Harvard doctors argue for and against this medical ritual
Doctors continue to debate the worth of a time-honored tradition of health care — the annual physical examination.
Some want the once-a-year physical abandoned, based on a growing body of research that these exams don’t reduce your overall risk of disease or death.
But yearly checkups help build the relationship between doctor and patient, leaving both better prepared when illness does strike, other doctors respond.
In editorials in the Oct. 15 issue of the New England Journal of Medicine, Harvard professors air both sides of the debate.
The original idea behind the annual physical examination held that these visits provide doctors an opportunity to practice preventive medicine, said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School in Boston.
Doctors would detect problems such as high blood pressure, increased cholesterol or high blood sugar, and help their patients take steps to prevent these early warning signs from developing into chronic illnesses such as diabetes or heart disease, he said.
But this idea has not withstood scientific review. “In good studies, in both randomized trials and in observational studies, we have not found any of those benefits,” said Mehrotra, co-author of the editorial questioning the value of traditional physical exams.
“We have not seen people have less illness, and we have not seen any decrease in mortality,” he said.
“I’m a big fan of trying to do anything that’s going to help the health of the U.S.,” Mehrotra added. “But in this case, we’ve studied it, and it hasn’t helped. We shouldn’t waste time and money on this.”
Overall, these annual visits cost more than $10 billion a year, Mehrotra said. And yearly physicals can be harmful, he added, noting tests like urinalysis in patients without symptoms often yield false positive results, causing patients needless anguish.
Proponents of the physical exam say critics overlook benefits that are harder to measure, but important to patient care.
By regularly seeing their patients, doctors can learn about many aspects of a person’s life — work stresses, family issues, financial pressures — that can affect their health and well-being, said Dr. Allan Goroll, a professor of medicine at Harvard.
That “can’t be done in five minutes, and it can’t be done by a questionnaire. It’s done by looking a patient in the eye and giving them the feeling they aren’t being rushed,” said Goroll, who wrote the editorial defending the annual exam.
“By calling for the elimination of the annual checkup, they risk compromising the delivery of a comprehensive, whole-person approach to health care,” he said.
Both Mehrotra and Goroll said there’s a need for reform of the annual physical.
Mehrotra believes regular checkups should be reserved for people who haven’t seen their physician in two or three years. “I do acknowledge for people who haven’t seen a primary care doctor for several years, going in to maintain that relationship does make sense,” he said.
Doctors should use electronic health records to maintain preventive health care for everyone else, Mehrotra said.
A health clinic’s computer can easily keep track of people who haven’t gotten their flu shot, or who need to have their blood pressure, cholesterol levels or blood sugar checked. Reminders can be sent to them, allowing the doctor to proactively pursue preventive care, he said.
“You don’t have to passively wait for patients to come in for this big annual visit to make sure people are up on their preventive care,” Mehrotra said.
Goroll argues that the annual physical should be continued for everyone, but in a team-based approach where nurses, medical assistants and care coordinators handle most of the routine preventive-care chores.
That will give doctors the time to have in-depth conversations with patients, which could help guide their future health care, Goroll said.
“Let’s not eliminate the annual physical, which is really an annual health review, but let’s enhance it so it’s a meaningful experience,” he said.
In his editorial, Goroll noted this already is happening for patients who can afford “concierge” physicians. These people pay generous fees for easy and regular access to their doctor.
“Many people are paying thousands of dollars to ensure they have that relationship with their primary care physician,” he said. “We need to come up with an approach that will give us concierge service at Wal-Mart prices.”
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