June 19, 2012

Do I Need that Annual Physical and All those Tests? - Part 1: The Annual Physical

Annual head-to-toe physicals for healthy Americans may become a thing of the past as we try to combat our soaring health care costs, physician Elisabeth Rosenthal argued earlier this month in an article in the New York Times.

A few days later, Dr. Nancy Snyderman made the same point on NBC's Today Show. (Sorry, a commercial appears first.)



A debate is underway about whether many formerly routine medical tests are really needed. But for now, let's just talk about annual physicals. Tomorrow, I'll discuss recommendations for other tests.

The Case Against the Annual Physical
Rosenthal contends that annual physical exams for asymptomatic individuals have little benefit, lead to unnecessary procedures, and have been abandoned by other western nations. For example, a Canadian government task force in 1979 officially recommended against annual physicals, citing a lack of evidence that the exams help with care, and instances in which they could be "potentially harmful." Rosenthal says:
Faced with such evidence, I have not gotten an annual physical since around the time I finished my medical training in1989. I religiously follow schedules for the limited number of screening tests recommended for women my age -- like mammograms every two years and blood pressure checks -- but most of those do not require a special office visit.
The costs of physicals add up, Rosenthal concludes. The blood tests alone performed during physical exams cost $325 million a year, according to one estimate.

Rosenthal suspects that the nation's attachment to annual physical exams stems from physicians' profit motives, malpractice concerns, the direct advertising of products and treatments to patients who don't actually pay their full costs, and pure habit.

"There's a lot of inertia and unwillingness to let go -- it's hard for doctors and patients," says Allan Brett, an internist and professor at the University of South Carolina.

The Care for the Annual Physical
I've been getting an annual physical for years. The practice started when my employer provided them as a "perk" for managers. We all went for the exams to a clinic that specialized in "executive physicals."

When that ended, I started seeing Dr. Richard Schubert, who is part of a group of physicians in an office five minutes from my house. I've been seeing Dr. Schubert for at least 20 years. A physical exam every April is part of our routine.

So when the drumbeat started in the media about whether these exams were necessary, I checked in with Dr. Schubert to get his views. He said he couldn't defend the type of physical exam where patients are put through the exam as if on an assembly line -- an initial interview of no more that eight minutes with the primary physician who then turns the patient over to medical assistants for a battery of tests.

But in his practice, Dr. Schubert schedules an hour for our annual visit. He asks a series of questions about my health, the health of my family members, my activites, etc. We have a relaxed conversation followed by his performing an overall physical checkup before sending me to the group's lab for blood and ECG tests, a lung X-ray, and any other tests deemed necessary.

The need for some of these annual tests is also being questioned -- my topic for tomorrow. But Dr. Schubert gave one example of what can happen during an annual physical that isn't picked up by statistical analysis. A woman in her 50s comes in for her annual physical, and the blood test show she's pre-diabetic. As a result, she is given recommendations on diet and exercise, which greatly enhance her quality of her life. Otherwise, she might have developed type 1 diabetes. She may not live any longer than she would have otherwise, so the mortality statistics don't show any benefit from the annual physical.

It's not unusual for doctors to find something like that during the annual physical. After my April visit this year, I learned that I was deficient in Vitamin D. I had assumed that I was OK on that score since I spend a lot of time outdoors (as witnessed by the skin melanoma found in my annual visit to my dermatologist recently).

Most experts agree that the number one challenge in America is disease prevention. Defenders of regular physical exams argue that patients are more likely to get assessment and counseling about disease prevention, weight, diet, exercise, fitness, smoking, blood pressure, and mental health.

At the end of my last visit, Dr. Schubert gave me a quiz, with recommendations, on what to do if I think I'm having a heart attack. I thought the advice was so important I made it the subject of a blog post.

With my established rapport with Dr. Schubert, I'm comfortable calling him when I'm sick and consulting him on any health issues. Sure, he often turns me over to a specialist. But he usually knows those local specialists personally. Most of them practice out of Sibley Hospital, which is near my house. It's my facility of choice if I need hospitalization or emergency room treatment. All these interconnections make me feel like I'm part of a family of care providers, not much different from a Mayo Clinic.

Dr.Schubert also argues that a doctor who is not familiar with the patient -- and only sees her for a few minutes -- is more likely to "play it safe" and rely on tests to see what might be going on. 

Bottom Line for Me
As is so often the case in the healthcare arena, there's no definitive "yes" or "no" answer in this debate about annual physicals. The ones I got in my younger years probably cost more than they were worth, but at age 83 -- and with my established rapport with Dr. Schubert -- I'll continue with my yearly checkup. 
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