In an essay published Wednesday in the Journal of the American Medical Association (JAMA), Dr. Michael Rothberg, vice chair of research at the Cleveland Clinic, asks the question, “Why do physicians continue to perform an annual physical examination on healthy patients?”
When he posed that question recently to a group of medical residents, he received what is probably a common response: “It couldn’t hurt.”
Ah, but it can, says Rothberg. To explain how, he describes what happened about a decade ago to his then-85-year-old father when the elder Rothberg went for a “checkup” with a new primary care physician after moving into an assisted-living facility:
He had a longstanding history of hypertension, glaucoma, and some mild mitral regurgitation, but was otherwise in good health. As part of his evaluation, the internist performed a complete and thorough physical examination. He palpated my father’s abdomen and thought that the aorta was too prominent; he suspected an aortic aneurysm. My father had never smoked, and there were no recommendations for aortic aneurysm screening at the time. Nevertheless, his physician ordered an abdominal ultrasound. The test revealed a normal aorta, but the ultrasonographer noticed something suspicious in the head of the pancreas. It was recommended that he have a CT scan. The CT revealed a normal pancreas, but there was now a solitary lesion in the liver, strongly suggestive of hepatocellular carcinoma.
Surgery was recommended, but Rothberg’s father initially decided against it. He had worked in the chemical industry, where he had been exposed to numerous toxic chemicals, so he reasoned he had cancer, and was resigned to it. His daughter, however, was against his decision and eventually persuaded him to undergo surgery to have the liver lesion removed.
“The good news is that he did not end up having liver cancer,” writes Rothberg. “The bad news: the lesion was a hemangioma, and he almost bled to death. He required 10 units of blood. He was in a lot of pain. He was given morphine and developed urinary retention.”
Fortunately, his father recovered and, a week later, went home without any permanent physical harm. The cost of that week in the hospital: $50,000 (presumably picked up by Medicare). Rothberg doesn’t say what all the other procedures cost.
The frustrating part of his father’s story, Rothberg points out, is that every step that his father’s doctors took after that first visit with the primary care physician is considered appropriate medical care.
“The only way to have prevented this outcome would have been to dispense with the initial physical examination,” he says. “The US Preventive Services Task Force recommends one-time ultrasound screening for aortic aneurysms in men aged 65 to 74 years who have ever smoked, but does not recommend palpation for aneurysms, because it is generally inaccurate, as was the case with my father. It also recommends against palpating the abdomen in search of pancreatic cancer. Similarly, one should not assess the liver or spleen. Apparently, unless the patient has a concern or complaint, the well-intentioned physician should avoid the abdomen altogether.”
“In fact,” he adds, “almost nothing in the complete annual physical examination is based on evidence. For a generally healthy 85-year-old, the physical exam could reasonably be limited to blood pressure measurement and assessment of the body mass index.”
‘An unstoppable cascade’
Why, then, do physicians continue to physically examine healthy patients? There’s plenty of blame to go around, writes Rothberg:
First of all, [physicians] get paid to do it. For an annual wellness visit for an 85-year-old, Medicare pays approximately $111. More important, all the tests and treatments my father received, including his hospitalization, generated substantial ‘downstream revenue’ for the health system.
Second, patients expect it. We have educated them about the importance of a thorough physical. Without it, patients may leave thinking, ‘The doctor didn’t even examine me!’
Finally, there is [the physician’s] own anxiety about missing something life-threatening. At each step of the process, my father’s physicians’ anxiety increased, in an unstoppable cascade that almost killed him.
Rothberg offers several solutions for stopping the cascade, starting with changing how Medicare and other insurance programs pay physicians for medical services. He also stresses that all of us — physicians, patients and payers — need to change our attitudes about routine health checks.
“During these visits, patients, physicians, and private insurers all expect an examination,” he writes. “To stop performing physicals requires embracing the evidence and sharing with our patients. Although an examination-free annual visit to a primary care physician may be worth preserving for other reasons, we must admit that this is an untested intervention that may not add value.”
Most important, he adds, physicians need to recognize the dangers of overdiagnosis and to suppress their own anxieties.
“There will always remain a small possibility that our examination might detect some silent, potentially deadly cancer or aneurysm,” Rothberg writes. “Unfortunately for our patients, these serendipitous, life-saving events are much less common than the false-positive findings that lead to invasive and potentially life-threatening tests.”
You’ll find the essay on the JAMA website.