As a physician, my beliefs about the annual doctor’s visit might be blasphemous. I sometimes wonder whether these encounters are useful.
Sympathetically, Dr. Ateev Mehrotra, a professor of health care policy at Harvard Medical School and a hospitalist, notes, “When I, as a doctor, say I do not advocate for the annual physical, I feel like I'm attacking moms and apple pie. It seems so intuitive and straightforward, and [it’s] something that's been part of medicine for such a long time.”
Society has come to expect this yearly trip to the doctor. It's the day to ventilate concerns about nagging aches and pains, inquire about the validity of fanciful findings on WebMD searches or ensure that a disease that has afflicted a friend or relative will not affect us.
But mostly it provides that modicum of reassurance that all is well, propelling us forward for another year.
My clinic schedule during residency was often teeming with patients who had urgent complaints or chronic medical conditions. Yet it included a generous sprinkling of these annual physical exams for individuals in impeccable health.
Overall, these physicals account for approximately 10 percent of overall appointments with primary care doctors. About 44 million American adults will be examined annually for this purpose.
Perhaps my qualms are warranted. Research is increasingly on my side.
A 2012 Cochrane systematic review and meta-analysis published in the BMJ found that “general health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular causes or cancer causes.” Years earlier, in 1979, the Canadian Task Force on the Periodic Health Examination recommended “that the annual checkup, as practiced almost ritualistically for several decades in North America, be abandoned.”
In 2013, the mounting data compelled the Society of General Internal Medicine to recommend against routine general health checks for symptom-free patients.
Given that there is no benefit to be gained from annual exams in terms of morbidity and mortality, it is appalling that the cumulative cost of these visits is more than $10 billion per year. According to Mehrotra, this is more than we spend on breast cancer care.
Furthermore, the sheer preponderance of these visits ensures that primary care providers have limited time to address the concerns and health of patients with more pressing medical issues. Instead, as the Cochrane review also found, these physicians are discovering new diagnoses of marginal benefit to overall health and survival and ordering an excess of potentially harmful tests to discover them.
Despite the data, the chasm between these evidence-based findings and actual practice continues to persist. Patients seek solace about their health. Doctors remain suspicious of the research and view the annual visit as a means of establishing a bond or rekindling it with their patients.
Thus, both patients and physicians have remained steadfast champions of the annual physical. Unsurprisingly, it has become dogma.
The risk of toppling this entrenched practice, however, is grave. This yearly routine is one of the few remaining bastions for the now endangered physical exam.
Medicine has slowly gravitated away from an emphasis on the physical examination of patients. Today, patients are interpreted and understood less through abnormal physical findings and more from lab tests and imaging studies.
Dr. Abraham Verghese, a Stanford medical professor (and well-known author), rues this deterioration in medicine. In an editorial for the BMJ, he writes:
If an alien anthropologist were to visit a modern teaching hospital, ‘it’ might conclude that, judging by where doctors spend most of their time, the business ... takes place around computer terminals. The alien might assume that the virtual construct of the patient, or the ‘iPatient’, is more important than the flesh and blood human being occupying the bed.
For Verghese, the physical examination is a transformative ritual that “in this case is the formation of the doctor-patient bond, the beginning of a therapeutic relationship and the healing process.”
The physical touch is thus considered essential here for both patient satisfaction and a doctor’s fulfillment from a scheduled visit. This is not something that can be quantified by a research study.
The elimination of the annual physical is perhaps a sign of further descent into this hollow physician-patient relationship, where intimacy, trust and sympathy are lost. There is no sacred exchange between two individuals here.
Dr. Allan Goroll, an internist and professor at Harvard Medical School, concludes that the enduring appeal of the annual physical is “people’s desire or need to establish and maintain a close, trusting relationship with the doctor they consider their personal physician.”
It is the patient’s hope that this physician will be present as a safeguard when health may inevitably falter. Viewed from this vantage point, annual visits are then the bricks that construct this sanctuary.
In hopes of creating a better system, the best plan likely incorporates ideas from both camps. Mehrotra argues for “a new type of visit ... whose exclusive role is to establish relationships.” These could occur every two or three years with a focus on dedicated examination and medical and social history. Testing would not be included.
The physical exam and its virtues would live on. A mechanism would still need to be installed to ensure that preventative care that provides a morbidity and mortality benefit, such as cancer screenings, is not neglected.
To encourage the creation of this new model and rein in profligate practices, Mehrotra recommends that health plans and federal payers should stop reimbursing annual physicals. Obamacare has already made that shift.
The successful realization of such a plan will surely contribute to making our healthcare system more efficient and economical. More importantly, the art of medicine and healing will not have to part with its soul.