The Annual Physical

     There has been much written lately about the utility or non-utility of the annual physical exam and its associated tests. There have been articles in the New York Times, the Annals of Internal Medicine and the Journal of the American Medical Association, as well as statements by the National Institutes of Health, the American College of Physicians, the American Academy  for Family Practice the Canadian Medical Society, and various other organizations. Since there has never been an overall consensus, the reading public is left confused and thrown back on its own resources and preconceptions.

     Firstly, what do we mean when we say that an annual physical exam is "beneficial" to the patient? The answer to that question depends in part on who we ask, and in part on how we measure "beneficiality". Do we ask the opinion of the patient, the doctor, a medical organization, a patient organization, an insurance company, or the government? Is an annual physical exam and its associated tests beneficial if it saves the patient's life,  or if it reduces future morbidity, or if as a result  the patient functions with more physical and/or mental energy? And what of the sense of well-being that a patient feels when he/she is told that the results of the annual exam were perfectly normal? Do we discount that feeling because there is no way to measure and quantify it? Isn't there  value in reassuring a patient that his/her aches and pains are not the symptoms of a serious disease? What if the meat of the annual exam lay in one question that the physician answered for the patient, or one medical misconception that the doctor cleared up and thereby enabled the patient to avoid a future medical problem?

     In previous blogs I have listed questions that should be asked at the annual physical, and which tests I think are medically beneficial and which are not, along with my reasons for the tests. One could make a case that just making sure that the patient received an annual flu shot is enough reason for an annual physical. One could also make a case for measuring blood pressure, since there is plenty of clinical evidence that treating hypertension with a regime that includes a diuretic reduces the patient's risk of a cerebral stroke. There is also an argument for annual testing for infectious diseases that can be treated, such as tuberculosis, syphilis and AIDS. What of the benefit to society when I ask a patient if he/she has trouble reading street signs at night while driving, and then suggest seeing an ophthalmologist if the answer is "yes"? I gloss over the obvious comments a physician would make to the patient about losing weight, stopping smoking and getting more exercise (although a recent study showed that 10% of the patients who exercise damage their health by doing so, two studies  published in Lancet showed that overweight people with a BMI between 26 and 29 had better odds of surviving a heart attack, and two European studies demonstrated that smokers have a reduced incidence of Parkinson's disease). And should I encourage teetotalers to have a daily glass of wine since every study shows that this nutritional intervention improves mortality?

     One fact that is never mentioned in all the discussions of annual physicals is state law: in every state it is a violation of "good medical practice" for a doctor to renew a prescription if the patient has not been seen  within the previous 12 months (and more frequently for DEA-controlled drugs, which includes sleeping pills and tranquilizers). By age 40 almost every patient is taking at least one prescription drug, and therefore needs to be seen annually. And for those only taking over-the-counter supplements, their regime should also be reviewed annually to keep them from consuming OTC drugs that might be harmful----e.g. we now know that daily doses of Vitamin E increases your risk for having a heart attack.