September 24, 2007
Annual Physicals May Cost More Than They’re Worth
PHILADELPHIA -- As a young physician, Mary Ann Forciea was taught to give patients an annual physical exam that included a chest X-ray.
Now 58, the internist shudders to think how many healthy patients were exposed to yearly chest radiation before doctors concluded it was pointless and possibly harmful.
"We thought that was a way to prove you were healthy," said Forciea, a geriatric medicine expert with the University of Pennsylvania Health System.
These days, doctors are questioning whether the annual physical exam itself is an outdated ritual that wastes time and money.
A new study led by the University of Pittsburgh may fuel the simmering debate. It found that an estimated 20 percent of U.S. adults receive these routine check-ups, at a cost of almost $8 billion a year. This includes $350 million for unnecessary tests _ such as urine analyses and electrocardiograms _ that are not recommended by preventive health experts.
The study, in Monday's Archives of Internal Medicine, also found that many preventive services that are recommended _ such as cholesterol screening and quit-smoking counseling _ are provided during visits to treat illness or chronic problems, not during routine physicals.
"Most patients believe they should see a doctor every year for a physical in which the doctor will examine them from head to toe and order lots of tests," said lead author Ateev Mehrotra, a physician and public health expert at Pitt. "There are many doctors who disagree. Physicians need to reach greater consensus on what we should advise patients to do."
The public is basically clueless about this controversy, and no wonder. Medical professionals harp on the importance of "early detection" and "prevention," without explaining that major medical organizations do not recommend preventive health exams, or agree on how to define them.
About 80 percent of health insurance plans pay for annual physical exams, however ill-defined. (Even Medicare, limited by law to covering treatment, recently added an initial preventive health exam for new enrollees.)
Why is the annual physical, which has been around for decades, so hard to define? Because the nature of the check-up depends on the patient's gender, age and risk factors.
"I personally believe an annual physical is a good idea," said Jefferson Medical College physician Christine Laine, senior deputy editor of the Annals of Internal Medicine, published by the Philadelphia-based American College of Physicians. "It would be very difficult for a patient to collect all the information about age-appropriate screening. For most people, even those who are very smart and motivated, unless you have time to sit and talk to your doctor about preventive health care, it's going to get back-burnered."
Still, even well-accepted, well-studied cancer screening approaches, such as mammograms and PSA tests, stir debate.
"There's a range of opinion about whether the PSA should be done annually," said Jack Ende, an internist and chief of medicine at Penn Presbyterian Medical Center. "I do it annually."
Many doctors now prefer a vague term such as "periodic health evaluation" to annual physical exam.
Standard parts of that exam _ peering in the patient's eyes, ears and mouth, listening with a stethoscope to the heart and lungs _ are popular with patients, even though they have not been shown to be beneficial.
"That doesn't mean it's not beneficial," Ende stresses. "The jury is out. It's certainly not harmful."
The idea of keeping patients healthy by checking them out regularly was first proposed in 1861 by British physician Horace Dobell.
While it sounds logical, the U.S. Preventive Services Task Force, an expert committee created in 1984 by the federal government, has found that some cherished preventive measures do not improve health _ while some that are effective can be performed without a head-to-toe exam.
Mehrotra's study, which analyzed data from a federally-sponsored survey of outpatient visits, estimated that physicians spend 10 percent of their time _ an average of 23 minutes per patient _ on periodic health exams.
Yet when Mehrotra and his Harvard co-authors looked at eight specific preventive care services, they found five _ cholesterol screening and counseling on weight, diet, exercise and smoking cessation _ were usually provided during visits for chronic or sudden illness.
"I find physical exams valuable because it helps build a relationship with the patient," said Mehrotra. "But I'm concerned that they're not useful for their major purpose, which is to prevent illness and to improve health."
The opposite conclusion was reached earlier this year by researchers from John Hopkins University.
In the Annals of Internal Medicine, they said routine physicals are justified because they increase the chance that patients will get Pap smears, cholesterol tests, and colon cancer screening. The exams also reduce patients' "worry" about their health.
Some physicians are looking at completely different approaches to keeping the human engine humming. At Thomas Jefferson University, researchers increased colon cancer screening rates simply by sending information and reminders to appropriate patients. The doctors didn't require patients to come in for a visit first.
"Does all preventive care have to be delivered in a practice setting?" asked Ron Myers, an epidemiologist and colon cancer researcher who led the Jefferson study. "Maybe the role of the physician could be to link patients to the services they need.