I was approached by The Wall Street Journal to write an article for their Big Issues in Health Care debate series. The subject was “Is the annual physical unnecessary?” I was to take the “yes” side and an internist was to take the “no” side. I wrote the following article. The editor wrote me a couple of times with questions. The internist pointed out the value of preventive medicine, developing a personalized healthcare plan, and developing a meaningful doctor-patient relationship. I said I wholeheartedly agreed, but I thought those goals could be accomplished just as well (arguably even better) with a periodic health maintenance interview or consultation. I pointed out that the traditional “physical” exam with stethoscope, routine lab tests, etc. provides no further advantages and can be counterproductive, with false positive or harmless findings leading to unnecessary worry, further testing, and expense. I said there was nothing magical about the interval of a year. I don’t know what the optimum interval would be; that could be studied. I suspect it would vary with the patient’s age, medical conditions, risk factors, and other considerations, and might be left up to the judgment of patient and doctor deciding together.
Finally I got an e-mail with apologies, saying they had decided not to continue with the debate because the internist and I agreed on too many important details. While I understand that stirring up a fight is good for selling newspapers, I think it’s a much better thing when people on two sides of a debate reach an agreement. It reassures me that they are converging on the truth. So I thought it would be worthwhile to publish my article here on SBM. (more…)
Last week I wrote about doctors who order unnecessary tests, and the excuses they give. Then I ran across an example that positively flabbered my gaster. A friend’s 21-year-old son went to a board-certified family physician for a routine physical. This young man is healthy, has no complaints, has no past history of any significant health problems and no family history of any disease. The patient just asked for a routine physical and did not request any tests; the doctor ordered labwork without saying what tests he was ordering, and the patient assumed that it was a routine part of the physical exam. The patient’s insurance paid only $13.09 and informed him that he was responsible for the remaining $3,682.98 (no, that’s not a typo). I have a copy of the Explanation of Benefits: the list of charges ranged from $7.54 to $392 but did not specify which charges were for which test. It listed some of the tests as experimental and not covered at all by the insurance policy, and one test was rejected because there was no prior authorization. (more…)
Please note: the following refers to routine physicals and screening tests in healthy, asymptomatic adults. It does not apply to people who have been diagnosed with diseases, who have any kind of symptoms or signs, or who are at particularly high risk of certain specific diseases.
Throughout most of human history, people have consulted doctors (or shamans or other supposed providers of medical care) only when they were sick. Not too long ago, the “if it ain’t broke don’t fix it” mindset changed. It became customary for everyone to have a yearly checkup with a doctor even if they were feeling perfectly well. The doctor would look in your eyes, ears and mouth, listen to your heart and lungs with a stethoscope and poke and prod other parts of your anatomy. He would do several routine tests, perhaps a blood count, urinalysis, EKG, chest-x-ray and TB tine test. There was even an “executive physical” based on the concept that more is better if you can afford it. Perhaps the need for maintenance of cars had an influence: the annual physical was analogous to the 30,000 mile checkup on your vehicle. The assumption was that this process would find and fix any problems and insure that any disease process would be detected at an early stage where earlier treatment would improve final outcomes. It would keep your body running like a well-tuned engine and possibly save your life.
We have gradually come to realize that the routine physical did little or nothing to improve health outcomes and was largely a waste of time and money. Today the emphasis is on identifying factors that can be altered to improve outcomes. We are even seeing articles in the popular press telling the public that no medical group advises annual checkups for healthy adults. If patients see their doctor only when they have symptoms, the doctor can take advantage of those visits to update vaccinations and any indicated screening tests.