Tech

Let’s Put an Finish to Annual Physicals

The doctor looked in my ears, shined a light in my eyes and mouth, and listened to my heart and lungs with his stethoscope, before ending the exam with this: “Turn your head and cough, sir.” I did what I was told, but the whole experience felt absurd. This wasn’t a physical I’d scheduled or wanted. And the last time any doctor had asked me to turn my head and cough—a hernia exam—Nixon was president and I was 12, in my skivvies along with 30 other boys, lined up in a cold Michigan gymnasium, getting cleared for basketball.

The exam was required because the hospital, where I’ve worked as an emergency room physician for 30 years, had just acquired my physician group. I and 100 colleagues were technically new employees, necessitating pre-employment physicals. It didn’t matter we are in the middle of a pandemic.

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Dr. Eric Snoey is vice chair for emergency medicine at the Alameda Health System—Highland Hospital in Oakland, California, and a clinical professor at UC San Francisco. He specializes in cardiovascular emergencies and bedside emergency ultrasound.

I’d have probably let the whole thing roll off my back. But I had a shift in the emergency room later that day, and I couldn’t avoid playing it back as I saw my first patient, a 40-year-old who probably had Covid-19, complaining of a cough and a low-grade fever. She didn’t get a physical exam, nor did any of the dozen “likely Covid-19” patients I saw that evening.

We had to speak just below a yell to overcome our physical distance and the constant din of the portable air-filtering machines. As I listened to her story, my focus turned to her breathing. What was her respiratory rate? How many words could she get out before needing a breath? She coughed occasionally but her oxygen saturation showed 94 percent; not normal, but adequate. The fact that her voice sounded strong and her breathing unlabored, especially through the mask and noise, told me she wasn’t sick enough to require hospitalization. I explained how to self-isolate, how to spot more serious symptoms, printed up her paperwork, and discharged her home.

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What I realized the next day was that, thanks to Covid-19, this had been my life—and my colleagues’ lives—for six weeks. Physical exams have been way down for all of us. Yet none of us felt like that’s hurt patient care. We’re avoiding physical contact with our patients as much as possible, and still doing our jobs thoroughly and getting patients the care they need. And it turns out that with tools like pulse oximeters, automatic blood pressure cuffs, good questions, and an experienced eye, most of the physical examination is superfluous. I used to never be without my stethoscope. Now it sits at home gathering dust—one less thing to disinfect.

Among the many aspects of medicine that may change after the pandemic, I hope that one of them is that doctors and insurance companies stop urging us to get annual physicals.

This may sound radical to my non-physician friends. But it’s less and less radical among doctors. Even before Covid, many health care systems like Kaiser were moving away from in-person checkups in favor of remote or episodic care while addressing health metrics and lifestyle modification through education and evidenced-based screening like Pap smears, mammograms, colonoscopies, and blood pressure checks. Medicare offers a “Welcome to Medicare” visit. But the only recommended physical examination elements are blood pressure, weight, height, and vision.

In 2019, the Cochrane Collaboration, an international group of medical researchers who systematically evaluate the world’s biomedical research, took up the topic of routine, general health checkups. Reviewing 17 studies that followed a combined 251,000 people for a median of nine years, they came to the unequivocal conclusion that routine health checkups and their accompanying physical exams had virtually no impact on overall health or longevity. This effect included disease categories thought to be most sensitive to preventive care, such as cardiovascular, stroke, and cancer mortality.

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There was also evidence that such encounters might be harmful as a significant driver of unnecessary testing and treatment, and that it had a high opportunity cost. A physical, the study found, rarely gave the physician information he or she wouldn’t have gotten with a pulse oximeter, a blood pressure check, and the most important part of seeing one’s primary care doctor—a simple conversation about health.

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