Feb 21 2012
Please note: the following refers to routine physicals and screening tests in healthy, asymptomatic adults. It does not apply to people who have been diagnosed with diseases, who have any kind of symptoms or signs, or who are at particularly high risk of certain specific diseases.
Throughout most of human history, people have consulted doctors (or shamans or other supposed providers of medical care) only when they were sick. Not too long ago, the “if it ain’t broke don’t fix it” mindset changed. It became customary for everyone to have a yearly checkup with a doctor even if they were feeling perfectly well. The doctor would look in your eyes, ears and mouth, listen to your heart and lungs with a stethoscope and poke and prod other parts of your anatomy. He would do several routine tests, perhaps a blood count, urinalysis, EKG, chest-x-ray and TB tine test. There was even an “executive physical” based on the concept that more is better if you can afford it. Perhaps the need for maintenance of cars had an influence: the annual physical was analogous to the 30,000 mile checkup on your vehicle. The assumption was that this process would find and fix any problems and insure that any disease process would be detected at an early stage where earlier treatment would improve final outcomes. It would keep your body running like a well-tuned engine and possibly save your life.
We have gradually come to realize that the routine physical did little or nothing to improve health outcomes and was largely a waste of time and money. Today the emphasis is on identifying factors that can be altered to improve outcomes. We are even seeing articles in the popular press telling the public that no medical group advises annual checkups for healthy adults. If patients see their doctor only when they have symptoms, the doctor can take advantage of those visits to update vaccinations and any indicated screening tests.
The Physical Exam Itself
The physical exam of a healthy, asymptomatic adult is unlikely to reveal any significant abnormality (1) that would not have been detected eventually when symptoms developed and (2) whose earlier detection and treatment would reduce morbidity and mortality in the long run.
A directed physical exam is sometimes indicated in patients with risk factors for specific conditions. A Pap smear is indicated in most women, but not every year, and the accompanying pelvic exam is likely a waste of time.
For healthy adults between the ages of 18 and 65, The American Academy of Family Physicians (AAFP) recommends only these components of the traditional physical exam:
- For men, a blood pressure measurement.
- For women, a blood pressure measurement and a periodic Pap smear.
They have other recommendations including vaccinations, counseling, and screening tests; but none of those require a physical exam.
Because they are so unproductive, routine physical exams are very boring to most physicians. My least favorite chore as an Air Force physician and flight surgeon was doing the required physicals. The system had some really idiotic requirements: for instance, the flight physical required a measurement of pulse rate after exercise, but there was nothing in the regulations that said what readings were considered abnormal or what actions to take if they were!
I heard about one doctor who had to do a lot of exams of healthy young men at a recruiting center and dreamed up a way to make it more interesting. He challenged himself to identify patients with situs inversus. This is a condition where the internal organs are on the wrong side (i.e. heart on the right, appendix on the left). It’s disqualifying for military service, probably because of the implications for battlefield trauma care. He soon held a record for the most diagnoses of situs inversus and was asked how he did it. He explained that he simply looked for men whose right testicle hung lower than the left and subjected those patients to a more intensive evaluation!
We are increasingly questioning screening tests that were formerly recommended. The annual chest x-ray, tine test, and urinalysis are long gone. The recommended age limits for mammography have changed. Routine PSA testing is being discouraged. A recent study suggested that a woman whose DEXA scan shows normal bone density or mild osteopenia need not be rescreened for 15 years.
We don’t need to examine all the published literature on screening tests, because the U.S. Preventive Services Task Force (USPSTF) has done all the work for us. They continually update recommended screening tests for different age and risk groups based on the latest studies. There are other organizations in the US and elsewhere that make similar recommendations but that may differ to some degree in different countries. In general, a specialty organization is likely to recommend more screening in its particular area of interest, based on a different focus in interpreting the same published evidence. The American Academy of Family Physicians, with a broader perspective, generally follows USPSTF recommendations.
The Early Detection Myth
There is a general perception, among the public and among doctors, that there’s no such thing as a bad screening test, that early detection is important, that knowing is always better than not knowing. If something is wrong with you, you need to know because, if you find a problem in time, it can be treated effectively to prevent morbidity and mortality. If you get a checkup and everything looks OK, you can breathe a sigh of relief and relax. Unfortunately this is all wrong.
A recent book explains why: Overdiagnosed: Making People Sick in the Pursuit of Health, by Drs. H. Gilbert Welch, Lisa M. Schwartz, and Steven Woloshin. It’s a comprehensive explanation of how test results make people sick and why visiting a doctor can be hazardous to your health. I reviewed it in an earlier article here on ScienceBasedMedicine.org. Please read that link and then come back.
Welch et al. commented
…some people may feel safer having their potential problems diagnosed and treated. For some, that may make the treatment side effects and hassle factors seem worth it… [but] the sense of being safer is likely an exaggerated view of the reality.
For a healthy, asymptomatic patient, the physical exam with the laying on of hands and stethoscope and other rituals is pretty much meaningless. If nothing is found, it can produce false reassurance. If something is found, it is not likely to prolong the patient’s life and it has a significant likelihood of leading to harm from unnecessary treatment or from a diagnostic cascade of tests, unnecessary surgeries, unnecessary expense, and unnecessary worry.
Re-inventing the Check-up
Doctors are not punished for overdiagnosis, but they are punished for failing to diagnose. We mustn’t let fear of lawyers interfere with our good judgment. The annual physical is obsolete.
On the other hand, there is a good argument for a periodic visit with a healthcare provider without the ritual of the physical exam. It’s helpful to have a systematic way of ensuring that the screening tests recommended by the USPSTF get done. An annual visit would be an opportunity for a preventive medicine interview and advice about a healthy diet, exercise, and other lifestyle factors. While an objective benefit has not been proven by any controlled studies, it can only be helpful for a doctor to get to know his patients before they get sick, for a patient’s history to be documented in a chart, and for patients to develop a relationship with a doctor they can trust. Instead of just rejecting the annual physical, maybe we ought to reinvent it.
Anyway, what’s so special about “annual?” The human body can’t read the calendar. A year is only a convenient way to jog the memory. Who’s to say that 365 days is better than 340 or 390 for any given purpose? In the absence of solid data, a range of suggested intervals might be more appropriate.
Welch et al. point out that health is more than absence of disease; it’s also a state of mind. They recommend health promotion efforts that lead people to feel more resilient, both physically and emotionally. Ironically, pursuing health requires not paying too much attention to it.
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