Comprehensive annual physical exams have no scientific value

Is the Ontario Annual Physical Exam going the way of the dinosaur? That appears to be the case for healthy individuals between the ages of 18 to 64 in the Canadian province of Ontario. Effective in 2013, these patients no longer would have available an annual physical examination, but instead a “personalized health review.”

The new personalized health review would only be available to those who were healthy and did not have medical diagnoses of cancer, diabetes, or others, in which those patients could still receive a more thorough examination. Other changes include not allowing routine chest x-rays prior to minor surgery and moving the screening rate for cervical cancer from one to every three years. The plan would save the government of Ontario about half a percent on payment to physicians as the reimbursement is less for these personalized health review.

Should people in Ontario be worried that their care is being rationed? Is it simply choosing wisely on how to spend finite health care resources more thoughtfully? As one doctor, Dr. Douglas Mark, a family physician of 26 years objecting the plan noted that:

So what does the latest medical science show? Though a 2002 article in the Annals of Internal Medicine found that a majority of the public still feels that a comprehensive physical exam is a good idea, research has consistently shown these annual physical exams don’t save lives.

Does this surprise you? It shouldn’t.

That’s not to say that these types of doctor’s visits have no value. Comprehensive annual physical exams have no scientific value.

Think about all of the physical exams or checkups you’ve had over the years. Did your doctor ever find anything surprising or earth shattering? Was the doctor’s office visit discussion mainly around what you already knew—lose weight, eat healthier, exercise, and stop unhealthy habits such as smoking? Far more valuable than a routine physical is the concept of tailoring screening tests and interventions based on your age. Certain illnesses are more common in specific age groups. Age-specific testing and interventions customized for you and your family history make more sense. The younger you are, the less likely you will need to see a doctor or have any screening tests or blood work done. Of course, there are always exceptions; i.e., for women, routine Pap smears/pelvic exams that screen for cervical cancer and sexually transmitted diseases occur at age twenty-one or when a woman becomes sexually active. The older you are, the more likely it is that you will be talking about mammograms, flexible sigmoidoscopies and colonoscopies, bone density testing, and screenings for breast cancer, colon cancer, and osteoporosis. Blood work may be ordered to check for high cholesterol and diabetes.

A good tool can be found at healthfinder.gov and using the web-based app which tailors recommendations based on a person’s gender and age.

The use of a routine chest x-ray before surgery? As Dr. Douglas Weir, president of the Ontario Medical Association noted:

  • procedures such as chest x-rays done generally for minor surgeries weren’t benefitting the majority of patients and can provide more harm through false-negatives or radiation.

In other words, not covered. What does the Choosing Wisely campaign, a new initiative by the American Board of Internal Medicine with various other professional medical societies like the American Academy of Family Physicians, partnered with Consumer Reports say?

How about moving the screening interval for Pap smears from one to every three years?  In 2010, the American Congress of Obstetricians and Gynecologists determined to begin screening at age to 21 (up from 18) or whenever a woman became sexually active but also continues to reiterate that three year screen works as well as annual screening in the Choosing Wisely campaign. For healthy women:

  • Women ages 21 to 65, including those who still have a cervix after a hysterectomy, should get regular Pap tests. However, having the test once every three years works as well as having it annually, since cervical cancer generally takes 10 to 20 years to develop. In addition, getting the test every three years can cut the number of follow-up tests.
  • Women ages 30 to 65 can go five years between Pap tests if they combine it with a test for the human papillomavirus (HPV), a sexually transmitted infection that can cause cervical cancer.
  • Women older than 65 who have had several normal Pap tests can stop having the test.

Based on the medical evidence and research, it appears that some tests which we used to do in the past either need to be adapted or no longer performed simply because we know more. Is this a good or bad thing? Do we want doctors to be scientists and practice based on data and studies or simply judge from the gut and intuition? For otherwise healthy patients, the standard set by doctors in Ontario and that of the Choosing Wisely campaign may indeed avoid unnecessary treatments, visits, and costs, and at the same time increase access and availability to care by those who do need it.

