To annual or not to annual, that is the question.

In our office, we have heard lots of language devoted to the annual visit. we have heard them called "yearlies", " annual exams", "checkups" and "my favorite time of year". We sometimes find patients dreading it beforehand, but mentioning afterwards that it was really worthwhile. 

For our office, it is not only about ensuring that girls and women stay on track with recommended screening procedures; it is about evaluating where they are presently with their health maintenance. Most importantly, we discuss a comprehensive and detailed plan of optimal health maintenance for the upcoming year. For the many women who we have seen for many years running, we are health base camp. 

Controversy

In recent years, there has been significant discussion in the press about whether or not the annual visit is worth it. With the cost of medicine being a concern, and new insurance regulations around every corner, it is important to understand the buzz. 

The annual exam became a fixture of American medical practice in the 1940s. By the 1980s, its utility was beginning to be questioned. More recently the United States Preventive Services Task Force (USPSTF) "recommended that this approach be replaced by periodic screening, counseling and PE tailored to a patient's "risk factors"." (Bloomfield and Wilt 2001). 

Unfortunately the lay press predominantly took this out of context and declared annual exams were no longer necessary. Making matters worse, this came on the heels of a badly conceived and badly reported recommendation from the USPSTF to curtail mammogram frequency. More on that later.

Witness the cynicism in this article from a physician, Elisabeth Rosenthal, writing for the New York Times:

http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?pagewanted=all&_r=0

In this article she states,

"I finished my medical training in 1989. I respect my doctors, but I see them only when I’m sick. I religiously follow schedules for the limited number of screening tests recommended for women my age — like mammograms every two years and blood pressure checks — but most of those do not require a special office visit." 

Perhaps because she is a physician she can show up to the radiology department and get a mammogram or slip in and out of the office for a pap or blood pressure check. Perhaps she thinks because she is a physician she is beyond having her history taken or her health maintenance behaviors assessed. Traditional medical training requires a history, pertinent aspects of the physical exam, and pertinent diagnostic studies followed by an assessment, plan and discussion with the patient, not just stopping by for a diagnostic procedure. In her New York Times article, Dr. Rosenthal cites Allen Brett, MD,  a professor of clinical internal medicine at the University of South Carolina, who comments thus: 

 “If you ask gynecologists why they still do yearly Pap smears they’ll say things like: Patients expect it; It keeps patients coming back; It’s what we do in an OB-GYN visit.”

I have several comments. How qualified is a university professor of internal medicine to comment on the yearly visit between a woman and her gynecologist in the private practice setting? His practice environment consists of a formal system of staffing by residents and medical students who do most of the direct patient care. Residents and medical students change every year and, though well educated and hardworking, they do not provide the continuity or the professional and life experience to shepherd an adult woman through the many life events that are seen in Obstetrics and Gynecology.

Intimations that OB/GYNs ask patients back for annual exams to make more money are unprofessional and groundless, since we could generally make more money seeing problem oriented patients, a fact which Dr. Brett would know if he were familiar with managing a practice. OB/GYNs see patients back for annuals because ACOG recommends it on an evidentiary basis. We also do it because it is satisfying professionally for us, and personally for the patients. 

Dr. Brett is known for his study of the scientific basis of medicine, and yet he does not seem to highlight that the USPSTF recommendations on annual exams are heavily qualified by the following: 

"The 10-member Task Force rejected the traditional emphasis on a standardized annual physical examination as an effective tool for improving the health of patients. Instead, they emphasized that the content and the frequency of the periodic health exam need to be tailored to the age, health risks and preferences of each patient. The panel recognized the proven benefits of specific measures such as periodic screening for high blood pressure and cervical cancer, scheduled vaccinations, and counseling about tobacco, alcohol and other lifestyle issues. (emphasis mine) (Guide to Clinical Preventive Services, Second Edition)

Listed as "Principal findings"  of the USPTF's document, Guide to Clinical Preventive Services, Second Edition is the following: 

" The report draws several broad conclusions about effective preventive care:

Counseling patients about personal health practices (smoking, diet, physical activity, drinking, and injury prevention and sexual practices) remains one of the most underused, but important, parts of the health visit (emphasis mine). Preventive services offered by the clinician should be tailored to the specific behaviors and risk factors of individual patients, not offered as a standard "routine checkup" given to all patients. Patients should share in decisions about preventive services. Their personal preferences are important in determining an approach to prevention that is optimal for them as individuals. This is especially true when the evidence of benefit is weak. Doctors and nurses should try to deliver prevention messages and services during every encounter with their patients, especially for high-risk patients who are often the least likely to see clinicians for routine checkups." 

