The ongoing debate about whether the annual physical exam should be abandoned popped up in the pages of the New England Journal of Medicine (NEJM) last week.
In dueling — but quite civil — commentaries, health care policy experts battle it out, listing their arguments for and against the long-standing medical ritual.
Taking the “against” position are Dr. Ateev Mehrotra of Harvard Medical School and Dr. Allan Prochazka of the University of Colorado Denver. As they point out, Canadian health officials called for the elimination of the annual physical as long ago as 1979. Similar positions have been taken by health organizations here in the States, including the Society of General Internal Medicine, which recommended in 2013 against annual exams for healthy adults.
There is good evidence for such a recommendation. Two major reviews of the scientific literature concluded that annual physicals do not improve health. Nor do they reduce the risk of premature death.
“Moreover,” writes Mehrotra and Prochazka, “the annual physical may actually be harmful. Some aspects of traditional annual physicals, such as the comprehensive physical exam (which might, for example, detect thyroid nodules) and routine tests (such as urinalysis), have low specificity, which means that most positive results in asymptomatic patients will be false positives.”
False positives often lead to unnecessary (and sometimes harmful) follow-up screening and treatment — as well as to needless worry and anxiety.
Not only is the annual physical ineffective at improving health, say Mehrotra and Prochazka, it’s also quite costly to the U.S. economy, draining dollars from medical care with proven benefits.
“Cumulatively these visits cost more than $10 billion per year — similar to the annual costs of all lung-cancer care in the United States,” Mehrotra and Prochazka point out.
Nevertheless, they add, about one-third of U.S. adults continue to receive an annual physical within any given year.
Establishing trust
In his commentary in favor of the annual physical, Dr. Allan Goroll of Harvard Medical School argues that the “continued enthusiasm” among both patients and physicians for the annual physical — “despite the dearth of hard evidence for its benefit” — is exactly why the practice should continue.
Both patients and doctors, he argues “desire or need to establish and maintain a close, trusting relationship with the doctor they consider their personal physician.”
“Calls for abandoning the annual physical also ignore the powerful effect of the ‘laying on of hands,’ appreciated by healers over the centuries and recently documented in dramatic neurophysiological terms through functional neuroimaging,” he writes. “When performed in a thorough, gentle, and considerate manner, the physical examination can communicate caring and help build trust. From this perspective, the performance of the physician’s annual physical examination becomes as much an act of relationship building and continuity as it is a means of searching for clinically significant findings.”
Goroll would like to see improvements to the annual physical exam, however. He says it should become an “annual health review” — an hour-long visit not with a single doctor, but with a team of healthcare practitioners. Nurses and physician assistants could handle much of the preventive aspects of the visit, he suggests, with doctors stepping in to discuss more complex medical concerns.
Moving forward
Mehrotra and Prochazka aren’t convinced. They say there is no evidence that annual physicals build patient-physician relationships. Most patients establish relationships with their physicians by seeing them for other reasons, they point out.
As for the minority of patients who have not seen a physician for a given period or who have recently switched doctors, scheduling a “primary care maintenance visit” every three years or so would be sufficient to establish a relationship with their physician, the two doctors argue.
“We believe it’s time to act on [the] evidence and stop wasting precious primary care time by having a third of the adult population come in for such visits,” they conclude. “Eliminating coverage for annual physicals, shifting our approach to preventive care delivery, and creating and reimbursing for a visit whose sole goals is to establish primary care relationships are key first steps to move us forward.”
You can read the commentaries (“for” and “against”) in full on the NEJM website. Next to the articles, you’ll also find a link to an audio podcast in which Drs. Mehrotra and Goroll discuss their differing views.
If the main reason for annual physical exams is to establish and maintain a “relationship” with a primary care doctor, the current standard of a quick 15-minutes appointment (including the stuff the nurse does) certainly fails to do the trick. Factory-style clinic appointments alienate, more than anything.
The physical
In my 71 years, I’ve only had a “…close, caring…” relationship with my primary physician once, and that was because I was seeing her every 3 to 6 months to get free samples of a cholesterol drug that had been left at her clinic’s office by the drug company sales rep. By “…close, caring…” I mean that the doctor could remember my name without glancing at the chart/folder she held in her hand, and my suspicion is that she could do that, at least in part, because I saw her regularly over an 11-year time span.
I’ve seen my current physician 4 times over the past 2 years, and I’m quite sure he wouldn’t recognize me on the street, or remember my name without prompting. “Close and caring” are not the words I’d use to describe what passes for a “relationship” between us, and unless someone has either seen the same doctor for a decade and more, or is ill often enough to have made frequent visits to the doctor’s office for some length of time, the superficiality of that “relationship” seems to me likely to be more the rule than the exception.
I’m inclined to doubt the value of the annual exam on the basis of that superficial relationship between doctor and patient. I have a similar relationship with the clerks at my local Target or Cub store. Beyond that, it occurs to me that, when one reaches a certain age, a visit to one’s physician, scheduled annually or more frequently, seems likely to be part of the normal course of life for many as health deteriorates. While there are exceptions, age tends to bring infirmity with it, welcome or not.
The lack of documented benefits when looked at systematically is the clincher for me. I’m a physician, and have not had an annual physical for many years. The few times I have gone to see a physician for something I needed (last time was a travel vaccination) I have spent most of my time politely declining tests/interventions for which I know no good evidence exists.
Specifically, last time it was suggested that I:
-Get a cholesterol panel (perfectly normal a few years ago for an insurance policy)
-Get a complete blood count “just to have as a baseline”– no evidence this helps; costs ~$100
-Get a PSA to screen for prostate cancer (an intervention that the US Preventative Service Task force gives a “D” recommendation for [do not perform this intervention])
The cost of those tests; none of which added any value, would have been about $500. As more of us are covered by high-deductible insurance plans with co-pays and other out-of-pocket expenses, people are going to start asking what they are getting for these fees. If the answer isn’t something that clearly improves health, what’s the point?