annually added to an already overburdened health care system.

“Doctor Recommended” – In Spite of the Evidence

Despite unanimous agreement by major health policy makers worldwide, a survey published in July of 2005 in the Annals of Internal Medicine revealed that nearly two-thirds of doctors still recommend annual physicals.6   The main reason given for this contradiction with the evidence is that doctors want to avoid having dissatisfied patients – doctors fear patients would be disgruntled by this lack of “proper medical care.” 

This is a valid concern since two-thirds of patients also consider the annual physical an important part of their health care and may not return to doctors who believe otherwise.5 In addition to the hope that an annual physical will ward off future problems, one common reason given for this kind of routine visit is to get to know their doctor better.  People fear becoming ill and having to be cared for by a doctor who is unfamiliar to them and unknowledgeable about their underlying health.  

The financial rewards to doctors for the annual physical exam play no small part in its continued existence.  Often medical insurances will pay for these examinations.5 (Even though the real purpose of insurance is to spread the risk of a catastrophic loss over the insured population.)  Two important consequences of this allocation of resources are that when money is spent on the annual physical examination then there is less money for treatments of proven worth, and premiums for everyone rise.  The very act of your insurance company reimbursing for this kind of care places a stamp of legitimacy on the annual exam.

Establishing the Doctor-Patient Relationships

People become patients in two ways:  1) they become ill and seek advice or 2) doctors come looking for them.  In the first case, the relationship was initiated by the patient – the patient asked for the doctor’s help.  In this situation the level of evidence that the treatments offered by the doctor will actually benefit the patient does not have to be great.

The second common way for you to become a patient is for the medical business to actively search for you, under the pretext that the ultimate results of their efforts will be in your best interest.  This is accomplished by performing examinations and tests to uncover unapparent, but potential, problems. Screening for cancers by using mammography, colonoscopy, rectal exams, and blood tests (PSA) are common examples of this kind of medical behavior.   In the case where the doctor seeks the patient, the evidence should be plentiful and unquestionable that future treatments will yield profound benefits for the patient – because by finding cancer, heart disease, hypertension, hypercholesterolemia, osteoporosis, and/or diabetes, a healthy person is turned into sick person (a patient).

Annual Exams Make People Sick

The annual physical exam is an intensive, well-orchestrated, experience designed to make apparently well people, sick (with good intentions).  You walk into the doctor’s office as George or Francine and you leave as a breast cancer, prostate cancer or heart-disease victim.  The initial exams commonly lead to more tests – some of which are painful, disfiguring, and dangerous, such as mammograms, breast/prostate biopsies, colonoscopies, and angiograms.  Ultimately, the costs of all this meddling can make you homeless and take away your life savings. 

The annual physical is supposed to be a means of prolonging your life – and it could have been, except for the fact that the treatments that follow the initial exam are at best useless, and at worst, dangerous.  Let me give you two fundamental reasons why the annual physical is doomed to failure, and because of lack of real life benefits all major health organizations have recommended against it:

First, Doctors Are Too Busy Treating Signs Rather Than Diseases 

The annual physical focuses on detecting and treating signs of disease. In 35 years of medical practice I have never seen a patient die of high blood pressure or high cholesterol (signs commonly detected during an annual checkup).  What do people with these signs of disease die from?  They die from rotten (diseased) arteries; made weak with atherosclerosis from a poor diet.  Rather than addressing the underlying cause (the diseased arteries) and making appropriate remedies (a healthy diet), the doctor prescribes pills that lower the blood pressure and cholesterol.  The result: the patient dies of a stroke or heart attack with a normal blood pressure or cholesterol level.  Not much to brag about, but the pharmaceutical companies have fulfilled their promise and collected their payment for providing better looking signs.

To clearly understand the impact of the everyday practice of medicine, please take a moment to identify a friend or relative of yours who has been under the care of a doctor.  This person, faithfully seeking a healthful life and acting responsibly, submits himself to an annual exam and regular office visits.  Problems are identified and treatments are initiated.  After several years of following the doctor’s advice what do you notice different about this person?  NOTHING!  They are still fat and sick, but now they have a medicine cabinet stuffed full of pill bottles.

Second, “Early Detection” is Really Late Detection

By the time serious diseases raise their ugly heads high enough to be seen by the naked eye, or even the x-ray scanner, disease is too far advanced to be effectively treated.  Cancer of the breast or prostate, for example, has been growing, on average, 10 years before it can be felt by the physician.  The same 10-year delayed detection applies to mammograms, x-ray detection of lung cancer, and PSA blood tests (for prostate cancer).  By the time the cancer is found, it has spread (metastasis) to all other parts of the body – places beyond the reach of the surgeon or the radiation beam.  Sad to say (and for most of you, hard to believe), the only real result of most early cancer detection efforts is that you now have to live more years knowing you are sick.  (For more information on this subject see my McDougall Program for Women book and the March 2003 newsletter article:  A World of Hope and Dreams - Early Detection - The Example - Prostate Cancer.)  (There are a few exceptions where treatments can make a substantial difference, like testicular and childhood cancers, and lymphomas and leukemias.  However, there is no evidence that early detection programs would make any meaningful difference in the outcome of even these cancers.)

Seek Help When You Are Sick

Even though the hopes are alluring that seeing your doctor regularly will save you, the evidence says otherwise.  So when should you see a doctor?

