You're sitting in the doctor's office waiting room anxiously thumbing through an old issue of Reader's Digest, while periodically checking your watch. You feel fine, just nervous about making a noon staff meeting and the parking meter running out. And of course, you've been fasting so you're ravenous. But an annual physical is a necessary inconvenience, right?
Actually, it's not.
If you're a healthy adult, it's unlikely that a doctor listening to your heart with a stethoscope or tapping your knee with a rubber hammer will find anything, which, detecting or treating before the occurrence of, will ultimately, affect the outcome.
Yearly checkups, often referred to now as "periodic health exams," burden our health care system, squandering time and money and ultimately raising the cost and availability of good medicine for everyone.
Too Much Information
Physicals typically include superfluous tests, an issue I've written about previously in this blog. Screenings like electrocardiograms, chest X-rays, urinalysis and complete blood counts -- all valuable tools in themselves and when used appropriately -- too often are doled out shotgun-style, whether patients need them or not. According to a recent study, complete blood cell counts were needlessly ordered at more than half of all physicals, making it the most common unnecessary test ordered, and one that totaled $32.7 million.
Worse still, between registering false positives and finding insignificant abnormalities -- for which thresholds of diagnosis and then care constantly change -- unnecessary tests can create a headache of costly and stressful trips to specialists, more tests and even risky treatments.
There's no better example of this than the prostate-specific antigen test (or PSA). As I wrote about here last year, the U.S. Preventive Services Task Force no longer advises the test be given routinely to healthy, middle-aged men, because rather than reduce deaths, it causes many men to undergo treatment for tumors that would not have killed them, and they suffered serious consequences as a result.
With new technology we can detect many abnormalities that will never cause problems. So if you're not among the elite who can fork over $2,000 for one of those intensive, head-to-toe executive physicals, it may actually be a blessing. The recent best-seller by a Dartmouth doctor, Overdiagnosed: Making People Sick in the Pursuit of Health, notes that more than half of people without back pain show bulging lumbar discs when scanned by an MRI, and 40 percent of those without knee pain or a history of knee injury show meniscal knee damage on MRIs. In one study, whole-body CT scanning revealed abnormalities in 86 percent of asymptomatic people.
To be sure, there are screenings that we should all get, however, not necessarily on an annual basis. And most of these don't require a physical exam. Take pap smears, for example. Cancer organizations advise that most women get one every three years, but do not recognize any benefit in an accompanying pelvic exam, which plenty of women would happily forego.
Other universally recommended screenings, such as a colonoscopy (every 10 years for adults older than 50) or a mammogram (recommended for women older than 40 every one to two years), are conducted outside the primary care setting. You can access a complete list of recommended screenings at the >United States Preventive Services Task Force website or the Choosing Wisely website.
Half of all adults are not up to date with even these, due to high cost, according to the Commonwealth Fund. That group and others clearly see the terrible divide in our current provision of preventive health care -- too much for some, too little for others.
A New Prescription
Instead of offering one-size-fits-all exams and a battery of extraneous tests, we need to redirect those dollars toward getting everyone into the lab or to a nurse practitioner for timely, appropriate screenings. We can reserve the higher levels of M.D. training, knowledge and experience to treating those in need of immediate care and keep physicians from routine, almost ritual exams.
With the increased use of electronic records, primary care offices can easily email and/or call patients with reminders to take tests when they appropriately are due. Physicians then could follow-up with a patient-tailored appointment based on any concerning results. That would allow a physician to give a 50-year-old man with a 240 cholesterol count real counsel about diet, exercise and healthy lifestyles, not just a hasty prescription for statins.
Canada replaced its annual physical with a handful of patient-specific periodic screening tests decades ago. But old habits die hard and many patients, even physicians, are unwilling to let go of the traditional checkup, especially when insurance foots the bill.
What's less clear, though, is the preventive medicine offered to those who undergo annual checkups religiously, as shown in tape recordings of 284 exams in offices of 64 Detroit-area general internist and family physicians. Researchers scrutinized up to a decade of records on these patients, looking to see if they should receive certain checks, as urged by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices. While patients were due for cholesterol screening, obesity counseling and other preventive measures, overall, only slightly more than half of them -- 54 percent -- got from these studied physicians what was recommended; just 12 percent of patients received the preventive services they were due for.
Some argue that the yearly checkup is a chance for patients and physicians to bond. Clearly, a trusting relationship is important to good medical care, but it shouldn't require a special visit and most likely doesn't. A study in Canada, where patients typically pay for the physicals out of pocket, found that appointments were most apt to be made by those who already saw their doctors often, including patients who'd had four extended chronic-disease exams per year.
While I've weighed in opposing the clockwork scheduling of annual physicals for adults, the consensus runs a different direction for young patients: If kids, particularly teens and young adults get to see their physicians annually, that would be a boon. Yes, youngsters spend more time with their physicians anyway because of the array of childhood illnesses. At the point where they outgrow some common sicknesses, though, that shouldn't be a reason for them to abandon health care, especially for an annual visit, including for vaccinations: One in 5 adolescents and young adults, for example, lacks current immunizations against preventable diseases like measles and mumps and this isn't good.
What may be more favorable for young people in the yearly checkup is the expert eye that can monitor tots and teens, especially, as they change and grow. Medical experts can give parents and their offspring a sensible check on not only illness but also developmental milestones and health issues -- which can be remedied -- that may impair youngsters' academic and social achievement. If your child's vision or hearing need correction or if she's got musculoskeletal issues, no amount of your pushing or prodding will make her excel in the classroom or on the playing field.
And let's face it, Mom and Dad: As close as you may be to your son or daughter, there will be a time when your teen may wish to talk about sexual and reproductive health issues and I think you'd rather have accurate, adult information given out by a medical professional than via random Internet searches or youth lore.
When pediatricians tackle this task, they discuss sports-related issues, including injury prevention and training practices; overtraining has become a significant issue for young athletes.
Still, the health exams that students undergo vary by district. There are no standardized sports physical. The American Heart Association offers guidelines for high school athletes. These call for a physical exam that includes listening to the heart, checking blood pressure and filling out a questionnaire about the athlete's personal and family medical history. More extensive testing is recommended only if initial findings suggest that's warranted.
Some highly-publicized, sudden cardiac deaths of several young athletes have prompted debate over whether sports physicals should uniformly include electrocardiogram (EKG) tests to screen for undiagnosed heart conditions.
An estimated 2,000 Americans younger than 25 die annually from sudden cardiac arrest. It can affect anybody but is three times more likely to occur in athletes. The most common cause is a condition called hypertrophic cardiomyopathy (HCM) a thickening of the heart muscle.
In Italy, all athletes who participate in competitive sports are required by law to undergo an EKG. As a result, rates of sudden cardiac deaths in Italian athletes have declined sharply.
Parents of young athletes, especially those playing football and basketball, should discuss with their child's pediatrician whether an EKG makes sense.
At any rate, at any age, common sense must play a key role in physicians and patients talking and working together to figure what's the best, necessary way to access health care, preventive or otherwise. For those of you who get annual physicals, check out with your physician whether this is a necessary checkup. You may be pleasantly surprised that you can forego this routine ritual and see that your kids do it, instead.
For more by Glenn D. Braunstein, M.D., click here.
For more on personal health, click here.