Your Yearly Physical Is a Waste of Time

…or at least that’s what some experts have increasingly been suggesting. According to the American College of Physicians (ACP), instead of having an annual physical, “healthy adults should undergo a much-streamlined exam that’s focused on prevention every one to five years depending on a person’s age, sex and medical profile.”

So what does that mean, exactly? According to the U.S. Preventive Services Task Force, doctors should focus on “interventions that help patients change health-impairing habits or that spotlight emerging illnesses for which reliable and effective treatments exist.”  These include “Pap smears, mammograms, cholesterol tests, blood-pressure checks, and counseling to stop smoking, lose weight, get more exercise and eat a healthier diet.” In other words, rather than just checking for everything, doctors should focus on interventions that can be substantively linked to treatments we know work. Currently, most check-ups are comprehensive run-throughs that seem to be administered  just for their own sake, regardless of how, or even if, they relate to meaningful treatments.

For many of us, the annual physical is a fixture of our health care
experience, something we assume to be both necessary and desirable.
Indeed, a study released last month found that 64 million Americans a
year get a physical or gynecological exam, costing a total of $7.8
billion.  Regular gynecological exams are important—they include Pap
smears that have made cervical cancer a rare disease. But the point of
the general physical is less clear.  More people get annual check ups
than visit doctors for respiratory conditions or high blood pressure,
and the price tag for yearly physicals closes in on the $8.1 billion
spent on breast cancer care.

The annual physical is second nature for both patients and doctors.
But in practice it doesn’t seem to pack all that much bang for the
buck. The Boston Globe reports
that a September study from the Archives of Internal Medicine (AIM)
found that “doctors routinely subject…patients to tests that are the
equivalent of looking for a needle in a haystack, even when there’s no
reason to think a needle exists – complete blood counts and urine
samples, for instance.” Worse still, “three-fourths of the patients who
underwent physicals from 2002 through 2004 visited the doctor for other
reasons in the year before their annual exam, suggesting that
counseling and tests performed at the physical could have been provided
earlier.”

The Buffalo News (see first link), quotes Dr. Ned Calonge, chairman of
the U.S. Preventive Services Task Force—which does not endorse yearly
physicals—as saying that “there is very little evidence, if any, that
doing [comprehensive] exams yearly on patients without symptoms is good
for anything.”

You might be surprised to learn that this lack of support for annual
physicals has become commonplace in many parts of the medical
community. Dr. Ateev Mehrotra, lead author of the September AIM study and assistant professor at the University of Pittsburgh, School of Medicine noted earlier this year
that "annual exams are not recommended by any major North American
clinical organization.” Despite this fact, says Mehrotra, “our health
system is clearly devoting a great deal of time, money and resources”
to annual check-ups—without really knowing why. "Physicians need to
reach greater consensus on what we should advise patients to do," he
said. The potential disparities between physicals are thus vast—as U.S.
News and World Report put it,
“one physician may order a slew of tests, even for outwardly healthy
patients, while another may do little more than tap on a knee and call
it a day.” So not only is the annual physical wasteful—it’s also
inconsistent.

But everything’s not necessarily lost. Concerns around annual physicals
revolve around two components of the traditional checkup, the
comprehensive physical exam and the gauntlet of blood, urine, thyroid,
and heart tests. That means that no one seems to be criticizing the
need for an updated patient history, the third pillar of the
conventional check-up, suggesting that perhaps there is a point to the
annual check-up.

Another potential benefit of the regular check-up is familiarity and
connection—there’s something to be said for checking in with the same
doctor every year, if only to maintain open channels of communication
and an ongoing sense of partnership. Dr. Jacques Carter, a primary care
physician affiliated with Beth Israel Deaconess Medical Center, told
the Boston Globe that regular face-to-face contact with patients is
important so that doctors can “know about their history, about their
kids’ names, that the dog was sick last year – all that Marcus Welby
kind of stuff. It’s very important to patients, and they also feel they
can talk to you about a lot of things.”

It’s not at all clear, however, that these potential benefits outstrip
the costs that come with seeing a healthy person who has no symptoms
every year and subjecting him or her to a battery of tests that will
not translate into effective care.

I’d be interested in hearing HealthBeat readers’ thoughts on how
efficiency, effectiveness, and prevention might play into the pros and
cons of the annual physical.

