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Update January 12, 2015- CBS conducted a a roundtable discussion about this topic. Dr. Narula came down on the side of Dr. Emanuel, using the same misguided interpretation of meta-analysis statistics. Read below for the entire discussion.
January 9, 2015- By Steven E. Greer, MD
Ezekiel Emanuel, MD, the brother of former White House Chief of Staff Rahm, and of Hollywood power-broker Ari, has once again demonstrated an utter lack of ability to translate large epidemiology numbers into proper lessons for real doctors treating patients. In his latest New York Times essay, he cites dubious meta-analyses numbers from the Cochrane Group (a European group that favors less medical and surgical interventions in order to save money, often justifying the poor care delivered by socialized medicine) showing that lives are not saved by the annual physical exam ritual that American health insurance plans encourage.
Well, let’s assume those Cochrane data he cites are rock solid (which they are not, because no retrospective meta-analysis is ever good enough to use for clinical decision-making.). He misses the point. The annual exam is not just meant to extend lifespan. A good annual doctor visit exam should be performed to improve quality-of-life.
The primary care physician should be looking for ways to improve the mental status and cognitive function, energy, libido, physique, and nutrition of the patient. The doctor should be treating what causes the patient to not sleep well, not have good bowel movements, or not be mentally sharp, for examples.
In almost all cases, the underlying ailments making the patient miserable can be treated. They can eat more fiber, lose weight, stop smoking, stop drinking, discontinue unnecessary medications that are causing mental side effects, or have surgery to correct conditions impairing quality of life.
Growing old and decrepit is not something that should be accepted as inevitable. We have many ways to prolong functional lives. As one example, hormone replacement therapy works miracles for many patients over 40 years of age. Women can benefit the most.
Other ailments are overlooked by most primary care physicians in the annual exam. Body parts often ignored by the primary care doctor should be examined. Are the ears full of cerumen?. Can the patient see at computer-screen distances? Do they need new eye prescriptions? Are the gums receding? How are the feet?
Not only can most quality-of-life issues be corrected, but the fixes are often very affordable. Cleaning out the ear canals costs almost nothing other than the doctor’s time. New eyeglasses costs $100. Even hormone replacements can be very affordable.
Ezekiel Emanuel is actually correct in his essay to encourage Americans to skip their annual physical, but not for the reasons he cites in his essay. The current annual exams often diagnose unimportant numbers and findings, which lead to prescriptions for drugs that do nothing but chase surrogate numbers. The blood draws measure lipid profiles, for example, which lead to hundreds of millions of people receiving cholesterol-lowering statins, which are drugs that do nothing whatsoever to “save lives” in most of the patients taking them. Blood pressure measurements are often wildly inaccurate, leading to unnecessary anti-hypertensive medications. The annual ECG is a waste of time and money as a screening tool.
And heaven forbid that the patient can afford to receive a “VIP executive physical”, like former President George W. Bush. Then, they will be bombarded with high doses of radiation from coronary CT-scans, or nuclear stress tests, which will lead to unnecessary coronary stents and lifelong blood thinners.
Dr. Emanuel would have written an important essay if he had advocated for a change in the annual physical exam paradigm. Instead, he urges Americans to skip their visit with the doctor altogether. He seems to have a hidden agenda of trying to persuade the masses to just get old and die, and stop using up our precious limited resources. Those same views are what made him so controversial as a White House adviser that he was kept in the closet by brother Rahm.
(Editor’s note: That last personal jab is based on an actual incident. I was approved by Dr. Ezekiel’s staff to interview him at The White House one week before his brother Rahm resigned from The White House. However, Dr. Emanuel failed to tell the full White House press staff. On my way to Washington, D.C., the White House cancelled my interview when they learned of it.)
I respect you for bringing health stories, such as Dr. Ezekiel Emanuel’s New York Times essay to my attention and for discussing your perspective. However, I disagree with your dismissal of the Cochrane Group (https://www.cochrane.org/) and their highly respected reports. As stated in Wikipedia (https://en.wikipedia.org/wiki/Cochrane_Collaboration), the Cochrane Group has “more than 31,000 volunteers in more than 120 countries. The collaboration was formed to organize medical research information in a systematic way to facilitate the choices that health professionals, patients, policy makers and others face in health interventions according to the principles of evidence-based medicine.” This is a massive effort by an international collection of physicians and medical researchers and does not reflect the health care system or policies of any country; rather it attempts to inform policy makers, doctors and patients.
While I appreciate the limitations of retrospective analyses and of meta- analyses; they are also the best and really only way to analyze existing data; in this case from published medical research. They do not claim to be producing medical research, but rather to be reviewing and analyzing all existing published research then producing a report on what has been demonstrated and the quality of that research (hence the results). The bottom line is that annual physical exams have not been shown to improve morbidity or mortality in any group that has been studied. Hence people should not bother with an annual exam if one’s goal is to increase early detection or to extend one’s life. However, as you discuss, physician visits can be made of value if the physician and the patient use the visit to review preventive measures, body weight, fitness, diet, stress, sleep patterns, etc. However, this is not the annual physical that Dr. Emmanuel was saying was ineffective. Since this type of visit is not a standard, it has not been researched nor reviewed by the Cochrane Group.
I do hope that readers listen to your advice regarding what type of information to request of their physician but I also hope that they understand what the Cochrane Group does. Their work is a valuable resource for those interested in learning about the evidence behind medical advice and practices as this will make them more informed consumers.
I worked with Cochrane as a researcher. You are telling me nothing new.