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The argument against the annual physical: It is 'basically worthless'

The argument against the annual physical: It is 'basically worthless'
REUTERS/Jessica Rinaldi
Dr. Ezekiel Emanuel: "From a health perspective, the annual physical exam is basically worthless."

Late last week, Dr. Ezekiel Emanuel, an oncologist, bioethicist and vice provost at the University of Pennsylvania, joined the growing call to end the annual physical for healthy people (those without any symptoms or pre-existing conditions). 

Writing for the New York Times, Emanuel points out that about 45 million Americans undergo a routine physical exam each year.

“Most think of it as the human equivalent of a 15,000-mile checkup and fluid change, which can uncover hidden problems and ensure longer engine life,” he writes. “There is only one problem: From a health perspective, the annual physical exam is basically worthless.”

To back up that statement, Emanuel points to a 2012 meta-analysis by the Cochrane Collaboration, which analyzed data from 14 randomized controlled trials involving more than 182,000 people who were followed for a median of nine years. The goal of these studies was to determine if routine health checkups (ones not triggered by a specific symptom or complaint) offered any benefits.

“The unequivocal conclusion,” writes Emanuel, is that “regardless of which screenings tests were administered … the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease. And the checkups consume billions, although no one is sure exactly how many billions because of the challenge of measuring the additional screenings and follow-up tests.”

This lack of evidence, he points out, is why the United States Preventive Services Task Force has declined to make a recommendation on routine annual health checkups — and why Canadian guidelines have recommended against these exams since 1979.

Not without potential harm

“Researchers have long noted,” writes Emanuel, “that screening healthy people who have no complaints is a pretty ineffective way to improve people’s health. If you screen thousands of people, maybe you’ll find tens whose exams suggests they might have a disease. And then upon further tests, you’ll find it is really only a few individuals who truly have something. And of those individuals, maybe one or two actually gain a health benefit from an early diagnosis.”

Furthermore, the people who undergo all those unnecessary follow-up tests and procedures do not always escape unharmed, as another physician Dr. Michael Rothberg of the Cleveland Clinic, pointed out last year in an essay in the Journal of the American Medical Association (JAMA) (which I wrote about at the time in Second Opinion). He described how a routine checkup for his asymptomatic 85-year-old father led to a series of unnecessary tests and even an unnecessary surgery, during which his father almost bled to death.

Fortunately, Rothberg’s father recovered and went home, although after amassing a $50,000 medical bill, presumably picked up by Medicare. But all of that pain, worry and expense, says Rothberg, could have been avoided if the initial routine physical examination had not occurred.

“My New Year’s resolution,” writes Emanuel, “does not mean I won’t get my annual flu shot or a colonoscopy every 10 years — or eat a balanced diet and get regular exercise. These are proven to reduce morbidity and mortality. Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial. If they cannot, join me and make a new resolution: My medical routine won’t include an annual exam. That will free up countless hours of doctors’ time for patients who really do have a medical problem, helping to ensure there is no doctor shortage as more Americans get health insurance.”

You can read Emanuel’s essay at the New York Times’ website.

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Comments (5)

Graphic

Whether worthwhile or not, it is very difficult to hear breath sounds and impossible through clothing. I "fired" a new internist who thought he could hear mine through my clothing. Your graphic, REUTERS/Jessica Rinaldi, is very disturbing.
The rest of your article is right on, though the value of a thorough medical history is relatively under appreciated.

Yes and no

I agree that the annual exam is largely worthless for someone who is asymptomatic and no pre-existing conditions and no significant family history. However, these are important caveats, and for many people, an annual exam can be worthwhile.

The main thing is Dr. Emanuel is an MD. He knows to -- get an annual flu shot and a colonoscopy every 10 years and eat a balanced diet and get regular exercise.

Not everyone knows this or does this. An annual reminder during an annual visit regarding flu shot (and maybe other vaccines), diet and exercise is not a terrible idea and probably does help patient's health.

Some sense

It's good to see some sense brought to our largely nonsensical healthcare empire. Now how about some advice/studies on dental visits every 6 months.

Contradiction

Dr. Emanuel was one of principle architects of the health law which mandates all insurance plans include coverage for the annual physical (which is part of premium cost of the plan) and now he publishes an article that suggests at minimum it is worthless and potentially could be harmful because of false positives.

I frankly think he is right so he should be pushing to remove this from a required plan benefit and people can take the premium savings and choose or not choose to pay out of pocket for an annual physical.

On The Other Hand . . .

As a primary care physician, I can go along with this to a point. But, if you should have your BP checked every 1-2 years, your blood sugar checked every 3 years, your cholesterol checked every 5, a tetanus booster every 10, annual flu shot, . . . Pretty soon you NEED a preventive care visit nearly annually. That doesn't mean you need a full comprehensive physical exam. But, reviewing your risk factors for chronic illness, doing the preventive care that is shown to be beneficial, and having a relationship with a primary care provider for when you need them is quite beneficial. Plus, given the number of potentially life-threatening illnesses I've identified at an asymptomatic stage during these "useless" visits over the years (e.g. breast cancer and melanoma) I would have a hard time dismissing them out of hand.