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Where controversy exists within medicine about the value of a procedure or drug, it is useful to put the arguments of proponents and opponents side by side, to help readers decide which are the more convincing. Of course, we generally take more than mere evidence into account when making our decision, and a graceful or witty style can disguise a multitude of defects; but where we have to make a decision we cannot wait until a perfect way of assessing the evidence is found.
A recent edition of the New England Journal of Medicine carried for and against articles about the practice of the annual medical examination, which about 30 percent of adult Americans undergo each year, taking up 10 percent of primary care physicians’ time.
The annual medical is a kind of ceremonial or ritual which, according to its critics, is without rational foundation despite the fact that so many patients, and perhaps a majority of doctors, believe in it. This proves that superstition is not dead: but perhaps that is no fatal criticism of the annual medical after all, because superstition will never be dead. If it does not attach to one thing, it will attach to another.
According to the critics cited in the contra article, however, annual medicals not merely do no good, as all such evidence as exists, imperfect as it is, tends to demonstrate, neither reducing the morbidity nor mortality of those who have them: but it actually can do harm. This is because of the problem of the incidental finding or false positive. If you examine a hundred people, some of them by definition will have abnormal results, and the more things you measure the more such results you will find. One thing leads to another – further examinations, anxiety, etc. – without improving anyone’s health, or at any rate not enough people’s health to counterbalance the harm done by incidental findings.
The article pro the annual medical seemed to me rather feeble. The author admitted that no research had ever found that it saved lives or even improved the health of him who had it, but he argued in favor of its intangible benefits. Chief among these was that it allowed the patient to have contact with his doctor which he might otherwise not have. It is therefore a kind of bonding exercise, such as some management experts recommend for team-building.
In fact, most medicals are bureaucratic procedures rather than exercises in getting-to-know-you (as The King and I put it). The doctor asks a few questions, ticks some boxes on a computer screen, performs a perfunctory physical examination equivalent to examining a cubic inch of haystack to find a pin, and does a few selected blood tests, the interpretation of whose abnormal results (if any) will be far from straightforward. In fact, what has been done and measured in annual medicals over the years has changed, without any change in their ineffectiveness.
All this the author in favor of them more or less concedes; but he suggests improvements and refinements instead of total abandonment. This overlooks the fact that such improvements and refinements have been suggested for the last forty years, so far without beneficial effect. The reasons for the annual medical are not medical.
The authors (two of them) who write contra annual medicals have one or two misconceptions of their own. Referring to the waste of primary physicians’ time that annual medicals cause, and to the fact that the time of such physicians is at such a premium that many patients experience difficulty in ever getting to see one, the authors conclude that abandoning annual medicals will free time for more important medical work. Alas, long experience has taught me that when we stop wasting time on one thing, we usually find something else to waste it on rather than using it productively.
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