Friday, April 20, 2018
Health

Annual exam benefits iffy

Once upon a time, an annual physical was just something you did if you cared about your health (and had the insurance to pay for the exam). But a recent review by researchers at the Nordic Cochrane Centre in Copenhagen suggests that people who don't go to the doctor until they feel they need to may be perfectly wise.

Researchers examined the most rigorous studies they could find (14 in all) comparing people who received so-called general health checks and those who didn't, some 182,000 people. Their analysis found that routine medical exams failed to reduce overall deaths, disease-related deaths, hospitalizations or costs.

The Cochrane review isn't the first to question the effectiveness of the annual exam. A 1979 Canadian panel convened by the government concluded that "the routine annual physical examination should be discarded in favour of a selective plan of health protection packages appropriate to the various health needs at the different stages of human life." The U.S. Preventive Services Task Force does not advise for or against annual exams; instead, it makes age-specific recommendations about which screening tests you need and when, says Michael L. LeFevre, a physician at the University of Missouri and co-vice chair of this independent group of national experts.

Even without formal recommendations, many Americans continue to see their doctor once a year, whether they have symptoms or not. The 2009 National Ambulatory Medical Care Survey showed that general medical exams were the No. 1 reason people visited their doctors.

The annual physical became popular, in part, because it seems so logical that a regular exam might catch medical problems before they get out of hand, says Ateev Mehrotra, a health policy researcher and physician at the University of Pittsburgh School of Medicine. But given the lack of evidence that the yearly ritual improves health, he says, "my own view is that the medical community should no longer encourage patients to receive an annual physical."

It's not just that these exams are unlikely to help the patient, Mehrotra says. They come with potentially serious downsides, too.

For patients, the negatives include time away from work and possibly unnecessary tests. "Getting a simple urinalysis could lead to a false positive, which could trigger a cascade of even more tests, only to discover in the end that you had nothing wrong with you," Mehrotra says.

There's also potential for false assurance that everything is okay, which may lead people to ignore or minimize new symptoms. "You may come in and have a completely fine bill of health, and three months later you develop leukemia," says physician Christine Laine, editor of Annals of Internal Medicine. "Unfortunately, we can't prevent that from happening."

When you go in for a physical, the doctor checks for things that are common and easy to screen for, but there remain plenty of other conditions that lack a good screening test, and there are others whose outcomes aren't improved by identifying them earlier, Laine says.

Mehrotra says that annual physicals also are straining the medical system. "We're spending 12 percent of our primary-care time on something that has no evidence to support it." Primary-care doctors are in short supply. "If physicians stopped doing annual exams and used that time to accept new patients, it would greatly alleviate the problem."

But that's unlikely to happen soon, he says, because so many health-care plans create a financial incentive for physicians to provide annual exams. "As a society, we're spending about as much money on annual exams as we are on breast cancer. That's a tremendous amount of money for something with no evidence base," Mehrotra says. He's particularly alarmed that Medicare recently introduced an annual wellness exam, because health plans are required to cover the same range of preventive services as Medicare. "This perpetuates the myth that the annual physical is important," Mehrotra says.

But, says Sung T. Kim, a family physician at the Inova Medical Group in Centreville, Va., the annual exam isn't just about improving the patient's health; it's also an opportunity to foster the doctor-patient relationship and a chance for him to check on a patient's mental health. He recommends annual physicals for his patients: "It's a chance to spend quality time together. We can discuss all the things that are recommended from a prevention standpoint." Kim routinely sees cholesterol readings that change from year to year and blood pressure that's gone up between one annual physical and the next.

"When they come in for an acute visit, a lot of times we can only focus on that problem. An annual visit allows me to take time to spent that extra 10 or 15 minutes really talking," Kim says. "When we don't see a patient for two or three years, there could be a lot of things we are missing in the interim."

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