Many people who are trying to be proactive with their health go in for a physical with their primary care provider. In my previous job as a family practitioner, I saw patients annually for a visit like this. At that appointment, I would ask the patient some questions about how they have been feeling. I’d specifically ask about potentially serious symptoms like chest pain, numbness, memory problems, and weakness. Then I would do an exam that included looking in their eyes, ears, and throat, listening to their heart and lungs, pressing on their abdomen, and checking their reflexes. Also, I would make sure they are up to date with age-appropriate health maintenance checks like screenings for breast cancer for women, prostate cancer for men, and colon cancer for both sexes over the age of 50. We’d talk about vaccines and some standard bloodwork would also be ordered.
This is a good start. But is it enough? If you get the results back that everything is looking good should you feel confident that you are free of disease and on a path of optimal health? In my opinion, no.
Here’s the crazy thing. What I did back when I was a family doctor is actually MORE than is recommended by the literature. According to the USPTF, the U.S. Preventative Services Task Force, the following are the recommended screenings backed by science for a patient like me (48-year-old married female, non-smoker, normal BMI):
- cervical cancer screening (pap smear)
- folic acid supplementation (to prevent neural tube defects in case I get pregnant–gosh I hope not!)
- HIV screening (I’ve been married for 26 years)
- hypertension screening (getting my blood pressure checked)
- screening for syphilis (again, married for 26 years)
- counseling regarding smoking cessation and HIV prevention (even though I don’t smoke and I’m low-risk)
Guess what? In a 2014 meta-analysis including six randomized trials, physicals like these did not decrease mortality.  I’m not surprised.
The conventional medical system is very good at treating acute problems like a broken arm, a heart attack, or an acute infection like strep throat. It’s also effective at managing chronic disease. However, after being a part of that system for 20 years, I don’t feel confident in its ability to proactively prevent disease. And I don’t believe following the science is enough. I understand people aren’t always honest on questionnaires. I learned in medical school when asking a patient how much alcohol they consume,I should double the answer given to get a more realistic assessment. But even given that people sometimes fudge on questionnaires, being in a stable marriage for 26 years, I don’t think screening for HIV and syphilis is the best use of health care dollars for a patient like me.
Getting a colonoscopy doesn’t prevent colon cancer. It detects colon cancer early. Getting a mammogram doesn’t prevent breast cancer. It detects breast cancer early. Having a PSA blood test doesn’t prevent prostate cancer. It detects prostate cancer early.
Additionally, the standard bloodwork is well, pretty standard. Typically what is checked is a cholesterol panel, electrolytes, kidney & liver functions, a blood count, and a basic thyroid test. Having normal results of these standard tests is reassuring but not at all a comprehensive assessment of how optimally your body is functioning overall.
What is recommended at an annual physical is based on several factors, one of which is the cost-effectiveness of the intervention. For instance, screening for ovarian cancer in average-risk women like me is not recommended because it isn’t cost-effective . I personally want to be screened even if it isn’t cost-effective. How do you put a price tag on someone’s life? According to science, in addition to costs, there are harms associated with screening, including anxiety produced by false-positive screening tests, harms associated with diagnostic testing after a positive screening test, and overdiagnosis of conditions that may be treated but would never have become clinically apparent [3-5].
The conventional medicine way is let’s wait till you get sick and then we’ll deal with it.
This is an okay approach for some patients. This is not an okay approach for me or for my patients. We want more for our health and for our life and we are willing to go the extra mile to get it.
What more can be done to feel great now and to protect yourself from future diseases?
In conventional medicine, there are 70,000 ICD 10 codes (the codes doctors use to let the insurance company know what is wrong with you). As a functional medicine doctor, I believe there are only a few root causes that lead to all chronic diseases and so I like to assess them all on my patients.
First, there is oxidative stress. We live on the energy we obtain from the foods we eat and our stored body fat. The processing of that energy results in a waste product called free radicals. These free radicals need to be bound up by anti-oxidants or they can cause damage to our cells and DNA leading to many chronic diseases. Having sufficient anti-oxidants in our diet is critical to preventing this damage.
Secondly, there is inflammation. Inflammation comes from many sources but the two biggest are the foods we eat and some of the bacteria living in our gut. An overabundance of inflammation leads to cellular and DNA damage and chronic disease.
A third cause of chronic disease is insulin resistance. The most common form of insulin resistance is Type 2 Diabetes, but the damage is occurring long before diabetes develops. Eating carbohydrates stimulates a rise in blood sugar followed by a spike in insulin to bring the blood sugar back down. Eating carbohydrates all day long leads to a chronically elevated insulin level which then allows the body to become resistant to the insulin. Many chronic diseases are associated with insulin resistance.
The final cause of chronic disease is catabolic physiology. Catabolism is the process of breaking down food and molecules in the body to be used for energy. It isn’t always a bad thing but it is a problem when the body is breaking down its own lean protein (muscle) and the gut lining to get fuel. Chronic stress leads to a catabolic state.
I do think an annual physical is a good thing. I also think the physical performed by most family doctors is superior to the ones being performed by academic physicians who only adhere to USPTF recommendations. These recommendations are often made by doctors working in big tall office buildings, but not actually seeing patients. I don’t think the annual physical is enough. Your body is designed to feel amazing and when it doesn’t there is a reason. Even if you do feel great, are you taking steps to proactively protect yourself from chronic disease in the future?
Maybe there is more that can and should be done. My suggestion is to trust your intuition. If you have a feeling something is being missed, you are probably right.
An annual physical is all you need is another lie that I learned in medical school that I no longer believe.
- US Preventive Services Task Force, Grossman DC, Curry SJ, et al. Screening for Ovarian Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 319:588.
- Si S, Moss JR, Sullivan TR, et al. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br J Gen Pract 2014; 64:e47.
- Woolf SH, Harris R. The harms of screening: new attention to an old concern. JAMA 2012; 307:565.
- Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst 2010; 102:605.
- Bouck Z, Calzavara AJ, Ivers NM, et al. Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA Intern Med 2020; 180:973.