Regular health checks (a.k.a routine visits) are probably the bane of many a primary care physician’s existence. I can’t imagine many things more boring than running through a standardized list of questions with a patient who feels absolutely fine, then going through a list of lab values that are almost invariably within the normal reference range, and finally topping it off with a perfunctory physical examination. Nothing converts a highly trained professional in to an unthinking automaton more than the regular health check.
Of course, the physician’s feelings about regular health checks aren’t really what matters (except in so far as they cause physicians to choose not to work in primary care, and thereby cause a shortage of primary care physicians). What matters is whether the regular health check results in objective benefits for the patient. Well, do they?
A review was recently published in JAMA (the Journal of the American Medical Association) that sought to answer that question. Regular health checks are a big part of what primary care physicians do in many countries. In the US for example, 8% of doctor’s appointments are for a regular health check. This means that a lot of money is poured in to them, and it therefore makes sense to try to figure out whether or not they actually do any good. Otherwise that money could be better used elsewhere, like for example launching Jeff Bezos in to space.
The review included both randomized trials and observational studies, with the only requirements for inclusion being that a study have at least 200 participants, that there be a control group, that the health check be conducted in a primary care clinic, and that it be a “general” health check, i.e. not designed to screen specifically for any one disease. 19 randomized trials and 13 observational studies were identified. The smallest study had 240 participants, while the largest had almost 500,000 participants, and the length of follow-up varied from six months to thirty years. The oldest included study was published in 1973, and the most recent was published in 2017. Virtually all were carried out in western Europe or north America, with a disproportionately large proportion of the studies being carried out in Denmark, because apparently the Danes are disproportionately interested in health screening.
The frequency of the health check varied quite a lot. Some of the studies had a single visit, some had a visit annually or bi-annually, and some had irregular intervals.
So, what were the results?
13 randomized trials studied the effect of health checks on mortality, and eleven of these failed to show any benefit. This includes the study that ran the longest, a Danish trial with almost 18,000 people that provided health checks at baseline and then after five years and again after ten years. It failed to show any difference in mortality after thirty years. It also includes the largest study, another Danish trial with almost 60,000 people that provided health checks at baseline and again five years out (and also at the one year and three year marks for those deemed to be at high risk). It failed to show any mortality benefit after ten years of follow-up.
As mentioned, two of the thirteen studies did show a mortality benefit. The larger, another Danish study with 50,000 participants, which provided a single health check and then followed participants for five years to see what happened, showed an extremely marginal benefit (10% vs 11 % dead five years out), but the result only just crossed the threshold for statistical significance and could thus easily be a fluke. The other of the two was a smaller study with 4,195 people conducted in the US, which provided a health check at baseline and at one year out. It showed an improvement in mortality at two years (8% vs 11%) and four years (19% vs 22%).
Overall, though, I think it’s safe to conclude that the totality of studies that have so far been done of regular health checks fail to show that they result in any reduction in mortality. Of course, whether you’re dead or alive isn’t the only thing that matters. So let’s look at other outcomes too.
Five randomized trials looked at whether regular health checks helped prevent cardiovascular disease and cardiovascular events (a.k.a. heart attacks and strokes). All five failed to find any benefit. This is a bit odd, since one rationale for regular health checks is that they catch problems like high blood pressure and high cholesterol early, one major goal of which is to prevent cardiovascular events.
Four randomized trials and six observational studies did seek to understand whether the health checks increased detection of disease. A randomized trial conducted in Denmark (of course), in which 1,104 participants aged 45-64 were randomized to either a health check or “usual care” (i.e. don’t bother the doctor unless you feel sick) and then followed for one year, the health check had resulted in more than twice as many people being treated with anti-depressants (5% vs 2%). As I’ve written about previously, anti-depressants don’t work (better than placebo), but do result in significant side effects, so it’s questionable whether this is a good thing.
