The annual physical has come under a lot of scrutiny of late; but doctors need to push back and highlight the real value physicals bring to patients.
A recent Danish study (1) concluded that annual physical exams were “probably not” effective in reducing morbidity or mortality rates. While the study came from a country that has socialized medicine, it seems to support the position that has been taken by the framers of the Affordable Care Act (ACA), which allows for only one preventive physical examination for Medicare recipients during their lifetime.
This study, and others of its ilk, is getting a lot of play right now. There is considerable debate about the pros and cons of physicals, especially the value of higher cost tests. Some are using such studies to validate efforts to minimize or ultimately eliminate the annual physical.
While it is important to assess the validity of physicals as well as their cost to society, I think their value goes beyond what was being measured in this study and how it was reported.
A few years ago, I asked a doctor why he believed in the annual physical. He said that it was not so much the testing that he did, but the mechanics of having regular annual awareness of a patient and their changing medical condition. Just waiting until there was a problem did not work for him. He wanted to be aware of the physical changes in his patients. What’s more, he wanted to know what was happening in their personal lives. Divorce, job loss, aging parents, etc., are all issues this physician realized were very important to a patient’s overall health.
What we need to understand about the Danish study
What does the Danish study really say? There are several important points to examine carefully. The authors noted:
1. One reason for the apparent lack of effect, “may be that primary-care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.” (1) (My contention is the ability to intervene comes from the foundation laid by the physical!And, what about those who do not visit their physician for other reasons? Their annual physical offers the one opportunity to be screened.)
2. Those at high risk of developing disease, “may not attend general health checks when invited.” (How can we accurately measure the effect of an annual physical if those that would be best served don’t get them?)
3. Many of the trials examined as part of the Danish study were older, making the results less applicable to today's settings as treatments and risk factors have changed.
Also, there was no standardized exam, or apples-to-apples comparison for physicals, which is a critical issue. Clearly there can be significant differences in physicals given to one patient versus another, and by one physician versus another.
What we can learn from the concierge physical
This discussion is especially timely in light of the new preventive services covered under the reform law. Adding Medicare wellness visits is an important step. Most physicians applaud the intent. My concern is the ACA wellness visit is simply a watered down version of the traditional physical. It can be conducted by a non-physician, thus negating the value many physicians believe is inherent in good traditional physicals - the ability to check for the conditions that may lead to disease and to build a better relationship, one that can lead to greater compliance and interest in prevention and overall better health.
Here’s where there are some lessons to be learned from concierge medicine, which uses the physical to become the foundation of care. I have heard a number of stories from concierge members about how their lives were saved or significantly improved by going in for an annual exam.
Physicians tell me they like the physical process as they get to know patients as people. The examination and testing provides important insights. The ability to have a history and benchmarks and to meet with patients to talk and review findings in-person is important. It’s also something you just can’t get from a quick wellness visit. I’d also make the case that many patients won’t come in for wellness visits – most wait as long as they can to schedule a visit. However, they will come in for an annual physical they’ve paid for, as happens in concierge programs.
To be clear, there is a legitimate issue of false positives with some testing and subsequent procedures that may be unnecessary. However, there is much to be gained by annual physicals for most patients. If they do not improve mortality, they can certainly help to improve the quality of life.
What are your thoughts on the annual physical and the current debate and discussion?
(1) KrogsbÃ¸ll LT, et al "General health checks in adults for reducing morbidity and mortality from disease" Cochrane Database Syst Rev 2012; DOI: 10.1002/14651858.CD009009.pub2.