My husband hasn't seen a doctor in at least five years. His last visit came when I insisted on taking him to the emergency room for help extracting a shard of wood he'd accidentally stepped on. Dave, a former athlete in his early 40s, is a fit, healthy nonsmoker. He's never had an annual physical, and he doesn't see any need to start now.
Once upon a time, an annual physical was just something you did if you cared about your health (and had the insurance to pay for the exam). But a recent review by researchers at the Nordic Cochrane Centre in Copenhagen suggests that my husband's "wait for a reason" approach may be perfectly wise.
Researchers examined the most rigorous studies they could find (14 in all) comparing people who received so-called general health checks and those who didn't, some 182,000 people in all. Their analysis found that routine medical exams failed to reduce overall deaths, disease-related deaths, hospitalizations or costs.
The Cochrane review isn't the first to question the effectiveness of the annual exam. A 1979 Canadian panel convened by the government concluded that "the routine annual physical examination should be discarded in favour of a selective plan of health protection packages appropriate to the various health needs at the different stages of human life." The U.S. Preventive Services Task Force does not advise for or against annual exams; instead, it makes age-specific recommendations about which screening tests you need and when, says Michael L. LeFevre, a physician at the University of Missouri and co-vice chair of this independent group of national experts.
Even without formal recommendations, many Americans continue to see their doctor once a year, whether they have symptoms or not. The 2009 National Ambulatory Medical Care Survey showed that general medical exams were the No. 1 reason people visited their doctors.
The annual physical became popular, in part, because it seems so logical that a regular exam might catch medical problems before they get out of hand, says Ateev Mehrotra, a health policy researcher and physician at the University of Pittsburgh School of Medicine. But given the lack of evidence that the yearly ritual improves health, he says, "my own view is that the medical community should no longer encourage patients to receive an annual physical."
It's not just that these exams are unlikely to help the patient, Mehrotra says. They come with potentially serious downsides, too.
For patients, the negatives include time away from work and possibly unnecessary tests. "Getting a simple urinalysis could lead to a false positive, which could trigger a cascade of even more tests, only to discover in the end that you had nothing wrong with you," Mehrotra says.
There's also potential for false assurance that everything is okay, which may lead people to ignore or minimize new symptoms. "You may come in and have a completely fine bill of health, and three months later you develop leukemia," says physician Christine Laine, editor of Annals of Internal Medicine. "Unfortunately, we can't prevent that from happening."
When you go in for a physical, the doctor checks for things that are common and easy to screen for, but there remain plenty of other conditions that lack a good screening test, and there are others whose outcomes aren't improved by identifying them earlier, Laine says.
Mehrotra says that annual physicals also are straining the medical system. "We're spending 12 percent of our primary-care time on something that has no evidence to support it." Primary-care doctors are in short supply. "If physicians stopped doing annual exams and used that time to accept new patients, it would greatly alleviate the problem."
But that's unlikely to happen soon, he says, because so many health-care plans create a financial incentive for physicians to provide annual exams. "As a society, we're spending about as much money on annual exams as we are on breast cancer. That's a tremendous amount of money for something with no evidence base," Mehrotra says. He's particularly alarmed that Medicare recently introduced an annual wellness exam, because health plans are required to cover the same range of preventive services as Medicare. "This perpetuates the myth that the annual physical is important," Mehrotra says.
But, says Sung T. Kim, a family physician at the Inova Medical Group in Centreville, Va., the annual exam isn't just about improving the patient's health; it's also an opportunity to foster the doctor-patient relationship and a chance for him to check on a patient's mental health. He recommends annual physicals for his patients: "It's a chance to spend quality time together. We can discuss all the things that are recommended from a prevention standpoint." Kim routinely sees cholesterol readings that change from year to year and blood pressure that's gone up between one annual physical and the next.
"When they come in for an acute visit, a lot of times we can only focus on that problem. An annual visit allows me to take time to spent that extra 10 or 15 minutes really talking," Kim says. "When we don't see a patient for two or three years, there could be a lot of things we are missing in the interim."
Some people don't want the responsibility of keeping tabs on their prevention needs, Laine says. "It takes a very organized patient to realize, 'Oh I haven't had my blood pressure checked in four years, maybe it's time.' " So a regularly scheduled doctor visit can ensure that a patient remains on track, but every 12 months is probably too often for many people, she says.
How often you see the doctor should depend on your age and your health status. A 25-year-old male in good health probably doesn't need to see a doctor more than every five years. But as you get older, or if you're taking medications or managing a chronic condition such as high blood pressure or diabetes, you might need to see the physician even more than once a year, LeFevre says.
I stopped seeing my doctor annually after the Preventive Services Task Force changed its recommendations on women's health screenings. Where it once advised yearly Pap smears for women of reproductive age, the panel and the American Cancer Society now recommend them once every three years for women older than 21 or every five years if done in combination with the HPV test for women older than 30. At 40, unless I develop unusual symptoms, there's no need for me to go in more often than that, LeFevre says.
What about my husband? Should I nag him to see a doctor, or can he wait until he needs his next screening exam?
Mehrotra says that given his health status, he's okay — for now. "If he doesn't smoke and isn't at risk for any major diseases and he's up-to-date on the screenings recommended by the task force, then I don't see a critical need for an exam."
On LeFevre's advice, I went to www.healthfinder.gov to get a list of government recommendations for someone of my husband's age and health status. Turns out that he's due for a blood pressure check (every two years for men his age) and a cholesterol screening (recommended every five years for his age category). But he may evade the doctor's office yet, since these are tests he can get at our annual community health fair, without a formal visit to a doctor.