The general health checkup: Its origins, its future

What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.

A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling.

The second JAMA article was an editorial with the title The Health Checkup: Was It Ever Effective? Could It Be Effective?. It elaborates on a limitation that the Cochrane study authors themselves point out: The trials used as data for the review were so old as to make them irrelevant to present day practice. There were 14 trials in the study, but only nine reported total mortality. Seven of those nine were conducted prior to 1975.

The editorial elaborates on why this matters. Checkups performed in those early trials did not include screenings now known to reduce deaths from cancer (sigmoidoscopy, fecal occult blood testing, chest CT scans, mammography). What they most commonly included was blood pressure, serum cholesterol levels, height and weight, and sometimes urinalysis, spirometry (breath measurement), and electrocardiography. “The 9 trials used screening tests whose effects on mortality are still unknown and failed to use screening tests now known to be effective.”

The origins of the health checkup

Contrary to what you might assume, it was not the medical profession that first advocated the value of general health checkups. It was the insurance industry. In the 19th century, a medical diagnosis was considered accurate only in the late stages of a disease. In order to stay solvent, life insurance companies couldn’t wait that long before deciding who to insure at what premium. The insurance industry – an early devotee of statistical analysis – discovered a connection between sugar in the urine of apparently healthy individuals and the subsequent symptomatic onset of diabetes and kidney disease. Urinalysis became a standard component of medical exams for insurance purposes as early as 1885. The medical profession added this practice reluctantly, and then only to satisfy the demands of life insurance companies. (For a detailed and fascinating account of the role of the insurance industry in the invention of the risk factor, see William G. Rothstein, Public Health and the Risk Factor.)

It was the life insurance industry that alerted the medical profession to the significance of elevated blood pressure. The annual physical exam became a much more common feature of (what we would now call) primary care only after the insurance industry made blood pressure readings a prerequisite for an insurance policy. (See Jeremy A. Greene, Prescribing by Numbers.)

In contrast to today’s eager identification and treatment of risk factors, the medical profession was slow to adopt a positive attitude towards disease prevention. This was partly for economic reasons. American physicians have a long history of making their living by charging patients a fee for each visit. In the early twentieth century, public health initiatives in disease prevention (such as publicly financed chest clinics to detect TB) were seen as a threat to physicians’ income and were opposed by the medical profession.

Resistance stemmed not only from economic interests, but from the medical profession’s concern for its social status. Disease prevention was the province of public health. Professionally, physicians considered themselves to be of a higher status than public health workers. The medical profession, after all, catered to middle-class, paying patients who required acute care. Not only were the patients served by public health of a lower social class. The diseases treated by public health were of a lower status (e.g., venereal disease). (On these economic and professional considerations, see Robert Aronowitz, Making Sense of Illness.)

There is still, BTW, a status hierarchy of diseases and of the medical specialties that treat them. See Are some diseases more prestigious than others?

What’s missing from this picture?

To return to the present (and the future), one reason the effectiveness of regular checkups is on the minds of health and medical professionals these days is the imminent implementation of the Affordable Care Act (ACA). Newly insured adults and children will be eligible for certain preventive services at absolutely no cost. Medicare (Part B) now offers a one-time “welcome to Medicare” visit, plus yearly “wellness” visits. Given the tremendous concern about health care costs in the US, are we certain these visits are worthwhile? How should we regard general health checkups now that a Cochran review has failed to confirm their usefulness?

The JAMA editorial both dismisses the Cochran study and praises its authors. On the one hand, it argues, since the data was outdated, we shouldn’t be discouraged from designing new disease prevention trials, as long as they are “closely aligned with the current medical care system.” The authors of the study are praised for thinking on a “grand scale,” the type of thinking we need “to plan and develop systems to optimize population health in the 21st century.”

On the plus side, I am encouraged whenever I see a JAMA article that refers to population health rather than patient empowerment. There are two things, however, that I find missing in this editorial. Not “missing” in the sense of things I would have expected, but things I miss because I wish they had been there.

Health is not health care

One of these stems from the perspective of “closely aligned with the current medical care system.” There is no acknowledgement (as I would not expect in JAMA) that health is not health care, as Daniel Goldberg so eloquently maintains in Global Health Care is Not Global Health. Goldberg argues against “the pervasive conflation of health and health care in conceptualizing global health.” This conflation is equally pertinent locally.

[H]ealth and health care must be distinguished, especially because the evidence strongly suggests that health care services are only a minor determinant of health and its distribution in human populations. … [S]ocial and economic conditions are far and away the most powerful determinants of health and its distribution in human populations …. Social inequalities are robustly correlated with health inequalities; class structures and power relations are significant macrosocial determinants of health. Social disadvantage tends to accumulate, which means that so too do risk factors and poor health outcomes, with those located on the tail of the social gradient experiencing disproportionate burdens of disease and suffering.

