Let’s Get Physical: Or Not?

 The annual physical exam: dreaded by patients and physicians alike. Why? Confusion regarding expectations, fear of judgement, discomfort with poking and prodding. Surprisingly there is no definitive way to perform an "annual physical exam" and you'll notice, if you see multiple doctors, that each has an approach unique to their practice style. Some will focus on your history, others on physical findings, and some on evidence-based guidelines.

We've had a few questions of late regarding the "complete" annual physical exam, a practice that dates back to the dinosaurs and one that has been revised over and over again in the last decade. Patients will notice that younger physicians don't perform complete annual physical exams and may incorrectly interpret this as us being rushed or indifferent. This is not the case. Let me try to explain why our training discounts the annual physical exam to help clarify expectations; in addition, we will also try to make this clear during our patient encounters to ensure no confusion on the matter.

As Choosing Wisely Canada, a campaign to help clinicians and patients engage in conversations about necessary tests and treatments, states: "Don't do annual physical exams on asymptomatic adults with no significant risk factors." Indeed, studies show that the exam isn't very helpful in discovering problems and leads to unnecessary tests and stressors.

Then why do some doctors still do this? For some, it's routine or practice habits they've established and choose to continue employing. For some physicians, it's money. In fact, the billing codes in Alberta were recently changed preventing physicians from billing for more than one complete physical per patient per year because many were billing for them numerous times per year. A few of my preceptors over the years have told me they do physical exams only because otherwise patients complain they aren't touched at each visit and therefore, they choose to go through the motions to "keep them happy." To me, these are all poor reasons to perform an annual physical exam.

I prefer to think of the annual physical exam as a Periodic Health Check. This means that some years, I may require seeing a patient more often for health checks rather than annually. Some years, I may not require seeing them at all. It individualizes the practice rather than generalizes the method with the assumption that one size fits all. Our aim is prevention and screening. What does that mean? Well, we look at preventing illness versus treating it (e.g.: exercise, lifestyle habits, diet). Screening means we follow the evidence-based guidelines on significant tests to perform to prevent illness (e.g.: cholesterol check when you turn 40, FIT tests at 50, etc). All these guidelines are also individualized, however, based on your risk factors (family history, personal medical history, etc), and will take into consideration concerns you may have regarding your health. Some patients like to have certain tests performed annually for specific reasons (e.g.: breast exam because of a family history of cancer), despite what the guidelines suggest. Talk to your doctor and together make a plan for what you expect from your health check and what he or she thinks is valuable or not. It's a team effort and it may take a few attempts to get right, but together, you can come to a mutual agreeable appointment framework.

Team: this is also something we thought could use some clarification. Riverside Medical is based on a Patient Medical Home framework, which means we are a team of nurses, health care specialists, patient coordinators and physicians that work together to make each appointment as complete as necessary. This means sometimes you'll meet with a nurse first, or after, or another inter-professional member of the team. As we discussed in the Patient Medical Home blog post in July, we know from practice and studies that inter-professional systems are more effective and thorough in evaluating and treating patients. It helps keep us all accountable.

So do you need a yearly check-up? No. It's not considered best practice to do annual exams. Yet this doesn't mean you shouldn't see your doctor for long periods of time. A check-in appointment to touch-base on any life changes is always appropriate, especially if you have health concerns or a problem. Physicals may be a thing of the past, but as our society begins to focus more and more on mental health and wellness, a periodic health check that may prove therapeutic rather than physically driven will continue to grow in popularity.

I hope this helps clarify some of the questions raised. I've included the link to Choosing Wisely Canada, in case you're curious about the Eleven Things Physicians and Patients Should Question. Together we can become better informed and ensure we make smart and effective care choices.

https://choosingwiselycanada.org/family-medicine/