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TIME TO CHECK IN ON THE CHECKUP:
Thirty million additional Americans may have access to health insurance in 2014 // New care models are changing the doctor-patient relationship // America may face an extreme shortage of physicians by 2020 // Will the annual physical survive another decade?

The End of the Physical?

By Linda Keslar // Photographs by Brian Finke // Fall 2012
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Brian Finke

As the head of a Florida advertising and public relations firm, Colleen Chappell, 46, has long viewed her health as a company asset. She exercises regularly, eats nutritiously, keeps her weight down—and always has an annual physical examination. “I’m religious about it,” Chappell says. The head-to-toe exam is supplemented by blood work and screenings including a Pap smear and a mammogram.

One in five American adults takes Chappell’s approach, seeing a physician every year, and an annual exam remains the most common reason for consulting a primary care doctor. Yet there’s little evidence to demonstrate the value of a yearly checkup, and no major U.S. health organization recommends one. “Many people just embrace this belief that seeing your physician every year is a good idea,” says Ateev Mehrotra, assistant professor of medicine at the University of Pittsburgh School of Medicine and a policy analyst at RAND Corp.

One reason for regular visits—to make sure patients get health screenings—has become less important in recent years as expert groups conclude that many tests can be skipped or done less frequently. The U.S. Preventive Services Task Force, which reviews evidence and issues guidelines, now recommends that mammograms for most women begin at age 50, and then be done every other year. (Others, including the Mayo Clinic and American Cancer Society, call for mammograms every year or two for women in their 40s and annually for those in their 50s and older.) The task force and professional societies such as the American College of Physicians have endorsed discontinuing several other tests and procedures typically done with an annual physical.

Still, to many physicians, the annual checkup has a value beyond detecting illness, helping them bond with patients while updating health histories, determining what screenings are needed and providing counseling. “It’s a way for physicians to gain the trust of their patients,” says Barron Lerner, a professor of medicine at New York University Langone Medical Center. “When I do a complete exam, I know my patient inside and out.” Studies have shown that patients also appreciate having a thorough examination.

While arguments about the annual physical are nothing new, the debate will become more urgent in 2014, when the U.S. Patient Protection and Affordable Care Act is slated to add an estimated 30 million insured patients to the nation’s roster. That influx, when many primary care doctors are stretched to capacity, could further alter where and whether people receive yearly exams. Many may opt for retail clinics, typically staffed by nurse practitioners, or they could become part of a “medical home,” a team approach that also makes extensive use of non-physician caregivers.

“What we think of as the annual physical lies at the intersection of all of this,” says L. Ebony Boulware, associate director of the Welch Center for Prevention, Epidemiology, and Clinical Research at the Johns Hopkins University School of Medicine in Baltimore. “There are a lot of unanswered questions about what aspects of it are useful, including the frequency.”

The notion of an annual physical goes back at least to ancient Greece and Rome, and though it fell out of favor for some 400 years beginning in the late Middle Ages—physician-scholars then felt that poking and prodding a patient was beneath them—it made a comeback in the late eighteenth century. Aided by scientific theories of disease and new technologies such as the stethoscope, physicians sought to learn as much as possible about the internal state of the body, and in 1861, British physician Horace Dobell identified components of a physical—a patient’s personal history, a meticulous exam and lab tests for detection and diagnosis—that persist today.

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1. “Support of Evidence-Based Guidelines for the Annual Physical Examination: A Survey of Care Providers,” by Allan V. Prochazka et al., Archives of Internal Medicine, June 27, 2005. The largest study of physicians’ attitudes toward the annual physical showed that most patients desire the annual physical and that the majority of physicians continue to believe in its value despite contrary evidence.

2. “Preventive Health Examinations and Preventive Gynecological Examinations in the United States,” by Ateev Mehrotra et al., Archives of Internal Medicine, Sept. 24, 2007. A groundbreaking study estimating what portion of the American population gets physicals (one in five adults) and the price tag ($7.8 billion), and an analysis of the potential benefits. Data on eight key preventive health procedures showed that almost all such services were also routinely provided at other types of office visits, bringing into question the annual physical’s relevance.

3.“Evidence Brief: Role of the Annual Comprehensive Physical Examination in the Asymptomatic Adult,” published by the U.S. Department of Veterans Affairs, October 2011. In this, the most current systematic review of more than three dozen studies devoted to the annual physical, VA researchers concluded by endorsing only two components—blood pressure screening and body mass index measures, delivered at select intervals for healthy adults—rather than a yearly comprehensive checkup.

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