The health check did not however result in an increase in the diagnosis of high blood pressure, hypercholesterolemia (high cholesterol), or diabetes. Which is a bit surprising, quite frankly. Other trials did find a difference, however. An American trial in which 906 adults were randomized to a single health check or usual care and then followed for a year found that the health check resulted in a significant increase in the number of people diagnosed with high blood pressure (14% vs 10%). A British observational study including over 85,000 people found that attending regular health checks was associated with an increased likelihood of being diagnosed with high blood pressure, diabetes, and chronic kidney disease. Participants were also more likely to be diagnosed with hypercholesterolemia and treated with statins.
So the totality of evidence suggests that regular health checks do result in an increase in the number of people being given diagnoses and thus the number of people being put on medical treatment. But they don’t improve mortality or the frequency of cardiovascular events. That is strange, isn’t it? How do we explain that?
Here’s what I think.
Firstly, some of these diagnoses don’t actually result in any treatment. Take chronic kidney disease, for example. As people age, their kidneys gradually wear out. Once your kidneys’ capacity is at around 70% of the normal value in a healthy young person, you will be diagnosed as suffering from “chronic kidney disease”. Luckily, the kidneys have an enormous amount of spare capacity, and you don’t actually develop any symptoms until the kidneys are down to 10 to 15% of their original capacity. Most people who have been diagnosed with chronic kidney disease die of other causes long before their kidney function gets to that point. So regular health checks might increase the number of people diagnosed with chronic kidney disease, but the diagnosis doesn’t actually change anything in reality (except for the psychological harms of now thinking that you have a chronic disease, of course).
Secondly, there are many diagnoses that are treated, but where the benefits of treatment are so marginal that it isn’t clear whether treatment actually improves overall outcomes. This applies to mildly elevated blood pressure and blood sugar. Treating very high blood pressure and very high blood sugar is undoubtedly a good thing. But when they are only marginally raised, then treatment is much more questionable, and it’s not clear that the benefits outweigh the harms. The reason this is relevant is that most of the people identified with these conditions through health checks are at the milder end of the spectrum, and thus statistically unlikely to benefit from medical interventions.
Another condition that falls in to this category is the aforementioned hypercholesterolemia. Reducing cholesterol levels in the blood results in a reduction in deaths from heart disease (at least, that’s what the trials produced by the corporations that own the cholesterol lowering drugs say), but it doesn’t result in a reduction in overall mortality. Which does rather beg the question why we even bother to treat high cholesterol.
Thirdly, if regular health checks increase diagnoses and thus increase drug prescriptions, then they also increase the problem of polypharmacy, which is now a leading cause of death. Polypharmacy (taking many drugs simultaneously) frequently cancels out the benefits seen in clinical trials, where unusually healthy and young patients are being treated with a single drug or just a few drugs (i.e. a situation very far from the clinical reality).
It is thus easy to see how regular health checks could result in an increase in diagnoses and an increase in prescriptions without there being any noticeable improvement in survival.
Let’s move on and look at some more results.
Overall, health checks were associated with small improvements in blood pressure and cholesterol, as would be expected given the increase in prescriptions. However, it is hard to see what the value of an improvement in a surrogate marker is if there is no actual improvement in survival.
There was also a consistent increase in the uptake of disease specific screening services in people who took part in health checks. Which intuitively sounds like a good thing, except that again the reality is far more complicated. As I’ve written about before, both breast cancer screening and prostate cancer screening harm far more people than they help, and don’t result in any reduction in overall mortality. So increasing uptake of screening interventions can actually be a bad thing overall. It all depends on which particular screening interventions are being recommended.
Ok, let’s sum up. Regular health checks result in an increased probability of receiving a diagnosis and an increased probability of being put on drugs. They do not however improve longevity. With that being the case, the increase in diagnoses and drug prescriptions is of questionable value, and might even be a net negative, when side effects of the drugs and the negative psychological consequences of thinking of yourself as someone with a “chronic disease” are considered.
Thanks for this blog Sebastian. I do have a question though regarding for instance vitamine D levels. Having low vitamine D levels isn’t something you immediately feel, or feel at all but we know that vitamine D is important for a proper functioning immune system. I can not know my vitamine D level without having it checked out so how does that fit into the conclusions of this blog?
Vitamin D is not one of the things that is usually tested for during routine check-ups in most countries.
