|Dr. Jacques Carter says the annual exam is important.|
The annual physical gets a checkup
A yearly exam may not be the best way to assure patients get proper care
The patient's ear was throbbing. You have an infection, Dr. Beth Averbeck told 37-year-old Diane Shannon. And that's where the trip to the doctor's office might very well have ended.
But Averbeck wasn't finished. With Shannon at her elbow, the primary care physician scanned the woman's medical record to make sure she was current on all her routine care.
Breast exam? Check. Cholesterol screening? Check. Tetanus booster? Check. Pap smear? Check. Flu shot? We can give it to you right now.
It was, in a sense, two medical visits in one: treatment for an acute ailment combined with a snapshot of the woman's overall health, the kind of review that historically has been the domain of the annual physical exam. "It saves them having to do two visits," Averbeck said last week from her practice in St. Paul, Minn. "And from the standpoint of my schedule, it gives time for more patients to be seen."
For decades, the yearly physical for adults has stood as an iconic fixture on the healthcare landscape, right next to tongue depressors and stethoscopes. Abraham Lincoln was in the White House when a doctor was first recorded suggesting that patients have a regular visit to detect and prevent illness.
And annual exams are still phenomenally popular: A study released last month found that 64 million Americans a year get a physical or gynecological exam, costing $7.8 billion and outpacing visits for respiratory conditions or high blood pressure.
But researchers and some health plans increasingly voice deep skepticism about the value of scheduling a separate annual exam for a healthy person. There's little scientific evidence, they maintain, to justify the time, money, and expertise being invested in a ritual that consumes appointment slots, especially when patients with immediate aches and pains can't squeeze into a doctor's frenzied schedule.
"If I'm spending 20 minutes or half an hour with you on an exam that's not necessary, that's 20 minutes I could be spending with one or two other patients who are ill and want to come in that day," said Dr. Robert Goldszer, associate chief medical officer at Brigham and Women's Hospital in Boston. "If we're doing visits that we bill for and someone pays for and we're doing tests that someone pays for and it's not necessary, that's waste."
Still, two-thirds of patients and doctors regard the physical as the human equivalent of the 10,000-mile car checkup, a chance to look under the hood whether it's needed or not. And it's a meeting that's treasured as a chance to forge a relationship that can prove indispensable during health crises.
"You know about their history, about their kids' names, that the dog was sick last year - all that Marcus Welby kind of stuff," said Dr. Jacques Carter, a primary care physician affiliated with Beth Israel Deaconess Medical Center. "It's very important to patients, and they also feel they can talk to you about a lot of things.
"The big question is how often should we do these big encounters?"
A sweeping national review of medical records published in the Archives of Internal Medicine in September found that patients in the Northeast were the most likely to undergo a physical (29 percent of adults a year); patients in the West, the least likely (16 percent).
The researchers from Harvard and the University of Pittsburgh found that doctors routinely subject those patients to tests that are the equivalent of looking for a needle in a haystack, even when there's no reason to think a needle exists - complete blood counts and urine samples, for instance.
And three-fourths of the patients who underwent physicals from 2002 through 2004 visited the doctor for other reasons in the year before their annual exam, suggesting that counseling and tests performed at the physical could have been provided earlier.
"Physicals are the number one reason for doctor visits," said the study's lead author, Dr. Ateev Mehrotra, of the University of Pittsburgh. "If you're coming in every three months for your diabetes, it's unclear whether an additional appointment on top of that for an annual physical is clearly needed to deliver the preventive services we think are necessary."
In fact, the study showed that the vast majority of preventive health services - mammograms and smoking cessation counseling, for example - happens at appointments other than physicals, further calling into question their worth.
Mehrotra said a chain-smoking patient stricken with pneumonia provides a perfect example of how prevention messages can be incorporated into treatment for an illness: Why not deliver an anti-smoking message along with the antibiotics.
But how realistic is that?
"The first thing that popped into my mind was, 'Do these guys see patients?' " said Dr. Dale Magee, a Shrewsbury gynecologist and president of the Massachusetts Medical Study.
With doctors' schedules already jammed, there's often barely time to address the urgent problem that prompted the visit, several doctors said. And if patients only get their screenings and other preventive measures when they come with a sore throat or the flu, what happens if they go years without an illness? "They don't have the test done because they didn't have a cold this year," Magee said.
Despite the debate, big insurers such as Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care continue to pay for physicals.
And big medical practices continue to perform thousands of them. At Harvard Vanguard Medical Associates, the sprawling Massachusetts practice, a review of scientific evidence concluded that while there's not sufficient proof to make physicals mandatory, physicians and patients should be given discretion on how often to schedule them.
"Under the circumstance, we owe it to our patients to cater to what they perceive their needs to be," said Dr. Jeff Levin-Scherz, the practice's chief medical officer. "For many of our patients, an annual physical can be a good way to establish goals for good health.
"But there are a lot of our other patients for whom an annual physical is very hard to fit into a busy schedule."
Diane Shannon, the Minnesota patient, falls into that camp. That's why she was so grateful that her routine needs were reviewed during her visit to a clinic run by an HMO called HealthPartners. While that company does not prevent patients from scheduling physicals, it doesn't encourage them, either.
"What we encourage our physicians to do is to check every patient for their prevention needs, whatever the reason they're seeing them," said Dr. Marcus Thygeson, HealthPartners' vice president. Electronic medical records, for instance, flag the doctor if the patient is due for a test or a vaccination.
Shannon, a manager with a telecommunications company, saw her visit as an opportunity to ask about adjusting a prescription.
"I said, 'I don't know if you have time for this,' because in the past I'd had a bad experience with a doctor who said, 'I don't have time - I'm past my 20 minutes with you,' " Shannon said.
Dr. Averbeck had the time. "And," Shannon said, "I think I conquered four visits in one."
Stephen Smith can be reached at firstname.lastname@example.org.