A little less than a year ago, President Donald Trump put his inimitable stamp on the presidential physical. White House physician Ronny L. Jackson pronounced the president in “excellent” health, despite some troubling cholesterol findings and a weight that put him just shy of the official boundary for obesity. He got a perfect score on a cognitive test meant to screen for dementia (not psychiatric problems). Trump was so pleased with Jackson that he soon nominated the doctor to be secretary of veterans affairs. Allegations of misconduct then surfaced. Jackson now is neither VA secretary nor the president’s doctor.
A White House spokesman did not respond to our questions about whether Trump, 72, will have another physical soon.
Given Trump’s background as a business leader, the approaching anniversary of his first exam made us wonder what happens when CEOs get “executive physicals.” They are, after all, powerful people whose health — or lack of it — can have wide implications.
In the business world, we learned, executive physicals are a health benefit, not a requirement imposed by a board of directors. This means that the medical results belong to the executive, who gets to decide whether anything is disclosed to the board or shareholders. Similarly, the president’s physical, while traditional at this point, is also voluntary, and he decides what the public learns.
The idea of an annual physical has been criticized over the years, but many doctors think it’s important for patients, especially older ones, to touch base regularly with a physician to at least discuss lifestyle issues like stress, diet, and exercise, as well as receive vaccines and screening tests like colonoscopies. Still, the extensive testing involved in executive physicals may detect benign abnormalities, spurring further testing that carries some risk of harm.
Jeff Levin-Scherz, North American coleader of the health management practice at Willis Towers Watson, a global business advisory company, said it decided to “sunset” questions about executive exams in its employer surveys because “they’re really not evidence-based.” Nonetheless, he said, demand remains high. He said a 2017 survey from another organization found that more than a third of S & P 500 companies offer the benefit.
In the absence of symptoms, he said, tests often included in executive exams, like CT scans for heart disease or stress tests, have not proved valuable. Still, he said, companies may see the exams as a way to head off medical surprises that sideline top talent. Annual visits could also be worth the money, Levin-Scherz said, if they provide “really good well-being coaching for the hard-charging executive.”
Health systems that perform executive physicals — Penn Medicine, Jefferson Health, and Johns Hopkins — said a key advantage is that patients can schedule multiple tests and exams on the same day. The blood tests usually ordered are fairly standard panels. Some other tests may appeal to action-oriented high achievers.
Jack Ende, a general internist who oversees Penn’s program, said Penn does from 200 to 300 of the health assessments, which cost $3,000 and last four to five hours, each year. Employers or patients themselves pay, not insurers.
Penn doctors take an unusually thorough history. Even subtle symptoms may lead to cardiac testing. A woman who needs a mammogram can get it that day. A dermatologist can do skin cancer checks. There are hearing and vision tests, and a session with a nutritionist. A physical therapist evaluates patients for flexibility, strength, and fitness. Patients are fed a healthy lunch and have an exit interview with a doctor. They leave with a binder holding their results and recommendations.
“It becomes one-stop shopping, a fluid, coordinated experience, but tailored to the individual patient,” Ende said.
As a group, executives tend to be healthier than average. Health often tracks with income and education. “These are people who have favorable socio-economic determinants of health,” Ende said. But doctors find problems “often enough to justify the assessment.”
He said Penn prides itself on being evidence-based. "We do not do silly things," he said, such as total body scans or tests of cardiac risk not shown to provide "actionable" results.
Cognitive testing is not the norm, but can be added if the doctor notices memory problems or a patient brings the subject up. Ende said there’s better evidence for doing such testing in the elderly. (Some health systems have started testing older doctors.) Most executives in the program are under 65, with the bulk between 50 and 60.
Jefferson’s Executive Great Life Program has more bells and whistles, and a higher price tag: about $5,900. It routinely includes stress testing and some imaging of major arteries. A “very comprehensive” blood test includes some genetic tests for enzyme function and Alzheimer’s risk, said Andrew Newberg, the director of research at Jefferson’s Myrna Brind Center for Integrative Medicine. There’s a test that measures the body’s reaction to stress and a whole-body MRI that looks for cancer. Patients have detailed conversations with a doctor about the results and what they can improve, including diet, nutrition, and stress management.
Newberg said the testing has found aortic aneurysms, Parkinson’s disease, iron overload, heart disease, and celiac disease. “These kinds of things happen quite often,” he said. Most patients only need this kind of exam once every three or four years. An alternative track includes a thorough evaluation of brain functioning, including a brain PET scan.
Even among this relatively healthy population, Newberg said, many are overweight, and most have a poor diet.
Doctors at Johns Hopkins do about 1,300 physicals a year at $2,500 to $3,500 apiece. Because some patients want it, Johns Hopkins has added neuropsychiatric testing, which assesses cognitive functioning, that can cost an additional $1,000 to $4,000. Bimal Ashar, medical director of the executive and preventive health program, thinks such testing would be good for U.S. presidents of any age. “This is the highest position in the land and in the world,” he said.
Ashar said long conversations with the doctor about risk factors and prevention are the best part of the executive health program. “I wish everyone could have the executive physical experience, because I think it’s better for health care,” he said.
David Levy, chief executive officer of EHE, a national company that used to specialize in executive physicals, agrees with him. Now that the Affordable Care Act requires insurers to cover preventive health exams, he’s urging companies to provide comprehensive health visits to all employees, not just the C-suite. Good health lowers health costs and also increases productivity, he said. With EHE’s program, everybody gets the same exam, although older people are urged to come more frequently and need more tests.
Baseline cognitive exams are a routine part of EHE’s package, said Anthony Wehbe, chief population health executive for Jefferson Health New Jersey. Jefferson provides the exams, which take about an hour, in four of its offices in the region.
Deciding whether to share health information is tricky legal territory, said Michelle Lowry, a finance professor who is academic director of the Gupta Governance Institute at Drexel University. Executives have a right to privacy, but they’re managing other people’s money. An executive who learns he has a deadly cancer and must quit immediately has to disclose. A CEO who’s a year away from retirement and learns he has slow-growing prostate cancer doesn’t need to tell. “That middle ground, it’s a tough call,” she said.
Tom C.W. Lin, a law professor at Temple University’s Beasley School of Law, said business law requires disclosure of information that is "material," meaning it would "alter a reasonable investor's investment calculus." This could mean a health condition that makes it difficult for a key person to carry out his or her obligations to the company. "It depends on the company. It depends on the executive," he said.
Lin said there should be flexibility, and companies should promote a boardroom culture that makes executives feel comfortable disclosing.
Tom Kline, a malpractice attorney whose name is on the Drexel University school of law, said it’s also important to have a culture where coworkers feel safe reporting problems. He’s 70 and tells his partners, “You’ve got to tell me if you think I’ve lost even half a step.”
He added, though, that staffers who’ve left the Trump White House have reported much behavior that would get the average executive in big trouble. The president “unfortunately has a contract with the American people,” he said, “and you can’t buy him out like you could a corporate executive.”
Other experts said they think on-the-job performance in a demanding role is often the best cognitive test — at least for executives. Vigilant boards don’t need a doctor to tell them when an executive’s performance is slipping, and they don’t put up with it. “The board always has the right to fire the CEO,” Lowry said.