10 thoughts on “Your Yearly Physical Is a Waste of Time

  1. Many years ago, I worked on experimental patient history-taking software. A variant for OB/GYN had been in a clinical trial, compared with the residents at Mass General.
    The patients preferred the computer. The most common reason? “It took its time with me and never seemed tired or frustrated.”
    There are parts of history taking where nonverbal communications are critical, and I’m not referring to the things more on the physical exam such as skin color. Tone of voice, speech problems, etc., all can be significant. No one knows, in a quantitative way, how significant. While I need some brain imaging to find the real reason, when I am sick or tired, I have trouble talking, but can write with perfect clarity — this is suggestive of reduced blood flow to Broca’s area of my brain. Does it have any significance? Probably not.
    So, I’d ask the question if the history update part could be handled, for many patient, by a computer-delivered questionnaire.
    Blood and urine screening are the other parts in question. Now, an ordinary urine sample is simple enough to take. I’d actually like to see some statistics on how often something significant comes up in urine — I did urinalyses in high school, and have done thousands that were perfectly normal. My great triumph was finding an Egyptian parasite in a patient that no one had asked about foreign travel. Besides that, I’m not sure the major value wouldn’t be drug screening.
    That leaves blood samples, and that’s a little more logistically complex — but, with most patients, it’s not that hard to get a sample. It’s best to be at a place with more than 1 person who can draw them; no one can quite explain it, but there’s a pretty good chance that if someone can’t get blood with 2 or 3 sticks, they won’t get you with 10. There’s just enough individual variation in technique that another person will strike oil the first time.
    So, we have the potential of kiosk-based screening, with limited human assistance for blood draws, and, if urinalysis really is worthwhile, marking and storing the samples.
    I should note that routine physical is decidedly NOT the same as monitoring and optimization visits for a patient with a chronic disease. For example, I’ve been on a very aggressive diabetes management plan, with a lot of drug complexity, and have had quantitative improvements from monthly visits — it’s now going to 6-8 weeks.
    Self-monitoring, for patients that can do it (and there’s a range of self-monitoring skills) can help for many chronic diseases. Blood sugar measurement in diabetics is obvious, and I am amazed my insurer will not cover supplies for the gold standard of 5 tests per day. Blood pressure is reasonable. Monitoring weight daily isn’t useful for weight loss, but can be quite important in detecting water retention in selected patients, especially cardiac on new drugs. Beyond those basic procedures, until there are more noninvasive measurements — which are coming — you drop to the tiny fraction of patients that can draw blood from their own veins. I can do it, painfully, because it’s really a two-handed procedure. Junkies manage, though.

  2. As a practicing internist/primary care physician, who spends a good part of his day doing these physical exams, there is much time, effort, and money that is wasted during such exams. Much of it has to do with patient expectations and insurance company restraints that do not easily adjust to innovative ways of improving primary care. For instance, when I took over for a retiring physician years ago, not long out of medical school, having been taught that many of the routine blood tests done at a physical are worthless, I attempted to talk my new patients out of having them performed. I rapidly started losing patients who perceived my lack of desire to performed these tests as “being not as thorough” as my predecesor. In other words, patients tend to view more testing as a good thing losing sight of the pitfalls of false positive tests that can send you on the proverbial wild goose chase resulting in increased costs or patient morbidity. Secondly, payers have criteria that define what constiutes a physical exam in terms of organ systems examined, review of past medical history, etc. etc., which must all be documented to qualify for payment. This makes the physician waste alot of time asking redundant questions that add little to the understanding of a patients health. What would be much better is time to have detailed discussion about issues like the value of a PSA test or spending more time delving into why the patient can’t sleep at night rather than throwing them a pill because you have exhausted your time collecting and documenting all the information necesary to get paid.
    Having said this, there is great value that is seemingly difficult to quantitiate from getting to know your patients better, and the physical exam is the only extended period of time that allows you to delve more into their concerns and to get to know them more intimately. Otherwise, the interaction between the primary care doctor and patient devolves into nothing more than a series of short, problem focused visits. Some have suggested that the routine preventive care can be conducted during acute care visits. I can tell you this is unrealistic given the time constraints of office visit slots and since some patients may not reappear for years at a time. This seems a rather hit and miss way to conduct and assure regular routine health screenings that are of proven value.

  3. I get a routine physical every year, mainly because my employer pays for it and encourages us to get it, though I only want the blood and urine tests and, as recommended by my PCP, a chest X-Ray every other year. I have cardiac issues so it’s good to get the annual cholesterol reading to make sure it is well controlled. Since a number of diseases can be quite advanced by the time symptoms are present, there could be value added in monitoring, say, kidney and liver function as well as glucose.
    As for the patient and PCP getting to know each other better and addressing the patient’s concerns in a systematic way, I wonder what the docs think about offering 30 or even 60 minute consults for a transparent cash price with the understanding that insurance will not cover them and no claim will be submitted. How much would docs have to charge knowing that there will be no administrative hassles in dealing with insurers and documentation requirements will be limited to what the PCP thinks is necessary to include in the office notes? How many patients might be willing to pay for an arrangement like this? I know I certainly would. Frequency could vary widely depending on age and health status. I envision a time based charge arrangement similar to the way lawyers bill except that any required tests and prescription drugs would cost extra but would also, presumably, be covered by insurance assuming the patient has insurance.
    I know the point will be made that the poor probably cannot afford to pay out of pocket for access to the doctor’s time. However, a large segment of the population can. Whether they would be willing to pay on this basis or not, I don’t know, but I think patients could be well served if PCP’s offered such an arrangement and patients paid that way.