This might be a good new standard to aspire to indeed.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    It depends on how you define the annual physical exam. It should be comprehensive in the sense that it covers the risk factors for the individual at whatever stage of life they happen to be at. Identifying risks and working together to reduce or eliminate them always makes sense. Doing expensive imaging and testing may be some clinics and patients idea of comprehensive but not necessarily what the individual patient needs. Using research to find out the effectiveness of different screening exams and what works makes sense as well. Integrating that info into age appropriate benchmarking visits can prevent illness and contribute to the individuals health

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Dr. Steve,
      How does an annual physical benefit those that already have ongoing multiple chronic medical problems? The reason I ask this is because the annual physical will show what both the patient and doctor already know about that person’s history. So I am not sure I understand the benefit of having them, and especially now when even though insurance may cover the annual physical and the screening tests at 100% the problem comes when a problem shows up on the tests but the patient can’t afford to get the additional testing and/or treatment necessary to treat the problem. This becomes an issue because the insurance company will not cover the additional testing and/or necessary treatment at 100%. The patient is left to pay another portion, and 15-20% of a lot is still a lot.

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        The annual physical is a term invented by insurers to put an encounter in a category for their purposes. The value of the comprehensive annual review depends on how many doctors and health care providers are actually caring for your multiple chronic problems. A relaxed session with a physician coordinating your care will be directed at making sure you are maximizing the care and treatment options for each of those conditions. It will look at whether the care of one is influencing the other conditions in a positive or negative manner. No additional testing or costs need occur if the data is obtainable and available. Newer and more effective options may be available and you are as of yet unaware of them so the session may be educational as well. On the other hand you may be a well educated consumer and have researched options you wish to discuss with a professional , options that the professional has not yet learned about. There is no question that seeing a health care professional results in a cost to you. Soliciting the opinion of someone with experience and knowledge treating your ailments is usually more fruitful than trying to interpret data yourself off the internet if you have no healthcare experience or perspective.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Dr. Steve,
          Thank you for this explanation. So I am guessing that when someone says about a “well adult” visit, etc that’s another term used by insurance companies to put the encounter in to a category for their purposes too then. I also find your statement about whether the care of one condition is influencing the other conditions in a positive or negative way to be very interesting. The reason is because that kind of sounds like the comment my PCP made once with regard to saying that multiple chronic conditions can interact with each other. Could you please give an example how the care of one condition could affect the others in a negative way?

        • Homeless

          The research indicates that healthy adult don’t benefit from a yearly exam. Since there are no chronic conditions to discuss or specialist care to coordinate, I am not sure what your point is.

          • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

            You may not have a chronic condtion yet but you may have dietary issues and choices, activity or lack of it issues, safety issues, family history issues that can effect you and should be periodically reviewed with you so that you have the data to make wise choices. The good clinician is your health educator as well as your health advocate. Its not all about ordering blood tests and imaging studies

          • Homeless

            Wouldn’t it be cheaper and more effective to pay a lifestyle coach to discuss personal habits and wise choices?

            How many nutrition classes does the typical doctor take? Are you going to be able to tell me in that whether my vegetarian diet provides the right nutrition?

            How many athletic training classes does the typical doctor take? Are you going to be able to give me a list of exercises I can do to prevent overuse injuries?

          • Docbart

            Still venting against doctors? Feel free not to go for medical visits.

          • Homeless

            Still unwilling to discuss tough issues? Look at scientific evidence?

          • Docbart

            I guess once a troll, always a troll.

