The Argument: Ditch The Annual

Every year, adults face the issues of is it “time to get a check up”? Do I really want to get my annual physical? Do I need to have a checkup? Well now, even your doctor is saying the same thing! A chorus of physicians have weighed over the past several years (especially after the Cochrane Report was released). The consensus has been, for the most part: ditch the annual physical if you are healthy and have no medical symptoms.

The need for an annual physical was first questioned in a 1979 Canadian panel convened by the government that concluded:

…the routine annual physical examination should be discarded in favor of a selective plan of health protection packages appropriate to the various health needs at the different stages of life

Ezekiel Emanuel MD stated in his OpEd piece in the NY Times “Skip Your Annual Physical” about the evidence in a 2012 Cochrane report:

In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world’s biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years than sought to evaluate the benefits of routine, general health checkups…. (with) the unequivocal conclusion: the appointments are unlikely to be beneficial.

Likewise, the United States Preventative Services Task Force does not specifically recommend routine checkups but argues for a tailored, age determinative approach for screening tests throughout life.

It is worth looking at the statements of physicians who have advocated for abandoning the annual physical as a waste of money and time or worse: possible complications. Eric Topol MD, in his most recent book “The Patient Will See You Now” states:

Not only do the unnecessary annual physicals cost more than $7 billion per year, but they also lead to all sorts of incidental findings – and more tests, more scans, more procedures, and more operations.

He argues further that there are huge opportunity costs of this wasted money i.e. missed prevention initiatives to improve the health status of those with chronic disease, key because 84% of the $3 Trillion healthcare budget in the US is spent on those with chronic illness.

Dr. Gill Welch, author of “Overdiagnosed: Making People Sick in the Pursuit of Health” and “Less Medicine More Health” takes a more nuanced approach. He suggests “check-ins” rather than “check ups” with the difference being instead of running a battery of screening tests on every healthy patient, doctors would assess their patientʼs lifestyle: working status, family/social wellbeing status, sense of health/how they felt, future goals etc as well as family history.

However as Dr John Mandrola states:

But (the annual physical) is not that way right now. Patients think of annual physical exams as they do auto maintenance, whereas doctors hold to the wrong surrogate markers of health. We look for irregularities in lab values and ECGs, and shadowy ultrasound images, rather than belt sizes and scale readings. And both parties underestimate the durability and variability of the human species.

Perhaps the most outspoken voice against wasteful (or worse potentially dangerous and common) healthcare practices, including the annual physical is Dr. Nortin Hadler, Professor of Rheumatology (see his books: “Worried Sick” and “The Last Well Person: How to Stay Well Despite the Health Care System”)

The Other Side

There has been some pushback from physicians about the futility of the routine, annual physical for the asymptomatic patient. Most of these concern the importance of an ongoing therapeutic relationship between the physician and patient: person to person.

Dr David Katz in his piece “The misguided case against the annual physical” argues that we simply do not know the (possibly enhanced) benefit of having a physician that we know when we have an acute issue, and need healthcare guidance and treatment. He also wonders about the (possibly added) value of receiving lifestyle advice from our own physician vs some other source. Additionally because there are still recommendations for screening, blood pressure monitoring, cholesterol monitoring he is concerned that these may be forgotten without ‘the checkup’.

Dr. David Himmelstein, a professor of public health at City University of New York takes a slightly different tack suggesting that the way the annual physical is structured is more the problem. He suggests not to throw out the physical but to improve it. Forget the checklists (for insurance billing) and unnecessary testing and leave plenty of time for MD/patient communication.

Other Considerations

Aside from the aforementioned, 45 M Americans have annual physicals each year to the tune of $10 B year. Annual physicals are the number one reason people go to the doctor. If not proven to be useful that’s a huge waste of money and time.

In summary about the annual physical.

The issue with the annual physical in patients without medical symptoms is that statistically, if something is found there is, ultimately, little that can be done to change the course of the disease (the patient will die anyway, despite treatments), or when something is done, it was unnecessary, as the disease was unlikely to affect patient’s health over course of life AND additionally the interventions themselves might be harmful. Quoting from the Cochrane Report:

One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.

For healthy adults pre age 65 (NOTE:children need milestone/growth checks, vaccine updates etc and older age comes with increasing medical problems) the American Academy of Family Physicians recommends only in person blood pressure checks and periodic pap smear, along with screening guidelines. At age 65 yo Medicare provides a “Welcome checkup” which is smart (IMO). Additionally physicians recommend getting certain screening exams, vaccines, blood pressure checks and of course as MD visit when symptomatic or concerned that something isn’t right.

My thoughts

Personally, I have a close relationship with my internist, and routinely see her once a year, even if I am feeling well, as a “check-in”. I do most, but not all that she recommends. Philosophically, we largely agree: not to over test, over diagnose or over treat.

I concur with a comment that I heard: The Medicare (age 65) welcome physical may be the first time some people see a doctor, which is NOT the same as a routine physical in a healthy person. I see this as a social justice/health literacy/population health issue and a policy that should be maintained and encouraged.