My personal thinking is also that it’s not necessary to check the vitamin D level. Get enough sun, eat a healthy diet, and take a vitamin D supplement in winter if you live in a country where that is necessary.
With respect, I think you’ve got the Vitamin D thing all wrong! About a year after I moved back to the UK after 10 years in South Africa in 2002, my GP (an Australian), one of the first things he did was get my Vitamin levels checked, informing me that 70% of people in northern latitudes were Vitamin D deficient and low and behold, mine were deficient as were others, B12 being one.
And who knows what lack of sunlight does for people with dark skins and its lack connected to our impaired immune systems and all that that means!
That’s gotta be wrong. Especially with D3’s 53% benefit rate against Covid (28 studies, all stages), which happens to be Twice the benefit of Remdisvir (at $7,000 a pop).
https://c19early.com/
Not checking D3 level is malpractice. Sun won’t do all that much. You might have a couple of Vitamin D receptor polymorphisms, or dark skin, or clothes on, or a high latitude. The test is only about $60 and nanograms per milliliter around 80 takes care of everything, maybe even cancer according to this:
https://paleozonenutrition.com/2010/07/28/vitamin-d-ideal-levels-and-how-to-know-if-you-are-taking-the-right-amount/
Twice have had my D3 up to 150 and never felt better. Had a 20 year old scar that disappeared. A weekly 50,000 IUs more or less will get you to around 60 ng/ml depending on the many variables. Researchers have stated that anything below 200 ng/ml is no problem. Apparently in the early 1900s people were taking Vitamin D in everything, including “Sunshine Beer,” and no one got sick. The MDs and new hospitals built to serve the rich got upset, and complained to the government. There was a study where med students were given horse-sized doses of D3 and they got sick. That’s why D3 mg were changed to IUs, and the allowed dosage was cut dramatically and every got sick again. People had been taking the equivalent of 1,000,000 IUs.
I have looked into this question of vitamin D.
“Get enough sun” means different things for people with double keratin genes, people with double melanin genes, people with heterogeneous skin color genes, and people with fair skin (which might be different between ruddy-complected and sallow coloration). Time exposed is a key factor and may vary from 10 minutes for fair-complected to 3 hours for dark-complected.
“Get enough sun” means different things for young v. old. The skin of older people has reduced ability to produce vitamin D. I haven’t seen studies comparing the two in terms of time of exposure needed to achieve comparable levels.
And degree of exposure matters. Exposing the face and forearms is minimal. Exposing the back is far superior. Go to the beach in summer for your health. Mow the lawn shirtless when the sun is out. Take vacations in warmer climes in the winter.
I found the following spergic site over at Dr. Kendrick’s blog in one of the comments and it looks interesting at first glance. (I use “spergic” in the sense of “obsessionally thorough.”)
https://vitamindstopscovid.info/05-mds/
The post is about a lot more than stopping covid. Even a tl;dr would take a page.
I have to join the chorus of disagreements on this. I am grateful that my PCP found that my vitamin D levels were low. I am not well enough in general to be as active as I once was and would like to be, so getting enough sun is often not an option for me. Being told to take vitamin D was one of the best health interventions I’ve experienced in the last decade probably. I had done it on my own years before, while working an overnight shift, and I had done it briefly under the advice of an acupuncturist, but I had discontinued it, thinking I didn’t really need it.
I wish one of my doctors had warned me that HCT depletes magnesium. I had to stumble across that on my own, and given the way I responded to taking magnesium supplements when I started on my own, I must have been in desperate need of it.
But wouldn’t it be beneficial to follow up on vitamin d during a routine health check, if you live in a country where people don’t get enough of it without supplementation many months of the year? Then a simple reminder by your doctor to take supplements would be beneficial.
Maybe doctors don’t care about vitamin d unless you seem to have a clear deficiency? I can’t recall any doctor ever mentioning it to me in Sweden, but given how important it seem to be for good health in general, I don’t really get that.