Seek medical attention when your body tells you that you are having trouble.  These messages come in the form of a few signs and symptoms, like pain, nausea, weakness, bleeding, and discharges; or as changes in your normal functions, like shortness of breath, difficulty in urination, hearing loss and decreased vision. Otherwise, as the saying goes: “if it ain’t broke, don’t fix it.”

You may need to be reminded along the way that you should improve your self-care.  For this purpose, check values that reflect your lifestyle, like your cholesterol, body weight (a mirror and scale will do), and blood pressure.  These values can be obtained without prescription.  If you read the McDougall books and newsletters (see my archives at www.drmcdougall.com), then you should not need to consult a doctor to tell you there is a diet-lifestyle problem and to give you the correct remedy. 

Those of you who expect your doctor to guide you to solve troubles caused by improper self-care will be sadly disappointed in most cases.  By education, doctors have insufficient knowledge and the interest to provide effective advice and counseling to prevent our major diseases. Research has shown that only about one-quarter of medical schools require training in medical nutrition sciences, and those medical schools that offered nutrition electives achieve very low enrollments by students.7,8

You may have an exceptional doctor.  A professional focused on your interests will be upfront about the shortcomings of highly-profitable tests and surgery/radiation/drug therapies.  Rather than supporting unnecessary examinations and laboratory tests during your visits, your valuable time and money will be spent learning about the benefits of and skills needed to follow a health-supporting lifestyle, like the McDougall Program outlines.  Whenever an examination or treatment is prescribed, the patient must ask, “How will this translate into a healthier outcome for me?” Until the answer is clear, the recommendation must be refused.

Take Advantage of Proven Tests

Modern technology using advanced testing methods, such as whole body scans, heart scans, MRIs, ultrasounds, angiograms, bone mineral density measurements, complete blood analyses, and genetic mapping, have created a world where disease can be discovered in everyone – no one will be acknowledged as healthy – and all of us will be patients.  Fortunately, most of these exposed imperfections are inconsequential and will not reduce the quality or quantity of your years – and therefore, in most cases, you should not be looking for trouble.

There are a few worthwhile examinations for cancer prevention.  These tests will find changes in your tissues before they have become actual cancer – discovery at precancerous stages.   Once progression to actual cancer occurs, then treatments are of very limited value.

 

I recommend these exams for the discovery of precancerous conditions:

 

 

PAP smears for cervical cancer prevention for sexually active women under age 50 years.  Performed every 3 years (after 2 normal exams).  Stop exams after a hysterectomy.

One bowel exam to detect colon polyps, at age 55 to 60 years.

Visual examination of the skin (early melanoma) periodically.

Visual examination of the mouth (leukoplakia) periodically.

[More information on screening tests is found in the McDougall Program for Women book]

Most common life-threatening cancers – breast, prostate, ovary, pancreas, and lung – begin deep within the body where early treatable precancerous changes are near impossible to detect.

Get Out of the System

The goal of every patient should be to remain out of the health care system.  This is accomplished by staying healthy. This highly desirable state is not simply a matter of good luck, but rather a result of your behaviors; more specifically, following a low fat, plant-food based diet, getting moderate exercise and having clean habits. 

People tell me that these regular doctor’s visits and tests are essential, because if they were ever told they had something serious, like cancer, then they would change their diets and destructive lifestyle.  How much pain and suffering does it take to cause sensible behaviors? 

Shouldn’t a look in the mirror be enough? 

Or arthritis that makes arising from a chair an agonizing chore? 

Or twice a day swallowing pills carrying warning labels, “This could kill you”?  

Or should just the love of life and respect for our bodies be enough for us to want the best for ourselves?

References:

1)  The periodic health examination. Canadian Task Force on the Periodic Health Examination.  Can Med Assoc J. 1979 Nov 3;121(9):1193-254.

2)  Periodic health examination: a guide for designing individualized preventive health care in the asymptomatic patients. Medical Practice Committee, American College of Physicians.  Ann Intern Med. 1981 Dec;95(6):729-32.

3)  Hayward RS, Steinberg EP, Ford DE, Roizen MF, Roach KW.  Preventive care guidelines: 1991. American College of Physicians. Canadian Task Force on the Periodic Health Examination. United States Preventive Services Task Force.  Ann Intern Med. 1991 May 1;114(9):758-83.

4)  Medical evaluations of healthy persons. Council on Scientific Affairs.  JAMA. 1983 Mar 25;249(12):1626-33.

5)  Oboler SK, Prochazka AV, Gonzales R, Xu S, Anderson RJ.  Public expectations and attitudes for annual physical examinations and testing.  Ann Intern Med. 2002 May 7;136(9):652-9.

6)  Prochazka AV, Lundahl K, Pearson W, Oboler SK, Anderson RJ.  Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers.  Arch Intern Med. 2005 Jun 27;165(12):1347-52.

7)  Kushner RF, Thorp FK, Edwards J, Weinsier RL, Brooks CM.   Implementing nutrition into the medical curriculum: a user's guide. Am J Clin Nutr. 1990 Aug;52(2):401-3.

8)  Heimburger DC, Stallings VA, Routzahn L.  Survey of clinical nutrition training programs for physicians. Am J Clin Nutr. 1998 Dec;68(6):1174-9.

 

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