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All Risk, No Reward

Annual Physical: Friend or Foe

Aisha Lofters, MD and Neda Frayha, MD
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23:16

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Tags Ambulatory Family Medicine · injury and illness prevention

Are you a fan of your annual physicals, or are you moving away from them in your practice? In this segment, Neda and our new PC RAP contributor Aisha Lofters debate the merits and drawbacks of the annual physical. Spoiler alert: Aisha wins!

Pearls:

  • Aisha and Neda discuss the pro’s and con’s of the annual physical.

  • Pros: improve screening rates, build rapport with patients.

  • Cons: time, cost, incidental findings, evidence of efficacy lacking.

  • Alternatives: period preventive health checks, engage your patients through technology or workshops or group classes.

 

  • Pros:

    • Screenings depending on age, sex, gender, etc.

      • Evidence that the annual physical does have a beneficial effect on the delivery of some specific, preventive services.

      • Prochazka AV et. al. Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers. Arch Intern Med. 2005 Jun 27;165(12):1347-52. PMID: 15983282.

    • Chance to maintain a relationship with a patient

    • Reorient towards preventative care as opposed to episodic acute care

    • Some evidence to support a mental health aspect of the importance of laying hands on a patient to build a therapeutic relationship

    • Improvement in health metrics> Meta-analysis of six different randomized control trials found that annual physicals were associated with statistically significant improvements in metrics like cholesterol, blood pressure and BMI. The differences were small (ie: decrease in BMI was only 0.45).

      • Si S et. al. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br J Gen Pract. 2014 Jan;64(618):e47-53. PMID: 24567582.

    • It is a nice visit for providers!

  • Cons:

    • There is no consensus on what exactly comprises an annual physical:

      • Does it include labs work?

      • Does it include a full physical exam?

      • Does it include imaging?

    • There is no consensus of what patients want:

      • A survey of 1200 adults in big cities in the US found that 66% thought an annual physical was necessary and 80-90% wanted different things in the annual physical (ie: physical exam, lab work). When asked if they wanted it knowing they would be charged, only 33% wanted it.

        • Oboler SK et. al. Public expectations and attitudes for annual physical examinations and testing. Ann Intern Med. 2002 May 7;136(9):652-9. PMID: 11992300.

    • Guidelines about the annual physical are inconsistent:

      • The USPSTF does not have any recommendations for an annual physical

      • Canadian guidelines have recommended AGAINST an annual physical

      • The Province of British Columbia does not even cover annual physicals as a benefit

      • The Choosing Wisely Canada states, “Don't do annual physical exams in asymptomatic adults with no significant risk factors”

      • The College of Family Physicians of Canada recommends instead of doing an annual physical, do a periodic preventive health check instead

    • Harms of incidental findings

      • May require repeat testing to patients or lead to unnecessary work-up

      • Anxiety provoking for patients

    • Cost: one study in 2007 cited an annual cost of physicals of $10 billion in the US

    • False reassurance that a head to toe physical exam is going to pick everything up

    • Time: general practitioners are spending about 10% of their time on the physical, which does not include the time spent following up incidental findings. This time could be spent increasing clinic access in other ways.

      • Mehrotra A et. al. Improving Value in Health Care--Against the Annual Physical. N Engl J Med. 2015 Oct 15;373(16):1485-7. PMID: 26465981.

    • Evidence for their benefit is lacking. Large Cochrane review in 2012 that included 183,000 people over 9 years found no benefit to health checks on a variety of factors including morbidity, mortality, hospitalizations or patient worry.

      • Krogsbøll LT et. al. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012 Nov 20;345:e7191. PMID: 23169868.

    • Alternatives:

      • Preventive health check or the periodic health check

        • De-emphasize the check needing to be annual

        • De-emphasize a full physical exam

      • Keep in touch with patients in other ways

        • Technology

        • Group education classes or workshops

        • Maximize acute care visits to include components of preventative care visits

Brian F. -

Aisha and Neda, excellent chapter! Please list which screening labs you draw in your practice among age groups, during annual (or periodic) exams, generally speaking. We are always debating this.

Neda F., MD -

Hi again, Brian. Aisha wrote me back with the following note: "So for me, for women over 50 and men over 40, I will definitely do lipids, glucose, and A1C assuming they haven’t done it recently. Anything else I order would be specific to the patient e.g. iron in a woman with menorrhagia. But I try to keep blood work where there is no clear indication to a minimum!" Hope this helps!

Neda F., MD -

Thanks so much for listening, Brian! I've asked Aisha to weigh in on her practice patterns and guidelines in Canada. I tend to refer to the USPSTF guidelines when deciding what to order. Usually a BMP once a year to screen for kidney disease in my hypertensive and diabetic patients in addition to what's listed here: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

Spencer B., MD -

Such a great segment guys - thank you so much for the thoughtful, patient-centered, evidence-based examination. So much of what you discussed resonated.

Neda F., MD -

Thanks so much, Spencer! We really appreciate your feedback.

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All Risk, No Reward Full episode audio for MD edition 187:18 min - 88 MB - M4AHippo PC RAP July 2018 Written Summary 362 KB - PDF