Editorial

The Annual Physical Examination: Needless Ritual or Necessary

Routine?
I magine that a 45-year-old married, premenopausal
woman with no chronic or acute medical problems,
unremarkable family history, normal cholesterol level 2
uled annual examination toward recommending selected
preventive services in the context of visits for other rea-
sons (1, 6 – 8).
years ago, and no tobacco use presents to you requesting Clearly, a powerful desire to remain well underlies
an “annual physical.” You ask whether she drinks alco- the public’s belief in annual examinations. People who
hol, feels depressed, or has HIV risk factors. She does periodically “check in” with a physician are taking pos-
not. Your assistant has recorded the patient’s blood pres- itive action toward maintaining their health. Americans
sure (normal) and weight (10 lbs over ideal). You exam- are accustomed to periodic checkups for their cars, so
ine the patient’s breasts and pelvis while counseling her why not for their own bodies? Evidence suggests that the
to lose 10 lbs, wear seatbelts, take calcium, and visit a more thorough physicians are (that is, the more physical
dentist regularly. As you leave the room, you tell her to and laboratory examinations they perform), the better
come back in 3 years unless the Papanicolaou smear is patients feel about their health and their physicians (9).
abnormal or she experiences new symptoms of concern. Laboratory tests, even those that are not indicated, may
Would this patient feel well cared for? Probably not. help patients feel better (10). Some evidence suggests
More likely, she would feel like a virtual stranger had that patients who do not get the tests, procedures, or
just pried into her private life and into her body. Yet, referrals that they expect are less trusting of their physi-
you would have completed a periodic health examina- cians and more likely to seek care elsewhere (11). Pa-
tion that fully adheres to preventive health guidelines tients leave annual examinations, perhaps especially
(1). Unfortunately, this patient has not read the guide- those that include tests, with a sense of well-being and
lines. She expected you to listen to her heart and lungs, with advice about how to foster good health until the
but you did not. She expected “blood work,” but you next examination. Annual examination is an important
did none. She expects to see you yearly, but you told her ritual for many.
not to come back for 3 years. The fear of becoming ill and facing complex medi-
In this issue, Oboler and colleagues (2) present evi- cal decisions without the benefit of a familiar physician
dence showing that many Americans are unfamiliar with may also motivate the public’s desire for annual exami-
prevention guidelines. Of 1203 surveyed adults, 66% nation. Regularly visiting one’s physician when well de-
believed in the necessity of annual physical examination. creases the chances of having to seek care from a stranger
Furthermore, when Oboler and colleagues compared the when ill. Imagine a 55-year-old woman who has no
desired services with those that the U.S. Preventive Ser- established relationship with a physician and develops
vices Task Force recommended in 1996, large propor- rectal bleeding. This patient finds herself with colon
tions desired the yearly performance of many physical cancer, thrust into the care of a stranger. Annual physi-
examinations (for example, of the heart and lungs) and cal examinations might have provided her with the op-
laboratory examinations (for example, urinalysis and portunity to establish a relationship with a physician
chest radiography) that the Task Force does not recom- before needing to grapple with life-threatening illness.
mend. Moreover, yearly preventive health visits might have
Since the British physician Horace Dobell first ad- spared her cancer by providing her with the opportunity
vocated annual examination of apparently healthy peo- for screening and polypectomy.
ple (3), patients have come to believe in the value of Guidelines advocate the provision of screening
annual contact with a clinician. The medical profession within the context of visits for other reasons, but this
has gone from resisting to enthusiastically supporting to strategy often fails. When Sox and her colleagues (12)
carefully reconsidering the value of the annual examina- studied 2775 primary care patients older than 42 years
tion (4, 5). Since the late 1970s, North American pre- of age who had visited their physicians at least once in
ventive task forces have moved from advocating sched- the previous year, the strongest determinant of receiving
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Editorial The Annual Physical Examination

