Is an Annual Physical Necessary?

By Sumathi Reddy | January 18, 2016

Every year on his wedding anniversary Louis Sinclair pays a visit to his family physician for what has become a ritual: the annual physical.

“That way I don’t forget my anniversary and I don’t forget my physical,” says the 66-year-old in Raleigh, N.C., who has been getting regular checkups since he was about 40.

About a year and a half ago, the doctor diagnosed Mr. Sinclair with atrial fibrillation and sent him to a cardiologist. A CT-scan picked up a tumor on his lung that turned out to be cancerous. “I would have never known that if I hadn’t gone to my physical and followed up on this stuff,” says Mr. Sinclair, who owns a commercial real-estate company. He says the tumor was removed and he now seems to be fine.

Nearly two-thirds of U.S. adults say they get a physical exam every year, according to a 2014 Kaiser Family Foundation survey of 1,500 people. The federal Affordable Care Act requires insurers to cover annual physicals free of charge.

At an annual physical, a doctor’s questions about lifestyle and overall wellbeing can help screen for problems such as depression, alcoholism and substance abuse. ENLARGE
At an annual physical, a doctor’s questions about lifestyle and overall wellbeing can help screen for problems such as depression, alcoholism and substance abuse. PHOTO: ISTOCK
In the medical community, however, experts are divided on whether there is a benefit to getting an annual exam. Some research has shown regular physicals don’t reduce rates of illness or mortality and are a waste of health-care resources. They also could be harmful, for example, when false positives result in additional, unnecessary testing.

Other experts say a yearly checkup is an important part of building a physician-patient relationship and can lead to unexpected diagnoses such as of melanoma and depression.

“I think there are probably subsets of people who can go longer than a year between visits but I think it’s quite important for people to know their doctor before they get sick,” says David Himmelstein, a primary-care doctor in Bronx, N.Y., and co-author of an editorial published earlier in January in the journal Annals of Internal Medicine in support of annual checkups.

Some health-care systems have begun to scale back the role of annual checkups. HealthPartners, a Minneapolis-based insurance plan and network of clinics, has moved to include certain functions of the annual exam into sick and chronic-care visits instead.

“What we’ve been trying to do is to use every engagement we have with patients as an opportunity to assess what they might need for their preventive care,” says Beth Averbeck, a senior medical director at HealthPartners. “Patients are trying to bring up more things at one visit instead of having multiple visits.”

The evidence most frequently cited against the annual physical is a 2012 analysis of 14 trials by the Cochrane Collaboration that concluded physicals don’t reduce mortality or illness. Dr. Himmelstein noted that the trials excluded elderly patients. Also, most were performed in Europe, where most patients were already regularly seeing doctors, he says. Thus, the analysis failed to examine the potential value for U.S. patients of seeing a doctor regularly.

The Society of General Internal Medicine, a professional organization, recommended in 2013 against performing routine physicals for asymptomatic adults. It noted such exams “haven’t shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential harm from unnecessary testing.” That recommendation is currently under review, says Zackary Berger, assistant professor of general internal medicine at Johns Hopkins School of Medicine who is coordinating the society’s review.

Other professional groups, including the American College of Physicians, which represents internists, and the American Academy of Family Physicians, take no stance on the issue. Individually, some internists and primary-care doctors say for healthy, young adults, a checkup may only be necessary every three years or so.

Annual physicals account for an average of 10% of patient visits for internists and primary-care physicians, experts say.

Competing editorials about annual physical exams ran in the New England Journal of Medicine in October.

“We’re spending time on something that really isn’t clearly helping patients,” said Ateev Mehrotra, an associate professor in the department of health care policy at Harvard Medical School, and author of one of the editorials. “There will be people who went to their annual physical and something was identified,” Dr. Mehrotra said, in an interview. “But on a population basis do we want people who are otherwise feeling healthy to come in?”

Dr. Mehrotra believes healthy adults should see their physician about every three years and the visit should focus more on relationship-building and less on random tests, such as blood and urine.

A physician who knows a patient well can detect health problems that another doctor may overlook, says Allan Goroll, a general internist at Massachusetts General Hospital, who wrote the NEJM editorial in favor of annual physicals. He notes that, in an era of fee-for-service medicine, physicals are often rushed and perfunctory. “So the question becomes how can we revitalize this important aspect of health care into what it was always intended to be, an annual personal health review meaningful to both doctor and patient,” he said in an interview.

Dr. Goroll supports delegating some of the work physicians typically do at a physical exam, such as reviewing medications and giving immunizations, to other medical professionals. This could “free up the primary-care physicians to do the more complex and personalized work,” he says.

On a recent day at NewYork-Presbyterian Hospital in New York City, internist Seth Feltheimer had a number of physicals scheduled. He said between 20% and 30% of his patient load is annual exams.

One patient he saw was a woman with four different types of cancer. When her blood cancer, which had been in remission, became newly active, Dr. Feltheimer caught the test result and notified her hematologist. The test had been ordered by a medical resident but no one read the results until he did.

“I see a lot of people with multiple medical issues,” says Dr. Feltheimer. “I want to make sure none of the specialists miss anything. It’s up to me to coordinate their care.”

Another patient of Dr. Feltheimer’s, Ben Rubin, a 20-year-old New York University student on the wrestling team, came in for a physical to clear him for a shoulder surgery the next day. “Your [blood] pressure’s high, 150 over 80,” Dr. Feltheimer tells Mr. Rubin. A retina exam also shows signs of hypertension. “We’re going to do some tests for your high blood pressure,” which can affect the kidneys, Dr. Feltheimer says. “And you should see me again a month after your surgery.”