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.
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.
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.
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.
Physicals aren’t useless. They’re a critical component when we evaluate a wide range of disease processes such as appendicitis, kidney infections, or strokes. Nor am I advocating we get rid of primary care physicians, or even that we not talk to them for, say, 20 minutes every year or two. But the experience should be different.
I’ve been watching what this new world might look like every day from my kitchen, and I think patients will ultimately prefer it. My wife, a cardiologist, hasn’t physically touched one of her clinic patients in over a month, instead meeting them via video chat. The adjustment, she says, has been surprisingly easy and oddly liberating for both her and her patients. In particular it levels the patient-doctor dynamic. No one wears a white coat or a skimpy, ill-fitting gown. Her patients sit from their kitchen table and have a conversation with their cardiologist wearing a comfortable sweater, seated at her kitchen table.
It’s going to be hard to break the annual physical habit. There is an iconic history to this form of patient-doctor interaction, harking back to a time when technology was nonexistent and the “art” of medicine was steeped in clinical exam skills. The annual physical became routine in the 1920s when pre-employment and insurance physicals became synonymous with health maintenance and disease prevention. Today, many patients view their annual checkup as something akin to getting their car serviced: a time-consuming, expensive but necessary hassle. Others see comprehensive exams as an indicator of quality care.
Many physicians themselves deem these encounters to be foundational to engendering trust between doctors and patients. There are also financial incentives. Reimbursement often depends on the number of organ systems examined. We get paid more if we examine the heart, the lungs, the ears, eyes, nose, throat, lymph, and vascular systems. We get much less if we put a pulse oximeter on your finger, check your blood pressure, and have a conversation about your diet and weight.
In an evidence-based world, driven by outcome metrics and scrunched by economic and capacity challenges, the routine physical feels anachronistic. For example, to diagnose a kidney infection, I need to ask about urinary symptoms, check for flank tenderness, and perform an urine test. I don’t need to listen to my patient’s lungs, look in his mouth, or check his leg and arm reflexes. I’d have a much better chance of catching an unmentioned medical problem by spending a few more minutes asking my patient questions about his overall health. We’ve continued to do complete physicals because inertia is a powerful thing. Patients expect them. And until Covid-19, not doing them required an explanation. Add Covid to the mix and this time-honored practice seems downright dangerous.
How do doctors in other countries think about the annual physical? Most don’t. In Britain, checkups are often referred to as MOTs (ministry of transport, the periodic safety check required for all vehicles) and occur only every five years. Germany encourages visits with a primary care provider every two years, although less than 50 percent of patients adhere to this recommendation. The Netherlands and Australia use a more targeted approach, reserving routine screening only for “high risk” groups and ages.
As we contemplate our iterative return to “normal,” we need to accept that normal doesn’t mean “same.” The move to more remote and virtual health care delivery is inevitable. So is the recognition that the routine physical exam offers little beyond serving as a pretext for doctors and patients to meet. The advent of wearables, home automatic blood pressure cuffs, pulse oximetry devices, video calls, etc. will bolster unlinking care from in-person visits to doctors’ offices and clinics. Economic incentives must follow suit by rewarding health care conversations and outcome metrics above physical exams and interventions.
While we may all be feeling a fair bit of nostalgia for what we have lost in this pandemic, I predict that few among us will regret the demise of the routine physical with all its indignities, hernia exam included.
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