For many complex reasons (which I hope to understand much better someday), it is very difficult – especially in increasingly neoliberal societies — to address the social determinants of health. The authoritative voice of the medical profession in support of this issue would be most welcome. Just as with disease prevention in the early twentieth century, addressing the social determinants of health in the twenty-first does not threaten physicians, financially or otherwise. And it is doctors, after all, who witness firsthand the health consequences of social injustice.

The Affordable Care Act, new patients, and primary care

The other thing missing from the JAMA editorial is a discussion of the special opportunity offered by the Affordable Care Act – an opportunity to strengthen primary care. Primary care physicians and family medicine practitioners will soon be able to perform health checkups for some 30 million new patients who were previously uninsured. There are numerous provisions in the ACA designed to expand primary care, improve reimbursement and incentive practices, and support “innovative approaches to delivering care.” To succeed, however, this requires the support of the medical profession, including editorial support from JAMA.

One of the ACA’s provisions could double the capacity of community health centers. This is especially important for the newly insured. Demographically, these individuals are overwhelmingly young, single, and poor ($18,542 median income for an individual). They are less educated and less regularly employed than those who are currently insured. (See Two children visit their doctors: Social class in the USA.) They report feeling fit, but it’s quite possible their first health checkup will reveal previously undetected chronic conditions or mental health issues that will require continuous care.

To be welcomed into the health care system, these new patients will need the sensitivity, compassion, and kindness that physicians exhibit every day, despite the unreasonable time constraints imposed in the interests of lowering health care costs.

I am aware that some GPs run to time. How they comfort a bereaved parent, tell someone they have cancer, explain the hazards of breast screening or counsel an anxious parent about MMR in ten minutes is a mystery to me.

This from Dr. Jonathon Tomlinson, a General Practitioner in the UK. Such problems as adequate time for patients, how doctors are reimbursed, and reducing health care costs by encouraging competition are not limited to the US.

In his essay, Diary: In the surgery, Dr. Tomlinson quotes the British GP Julian Tudor Hart:

The availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces.

I sincerely hope that a majority of the 37 million potential new US patients will choose to participate in health insurance programs. I hope they will be welcomed into the health care system. I hope they will avail themselves of general health checkups and benefit from whatever continuing care those checkups may indicate are in their best interests. As a country, we do not yet have the will to address the social determinants of health. What we do have, however, are the individual doctors who will treat these new patients with wisdom and compassion.

(For additional thoughtful and beautifully written reflections by Dr. Tomlinson on the contemporary practice of medicine, see his blog posts on kindness, loneliness, forgiveness, shame, and death.)

Image source: Anadolu Medical Center

Resources:

Lasse T. Krogsbøll, MD; Karsten Juhl Jørgensen, MD, DMSc; Peter C. Gøtzsche, MD, DMSc, MSc, General Health Checks in Adults for Reducing Morbidity and Mortality From Disease, JAMA, Vol 309, No 23, pp 2489-2490

Harold C. Sox, MD, The Health Checkup: Was It Ever Effective? Could It Be Effective?, JAMA, Vol 309, No 23, pp 2489-2490

Lasse T Krogsbøll, Karsten Juhl Jørgensen, Christian Grønhøj Larsen, Peter C Gøtzsche, General health checks in adults for reducing morbidity and mortality from disease, The Cochrane Library, October 17, 2012

William G. Rothstein, Public Health and the Risk Factor: A History of an Uneven Medical Revolution

Jeremy A. Greene, Prescribing by Numbers: Drugs and the definition of disease

Robert A. Aronowitz, Making Sense of Illness: Science, Society, and Disease

Bonnie Bullough and George Rosen, Preventive Medicine in the United States, 1900-1990: Trends and Interpretations

Daniel Goldberg, Global Health Care is Not Global Health: Populations, Inequities, and Law as a Social Determinant of Health, in Glenn Cohen (ed), The Globalization of Health Care: Legal and Ethical Issues

Thomas S. Huddle, The Limits of Social Justice as an Aspect of Medical Professionalism, The Journal of Medicine and Philosophy, August 2013

Melinda Abrams, How Will the Affordable Care Act Bolster Primary Care?,

Kelly Barnes, Examining the Newly Covered under the Affordable Care Act, Health Affairs Blog, October 30, 2012

Jonathon Tomlinson, Diary: In the surgery, London Review of Books, June 30, 2011

Jonathon Tomlinson, Loneliness, Abetternhs’s Blog, May 4, 2013

Jonathon Tomlinson, Do doctors need to be kind?, Abetternhs’s Blog, May 4, 2012

Jonathon Tomlinson, Forgiveness, narratives and listening, Abetternhs’s Blog, February 16, 2013

Jonathon Tomlinson, Shame, Abetternhs’s Blog, November 16, 2012

Jonathon Tomlinson, Doctors and death, Abetternhs’s Blog, July 9, 2013