What does the public want in an annual check-up?
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* John Hoey

**Oboler SK, Prochazka AV, Gonzales R, Xu S, Anderson RJ. Public expectations and attitudes for annual physical examinations and testing.** ***Ann Intern Med***** 2002;136:652-9.**

Background: Ever since the Canadian Task Force on the Periodic Health Examination stated in 1979 that the annual check-up could be replaced by a few evidence-based clinical manoeuvres aimed at detecting specific illnesses, physicians have been urged to abandon making appointments for annual check-ups with their patients.1 However, physicians continue to schedule such appointments and carry out examinations and laboratory tests that carry grade D and E ratings by the task force.2

Question: What is the public's perception of the need for and content of an annual physical examination? Would having to pay for it out-of-pocket alter the public's expectation?

Design: In 1997 (phase I) and 1998 (phase II), telephone surveys were conducted of English-speaking adults living in Denver, Boston and San Diego. In phase I, 603 Denver residents were surveyed on their desire for and content of annual examinations; in phase II, 600 participants (205 in Denver, 186 in Boston and 209 in San Diego) underwent a similar survey that also determined their willingness to pay.

Results: Of the 1203 respondents 66% believed that, in addition to regular care, an annual physical examination is necessary. When asked what they wanted in such an exam, more than 90% desired blood pressure measurement and examination of the heart, lungs, abdomen, reflexes and (in men) prostate. Only 89% of women expected a breast examination and 78% a Pap smear.

Regarding tests, 92% of the respondents in phase I expected their cholesterol to be measured, and over 80% expected tests to measure their glucose and hemoglobin concentrations and their liver, renal and thyroid function. Fecal occult blood testing (a manoeuvre recommended by the task force) was expected by only 58%, whereas 78% expected urinalysis (not recommended by the task force). Annual chest radiography was desired by 36%.

In general, information about charges provided in phase II significantly decreased respondents' desire for an annual physical examination and for specific tests. The proportion of respondents who wanted an annual physical examination dropped from 63% to 33% if they had to pay for it (US$150). Similar decreases were observed when respondents who wanted specific tests were informed of the charges (all in US dollars): Papanicolaou smear ($150), from 75% (without knowledge of charges) to 38%; mammography ($160), from 71% to 38%; and prostate-specific antigen test ($50), from 66% to 43%.

Commentary: In an editorial accompanying the research article, Christine Laine describes the hypothetical case of a 45-year-old married woman with no chronic or acute problems who presents to her evidence-based practising physician requesting an “annual physical.”3 He reviews her blood pressure (normal), and while examining only her breasts and pelvis tells her to remember to wear a seatbelt, to take calcium, to visit a dentist regularly and to come back in 3 years if the Pap smear is normal, as expected. Would this patient be satisfied with the visit? Perhaps not. Which might explain why many physicians continue to perform annual examinations of patients' hearts, lungs, abdomens and even reflexes and continue to order some of the tests that have been proven ineffectual or even harmful.

As Laine points out, there is more to the annual check-up than the early detection and diagnosis of specific diseases. Many patients apparently need to form and maintain a therapeutic relationship with a physician that is based on trust and confidence. This takes time and some evidence that the physician does indeed care about them and has knowledge of their state of health. As most physicians schedule longer appointments for the annual examination, the additional time, while building trust and confidence, almost surely allows for some (un)necessary diagnostic probing and actions. Should such placebo clinical manoeuvres be encouraged? Probably not. But we do need to consider other benefits of the annual check-up such as maintaining a better sense of well-being and having patients who are more likely to follow advice about weight loss, diet and exercise. 

Practice implications: It is clear that patients have not adopted or are even aware of task force recommendations. But rather than performing unnecessary (and sometimes contraindicated) physical examinations and laboratory tests during an annual visit, perhaps physicians should spend some of the time saved by telling their patients why they are not examining their abdomens, hearts and lungs. As well, the various expert task forces might wish to broaden their target audience for education beyond health care professionals to include the general public. Finally, we need to look more closely at the benefits of an annual visit to a physician, a visit whose value could be more than the sum of its parts.

**John Hoey** *CMAJ*

## References

1.  1. Canadian Task Force on the Periodic Health Examination. The periodic health examination. CMAJ 1979;121(9):1193-254.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=115569&link_type=MED&atom=%2Fcmaj%2F167%2F2%2F171.atom) 

2.  2. Hutchison B, Woodward CA, Norman GR, Abelson J, Brown JA. Provision of preventive care to unannounced standardized patients. CMAJ 1998;158(2):185-93.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNTgvMi8xODUiO3M6NDoiYXRvbSI7czoyMDoiL2NtYWovMTY3LzIvMTcxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  3. Laine C. The annual physical examination: Needless ritual or necessary routine? Ann Intern Med 2002;136:701-3.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.7326/0003-4819-136-9-200205070-00013&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11992306&link_type=MED&atom=%2Fcmaj%2F167%2F2%2F171.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000175357900008&link_type=ISI)