Redefining the Annual Physical

Dr Ezekiel Emanuel is not bashful about disrupting the status quo. In a recent op-ed in the New York Times,^[1] he suggested that healthy people should skip their annual physical exams. It's a lighter topic than his last essay,^[2] in which he wrote about hoping to die at age 75, but the idea of skipping preventive maintenance goes against medical dogma.

Dr Emanuel is correct. His reasoning highlights a core problem in American healthcare today: overdiagnosis, overtreatment, and the creation of misplaced fear.

It is important to make clear that my commentary and Dr Emanuel's refer to annual physical exams in patients without symptoms or disease.

Dr Emanuel points to a 2012 systematic review^[3] of 14 clinical trials involving 182,000 patients followed for a median of 9 years. This study revealed that well patients derived no benefit from an annual physical exam. Although the study was conducted in a different era and had other limitations, the findings are plausible and relevant. Dr Emanuel cites the obvious reasons: Annual checkups do not prevent many common causes of death, such as unintentional injuries and Alzheimer's; many important abnormalities are detected during sick visits; and screening very low-risk people simply does not work.

In theory, the annual physical exam could be beneficial. It could be, as Dr Gilbert Welch (Dartmouth Institute for Health Policy) suggests,^[4] a "check-in" rather than a "check-up." But it is not that way now. Patients think of annual physical exams as they do auto maintenance, whereas doctors hold strong to the wrong surrogate markers of health. We look for irregularities in lab values and ECGs, and shadowy ultrasound images, rather than belt sizes and scale readings. And both parties underestimate the durability and variability of the human species.

The recurring case that tells this story is the 90-year-old who presents with any acute problem. Someone invariably remarks that this man hasn't seen a doctor in 40 years. The inference, of course, is that a doctor could have inoculated him against age-related disease or bad luck. My take is that he lived that long, in no small part, because he avoided harm from us.

One of the lines that I use with patients is that the first rule of doctoring is that if a patient says she feels well, my main job is to not mess that up. Do no harm. Resist the urge. This has become no small thing in our medical system—which some refer to as a "machine."

Another (real) case reminds me of the children's book If You Give a Mouse a Cookie. An ECG is done during an annual physical on a patient with no complaints. The doctor notes a PVC (premature ventricular contraction). A stress test and echocardiogram are ordered. There are nonspecific "cannot rule-out" findings. Of course there are.

Now the well patient is worried. Fear has been created. Cardiology gets involved. "The stress test could indicate a blockage," says the cardiologist who would not have seen the patient if not for that lonely, asymptomatic PVC.

An emergency code is called to the cath lab. The guiding catheter somehow dissected the otherwise normal left main coronary artery. It is a known complication of cardiac catheterization. A formerly well patient is being rushed to the operating room. She is now decidedly unwell.

Herein lies the problem with preventive health maintenance. It is one thing to have a complication when treating an acute or dangerous condition. You don't like complications, but you were treating a sick person. You were trying to make her well. It didn't work but the odds favored action over inaction. You, and the sick patient, would probably make the same decision again.

It is a much different story when a well patient suffers a complication. That, in my mind, is the real never event in the practice of medicine. Taking patients who grade their health as an A and making them a D or F is the ultimate medical error. This is the risk of preventive maintenance: Once in the machine of healthcare, it is hard to get out.

It Doesn't Have to Be This Way

It doesn't have to be this way, but change will be hard. It means adjusting how we think about health, healthcare, and the role of patients and doctors. I see three changes of philosophy that must occur:

Health does not come from healthcare. First is the understanding that health does not come from healthcare. It comes from basic things: good food, good exercise, good sleep, good attitude, and good luck. Caregivers cannot do these things for people. We can advise, teach, and support but we cannot stop someone from eating cookies. Professional caregivers are not patients' mothers. And we worsen lifestyle-related diseases when we accept drugs and procedures as replacements for healthy choices.

Fearing the right thing. The second change of thinking involves adjusting what we fear. Rather than being fearful of not detecting disease, both patients and doctors should fear healthcare. The best way to avoid medical errors is to avoid medical care. The default should be: I am well. The way to stay that way is to keep making good choices—not to have my doctor look for problems. I will see my doctor if I have a problem. I will see my doctor to ask questions. I will check in with my doctor but I have no need for a check-up.

Understanding the human condition. The third change will be the hardest. It entails a better understanding of the human condition. Take heart rate, for example. The damage done to humans in the name of asymptomatic low heart rates is immense. There is the misplaced fear that the heart will stop. That leads to consults and tests. Abnormalities are discovered, catheters are inserted, and pacemakers are implanted. The problem, of course, is that the Spanish cyclist Miguel Indurain won the Tour de France five times with a resting heart rate of 28!

My point is that humans come in infinite shapes and sizes. The challenge of future doctors and futurists will be to resist the urge to make disease when there is none. And this will only get harder as technology seeks to digitize more and more of humanity.

Health surrogates of the future should be measured against these basic five factors:

• How a patient (not doctor) grades her/his health;

• How often (s)he smiles;

• How much (s)he weighs;

• The circumference of her/his belt; and

• How well (s)he moves.

Does any person need an annual physical exam to know these things?

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