      • diana ford

        THE BENEFIT OF ANNUAL MEDICAL CHECKS FOR ALL AND FOR THOSE WHO ALREADY HAVE ONGOING MEDICAL PROBLEMS ARE:

        1. The medical problems could have been misdiagnosed. There are an enormous amount of medical errors that are carried out each ear in Canada.
        2. New problems could have developed and old ones may have disappeared. By treating a patient for a condition they don’t have one may in fact cause illness unnecessarily.
        3. By not treating a patient for something very minor that can be detected on an annual routine test one can cause serious problems if not death. For example, a blood test may show low hemoglobin, indicating anemia. If the patient does not get treated right away, they may develop kidney disease and need dialysis for the rest of their lives or, worse, die from it. He may also develop heart disease and either need a pacemaker or other surgical interventions or die from it. A small little routine blood test that is ignored can cause a prolonged anemia that could have been treated immediately with a little iron or at worst a small transfusion, could turn into enormously more costly necessary medical interventions because the ischemia can cause multiple organ failure, such as arrhythmia that will eventually cause tachycardia and death, kidney disease, liver disease, that can all be deadly if not treated appropriately but the treatments are very expensive, etc.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Diana,
          Thank you for your response. What happens when patients can’t afford the additional testing to find the exact problem, or the treatment for the problem once the problem is found? The reason I ask this is because for many even though they may have insurance still can’t afford to do these things. They have to make a decision about which is more important: eating and keeping a roof over one’s head, or taking medications regularly for chronic illnesses they may have. It shouldn’t have to be this way, being forced to choose between the two of which is more important. One should be able to do both things, but in this day and age that is just not possible.

    • trinu

      Many if not most of the studies included in the 2002 metanalysis, commonly cited as “proof” that physicals have no benefit did not include the scope of the physical in their methodology. What’s more they came mostly from the 60s and 70s, so they may not accurately reflect what the benefits of early detection of problems would be today.

  • http://www.revitolforacne.com/ Laira wolf

    Great article. I do not believe that a cookie-cutter solution would solve every personal health issue. Given the time allocated on one patients it would definitely not

  • Homeless

    RE: Far more valuable than a routine physical is the concept of tailoring screening tests and interventions based on your age.

    It would be nice to have screening tests based on lifestyle, genetic risk factors and environment. The physical is for overweight potential diabetics with heart disease.

  • sj0

    I feel compelled to share an anecdote. I once found an apical lung cancer in a patient while doing a routine physical – it showed up as a visible supraclavicular mass. The patient never noticed it; even after I pointed it out to her, she said she couldn’t see it. The cancer was early enough in its disease course that she needed only surgery, no chemo or XRT. I realize my “n of one” story won’t affect guidelines, but it certainly made me respect routine physicals.

  • buzzkillerjsmith

    Davis is right about this one. Ontario is ahead of us on this issue.

  • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

    I have seen the literature on annual exams, but I would argue this.

    Most providers don’t do a comprehensive exam for a sick visit (cold). They do a focused exam in a short time period. So other findings don’t come up.

    I can think of numerous times where someone came in for a “wellness” check only to be found hypertensive, found to have a cancer or concerning sign. These wouldn’t have been picked up without annual exams.

    The reasons annual exams don’t show well in literature is because they look at it not from a “lives saved” perspective but a “cost-benefit” perspective. Their are ALOT of well exams. That means ALOT of cost and only rarely is something picked up so the benefits tend not to be large.

  • diana ford

    I have seen far too many instances where the politics of saving money by
    rationing care has led too spending money tenfold in what could have
    been avoided medical procedures. People recommending the abolition of
    preventive medicine in favor of treating only after symptoms are present
    not only put the patient’s life at risk in doing so but create expenses
    that could have and would have been avoided had medicine been carried
    out in a responsible and thorough fashion where an ounce of prevention
    is worth a ton of remedies and more! If we want to replace preventive
    medicine with irresponsible medicine, we can do it but let’s not pretend
    that it will save money becuase studies and statistics show that this
    is not the case!

  • http://twitter.com/bergamotley Dorothy Pugh

    I’m an American, but we’re having a similar experience here. One of the things to fall by the wayside was the (manual) annual abdominal exam, now done only once every five years. One of my relatives grew a 15-pound intestinal tumor while under the regular care of a doctor for a thyroid condition, so this makes little sense to me. Besides, since large waist size is considered to be such a strong predictor of health problems, why not figure out what’s causing it?