I don’t see that the test changes anything. In my opinion everyone who lives in a country with limited sunlight for much of the year and/or spends limited time outdoors is likely to benefit from a vitamin D supplement. Therefore a test that shows you are deficient won’t change the recommendation.
Dr. Rushworth,
Testing D levels matters because if you are to some degree deficient, you may require supplementation, especially in winter. Doctors can use vitamin D levels to help estimate a patient’s immune system competence and perhaps to add supplementation–it can be given by IV to very sick patients.
There is an optimum level of vitamin D from Robin Whittle’s site (which I previously linked) to provide mucosal IgA immunity. If you haven’t yet read it, I strongly recommend reading it. It’s aimed at MD’s specifically.
A test that shows deficiency may cause the patient to place more weight on the recommendation.
Ron, there will *always* be some “thing” that seems convincing enough, seems necessary enough to us to “get it checked out.” For some it’s cholesterol. For others it’s the possibility they have cancer in them, somewhere. For some it’s “chronic kidney disease.” For you it’s low vitamin D levels.
See how that works? You now get to get your vitamin D levels checked out at doctor visits every year and it won’t change your mortality one iota.
Also: go out in the sun more, and stop worrying about things the medical industry tells you to worry about.
Here where I live there is a lot of sun. I get out in the sun, but also wind up yearly with skin cancers being removed. One needs to be careful. Skin cancer and pre-cancer is one “yearly” physical I’d recommend. That of course, was not the gist of the good doctor’s posting as dermatologists in the US are considered specialists—not GP’s.
Deficiency can be defined medically in 2 ways, clinically or statistically. If someone has a deficiency disease like scurvy or osteomalacia, the definition of deficiency is obvious. Commonly, deficiency is defined statistically. A large number of healthy people have blood levels analysed, an average and range is defined, and anyone outside a chosen limit, usually the 95% or 99% confidence limits is defined as ‘deficient’, despite being ‘healthy’ If you advocate these healthy people need treatment, then 3 questions need to be answered.
1 What is the benefit these treated people can expect, ie what is the purpose and end point of treatment? The cholesterol and statin story tell us that treatment aimed at achieving a change in blood concentration of something does not translate into clinical well being.
2 How effective on a population level is this treatment, eg what is the NNT – number needed to treat?
3 What are the risks?
I do not see any of these questions being answered satisfactorily around the vitamin D debate.
There is a third way to define “deficiency.”
Symptoms of deficiency may depend on the degree of vitamin D deficiency.
Mild vitamin D deficiency may result in incompetence in mucosal immunity (< 55 ng/ml of 25OHD
Moderate vitamin D deficiency may result in fatigue and depression.
Severe vitamin D deficiency may result in bone loss and muscle pains.
"Interestingly, it has been recently demonstrated that the expression and antimicrobial activity of cathelicidin in the oral mucosa is induced by vitamin D."
https://downloads.hindawi.com/archive/2012/492761.pdf
Looking at the statistical means of deficiency misses disparities between people of different complexions and ages. Even the use of sun block can cause vitamin D deficiency.
Amazingly, I’ve never, ever had a ‘regular’ health checkup and now such things look even more remote! I got a text from my GP yesterday which put it bluntly that due to extra demands on the surgery, visits are no longer possible!
“The demand for appointments has greatly increased over the past year.” Oh really? I’ve seen my doc once in this past year!
“This has led to longer waiting times to see a doctoer, we are now triaging phone calls from patients between 8am and 10:30am only.”
I don’t believe a word of it!!! If they’re not seeing patients, what the hell are they doing?
Spending their time in seminars given by pharma.
But, seriously, what ARE they doing if they’re not seeing patients? What is going on? I asked my GP (who is decent enough and actually listens) and she said she’s working 12 hour days but when I saw her maybe 6-7 weeks ago (after over 1 year and nearly 2 months wait time) there just 2 patients, me and one guy waiting after me.
No love for Jeff Bezos there Sebastian 😉 I contributed to his flight recently by buying three copies of your COVID book, which I am distributing to my hypnotised friends, trying to win them over one by one from the dark side.
