Your annual physical wastes time, money, some doctors say

Mary Ann Bauman, an internist in Oklahoma City, says she has a rule for her patients: “I tell them if they want to see me as their doctor, they have to come in once a year” for a checkup.  It’s a chance, she says, for doctor and patient to get to know one another, to fit in any tests that are due and to talk about everything from exercise habits to stress.

Zackary Berger, an assistant professor at Johns Hopkins School of Medicine in Baltimore, takes a different approach. “I like to see patients regularly," he says. "But when patients ask me ‘When should I see you next doctor?’ I say, ‘I’ll see you when you need to see me.’ “

The fact that patients are getting such differing messages on what was once an unquestioned pillar of medicine — the routine or annual checkup — is not surprising.

A debate over the value of such appointments has been gaining steam among physicians, with views pro and con appearing in major medical journals and in the popular press in recent months.

“Opinions are decidedly mixed,” Berger says. Under the Affordable Care Act, insurers must cover annual "wellness visits," and many U.S. medical groups take no official stand. But in 2013, the Society of General Internal Medicine put “routine general health checks” for healthy adults on a list of practices that are not recommended because they are not backed by studies. Berger leads a committee now reviewing that list.

The American Heart Association has no official position but will promote regular “well-woman visits” as part of its annual Go Red for Women heart health campaign in February. Bauman is an association spokeswoman.

What’s a health care consumer to think?

Here are some possible pros and cons of routine checkups (defined, more or less, as a head-to-toe physical exam, a few tests and some questions and counseling about your health habits – all done when you are not seeing the doctor for any particular problem).

Pros:
• They help build relationships between doctors and patients. “It means you are not going to a stranger” when you do get sick or have a problem, says internist David Himmelstein, a professor of public health at the City University of New York. That, he says, can result in more openness and better care. Bauman agrees: “There is a benefit to having someone who knows what’s going on with you.”
• They are chances to fit in proven screening and prevention practices. Those include such things as testing cholesterol, ordering timely mammograms and colon cancer tests and looking for signs of depression and alcohol abuse. There’s little time or inclination among rushed doctors or suffering patients to do all that when someone comes in for the flu, Bauman says.   
• They give all patients a reason to show up. Men, Hispanics and poor people are more likely than women, non-Hispanic whites and affluent people to go more than a year without seeing a doctor, according to research cited by Himmelstein in an editorial he co-wrote for the Annals of Internal Medicine. Discouraging annual physicals could increase gaps in care and prevention, he says.

Cons:
• Studies have found no evidence they reduce deaths or illnesses. While critics find fault with those studies —  saying they are outdated and not based on current U.S. medical practice — the studies are remarkably consistent in finding no significant benefits, says Ateev Mehrotra, an associate professor of health care policy at Harvard Medical School. He asks: “Do we want to have all 240 million adults in the United States doing something that isn’t evidence-based?”
• They sometimes harm patients. When doctors go looking for problems in apparently healthy people, they sometimes find things that look ominous but are harmless, Mehrotra says. The result: Some patients end up getting additional tests and treatments they do not need and that actually harm their health.
• They waste time. If physicians were not setting aside lengthy appointment slots to see their well patients, they would have more time to see sick patients, says Ezekiel Emanuel, an oncologist and medical ethicist at the University of Pennsylvania. Patient time is wasted, too, Mehrotra says.
• They waste money. About one-third of U.S. adults get a checkup in any given year, Mehrotra reported in a editorial  he co-wrote in the New England Journal of Medicine. Estimated cost: $10 billion. Continuing to spend those billions without strong scientific reasons "is not a responsible thing to do," Emanuel says.

Here’s something those on both sides agree upon: Relationships between doctors and patients are important and should be nurtured. Some doctors suggest that could be accomplished with less frequent visits or through other means — including increased digital communication. And the right mix may vary patient to patient, Berger says: "Hopefully, as a society, we are becoming a little more sophisticated than saying that we have to do the same thing for every Dick and Jane."