The Annual Physical Exam: Time to Discard or, Better Yet, Adapt It?

A recent article made me reconsider a medical tradition that I have taken for granted and, in certain instances, that I may have inappropriately continued.¹ The annual ambulatory history and physical examination is a persistent vestige from a time long gone. This yearly ritual started back in 1861 and later became officially entrenched in the health practice of Western culture through such respected groups as the American Medical Association. Its performance was valued as a way to maintain good health.

OLD HABITS DIE HARD

Despite falling into disrepute in the eyes of the Canadian Task Force on the Periodic Health Examination, the American College of Physicians, the US Preventive Health Services Task Force, and the US Public Health Service, these comprehensive examinations still account for 4.4% of all health care visits in the United States. About 36 million of them were performed between 1999 and 2001.¹ What dynamic has been driving the yearly "physical" despite data that suggest it is unlikely to benefit asymptomatic adults?² Both patients and physicians still trust in the efficacy of this medical practice. In one study, 65% of physicians surveyed believed that this examination has proven value.³ Evidence-based medicine differs with this conclusion and has a great deal of ammunition on its side. So, is it time to jettison an archaic practice by not reimbursing it? The question-and answer-may not be as straightforward as they seem.

ARE WE MISSING SOMETHING?

When the Canadian health care system stopped advocating the yearly physical back in 1979, there was a bothersome downside: the provision of evidence-based preventive care deteriorated.⁴ Only 41% of patients received proven, appropriate preventive care during the newer, more focused establishment examinations that replaced annual comprehensive examinations, and another 17% of patients received services without proven value. It appears that the structured yearly physical provided a template for evidence-based preventive care. What will be the fate of the annual comprehensive examination? On the one hand, it has been scientifically debunked as a valid instrument for screening healthy, asymptomatic adults, and abandoning it could save significant human and monetary resources. On the other hand, the narrower focus of the establishment visit has not translated into better preventive health care.

A POSSIBLE SOLUTION

So, what is the answer? The yearly complete ambulatory history and physical examination has served its purpose in asymptomatic adults and should be discarded. However, a checklist must be made available in its absence so that establishment examinations fill the resulting vacuum with evidence-based preventive care 100% of the time.

References:

REFERENCES:

1.

Chacko KM, Anderson RJ. The annual physical examination: important or timeto abandon?

Am J Med.

2007;120:581-583.

2.

Frame PS, Carlson SJ. A critical review of periodic health screening usingspecific screening criteria. Part 1: selected diseases of respiratory, cardiovascular,and central nervous systems.

J Fam Pract.

1975;2:29-36.

3.

Prochazka AV, Lundahl K, Pearson W, et al. Support of evidence-based guidelinesfor the annual physical examination.

Arch Intern Med.

2005;165:1347-1352.

4.

Hutchinson B, Woodward CA, Norman GR, et al. Provision of preventive careto unannounced standardized patients.

CMAJ.

1998;158:185-193.