Thank you for such an interesting and thorough analysis. You mentioned breast and prostate screening as net negative effect. Have you looked at data on colorectal cancer screening at all? That is routine for men at 50 in France so wondering if it is worthwhile or not.
I plan to write an article about it in future!
I look forward to your colonoscopy post. Maybe it will address using Cologuard as an alternative as well?
Not sure of whether one should screen at what age or sign of symptoms, but after many years of symptom neglect, I had a colonoscopy at age 65. A cancerous polyp was removed the size of my thumb. The discussion was at the time—and still is—whether it had spread outside of the polyp. The “safe treatment” was removal of colon with lymph nodes and resection. Got to love those surgeons. 😉
Bottom line is we are monitoring for the last three years, no further signs. Monitoring includes blood test for tumor antigen and CAT scan of intestinal track for lymph node changes. The colonoscopy procedure is infinitely better than the surgical alternative when the situation progresses to a crisis which in my case was imminent. Had I underwent my first colonoscopy at age 60, pre-symptomatic and recommended by my insurance company, I’d have saved myself a whole lot of anxiety. Had I waited after seeing my physician (GP) because I felt fine, the situation would surely have reached a level of intestinal spread. Fortunately, my physician was gently insistent and I was uncharacteristically cooperative. God’s Grace.
There is a lot of value in healthy people getting confirmation they are ok, and pushing their life and the economy forward as a result.
Good stuff, thanks. Always nice when an analysis backs up my own gut feeling.
“what the value of an improvement in a surrogate marker is if there is no actual improvement in survival”
Treat what you can measure, whether or not it matters. Works great for those selling the treatments….
PS Typo on para 4: “a lot of money is pored in to them” – that should be poured, I think. (Not sure whether this is too late for you to correct it or not.)
Thanks! Will fix!
Wow, thank you Dr. Rushworth! I personally know 2 people who went for checkups yearly, then within 4 to 6 months of the checkup, went in for a specific complaint and ended up diagnosed with stage 4 cancer. Neither survived.
The only thing I’ve gotten at a yearly checkup was a bunch of prescriptions I refuse to take. Each had side effects that reduced quality of life for me.
Finding a doctor that isn’t part of a big corp that requires a certain number of appts a day is the real problem.
Thanks Sebastian,
I agree with most of your conclusions. However there are tests that give the recipient information which they can act upon. E.g. Glucose/insulin levels (prompts moving to a low carb diet, no drugs need be involved) CAC artery levels (early indication of blocked arteries which, through intervention, may stop a heart attack or stroke. Sadly thin on the ground in the UK). Drugs need not be the answer when trying to improve a poor potential outcome. Lifestyle for me makes sense.
“An apple a day keeps the doctor away.”
This old saying is even more significant given that the role of quercetin, that is present in apples and is a zinc ionophore, is clearly important for prophylaxis.
Thank you for interesting article. I recently had a routine blood test, including a full blood count, as I had recently been diagnosed with OA in my hands following x-ray. This blood test was to rule out any other issues such as RA. I have never had any results before coming back as abnormal. However, this time results did come back as abnormal with a low platelet count of 138 (female). No RA. My blood test took place four days after my second dose of the Pfizer BioNTech vaccination. The blood test was repeated after four weeks and then was in the normal range. Now, I am left wondering if the Pfizer vaccination caused this, as I have no history and no family history of a low platelet count. I don’t know whether to have any booster vaccination in the Autumn now, as is being discussed in the UK. So, this was an eye-opener for me. I wonder how many other people might also have a low platelet count if they also took a routine blood test with full blood count after vaccination?
Incidentally, I was not put on any medication or diagnosed with any illness by my GP. I would be interested to hear your thoughts. Thank you.
Low platelets are associated with the spike protein. The spike protein likely caused it–either from covid or the jab.
correction:
“likely _causes_ it” not “likely _caused_ it”…
I have no idea in your case.
Thank you for your suggestion. I will look into it.
It makes people feel better to be told that everything is OK. Especially if it is.
Not me. I got over the panic long ago.
