Before we were able to Google our every itch and twinge and ache, we had very different relationships with our doctors.
“In the early years of my career, information was something the doctor had and the patient didn’t,” Dr. Michael L. LeFevre, a professor and physician at the University of Missouri, tells The Huffington Post. Today, he says, patients bring their information to him for his input. “They want my opinion about how good the information is and what it means and how to interpret it for them in their lives.”
Of course, the Internet is rife with misinformation, and sometimes a well-meaning patient will ask for a bout of tests that are completely unnecessary. But at the end of the day, LeFevre thinks this has still resulted in a more empowered patient, one who can arm herself with the tools to help get herself the best care.
That is, assuming patients still go to the doctor's office at all. Recently, bioethicist and physician (and no stranger to controversial proclamations) Dr. Ezekiel Emanuel declared the annual physical "worthless." Using slightly milder language, other medical authorities have also suggested that getting a yearly screening might not be the best use of time or money.
Much of the conversation has to do with the types of screening tests that are done at the doctor's office.
LeFevre is also chair of the U.S. Preventive Services Task Force, an independent panel of experts that provides screening and prevention recommendations to the U.S. government. These experts are, essentially, the ones deciding how often you get a mammogram or a colonoscopy -- or a regular check-up.
Studying the benefits of preventive tests and screenings isn't a fool-proof science, says David Howard, Ph.D., an associated professor of health policy and management at Emory University's Rollins School of Public Health, who is not involved in the Task Force. Some of the Task Force's recommendations don't have long-term, randomized studies behind them (since such studies would take so long the findings would likely no longer be relevant, he says) and are based on mathematical models to assess their benefits instead. Better than nothing, he says, but they should be taken with a grain of salt.
Not to mention, each individual patient is just that -- an individual. “It's important for patients to communicate their preferences, too,” says Howard, whether that’s staying off prescription meds or avoiding excess testing when possible.
One of the biggest risk factors the Task Force takes into consideration is what’s called overdiagnosis. Howard explains the concept as follows: “If a patient is found to have a condition -- be it hypertension or early stage cancer -- the inclination is often to treat it,” says Howard. “Patients who receive treatment often think, ‘Ah ha, my life has been saved through early detection.’ But for many conditions, only a fraction of patients whose disease is detected through early detection would have actually died from the disease had it gone undetected. People would have died from something else before the disease became clinically apparent, but there’s really no way to know ahead of time.”
LeFevre says there is "almost certainly" overdiagnosis in preventive screenings, but there are two sides of the spectrum. On one end is prostate cancer: “We’re finding a lot of tumors that would never have caused problems in the patient, and they’re being treated and exposed to the risk of treatment.” On the other is lung cancer screening for high-risk smokers: "[B]ecause lung cancer is so lethal to start with … in that particular case we believe that the benefits outweigh the harms.”
So if more screening isn't always better, but it can be, how does an informed patient know where to start? We asked the experts about a few of the most common health screenings.
The recommendation: In adults 18 and older. There's some evidence to suggest every two years in people with blood pressure under 120/80 and every year if that top number is 120 to 139 or the bottom number is 80 to 89.
What the experts say: LeFevre used blood pressure screening as an example of the big-picture benefits the Task Force is looking for. Recommendations are based on whether there are tangible positive health outcomes of screening, like heart attack and stroke prevention, not just lowering blood pressure, he said -- and we've seen large-scale improvements in these areas.
Colorectal Cancer Screening
The recommendation: In adults ages 50 to 75. The most common method is the colonoscopy, which is recommended every 10 years. Also available and recommended are yearly fecal occult blood testing or sigmoidoscopy every five years with fecal occult blood testing every three years.
What the experts say: “Colon cancer screening is one of the harder things to talk people into,” says LeFevre, mainly because it has “become synonymous with colonoscopy, though there are other strategies.” Some patients simply say they won’t do that test, leading to some under-screening, he says.
The recommendation: Every two years for women 50 to 74. There’s not enough evidence currently for the Task Force to recommend regular mammograms for women younger or older. And the Task Force actually recommends against breast self-examination, because it typically leads to more (unneeded) tests and biopsies.
What the experts say: “I think most people don’t follow [the government’s] recommendations and most are following the recommendations from the American Cancer Society,” says Dr. Nieca Goldberg, medical director of the Tisch Center for Women's Health at New York University's Langone Medical Center. Those guidelines suggest mammography should begin when a woman is 40. “I’m aligned with those doctors who believe in earlier screening,” she says.
The recommendation: Every three years in women ages 21 to 65. Or combined with human papillomavirus (HPV) testing every five years for women 30 to 65.
What the experts say: Many women breathed a sigh of relief when the science evolved enough to get them out of a yearly Pap test, but there are a significant number of women who don’t even make a point of being screened every three years. “At least half of the cases of cervical cancer are not a failure of screening, they are a failure of being screened,” says LeFevre. “If we could just reach all the women of America, we would eliminate [much] of the remaining cervical cancer that occurs in the U.S.”
The recommendation: In men 35 and older and women 45 and older, and in younger adults after age 20 if they are at an increased risk of heart disease. The timing is uncertain. Some experts say every five years, some say more frequently for people at risk of high cholesterol and some say less frequently for people with repeatedly normal levels.
What the experts say: It all comes down to knowing who the right people are to screen, says Goldberg, like someone with a family history of high blood pressure or stroke. “I think these people should get a checkup to find out what their personal risk is,” she says. “I think it’s really important to be proactive about their health.”
The recommendation: The Task Force has no official position on the yearly physical.
What the experts say: You probably don't need a yearly checkup. However, experts argue that without it, patients may miss out on a whole host of screenings, tests, advice and counseling they would not have access to without scheduling some appointment with their docs. Counseling options are recommended, ranging from topics like nutrition and physical activity to breastfeeding to domestic violence, but few Americans would have access to such care without scheduling a yearly physical. “There are preventive services that we are sure work,” says LeFevre. “The question is, how can we best deliver those services? I believe there are services we need to deliver, and often those are best delivered and attended to in the context of a visit where we focus on prevention. It’s hard to incorporate preventive services into sick care. Going in every year may not be necessary, but we do need to make sure that people do get the things that we know work.”
Goldberg agrees. “The guideline may say that you may not need a Pap smear,” she says. “But they didn’t say you don’t have to go to the doctor.”