Patients in my health maintenance oriented practice would not even recognize the standard annual visit to which the USPSTF refers. Typically, the standard visit would involve seeing the nurse for vitals signs and a cursory history update. Following this urine or blood might be taken and the patient is placed in a room and asked to undress. The doctor would enter and perform some combination of examination of heart, lungs, abdomen and possibly other systems. Discussion may or may not take place and the patient would be dismissed. I know this because I hear about it from patients who have been seen by other caregivers from other specialties elsewhere. I also know it because it is a common vignette painted by dissatisfied patients airing their views in the media. 

The exam referred to in the guidelines of the USPSTF document referenced above refers to certain components of the physical exam, combined with stereotypical tests like cholesterol or an EKG. Apparently, these are done routinely without indications in offices across the country, and is this which the USPSTF document is attempting to address. 

Here are some examples of parts of the physical exam which the task force has concluded are not generally indicated:

The USPSTF has never dismissed the importance of a tailored exam, a health maintenance discussion, or screening according to guidelines.

Finally, the following is from Allan Goroll, MACP, a professor of medicine at Harvard Medical School and practicing general internist: 

“Not to be underestimated is the value of maintaining the doctor-patient relationship, as well as counseling for life stresses and personal issues that come up,” he said. “A lot of behavioral and mental health problems emerge during the annual visit.” (Darves) 

The American College of Obstetrics and Gynecology (ACOG) position on annual exams: 

ACOG has an entire document devoted to the "well woman visit" and its importance. Included in its abstract is the following: 

"The annual health assessment ("annual examination") is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the clinician-patient relationship. The annual health assessment should include screening, evaluation and counseling, and immunizations based on age and risk factors. The interval for specific individual services and the scope of services provided may vary in different ambulatory care settings. The performance of a physical examination is a key part of an annual health assessment visit, and the components of that examination may vary depending on the patient's age, risk factors, and physician preference." (American College of Obstetricians and Gynecologists)

Details about the time and content of the annual exam

Annual visits with the OB/Gyn include screening, evaluation and counseling about illness, prevention and health maintenance.

Annual visits with the OB/Gyn should begin somewhere between 13-15 years of age. Please see our section on Adolescent Gyn for more details on the younger years.

The speculum exam part of the pelvic exam is not generally indicated until 21 years of age, when the first pap is due. However, specific symptoms or conditions may require a speculum exam to be conducted earlier. Speculum exam is not necessarily a prerequisite for prescribing birth control pills or checking for STDs, either of which may be needed in women under the age of 21.   

The pelvic exam itself consists of three elements: the external exam, the internal speculum exam of the vagina and the cervix, and the bimanual exam. During the bimanual exam, the examiner inserts two fingers in the vagina and the other hand on the patient's abdomen, enabling her to palpate the uterus and usually the ovaries as well. The examiner can then discern the size, contour, mobility, and tenderness of these pelvic organs. For those over 40 or with certain symptoms, a rectal exam may also be done. 

Of course a speculum exam is needed when a pap is indicated. Please see our page on Pap smears, HPV and cervical health for more details on this. 

Based on available evidence ACOG, the American Cancer Society, and the National Comprehensive Cancer Network recommend offering periodic clinical breast exams at the annual visit if the patient is over 20. The same governing bodies recommend them annually in women over 40. All of these organizations recommend breast self awareness which may include breast self exam. For specific information about mammograms, please see our section on Breast Care. 

Beyond this, physical examination is tailored to the specific patient. Factors which bear on this include their symptoms, concerns, personal past history and family history as well.

The annual visit is not to be confused with the pelvic exam.

The visit is a multifaceted doctor patient encounter which includes history, a tailored physical exam which may or may not include a pelvic exam, as well as discussion about any needed screening or diagnostic studies like blood work or imaging. It also includes a detailed assessment of prevention and health maintenance measures like vaccinations, nutrition, and exercise. Finally the visit should identify any mental health needs and initiate the process of addressing them. 

We chronicle the successes of the year. We tackle problems together. Despite the controversy and confusion over the annual checkup, we believe it is a well founded holistic practice. Honestly, we usually have a great time with our patients. 

Welcome to your annual!

References about the Annual Exam:

American College of Obstetricians and Gynecologists, Well-woman visit. Committee Opinion No. 534. Obstet Gynecol 2012;120:421-4

Bloomfield, Hanna E MD, MPH and Wilt, Timothy J MD, MPH. Evidence Brief: Role of the Annual Comprehensive Physical Examination in the Asymptomatic Adult, PMID: 22206110

Darves, Bonnie, Rethinking the Value of the Annual Exam, January ACP Internist, copyright © 2010 by the American College of Physicians

Rosenthal, Elisabeth, MD, Let's (Not) Get Physicals, The NewYork Times Sunday Review, June 2, 2012

USPSTF, Guide to Clinical Preventive Services, Second Edition , http://odphp.osophs.dhhs.gov/pubs/guidecps/default.htm