Arguing for and Against the Annual Physical

Two Harvard Medical School professors debate the merits of the annual physical in editorials published in New England Journal of Medicine.

Harvard Medical School professors Ateev Mehrotra, MD, MPH, and Allan Gorroll, MD, debate the worth of the annual physician examination in editorials published in the New England Journal of Medicine.

Dr Mehtrotra wrote that reducing the use of annual physicals saves time and money, as they are the single most common reason patients seek care, and cumulatively these annual physicals cost more than $10 billion per year. And with the use of these visits reduced, primary care physicians will have more time for other issues.

“Approximately 10% of all visits with primary care physicians are for annual physicals, which might be crowding out visits for more urgent health issues,” Dr Mehrotra wrote. “Poor access to primary care has been cited as one reason why patients seek care in emergency departments for low-acuity conditions.”

However, Dr Gorroll argued that the annual physical should be improved rather than eliminated and discussed the importance of the physical in creating a trusting relationship between the physician and the patient.

“Time and continuity are clearly in short supply in primary care, yet both are critical to establishing and maintaining a trusting doctor—patient relationship,” he wrote. “There needs to be sufficient time for an unhurried inquiry into the aspects of a person's life (work, personal relationships, family issues, financial pressures) that can affect health and well-being.”

Overall, though, the 2 doctors are not completely on opposite sides of the spectrum. For instance, Dr Mehrotra recommended a new type of visit that establishes relationships, focused solely on determining the patient’s medical history and social situation.

As for the actual physical itself, he recommends a change in the approach to ensuring preventive care is up to date through active surveillance with electronic health records, online health risk assessments, and delivery of preventive care at any type of healthcare encounter. Lastly, he said health plans and federal payers should no longer reimburse for annual physicals.

“Eliminating the annual physical might appear contradictory to our health care system's increased attention to prevention,” Dr Mehrotra concluded. “Indeed, Medicare just began reimbursing for the annual wellness exam in 2011. But it is evidence-based prevention that's key, and the annual physical is not evidence-based: research has demonstrated both its minimal benefit and potential harms.”

In his call for improving the annual physical, Dr Gorroll views the multidisciplinary team-based approach as one possibility to free the physician from the more routine aspects of screening, prevention, data collection, and recording. For patients with active medical problems, the annual physical would actually become “the annual health review, he wrote,” while low-risk patients could have more than a year pass between such visits.

“Pending advances in measurement science that permit better assessment of the effects of relational elements of doctoring, it seems reasonable for physicians to redouble their efforts to build meaningful relationships that can be trusted and sustained, particularly at a time when patients are encountering an increasingly problematic delivery system,” Dr Gorroll concluded.