Let’s not get rid of the annual physical

Recently a physician reporter for the New York Times, Elisabeth Rosenthal, argued in the cover article of the Sunday Review that routine physicals are in many ways pointless, and perhaps even dangerous.

In the article, entitled “Let’s Not Get Physicals,” Dr. Rosenthal goes on to point out that many routine tests performed during physicals — EKG’s, pap smears and blood work, are unnecessary. In my opinion, Dr. Rosenthal’s front page skepticism of the utility of the annual ritual misses the key point and sets a dangerous tone.

As every good primary care physician knows, the key benefit of an annual check-up (aka “physical”) is not the litany of tests ordered, but the opportunity it provides to do a complete review of a patient’s medical history and risk factors.  The “annual physical” also provides an opportunity for healthy people to get to know their physicians and vice versa, so that when illness arises, as it always will, the physician will understand a patient’s personality and healthy baseline.

After years of criticism by proponents of prevention Medicare recently started to cover an annual exam, which is referred to as a “Wellness Exam.”  The Medicare preventive exam, which became a covered benefit in 2011, emphasizes history-taking as opposed to testing, which in my view is appropriate.   The Affordable Care Act also regulates the provision of preventive care by health plans requiring that plans provide a core set of preventive services without requiring a co-pay, co-insurance, or deductible.

While the physician author of the New York Times piece surely understands many of her own personal risk factors for disease and also the signs and symptoms of potentially serious underlying conditions, the general public does not have this expert knowledge. Why shun a once a year, hour-long (or, as is more often the case these days, 20 minute-long) visit to a medical expert to review one’s personal health profile, risk factors and family history?

I suppose that Dr. Rosenthal’s point is to de-emphasize the testing component.  In my view, if anything many individuals could benefit from more frequent (biannual or quarterly) preventive checks to keep them on track with their health goals and risk factors — perhaps this would keep more folks out of the ER and hospital.  As to the “testing” component of the annual physical, the visit provides an opportunity for patient and physician to discuss the state of the art, information that the patient might be reading online, and the evidence for and against screening for particular conditions. Which screening tests health insurance should pay for is a separate question.

The issue here may be semantic—should it be called a “physical,”  a “wellness visit,” or a “preventive check-up–” but, let’s not get rid of the annual visit.

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

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  • MarylandMD

    There is so much confusion about physicals that I think we should just scrap the whole thing and start over from scratch. Insurance companies have one idea what is required, physicians have another idea what we think is best, and patients have quite another idea of what a “physical” really is.

    I would **love** to have every preventive health exam focus on risk factors and wellness, but instead, the patients think it is time to bring up every minor (and major) symptom and complaint that they can think of. So instead I end up trying to wedge in a few minutes preventive health in what really is a level 4 visit for some new problems and follow up on some old ones. When I try to explain to patients the difference between a “problem focused visit” and a “preventive health visit” their eyes glaze over. I don’t really blame them, because the whole distinction is a construct established for billing purposes, not for health promotion.

    To be honest, the only “wellness” visit design that at least begins to get things right is (believe it or not!): MEDICARE. The Medicare Wellness Visit doesn’t have you run through a long ROS and doesn’t insist on a comprehensive exam. Instead, you ask about important risk issues for older patients and review preventive health services that are available. It isn’t perfect, but at least it starts to get the priorities right.

    So, why don’t we bag to old, tired “physical” and come up with a new model?

    • http://www.facebook.com/devang.patel.129142 Devang Patel

      I agree. I have been doing the Medicare annual wellness visits for the past few months. I have seen that many of the preventive screenings that I have been harping about for years are getting done in a matter of weeks. The best part of it was that I ended up doing less work because most of my patients ended up scheduling, getting, and reporting the results back to me. They were genuinely excited to tell me that they “did their homework”.

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