Is the Annual Physical Past Its Prime...Again?

Diana Swift

January 15, 2015

Few medical societies still recommend healthy adults undergo annual physicals, and some groups actively recommend against them, yet many physicians continue to offer the visits to their patients. This week, oncologist and health policy expert Ezekiel Emanuel, MD, PhD, has taken the debate to the opinion pages of the New York Times, where he explains again why the formerly prescribed practice should be proscribed. Once again, however, not everyone agrees the healthy patient exam should be a thing of the past.

According to Dr Emanuel, who is vice provost, global initiatives, and chair, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, recent estimates say about 45 million Americans will have a routine general physical this year, which he likens to the human equivalent of the 15,000-mile check-up on their cars. "If you estimate the cost of the exam alone conservatively at $100, it's beginning to be a nontrivial amount of money," Dr Emanuel told Medscape Medical News.

And that is before you add in the costs of laboratory panels, follow-up tests, patient anxiety, and the overdiagnosis or overtreatment of conditions that, if left undetected, would never have become clinically significant. "We see this with prostate cancer and thyroid cancer," Dr Emanuel said.

As he writes, "If you screen thousands of people, maybe you'll find tens whose exams suggest 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."

From a health-promotion perspective, then, the annual physical exam is of little value, does not reduce morbidity and mortality from acute or serious chronic conditions, and may even lead to unwarranted complacency in "people who just want to make sure," he said to Medscape Medical News.

To support that statement, Dr Emanuel points to evidence from a 2012 Cochrane Collaboration review of 14 randomized controlled trials involving 182,000 people followed for a median of 9 years. The unequivocal conclusion of the analysis was that routine general check-ups, not prompted by actual symptoms, are unlikely to yield much benefit. No matter what screenings and tests were administered, annual physicals did not reduce mortality overall or specifically from the big killers, cancer and heart disease.

More recently, data from the Danish Inter99 study, a large, randomized trial, supported the conclusion that general check-ups are ineffective. The community-based trial of almost 60,000 adults aged 30 to 60 years, with screening for ischemic heart disease risk and repeated lifestyle interventions over the course of 5 years, found no effect on ischemic heart disease, stroke, or mortality at the population level after 10 years.

Another impetus for Dr Emanuel's article was the mounting demand on physician time with the broader access to medical care promised by Obamacare. "Doctors are already saying they don't have enough time for all their patients, so with annual check-ups, you're devoting time to exams in healthy asymptomatic people who probably don't need them," Dr Emanuel said. Avoiding annual exams would free up many physician-hours for patients with manifest acute or chronic medical problems. But even healthy, "never-sick-a-day-in-my life" people should check in with a physician once in a while, Dr Emanuel conceded. At that time, appropriate evaluations can be made.

Many US physicians continue to offer this annual staple, motivated, he said, by a combination of financial considerations, habit, and patient expectations. "Many patients are confused and think they need an annual physical to get recommended procedures like flu shots, cholesterol tests, and blood pressure checks," he said.

Dr Emanuel noted that the US Preventive Services Task Force does not recommend routine annual check-ups, and the Canadian Task Force on the Periodic Health Examination has recommended against the practice since 1979. "Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial," he writes in his article.

So far, physicians' response to his op-ed piece "has been 90% supportive. They've looked at the data and are not convinced by the data [of the annual check-up's value]," he told Medscape Medical News.

Many physicians, however, stand by an annual visit to the consulting room, including Peter C. Galier, MD, professor of medicine, University of California, Los Angeles, School of Medicine. "You can manipulate the data from these meta-analyses any way you want, but when you see patients regularly, you get important information that you may never get until there's an acute problem," he said.

And that has major implications for cost-saving health promotion and disease prevention, added Dr Galier, noting that the Affordable Care Act mandates annual wellness visits. "If I find out that another member of the patient's family has since been diagnosed with colorectal or prostate or breast cancer, that changes what I do for that patient," he said.

In addition, compared with the cost of treating the damage done by the big silent killers, the costs of regular check-ups are modest. "I don't want to find out about a patient's unmanaged hypertension when he comes in with an acute stroke or about his unmanaged cholesterol when he comes with an acute [myocardial infarction]," Dr Galier said. "Unless patients get regularly checked, by the time they come in, it's a catastrophe."

Danielle Ofri, MD, PhD, associate professor of medicine, New York University, New York City, agrees there is still place for the routine check-up. "In medical training here, we don't consider it laid to rest," she said. "I still feel there is benefit to the annual history, if not the whole exam and a big panel of blood tests. There's a lot to be found out by checking in." Skipping the laboratory work but keeping the 20-minute consultation may make the exam economically viable.

An internist at Bellevue Hospital, Dr Ofri uses routine check-ups in the refuge of the consulting room to sound out her patients, many of whom are financially and psychosocially stressed, about health promotion through nutrition, weight loss, exercise, smoking cessation, immunization, and appropriate age-related screening for colorectal, cervical, breast, and in some cases, lung cancer. "Many people are not aware of the recommendations for screening and flu shots," she said. "I also screen at this time for depression and domestic violence, things that won't come to the forefront otherwise."

She noted that the number of truly healthy people with no medical problems is "really just a small handful in my practice. Many have psychosocial issues and might need referral to a psychiatrist. A patient with nothing wrong is a rarity." Dr Ofri conceded, however, that for such consultations, "perhaps there's a more cost-effective alternative than a physician."

Ultimately, the biggest benefit of the regular check-up may be establishing a solid connection between patient and physician in advance of medical emergencies. "When you have a major health issue, you already have a doctor to call that you feel comfortable with, not the [emergency department] doctor," she said.

"Skip Your Annual Physical." New York Times. January 9, 2015. Full text

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