Skip your Annual Physical???

Should you skip your annual physical?

On 1/8/2015 the NY Times published an article on this topic (http://www.nytimes.com/2015/01/09/opinion/skip-your-annual-physical.html?_r=0).  There are many interesting comments on this article, as well.  Basically the author, an oncologist named Ezekiel Emanuel, reviews the research that shows there is no benefit to an “annual physical.”  The research is based on a Cochrane review from 2012, and the United States Preventive Services Task Force (USPSTF).  Furthermore he proposes that we could save wasteful healthcare spending by not getting an annual physical.  The last paragraph adds necessary detail to his claim:

…My New Year’s resolution does not mean I won’t get my annual flu shot or a colonoscopy every 10 years — or eat a balanced diet and get regular exercise. These are proven to reduce morbidity and mortality…

Annual Physical vs. Evidence-Based Prevention

Here we run into a terminology issue…  Many insurers will cover a “preventive visit” which consists of a age-specific screening questions, diagnostic testing, and a physical exam.  There is definite agreement that many parts of this visit are “evidence-based.” See the USPSTF/AHRQ calculator below.  You can type in your info to see what is recommended for you.

What do I think?

When I was a family medicine resident I struggled with this question.  Did patients that came in for an acute complaint (sore shoulder, strep throat, etc.) necessitate reviewing all of the evidence-based guidelines for their age/sex/medications, etc?  As it turns out, that wasn’t possible, unless resident duty hours were ignored, and we doubled the amount of time in clinic.  There are robust studies that show how time-intensive it is to administer evidence-based prevention (this isn’t the “annual physical,” but the time to counsel/order evidence-based tests).  From this article in 2003 from the American Journal of Public Health (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447803/):

Results. To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services.

Unfortunately when the acute issue resolved, most of my patients didn’t heed the recommendation to return for a “preventive” visit.  Therefore the percent of my patients meeting evidence-based preventive screenings was dismal.  Then 0ne big change occurred.  It will be a day that will be remembered by all in attendance, 1/11/11, the day we transitioned to Electronic Medical Records.

Prior to the EMR, finding and documenting the pertinent evidence-based screens in the paper charts was extremely cumbersome.  Furthermore there are countless rules on who needs which tests (see calculator above).  Fortunately calculations and algorithms are 2 tasks that a computer is well-equipped to handle.  At each visit the EMR automatically calculates most of the USPSTF A/B recommendations based on the patient’s age, sex, smoking status, weight/BMI, sexual activity.  Furthermore the EMR is programmed to evaluate if tests are needed based on medical problems, medications, lab values, smoking status, quit date, and pack-years smoked.  In the bottom of each progress note we have a soft prompt to remind providers what is overdue:

Annual Physical

It takes about 5 seconds extra per note for the computer to evaluate the hundreds of rules.  Furthermore many clinicians open the note from their work station, and the 5 seconds elapses while they are opening the door and greeting the patient.  Certainly there is still some time required to discuss and order the needed tests, but this has drastically cut down the wasted time in this process.  This system allows the clinicians to choose to order/recommend needed tests, or for them to wait until the next encounter.  I try to do this with every visit, but I don’t always get to each item.

In addition to the prompts to the provider at each office visit, we have implemented 3 more systems to help improve this evidence-based care.

  • First we made an internal quality reporting website that extracts the health maintenance rates for each provider’s patients.  This allowed providers to compare themselves to their peers and develop methods to improve.
  • Secondly we added some of the more common tests (mammogram, pap smear, colonoscopy, pneumovax, flu shot, etc.) to the check-in sheet that is automatically generated, for each patient (with information specific to them: i.e. your mammogram is overdue).
  • Lastly we have letters that incorporate the same computer logic that allow the providers (or their nurses) to send to patients indicating which item(s) the patient has overdue

Bottom Line

I agree that the annual physical exam is not an evidence-based test that is proven to improve health.  Here are my recommendations:

  1. If you have chronic conditions and aren’t seeing a doctor, you should see one.
  2. If you have chronic conditions, ask your doctor if you are up to date on all necessary screenings.  Your provider may be recommending these piecemeal throughout the year, or they may require an “annual physical” to review all of the preventive measures.
  3. If you are healthy without any “complaint/problems,” then you will likely need to schedule a periodic “annual physical” if screening tests need to be ordered.
  4. If you are meeting a new provider at a new office, and don’t have any medical problems, you could use the annual physical appointment to get to know the new provider/office.
  5. If you get a lower copay on your health insurance by getting an annual physical, then you should get one.