There is this new ad from the health insurer Cigna that suddenly I’m seeing everywhere. It features America’s favorite TV doctors — from ER’s Noah Wylie to Grey’s Anatomy’s Patrick Dempsey — urging Americans to get their annual physicals.
“We are the TV doctors of America,” Wylie announces. “And we’re here to save lives.”
The actors in the video have taken to Twitter to spread the word even further.
As thrilled as I am for another opportunity to look at Grey’s Anatomy’s McDreamy, this ad infuriates me. It’s completely divorced from a significant body of medical research finding that annual exams do not save lives. Instead, annual exams for healthy people can waste money and often lead to unnecessary follow-up care.
Cigna wants to keep the tradition of annual physicals alive when the doctors who write and think about the issue want it dead.
“From a health perspective, the annual physical exam is basically worthless,” Zeke Emanuel, an oncologist at the University of Pennsylvania, has written after reviewing the research.
"Almost nothing in the complete annual physical examination is based on evidence," Michael Rothberg, who directs the Cleveland Clinic Medicine Institute Center for Value-Based Care Research, wrote in the esteemed Journal of the American Medical Association in 2014. "Why, then, do we continue to examine healthy patients?"
A massive review of the evidence in 2012 found annual exams don’t save lives
The key claim of Cigna’s TV doctors ad is that more people getting annual exams will save lives. The ad associates the health insurer with popular actors, and that could be good for their corporate image.
But there is scant evidence to suggest that this is true — and more evidence piling up that it isn’t. The Cochrane Review did a meta-analysis on the issue in 2012, looking at 14 randomized studies including more than 150,000 patients.
These studies all had limitations. They only looked at two types of diseases, cardiovascular and cancer (although these are the two leading causes of death in the United States). Most studies lasted just about a decade, and it’s possible effects of the exam could have surfaced later.
Still, the Cochrane researchers were pretty clear in their conclusions. “Current use of general health checks is not supported by the best available evidence,” they wrote.
They found that “although general health checks increase the number of new diagnoses, they do not [emphasis mine] decrease total, cardiovascular-related, or cancer-related morbidity or mortality.”
In other words: Annual reviews are good for diagnosing new disease. People walked out of their appointments having been told they had a condition they might not have known about before. But those additional diagnoses didn’t seem to save lives. Knowing about a particular condition didn’t, in these studies, correlate with better health outcomes.
This can be a hard thing to wrap your head around — why don’t more diagnoses save lives? Wouldn’t knowing about a disease make treatment easier? I’ve found this metaphor, shared in an Atul Gawande story, to be a helpful way to think about how this happens:
H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.
In other words, doctors in physicals might be catching a lot of turtles and birds — but not a lot of rabbits.
Annual physical exams can “do more harm than good”
If it were just the case that annual physicals don’t help us but also don’t hurt us, then the practice might be defensible. Some studies do find, after all, that annual physicals make people feel better about their own health even if there isn’t an actual improvement.
But this isn’t the case: We also know of ways that the annual physical can put patients through unnecessary, expensive, and sometimes harmful testing.
Rothberg, the Cleveland Clinic physician, wrote a journal article about his father's experience a decade ago, when an annual checkup triggered a number of follow-up tests that cost $50,000 and ended up doing more harm than good.
In the physical, the doctor used his hands to examine the patient’s stomach. He thought the aorta felt a bit enlarged there and might be an abdominal aortic aneurysm. This led to a cascade of tests — even though the patient turned out not to have an aneurysm — and during one, he nearly bled to death.
Rothberg reflected on the experience as follows:
Once the primary care physician felt an enlarged aorta, he was correct to order the ultrasound, the abnormal pancreas on the ultrasound warranted a CT scan, and the CT finding required a biopsy. The only way to have prevented this outcome would have been to dispense with the initial physical examination.
Rothberg and I spoke about the article shortly after he wrote it, and he reiterated his concerns about the tradition of the annual physical.
“Let's say you're 35 years old and you have a scale in your home, and you can check your blood pressure at the grocery store,” he said. “I'm not sure you need an annual visit to the physician. You're very unlikely to have any serious diseases that haven't shown symptoms.”
And it's not just Rothberg. The Society of General Internal Medicine makes a similar case: It instructs patients only to go to the doctor when they have specific health care needs, like help managing a chronic condition, or think they might be sick.
“Healthy people often don’t need annual physicals,” the group cautions, “and they can even do more harm than good.”
What if we used all that money and time we spend on annual physicals on something else?
About one-third of Americans say they get an annual physical, which costs an estimated $10 billion each year — roughly as much as we spend on all lung cancer care in the United States.
This means that in the midst of a primary care shortage in the United States, doctors are spending several hours on visits that evidence suggests are a waste of time and could be harmful.
What if we replaced the annual physical with a different type of visit? I particularly like one idea from physicians Ateev Mehrotra and Allan Prochazka. They note that one thing the physical exam does do is help establish a relationship between a patient and doctor, so that the patient is more comfortable coming in when she is sick.
So Mehrotra and Prochazka suggest a new type of visit: a “relationship establishment” visit, free of blood draws and any poking or prodding, for patients who have not come in recently.
These types of visits wouldn’t be for everyone. They could, perhaps, be just for “the minority of patients who have not seen a physician for a given period, perhaps 3 years, or who are switching to a new primary care provider.”
There are probably other ways to rethink the $10 billion we spend on annual physicals — ways that would be more effective in improving health outcomes. But having television doctors advocate for more patients to take part in wasteful care certainly isn’t one of them.