cancer prevention services was having had a specific visit nurturing patient–physician relationships. If careful
for a periodic health examination during the previous study documents that patients who get annual examina-
year. Similarly, Kottke and coworkers (13) found that tions feel better, behave healthier, undergo more appro-
patients who were candidates for preventive services at priate screening, and trust their physicians more than
the index visit more often received indicated services if patients who do not have annual examinations, skeptics
the visit was designated for physical examination than would need to reconsider the value of this yearly ritual.
for another reason. Another study revealed that fewer Third, we need to figure out how often we need to see
than one third of visits for illness included the delivery patients to help them feel well cared for and keep them
of any preventive service (14). In a study of compliance from falling through the system’s cracks. Last, if low-
with Canadian prevention recommendations (15), tech maneuvers, such as listening to patients’ chests, en-
screening was more complete for patients who had pe- gender patients’ confidence, we might consider includ-
riodic health examinations than for patients who had ing them in periodic health examinations despite their
opportunistic screening. lack of proven benefit on more tangible outcomes.
The annual examination carves out a time and place After seeing a physician, my grandmother would
for prevention. In this issue, Stone and colleagues (16) routinely gripe, “All he did was talk to me. He didn’t
report a meta-analysis of studies of strategies for improv- take his stethoscope out of his pocket or draw a drop of
ing adherence to adult immunization and cancer screen- blood!” Was Grandma missing something of value? The
ing guidelines. Interventions that involved organiza- regular laying-on of hands and stethoscope (and maybe
tional change powerfully increased the use of preventive phlebotomy needle, too) is not a needless ritual if it
services (adjusted odds ratios ranged from 2.47 to 17.6), fosters trusting clinical relationships and ensures that
patients receive effective counseling and preventive in-
and planned visits for prevention were potent compo-
terventions. Annual examinations provide the opportu-
nents of these interventions. It is becoming increasingly
nity to plug cracks in the system and assure that patients
clear that acute care visits leave little time for effective
are getting indicated preventive care. While some say
preventive care and counseling. The medical profession
that we should abandon annual examinations and
has recognized the value of relegating pediatric preven-
squeeze prevention into visits for other reasons, patients
tion issues to “well-baby” visits. During such visits, par-
implore us not to.
ents and physicians are primed to address issues related
to health promotion rather than being preoccupied with
Christine Laine, MD, MPH
issues related to health restoration. Why shouldn’t the
Senior Deputy Editor
same be true for well adults?
Given the gap between patients’ enthusiasm for and Current Author Address: Christine Laine, MD, MPH, American
guidelines’ skepticism about annual head-to-toe exami- College of Physicians–American Society of Internal Medicine, 190 N.
nations, what are physicians to do? First, we must edu- Independence Mall West, Philadelphia, PA 19106; e-mail, claine@
cate patients about preventive practices of proven and acponline.org.

unproven benefit. Patients familiar with the guidelines Ann Intern Med. 2002;136:701-703.
and their rationale may be less likely to seek unnecessary
care and more satisfied with visits that include only
evidence-based services. If patients are not checking in References
annually, they must know when to check in and for 1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services:
Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore: Williams
what. Second, we must call for careful investigation of & Wilkins; 1996.
the annual examination’s impact on difficult-to-measure 2. Oboler SK, Prochazka AV, Gonzales R, Xu S, Anderson RJ. Public expecta-
outcomes, such as patients’ health perceptions, health tions and attitudes for annual physical examinations and testing. Ann Intern
behaviors, and receipt of guideline-recommended pre- Med. 2002;136:652-9.
3. Dobell H. Lectures on the Germs and Vestiges of Disease, and on the Preven-
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the U.S. guidelines have given evaluative weight to these Churchill; 1861:142-63.
and other objectives of annual examinations, such as 4. Han PK. Historical changes in the objectives of the periodic health examina-

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 The Annual Physical Examination Editorial

tion. Ann Intern Med. 1997;127:910-7. [PMID: 9382370] [PMID: 11903773]

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How are patients’ specific ambulatory care experiences related to trust, satisfac- © 2002 American College of Physicians–American Society of Internal
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