The Annual Physical: Not So Routine Anymore?

The annual physical has recently come under fire.  From the New York Times article this Summer describing routine screenings as "in many ways pointless or (worse) dangerous" to the surge of new media covering the topic this month, individuals and health care providers are calling the annual physical's necessity into question.

What Does Research Say About the Annual Physical?

The latest review of the annual physical published in the Cocharane Library examined studies involving a total of 182,880 individuals some of whom received annual physical exams and some who did not.  The study showed no difference in the number of deaths between the two groups.  Not only was death rate the same regardless of receiving a physical exam, there was no difference in the number of hospital admissions, disabilities, worry about health, referrals to specialists or time off work between the two groups. 

One study did find a difference between individuals receiving an annual physical and those who did not.  Researchers found that individuals presenting for annual physicals were 20% more likely to take medications for hypertension.  Taking these medications, however did not translate into a better overall outcome.

Why Are Studies Deeming the Annual Physical 'Dangerous'?

It is undeniable that a routine physical often leads to unnecessary medical procedures such as biopsies, imaging and referral to specialists.  Most primary care provider's routine physical exams include tests that are not recommended.  For example, the only routine blood test recommended by the United States Preventative Services Task Force is a cholesterol check every five years.  According to Ateev Mehrotra, professor at the University of Pittsburg School of Medicine, the health care system wastes at least $325 million each year on unnecessary labs drawn for routine physicals.

Unnecessary blood work is not as benign as it seems.  The PSA test, for example, has recently received some heat.  An elevated PSA result can lead to invasive biopsies and surgical treatment of tumors.  Logically, it is positive that prostate cancer was detected as a result of the annual physical and treated, right?  Not so much.  Experts say that these tumors are unlikely to have any negative side effects and to be so slow growing.  They are unlikely to cause serious disease during an individual's lifetime.  Treatment, however results in physical and emotional strain. 

What Do Health Care Providers Say About the Annual Physical?

Overall, health care providers are hesitant to accept research showing that the routine physical does not confer any long-term benefits.  Dr. Frank Spinelli states that the annual physical is so much more than cancer testing and routine EKG's.  He uses the annual physical to monitor weight and discuss health issues like smoking cessation, alcohol consumption, diet and exercise with his patients.  More importantly, he also notes that he has diagnosed multiple prostate cancers, melanomas and kidney tumors based on abnormal test results found during an annual physical exam.

There is also the logical conclusion one can draw about provider's opinions- if patients don't present for routine physicals, clinics will schedule fewer appointments resulting in loss of revenue.  From the perspective of a specialist provider, less testing in primary care clinics will result in fewer abnormal findings and therefore a decrease in referrals for specialized medical care.

What Do You Think About The Annual Physical?

In reaction to these studies, my primary care nurse practitioner trained intuition says "What?!  You don't want me to check my patients for prostate cancer?  They may have an undiagnosed tumor!".  But, after reviewing the research it makes sense not to order these studies. Yes, maybe my 70 year old male patient does have prostate cancer, but if it is not going to cause him any perceivable problems, why put him through a series of visits to specialists and surgeons?  

Additionally, most harmful medical problems have symptoms.  Even the 'silent killer', hypertension, causes headaches, dizziness and blurred vision.  Most individuals will seek treatment for these symptoms.  The ones who would not are the same individuals who already do not receive an annual physical exam.  Yes, you may discover a concerning skin lesion during a routine physical but most patients are aware of the odd-looking moles that pop up on their bodies and will eventually come to you for a skin biopsy anyway.

Although my training heavily emphasized the annual physical exam, I have to say that the research recommending against routine screenings is compelling enough for me to change my practice.

What do you think?  Post your comments below!