Physicians examine the role of annual checkups in prevention

Preventive health or gynecological examinations are designed to be a time for physicians to check with patients, discuss preventive measures and conduct necessary tests -- all in the name of disease prevention.

However, research is raising questions about whether annual physicals -- the most common reason patients visit the doctor's office -- serve as much of a preventive role as once thought.

"Some have argued that preventive exams are the only time that preventive care is happening, and our findings are contrary to that assumption," said Ateev Mehrotra, MD, MPH, who examined the issue of preventive health exams and preventive gynecological exams in a study in the Sept. 24, 2007, Archives of Internal Medicine.

Dr. Mehrotra said he was surprised to learn that 80% of preventive care, such as cholesterol screenings and weight loss counseling, occurred at visits other than annual checkups or yearly trips to the gynecologist.

"It was contrary to what I believed," said Dr. Mehrotra, who was taught to recommend that patients schedule annual physical examinations, although his training in evidence-based medicine did not support that recommendation.

About two-thirds of physicians and patients believe patients should have annual physicals.

If all patients had physicals, those visits would account for 41% of primary care physicians' direct patient time, the study said.

"We don't have the work force to do that," said David Dale, MD, president of the American College of Physicians, noting that the role of the annual physical has been an ongoing issue for physicians. "It has been a topic for the 40 years I've been in medicine."

He did not view the study as saying annual physicals are not valuable, rather their value is difficult to prove. Preventive care, by nature, is hard to define, he added.

"There's hardly ever a true preventive visit," he said.

For example, patients who come in feeling fine usually have a problem or issue to discuss with their doctor.

Likewise, some part of every visit includes elements of both prevention and treatment.

However, one should not underestimate the value of yearly physicals, Dr. Dale said.

"We are all better to have a doctor who's on the lookout for our health problems, even if it's a brief visit once a year. That seems worth it to me," said Dr. Dale, a Seattle internist and professor of medicine at the University of Washington.

An ounce of prevention

The Archives study said 64 million Americans receive preventive physical and gynecological exams each year at a cost of nearly $8 billion. The study based its findings on 8,413 ambulatory visits from January 2002 to December 2004 obtained from the National Ambulatory Medical Care Survey and the outpatient component of the National Hospital Ambulatory Medical Care Survey.

Researchers examined the timing of eight preventive or counseling services, including discussion of weight loss, nutrition and smoking cessation, as well as cholesterol testing, mammograms and Pap smears for women and prostate testing for men.

These visits frequently included preventive services, but most preventive care was provided during other visits, the study said.

A high proportion of gynecological exams are integrated in other services and visits, said Herbert Peterson, MD, professor and chair of the department of maternal and child health at the University of North Carolina at Chapel Hill.

"It's critically important that these services are put into practice," Dr. Peterson said. The question is, "How do we do that?"

Internist Douglas K. Owens, MD, a professor of medicine at Stanford University School of Medicine in California, agrees.

"The debate is not about whether preventive services should be done," said Dr. Owens, also a senior investigator at the VA Palo Alto Health Care System. "The issue is how and when. Do you need to do it during an annual exam?

"My personal view is that it depends on the patient and the practice," Dr. Owens said.

There should be more standardized practices for what happens during preventive exams and when they should be scheduled, said Dan Merenstein, MD, director of family medicine research at Georgetown University Medical Center in Washington, D.C.

But not every patient needs the same battery of tests, he added.

For a 25-year-old male, it may be poor medicine to order several tests. Instead, the time may be better spent talking about risk factors.

"You don't need to do a thousand labs," he said.

However, the needs of a 55-year-old patient may be the opposite, Dr. Merenstein said.