The Medical Minute: Rethinking the annual physical

By John Messmer, M.D.
Penn State Milton S. Hershey Medical Center

Maybe you made a New Year’s resolution to get more exercise, and you want to be sure you’re fit enough to do it. Or perhaps you’ve been having a little ache you can’t quite get rid of and wonder if the doctor can figure it out. So you make an appointment for a physical, right? Maybe not.

In the 1920s, life insurance companies promoted the idea of the annual physical based on a misunderstanding of data that showed those who got one lived longer. It’s more likely those who could afford health care in the early 20th century took better care of themselves and would have lived longer anyway. Prevention is an important goal of modern medicine, but 64 million office visits were for routine annual exams in 2000, according to the Centers for Disease Control. These and the associated routine tests may cost up to $7 billion a year with little return on investment.

An examination or test is useful if it finds problems early enough that fixing them will improve health. Also, the exam or test should be performed on someone in whom there is a possibility of the problem being present. For example, screening for prostate cancer is not done on teenage boys because the disease does not occur in that age group.

The cost of the exam or test is considered against the savings associated with treating positive findings. This may sound cold-hearted, but if we spend all our money looking for rare conditions, we may not have enough left to pay for interventions that really help, such as immunizations. To help in determining what is useful, the Agency for Healthcare Research and Quality (on the Web at http://www.ahcpr.gov/ ) analyzes data on various exams and makes recommendations in the U.S. Preventive Services Task Force’s Guide to Preventive Services.

There are many areas that have good evidence of benefit and many that have been shown to lack benefit, but many areas still need study. Often disease specific agencies such as the American Diabetes Association and the American Cancer Society make recommendations slightly different from the U.S. Preventive Health Service. Newer tests and technology may cause doctors to reconsider what screening to perform before organizations have been able to make updated recommendations.

If you are having a symptom, don’t ask for a physical; ask for an evaluation of the symptom. Your doctor may not look in the right area without knowing he or she is actually looking for something. In the case of routine exams, one size does not fit all. Currently, doctors think of the annual physical as a health maintenance or preventive medicine examination to help you stay healthy.

Health maintenance exams are different for various ages and genders. Children have a series of exams looking for problems of growth and development, to provide anticipatory guidance to parents and to immunize against diseases such as measles and polio.

Recommendations for adults depend on a person’s family and personal history. All people should be screened for obesity and counseled regarding smoking, diet, exercise and risks of certain behaviors, such as lack of seatbelt use and high risk sexual activities.

Women should have regular Pap smears starting within three years of first intercourse or age 21 whichever comes first. Paps should be at least every three years to as often as annually depending on her specific history.

Blood pressure measurement, cholesterol checks and diabetes screening are beneficial in certain situations based on age and personal and family history. Glaucoma checks usually begin by age 40 depending on family history. Colon cancer exams begin at age 50. Mammograms should be annually after age 50 but there is controversy as to their benefit in women under 50 and in the elderly.

Still, there are many things that, even though they have been part of conventional wisdom, are clearly not useful: routine chest X-rays, even in smokers, have no benefit; routine electrocardiograms do not detect heart disease; routine blood chemistry profiles, blood counts and urinalysis find abnormalities that are of little consequence more often than they find real disease; routine stress tests are poor screening tests for heart disease. A new fad, the full body MRI, like the routine chemistry profile, is more likely to find inconsequential abnormalities than real problems.

Rather than trying to remember when to go for a check-up, call your doctor and ask what is recommended. If you see your doctor regularly for a medical problem, you do not also need a general physical, but your doctor may recommend a specific screening test, such as a colon cancer exam, Pap, cholesterol check or mammogram in addition to your regular office visits.

Remember that looking for problems is just the start -- it’s equally important to do something about them.