Demographics will greatly dictate the future of the “routine” annual physical regardless of what is happening now. It simply isn’t in millennials’ DNA to spend time and money on something that seems counterintuitive. If they don’t feel sick, they are sure as heck not going to go looking for a physician to tell them they are.

The above discussion addresses the “routine” annual physical. Note, I have not addressed specific screening (lab, cancer) guidelines, as there continues to be disagreement in the medical community on these issues.

The above discussion specifically does NOT apply to the geriatric population nor the palliative care/supportive care patient. The intimate therapeutic relationship for the more fragile among us must be preserved. Read anything that Dr. Abraham Verghese says about the value of touch, of presence, and of the intimacy of the physician/patient relationship, for further elucidation.

Additionally, if indeed we bypass the annual physical, it is incumbent on government, the public health service, and community health services, as well as each of us as individuals, to insure we are health literate and consistently engaged with our health. It is fine to wait until symptomatic to see a physician, but there are two pre-requisites: a healthy lifestyle, and personal knowledge of one’s body/mind/spirt and general health status. Such knowledge and awareness allows us to be attuned to possible illness, abnormal sensations that would prompt us to seek a physician consult.

Lastly, a word about dental health. Dental health and dental healthcare is extraordinarily important, but it is expensive, and not covered by the government or routinely in most insurance policies.

Many people cannot afford dental care, and thus forgo it. Poor dental hygiene (and often accompanying low levels of dental health literacy) as well as woefully inadequate access to dental care, can lead to serious complications in the form of extensive tooth decay, tooth loss, severe gum disease, and mouth abcess. Oral cancers can be discovered in a timely manner by dentists in those patients with history of alcohol, smoking, or infection with the human papilloma virus. Ideally we would have universal coverage for an annual dental hygienist visit for each person in the U.S.

 

BKmd

 

References

”Do I Need An Annual Physical?”, Karen Weintraub, New York Times, April 17 2015,http://well.blogs.nytimes.com/2015/04/17/ask-well-do-i-needan-annual-physical/?_r=0, accessed April 23 2015

“The Misguided Case Against The Annual Physical”, David L Katz MD, KevinMD, February 19 2015,http://www.kevinmd.com/blog/2015/02/misguided-case-annual-physical.html, accessed April 23 2015

“Skip Your Annual Physical”, Ezekiel Emanuel, New York Times, January 9 2015,  http://www.nytimes.com/2015/01/09/opinion/skip-your-annual-physical.html, accessed April 23 201

“Ritual Not Science Keeps The Annual Physical Alive”, Jenny Gold, Kaiser Health News, April 6 2015,http://kaiserhealthnews.org/news/ritualnot-science-keeps-the-annual-physical-alive/, accessed April 23 2015

“Annual Physical Exam is Probably Unnecessary If Youʼre Generally Healthy”, Chrsitie Aschwanden, Washington Post, February 8 2013, http://www.washingtonpost.com/national/health-science/annual-physical-exam-is-probablyunnecessary-if-youre-generally-healthy/2013/02/08/2c1e326a-5f2b-11e2-a389-ee565c81c565_story.html, accessed April 23 2015

“Re-thinking the Annual Physical”, Harriet Hall, Science-Based Medicine, February 21 2012,https://www.sciencebasedmedicine.org/re-thinking-theannual-physical/, accessed April 23 2015

“Do I Need An Annual Physical?”, Skeptical Scalpel, Physician’s Weekly, April 20 2015,http://www.physiciansweekly.com/need-annual-physical/, accessed April 23 2015

“Redefining the Annual Physical: A (Broken) Window Into American Healthcare”, Medscape,http://www.medscape.com/viewarticle/838132, accessed April 23 2015

“Is It Time To Cancel Your Annual Check-Up?”, Naomi Freundlich, Reforming Health Blog, October 25 2012 http://reforminghealth.org/2012/10/25/is-it-timeto-cancel-your-annual-check-up/, accessed April 23 2015

“General Health checks in adults for reducing morbidity and mortality from disease”, Krogsboll, Lasse T; Jorgensen, Karsten J et al, The Cochrane Library, July 4 2012,http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/pdf/abstract, accessed April 23 2015

“The periodic health examination. Canadian Task Force on the Periodic Health Examination”, CMA Journal, November 3 1979, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1704686/, accessed April 23 2015

Photo Credit: Norman Rockwell

The topic questions for the weekly #hcldr tweet chat on Tuesday April 28^th 2015 were:

• T1 Assuming you have no medical symptoms and are generally healthy, would you go for an annual physical? Why, why not?
• T2 Would you encourage a healthy family member in their 20s, 30s, and 40s to have an annual physical? Why, why not?
• T3 If you need medical care now, does it matter to you whether its your doctor or can it be another physician at the same facility?
• T4 Would you be comfortable with telehealth, telemedicine, or retail health clinic for most medical problems? (Assume don’t know healthcare professional, could be MD or NP)