  4. The yearly physical, as it currently stands is an economically driven phenomenon. I must agree there is great value in the development of the Dr.-Patient relationship here but beyond that it is age, gender and history specific. A physical exam on, say, a healthy young man can be done quickly and helps pay the bills!! On some of the months when my practice was struggling I would have my staff send letters to anyone due for a phyical. I must agree totally with Keith, in order to get paid for a yearly physical you must reveiw and examine all systems, in actuality this is pretty much a total waste of time. Doctors know this already, we havn’t driven this, economics has. i.e. to get paid for a medicare physical you must do an ECG and a urinalysis, indicated or not. When economics stops driving medicine you will see an evolution of the yearly physical such that evidence can drive medicine. I do submit though regular contact is important to maintain a strong Dr.-patient relationship, the importance of this is difficult to measure but here are some examples of important issues that have been discussed with me based on trust that had to be built; STDs, drug and alcohol abuse, phsyical and sexual abuse, sexual dysfunction, infidelity.
    Barry, just a quick note on the no overhead visit that you suggest, if I see patients for a cash visit for say the physical the overhead doesn’t go away. The insurance companies require that I bill them first for everything, and only after they deny payment can I then bill you. The only way that there is an advantage to doing the physicals for cash would be to remove the overhead all together, which as far as insurance company, expensive, red tape is concerned, I would happily do with a joyful tear in my eye!

  5. This is somewhat to Barry, but may also be something to consider. Now, I’ve seen physicians who are absolute masters of history-taking, often in an obscure specialty or subspecialty, get incredible information from a careful, customized history. Neurologists often are very good at this.
    Either with health maintenance or chronic disease management, there are an abundant number of cases where mid-level practitioners can be the people who really begin to understand and coach the patient. They may be nurses with case management training or advanced practice training.
    A very significantly underused resource, often because there is no reimbursement, is community pharmacists. Many patients have trouble complying with a complex drug regimen — I have about 15, but have gotten almost all to once or twice daily, they are organized for that — and, if you think about it, the pharmacist is the last professional to see the patient before they start taking the drug. Getting prescription refills is a natural opportunity for a brief, expanded if necessary, talk with the patient. Remember that pharmacy education is now up to 6 years. Hospital pharmacists often provide this sort of cognitive service, but it has only been done experimentally with retail. I’m not talking about “any questions for the pharmacist”? but something more structured.

  6. “having been taught that many of the routine blood tests done at a physical are worthless, I attempted to talk my new patients out of having them performed. ”
    I’d be happy if any doctor would take time to tell me that some tests are useless. I understand that more testing doesn’t equate better care. I also understand that even something seemingly innocuous and simple like urine tests is not harmless. Yes occasionally, something may come up, but this something may be a false positive that may lead to invasive tests that have risks. Or it could lead to an overdiagnosis of something that isn’t likely to cause me any harm in my lifetime but may lead to treatment that in itself has risks. In fact, according to USPSTF urine analysis to test for bladder cancer is likely to cause more harm than good. Why would I want a test that is more likely to cause me harm than good? Why is it ethical for a doctor to do something that is more likely to cause me harm than good without even informing me about it?
    “Now, an ordinary urine sample is simple enough to take. I’d actually like to see some statistics on how often something significant comes up in urine”
    The only useful statistics is the mortality reduction from the desease you are testing for; and not as rate of cured/detected but per number of people test vs non-tested. Just because something is detected early doesn’t mean this early detection makes a difference. False positive statistics will be useful as well. Additionally, this “something significant” may represent overdiagnosis.
    I used to go to annual physicals, but I stopped. I don’t have energy or desire to argue with my doctor about not having an unnecessary EKG or urinalysis, especially since this may be a requirement for him to get payment from my insurance. I still go to my ObGyn. When I am 50 I may go in order to get colon cancer screening. Wish I could trust a doctor NOT to order unnecessary tests.

  7. I called my Doctor today to send in a new perscription for breathing. I was told she would give me one month only untill I get a physical. How can a doctor hold back a medication needed for COPD in lue of a physical??? I have had this perscription for over 5 years and this is the first time I have received this treatment. What is going on????

  8. I mean, just the thought of forcing these Republibabes to abandon their principles, as a condition of getting laid, adds a whole new sexual aspect. “Come on, Michelle, tell me you think Obama is a wonderful American and you can have THIS!”

  9. Oh, and by the way, I once spent a blissful evening with Condi Rice, a 60-gallon drum of motor oil and the Broadway cast of “Hairspray.” She insisted on referring to me during the entire evening as “Vlad the Impaler.”