The wicked draw your teeth and cut out your tongue, though they still let you breathe and swallow … all of which is a hyperbolic way of emphasizing the prudence and caution needed before unthinkingly accepting unchallenged habits and the advice of “experts,” all of whom have self-interests that may favor themselves at your expense. Thank you, Dr. Rushworth, for your invaluable contributions to mitigating against these tendencies.
Interesting article, thanks for posting. I wonder if there is any data (or you have any thoughts about) regular checkups as we get older . I’m about to be 64, and have felt for a long time that my annual checkup was a waste of time. But now as i age, maybe it makes more sense?
I’m British and don’t remember my NHS GP calling me in for the sort of health checks you describe. But they do ask me to have annual blood tests. And after I’d been diagnosed with COPD they wanted annual breathing tests for a while, until I poited out it was pointless because there was nothing more they could do for me.
There have been other schemes like mammograms and poo sampling etc.
In other words various ‘tests’.
I can’t see that any of this has been of any benefit to me at all and some of the ‘treatments’ I have been prescribed have actually done me harm.
The best health system, I think is one arranged so that it is easy for the patient to consult the GP when they feel themselves to be ill.
Home visits by a GP are now a distant memory unfortunately. Let’s face it if the patient is ill, they SHOULD be at home in bed!
A mammogram saved my life by catching my breast cancer early on.
Great!
I suggest (humbly) a main confounder/bias: People taking regular health checks are more health conscious.
Very thought provoking. Thank you for this. I have to say that the results don’t surprise me. I think serious outcomes can come from Overdiagnosis. I personally will never agree to screening mammography ( I am fairly low risk as there is no family history). I have read Cochrane Collaborations Nordic study on Screening Mammography. The study is from 2012 I think. I really wish they would update it as I’d be very interested to see more recent data. Regarding annual medical check ups, I have never thought they were beneficial. If I’m sick and am not able to cure myself, I go see my doctor. But I rarely do. As for the PSA test, obviously I don’t need to worry about that. But a couple years ago, my brother told me he was gonna have a PSA test. I was mildly alarmed. I sent him a link to the latest studies and advised him to give the test a miss. A week later he’d proceeded with it anyway. I was surprised, and asked what he thought about the information is sent him. He said ” I haven’t read it yet” !!!!!
I recall a doctor in the Canadian Air Force telling me more than 40 years that they had found annual “physicals” did not have any effect of the health of the troops.
In regard to statins, they had disastrous effects on my husband’s intellect and made him entirely impotent. The doctors simply did not believe this and kept hassling him to try a different one. On the final trial, low dose, after 4 days he had driven through a red light, bought an OTC drug that had previously given him vasculitis, and wandered about wondering what he was doing. Docs still “strongly recommend” he try another at a low dose due to heart risks!!!!
Fran. You have to laugh, don’t you, or you’d cry!
Those doctors sound worse than any I’ve met. The only thing we can do is avoid ANY ‘medication’ for as long as possible. That’s what I’m doing now, age 76, nearly 77.
Trouble is, I am driven up the wall by various small problems. There may be harmless remedies but even searching the net, I can’t find out.
The ridiculous covid19 lockdowns have made it even more difficult to get sense out of the GPs here. (U.K.).
In the less affluent postcodes GPs became totally impossible to contact in April 2020. There were posters plastered all over the surgeries’ walls, doors and windows instructing people to not go to hospital unless you had coronavirus sysptoms. It seems that policy has been rolled out to the more affluent postcodes recently. I now know that if you want hassle and no help, go to the NHS. If you want help & no hassle, go private.
Personally I refuse screening until such time as all forms of cancer can be cured. I will not support anything that might increase a person’s distress without being able to help them. At the same time I do not object if others want to avail themselves of such a tactic.
I have a years’ long battle over health-checks with my GP. I see it as ‘jobs for the boys & girls’, increasing misdiagnoses, for the financial benefit of Pharma.
I have better things to do with my life than worry about how soon I’m going to die. I fully intend to make the best of whatever I happen to have.
A good book on this topic everyone here might find of interest:
LESS MEDICINE – MORE HEALTH (7 Assumptions That Drive Too Much Medical Care)
by Dr. H. Gilbert Welch