In the United States, annual physicals are part of the fabric of our health care system. For adults, even perfectly healthy ones, an annual visit to the doctor has long been considered to be the foundation of good care. But recently, experts have begun questioning whether our collective belief in this ritual is reasonable. Are the benefits of annual care actually as great as we think? Can patients get the benefits of the yearly checkup in other ways?
In an editorial recently published in The New England Journal of Medicine, Drs. Ateev Mehrotra and Allan Prochazka explored the complex issues surrounding annual physical exams. In the name of improving "value" in health care, they argue that these routine visits should not continue.
Evaluating the benefits and risks of the annual checkup
As physicians and health care policy experts, the authors understand that it will be difficult for all of us to change this practice. Although a number of professional guidelines recommend that physicians should no longer follow the tradition of the annual exam, data show that the frequency of these exams hasn't diminished. Both doctors and patients are strongly wedded to the practice, and surveys show that the majority believe they should continue.
But what are the true benefits of this practice? Careful reviews of several large studies have shown that these annual visits don't make any difference in health outcomes. In other words, being seen by your doctor once a year won't necessarily keep you from getting sick, or even help you live longer. And some of the components of an annual visit may actually cause harm. For example, lab tests and exams that are ordered for healthy patients (as opposed to people with symptoms or known illnesses) are statistically more likely to be "false positives" — that is, when test results suggest a problem that doesn't exist. Even if these inaccurate findings affect only a tiny percentage of the more than 200 million adults who would undergo such exams, the monetary, practical, and emotional costs are huge.
Drs. Mehrotra and Prochazka indicate that reducing the number of annual exams would save both money and time. The time that primary care doctors currently spend on these visits could be used to address urgent needs and expand access to health care for those in need. They recognize that this change will be a hard sell, in part because many doctors and patients perceive the annual visit as a critical opportunity to cement the doctor-patient relationship and a way to ensure that people receive appropriate screenings and preventive care.
Three steps to a better model of care
In order to encourage this shift, the authors propose three steps. First, they recommend a new type of visit solely to focus on the doctor-patient relationship. This would allow those who are new to a physician to have an initial visit to establish a relationship, and allow others to be seen on some routine interval (perhaps every 3 years or so) to maintain it. The emphasis would be more on medical and social history, and less on the exam or screening laboratory tests.
Second, they acknowledge that if the annual visit is to be discarded, primary care doctors will need to find a more proactive way to monitor their patients' attention to preventive care. They suggest that waiting for patients to keep their annual visits to review this is too "passive" an approach, and encourage practices to shift to "active engagement" of their patients. Ways to do this might include: online risk assessments, waiting-room questionnaires, and a review of preventive care at any visit to the doctor.
Finally, they suggest that in order for doctors and patients to embrace this shift, payers must make changes as well. The authors recommend that health plans and government programs no longer pay for annual visits or use regular checkups as a measure of health care quality.
The demise of the yearly checkup will feel like a loss to many patients and their doctors. But the authors encourage us to think creatively about ways to maintain the important values of this visit in new and more efficient ways. Their "checkup" suggests that the "checkup" needs a major surgery. To push the metaphor, if we follow through on their suggestions, then like any procedure, it will be healthier in the end, but we will all likely feel some pain as we go through it.
This discussion isn't just theoretical for me. As a primary care doctor, I agree that the benefits of the yearly checkup can and should be achieved in other ways. At the same time, I know that making these changes with my patients will be difficult. Discontinuing the annual physical will be felt as a loss, as a form of abandonment, for some. The most powerful way to address this will be to recognize and name that loss, and to let patients know that the important parts of the annual will endure: attention to their needs, attention when they need it, and attention to their routine preventive care — just all without the annual visit.