Are Annual Exams Really Necessary?

I hear it at least every week, if not more. “My doctor gave me a clean bill of health.” OK. So maybe the annual battery of tests and exams didn’t reveal any serious underlying diseases, but that hardly equates to being healthy. Unfortunately, we’ve become so accustomed to physical exams, even the insurance companies consider them “preventive care.” The chief cited rationale is that the annual offers a regular opportunity to address risk factors and health or life concerns. There may be some truth to this, but both insurance companies and doctors could be doing so much more to provide preventive care for patients.

“There’s little evidence that a routine physical exam and a standard 20-30 item chemical panel improve outcomes,” said Allan Goroll, MACP, a professor of medicine at Harvard Medical School and practicing general internist.  In 1979, a Canadian government task force officially recommended giving up the standard head-to-toe annual physical based on studies showing it to be “nonspecific,” “inefficient” and “potentially harmful,” replacing it instead with a small number of periodic screening tests, which depend in part on a patient’s risk factors for illness.  Yet, doctors and patients both continue to be dependent on “screening tests” that are thought to rack up an unnecessary cost of $325 million annually.

Instead of strictly focusing on “disease prevention”, our model of healthcare needs to move in the direction of teaching people how to be healthy.  It’s great if your test results are “normal”, but what changes can you be making to truly improve your health?  As doctors, we need to make it a point to not give people a false sense of security by sticking to the current standards of the annual physical exam.  This only reinforces bad habits, and most likely makes people more prone to chronic disease in the long-run.  As more and more doctors begin to move away from testing and towards individualized lifestyle counseling, patients will come to expect this with their annual exams, hopefully changing the standards altogether.

But that’s not what happens in many primary care practices, Dr. Prochazka and fellow researchers found in a 2005 survey published in Archives of Internal Medicine. Nearly half of the physician respondents, despite evidence to the contrary, still believed in annual mammography, lipid panels, blood glucose levels, CBCs and urinalysis.

“In general, there’s a bit of a disconnect,” he said. “Many patients wish for tests and think that’s what a physical actually means. And many physicians think that the traditional annual is necessary and of proven value.”

Ateev Mehrotra, an assistant professor at the University of Pittsburgh School of Medicine, has estimated that unneeded blood tests during physical exams alone cost $325 million annually.  And the over-screening for some occurs in a country where 50 million people are uninsured and receive little medical attention. More than half of uninsured adults in the United States did not see a doctor in 2010. Fifty percent of Americans are not up to date with the few screening tests that are recommended — like a colonoscopy once every 10 years for those over 50 — because of high costs, said Karen Davis, president of the Commonwealth Fund.

Intensive screening can prove useless for a number of reasons, experts say: Tests can have high rates of “false positives,” signaling that there may be disease, when further tests and procedures reveal none. Likewise, they can screen for conditions where early detection does not alter the course of the disease, either because the body might heal itself or because there are no effective remedies. In either case they can lead to aggressive procedures to clarify the diagnosis or provide treatment, which themselves can be harmful.

Ultimately, I think broader policy changes will need to be made to allow doctors the freedom to spend more time with their patients, especially since most insurance companies determine the definition of “preventive” services.  But if doctors can start emphasizing that “healthy” involves far more than just normal blood results, I expect that great progress will be made in our health care system.

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