American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, February 5, 2015

Examining the annual exam

In last week's New York Times, Dr. Ezekiel Emanuel suggested that this year's resolution might be to abandon the ritual of your annual physical. The title of his column, perhaps chosen by an editor to maximize glibness and thus provocation, was: “Skip Your Annual Physical.”

But permit me to suggest you don't commit to that just yet. The annual physical exam warrants some more examination, a defense to follow its prosecution.

Dr. Emanuel is a knowledgeable and thoughtful source, and reliably on the side of the patient even while representing public health. He thus represents both an able and reasonable prosecutor. His case is built on rather prodigious precedent, namely opinions rendered (or not) by the Cochrane Collaboration, and the U.S. Preventive Services Task Force. The former is a non-profit research group devoted to generating and disseminating systematic reviews of important biomedical topics. The latter is a government commissioned group of experts empaneled to offer stringently evidence-based guidelines for all matters in the area of disease prevention.

As Dr. Emanuel damningly propounds, the first of these august bodies has inveighed against the annual physical. Specifically, the Cochrane Collaboration found, as Dr. Emanuel notes, no benefit of the annual check-up in randomized trials. The matter of who, exactly, would be willing to be randomized to either receive or avoid a check-up for years is not clear, but cause for rumination; as are the practices in general of participants in a randomized trial as compared to the population at large. Be that as it may, there was no benefit of the annual check-up related to morbidity or mortality, and the possibility of harm from over-diagnosis and over-treatment.

The second of these authoritative bodies, the USPSTF, may, I suppose, be cited for passive opposition. They have thus far failed to evaluate the annual check-up at all, and thus offer no recommendation in its defense. Their Canadian counterpart has, like Cochrane, opined against.

There the prosecution rests, leaving things looking admittedly bleak for the defendant.

The case against the annual check-up is based on data-driven scrutiny of what, exactly, it yields. The case is sound. The routine, annual exam is very unlikely to find some otherwise occult pathology. Consider the probability of finding some otherwise unsuspected disease in an apparently healthy person with a battery of routine lab tests at the time of a routine check-up. The enterprise makes playing the lottery look like responsible investing.

Further, I rather doubt medical training is required to know that the chances of detecting a lurking neurological disease by tapping on the patellar tendons of a person neurologically intact enough to run a household and a career, and stride with a normal gait into an exam room makes zero look like a big number. These are the glaring fallibilities of the routine check-up. There is no refuting them.

But there is a defense just the same. It has nothing to do with refuting the answers, and everything to do with questioning the questions.

What is the benefit, when we do get acutely ill, of having a doctor we know and who knows us be the one to get that 3 a.m. call and either turn up in the ER, or at least guide the decisions made? That's hard to measure, and to my knowledge has not been measured, but surely is not zero.

What is the value of the information exchange for which the annual check-up serves as an excuse, and perhaps in an apparently, thus far healthy person, the only excuse?

Those same authorities, Cochrane and Task Force, have found clearly in favor of smoking cessation advice by a clinician. When will a smoker who never goes to see their doctor get that counseling? They have found in favor of dietary and weight management counseling as well, at least in select circumstances; the same question pertains.

More robust evidence and stronger expert opinion favor blood pressure monitoring, cholesterol monitoring, various cancer screening, and certain immunizations. The immediate question is again: when will these be addressed in a healthy person if healthy people all skip their check-ups? The related and perhaps more important question is: will people do these things if never advised by a clinician they actually know and trust? The extent to which trust, or the unmeasurable elements of a doctor/patient relationship figure in the uptake of those preventive services which are highly recommended and irrefutably evidence-based is, to my knowledge, unassessed and unknown.

If, for instance, an annual reminder from a physician is part of the reason someone quits smoking, that won't show up on any spreadsheet as pathology discerned thanks to that encounter. Rather, there will be a blank space on some spreadsheet where a diagnosis of emphysema, or lung cancer might have gone. Sometimes it's what you don't find that matters most. In fact, in my field, preventive medicine, that's always true. Our successes are measured in things that don't happen.

The annual exam may be the only real opportunity for lifestyle counseling in a healthy person. It may, at least occasionally, be part or even much of the reason that person remains healthy over the years. But again, that won't show up as data in favor of the annual exam. It will only add to the tally of absent data. A bad outcome that doesn't occur for reasons that are hard to discern.

If the case against the annual check-up is that it performs poorly as a hunt for occult and unlikely pathology at any given time, it is guilty as charged. But if the case is that it contributes nothing to the prevention of pathology over time by a variety of indirect causal pathways, the case falls apart for want of evidence. We know the ways in which the annual check-up is not helpful and inefficient. We do not know what the harms would be of abandoning it.

I would argue, then, that glib dismissal is misguided. Rather, the safest and most promising option in the absence of answers to all relevant questions, is to optimize the annual exam, not discard it. There is no need for a battery of perfunctory procedures or ridiculously low-yield lab tests. But these could be replaced with a review of lifestyle practices and use of relevant preventive services; with time for pertinent, customized lifestyle counseling; and with attention to whatever happens to be on a patient's mind, building that very thing to which modern, evidence-based medicine may pay all too little attention: a relationship. A fundamental human connection.

As others have before him, Dr. Emanuel indicts the annual exam for the pathology it unnecessarily seeks, and predictably fails to find at a given time. But they in turn may be failing to consider that the annual reaffirmation of the doctor/patient connection may itself be a defense, and part of the reason some pathology isn't found in the fullness of time.

We can't say for sure, but that's my point. The case is not closed because, at best, we only have answers to the questions we have thus far posed.

See you next year?

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

Labels: , , , , , , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home

This is a printer-friendly version of this page

Print this page  |  Close the preview




Contact ACP Internist

Send comments to ACP Internist staff at

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

Powered by Blogger

RSS feed