Quality

I was approached by The Wall Street Journal to write an article for their Big Issues in Health Care debate series. The subject was “Is the annual physical unnecessary?” I was to take the “yes” side and an internist was to take the “no” side. I wrote the following article. The editor wrote me a couple of times with questions. The internist pointed out the value of preventive medicine, developing a personalized healthcare plan, and developing a meaningful doctor-patient relationship. I said I wholeheartedly agreed, but I thought those goals could be accomplished just as well (arguably even better) with a periodic health maintenance interview or consultation. I pointed out that the traditional “physical” exam with stethoscope, routine lab tests, etc. provides no further advantages and can be counterproductive, with false positive or harmless findings leading to unnecessary worry, further testing, and expense. I said there was nothing magical about the interval of a year. I don’t know what the optimum interval would be; that could be studied. I suspect it would vary with the patient’s age, medical conditions, risk factors, and other considerations, and might be left up to the judgment of patient and doctor deciding together.

Finally I got an e-mail with apologies, saying they had decided not to continue with the debate because the internist and I agreed on too many important details. While I understand that stirring up a fight is good for selling newspapers, I think it’s a much better thing when people on two sides of a debate reach an agreement. It reassures me that they are converging on the truth. So I thought it would be worthwhile to publish my article here on SBM.

Annual physicals are wasteful and lead to overdiagnosis

The annual physical is obsolete. Routine physicals don’t reduce mortality or morbidity and can no longer be recommended for asymptomatic adults. They waste resources and can sometimes lead to harm.

People used to consult doctors only when they were sick. The routine annual physical originated in the 1940s. The idea was that if healthy people with no symptoms saw a doctor every year, diseases could be detected early and treated before they could cause any harm. It seemed like a good idea at the time.

The annual physical was never clearly defined. Depending on the doctor, it might include vital signs; eye/ear/throat exams; palpating necks, breasts, testicles, and abdomens; inserting fingers into vaginas and rectums; updating immunizations; and various tests like Pap smears, stool guaiacs, complete blood counts, urinalyses, chemistry panels, TB tine tests, mammograms, chest x-rays, EKGs, and others.

The interval of a year was arbitrary, based on calendric convenience rather than on any scientific rationale. There was a risk that routine exams would give false reassurance of health and lead patients to minimize the significance of new symptoms or delay reporting them until the next annual physical.

By the 1980s, doctors had begun to question which components of the annual physical were worthwhile. Little by little, practices changed. Annual CBCs, urinalyses, TB tine tests, and chest x-rays were found to be useless and were dropped. Pap smears and STD screening were proven worthwhile, but the routine pelvic exam with speculum and bimanual palpation was not.

The physical examination of a healthy, asymptomatic adult is unlikely to reveal any significant abnormality (1) that would not have been detected eventually when symptoms developed and (2) whose earlier detection and treatment would reduce morbidity and mortality in the long run.

It is very rare for a finding on a routine physical to save a life. Far more often there are false alarms and minor findings that would never have caused harm. These can lead to diagnostic cascades and dangerous invasive procedures. In many cases early diagnosis doesn’t change final outcomes, but only puts people in the “sick” category for a longer period. The United States Preventive Services Task Force (USPSTF) is an invaluable clearing house for up-to-date evidence about which preventive health measures improve outcomes, which do more harm than good, and which can neither be recommended nor discouraged because there is insufficient evidence.

The preventive services recommended by the USPSTF have been proven to reduce morbidity and mortality, but they don’t require an annual physical exam by a doctor. There are arguments for components of the physical exam that don’t affect mortality but that provide subjective benefits. It’s an opportunity for patients to ask questions they wouldn’t consider important enough to make an appointment for, to get to know the doctor before illness strikes, to review current meds, to educate, and to reassure patients about minor health worries. But those same opportunities can be provided without an annual physical exam.

By the 1980s, most medical organizations were no longer recommending an annual physical. Instead, they recommended periodic (not necessarily yearly) screening, counseling, and selected components of a physical examination only as indicated by the individual patient’s history and review of symptoms. It’s called a health maintenance visit. Another feasible alternative is to take advantage of illness appointments to update the recommended preventive measures. Most preventive screening tasks can be delegated to auxiliary personnel, leaving more time for doctors to interact meaningfully with patients. It’s time we stopped meaningless rituals like perfunctorily applying stethoscope to chest once a year.

Addendum

The Medicare Initial Preventive Physical Examination (IPPE) might serve as a useful template. It consists of a review of the patient’s medical and social history, risk factors, functional ability and level of safety, end-of-life planning, and a physical exam consisting of height, weight, blood pressure, visual acuity, and “other factors deemed appropriate based on the beneficiary’s medical and social history and current clinical standards.”

 

 

Posted by Harriet Hall

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly.