A new suggested lifetime health checkup schedule--based on a five-year time sequence for adults 20 to 65--was unveiled Monday by the American Heart Assn., substantially contradicting the traditional notion of the annual physical examination.
The new heart-association plan is part of a broader movement away from the annual checkup not unlike the trend toward longer maintenance intervals for the family car. Some doctors warn, however, that increasing the gaps between checkups may mean some serious illnesses go undetected.
The idea of a yearly checkup was introduced by the American Medical Assn. as early as 1923, but is currently under significant international revisionist pressure.
Annual Physical Losing Favor
In fact, the annual physical has been steadily losing favor for the last decade, giving way to what might be called the super-checkup.
The heart association, according to the organization's statement at a Dallas press conference Monday, "takes the position that prevention is the greatest need in cardiovascular medicine. Prevention, however, demands an aggressive approach and the involvement of both the general public and the medical profession.
"The physician . . . should be concerned with the whole person, and a full evaluation of an individual's overall health needs to be incorporated into any plan for periodic examinations."
The proposal is being introduced amid a rapidly developing movement in the U.S. and Canada to substantially revise the timing and nature of preventive health screenings. Government-sponsored commissions from both countries are planning a joint meeting later this year to discuss a unified international strategy to speed change.
The Canadian Task Force on the Periodic Health Examination has already produced a series of comprehensive proposals for reform, though commission officials say doctors have been slow to adopt them. The U.S. Preventive Services Task Force expects to publish a series of medical-journal articles calling for specific reforms this year and follow up with a book-length work early in 1988.
The basis for checkup reform is that, for most adults in apparently normal health, blood and other laboratory tests performed on an annual basis are pointless and waste health-care resources.
The annual physical also has been widely criticized for being an empty, rote exercise for physicians in which there has been little agreement on what information should be obtained. What is needed, reformers contend, is a new sense of the checkup as a periodic interaction aimed at finding previously hidden disease and intervening--aggressively and effectively--in unhealthy life styles.
The annual checkup has also suffered because some physicians are uncertain about what kinds of habits they should inquire about--with sexual disorders, smoking behavior and weight-loss issues often being ignored.
While the proposals differ as to the timing of these new physicals--which are intended to utilize the latest diagnostic tests and equipment and rely on more comprehensive sets of questions to be asked by doctors--most proposals share these common elements:
- They increase the time between physicals, the most common interval being five years for healthy adults 20 to 60 or 65. The gaps narrow to a physical every 2 1/2 years between 65 and 75 and annually after that. Examinations for pregnant women and young children remain much more frequent. Nor does the new schedule apply to people known to have chronic diseases like diabetes, cancer or heart problems.
- The new physicals are supposed to emphasize more comprehensive laboratory work, with a variety of blood tests routinely performed and often quickly analyzed by increasingly common in-office testing equipment. The new generation of machines includes those that determine levels of fat in the blood within 10 minutes after a tiny sample of blood is taken from a pinprick in the finger.
- Some procedures traditionally performed during the annual checkup--such as the chest X-ray and the conventional electrocardiogram--are to be done much less often. But others, such as a procedure using a fiber-optic viewing device to explore the colon for evidence of cancer, are to be more routine at certain intervals--especially for older patients.
- Doctors are encouraged to ask more comprehensive questions and follow up more aggressively on their discussions of such habits as smoking. They also are urged to help patients plan life-style modifications to reduce cholesterol levels, weight and blood pressure.
The American Heart Assn. proposals for a new timetable for checkups--the first of their type ever made by the organization--emerge in the midst of this mounting pressure for change. The association's plan was formulated by a seven-member committee headed by Dr. Scott Grundy, director of the Center for Human Nutrition at the University of Texas Health Science Center in Dallas.
The heart association schedule adopts the five-year interval, with exams more frequent between 60 and 75 and annual after that. At the first such super-checkup, the doctor takes a complete medical history and conducts a thorough physical examination, with information in a wide variety of standardized categories to be updated at each subsequent super-checkup.
Blood pressure is to be taken every 2 1/2 years, and electrocardiograms are called for at ages 20, 40 and 60. A chest X-ray to establish the so-called "baseline" condition of the chest is not to be done until age 40. Special provisions are made for smokers, who should have lung-function tests every five years to assess any deterioration in breathing ability. Smokers should have annual chest X-rays and annual electrocardiograms.
Doctors are instructed to focus on patients' blood pressures, cholesterol levels and weight. Smoking habits and sedentary life styles are to receive aggressive remedial attention.
In a telephone interview, Grundy conceded that the new heart-association schedule conflicts somewhat with similar guidelines from the American Cancer Society, which suggests several types of screening examinations at three-year intervals. The cancer society said that, except for a study of possible revision in suggested frequency of Pap smears for women--now called for annually until two successive tests are negative, then every three years after that--no changes in its checkup schedules are contemplated.
Great Pressure for Change
"When you're talking about overall health, it's a little bit of a controversial issue," Grundy said of the slight conflicts between various super-checkup proposals. He said the heart association decided to issue its own standards in part because it feared that the trend toward less-frequent physicals--which originated about 10 years ago--may have stretched out intervals too much.
Ironically, Grundy said, there has been such pressure for change in the checkup within medicine that the heart association was concerned its new guidelines would "create a furor (because of fear) that maybe we're taking a step backward."
"We're trying not to overdo it and subject people to monitoring when there's no reason to do it. This plan seems fairly conservative but not overly aggressive."
Grundy noted that "the old idea of the annual physical went out the window for a while and nobody is recommending it any more." The new scheduling proposal, he said, "is not radical. It's just systematic."
The traditional checkup has its roots in a 1923 AMA report that urged an educational campaign among doctors. The report led to publication just before World War II of a manual on periodic physical examinations that began urging annual checkups. The manual had not been revised after 1947 until four years ago, when the AMA moved toward the five-year super-checkup for most adults between the ages of 20 and 40.
After age 40, AMA recommendations call for checkups about every three years until age 65 and annually after that.
But Dr. Joseph Skom, a Chicago internist who is a member of the AMA council that drafted the 1983 report, said that while an unmistakable trend has developed in which the annual checkup is rapidly becoming a thing of the past, the changes in question may not be entirely beneficial. "Most of these (studies calling for longer intervals between physicals) are oriented toward cost effectiveness," said Skom, "which is unfortunate because a few people are going to slip through the net and have something that may not be picked up until it's too late."
Skom emphasized that people with family histories of colon cancer, stroke, heart attack, high blood pressure and diabetes should have examinations more frequently--often annually. The American Heart Assn. proposal unveiled Monday, in fact, emphasizes special, more frequent monitoring of high-risk groups.
The movement to change the checkup first became prominent in 1976 when the Canadian government established its task force on the periodic physical examination. A year later, Dr. Lester Breslow of the UCLA School of Public Health and Princeton University researcher Anne Somers published what is widely thought to be the pivotal paper in the field, proposing a "lifetime health monitoring program" that would decrease the frequency of physical exams but make them more thorough, comprehensive and tailored to achieve necessary life-style change.
In the Breslow-Somers plan, adults 25 to 39 would have just two checkups in a 15-year period, but would receive improved counseling on nutrition, exercise, smoking, drinking and other health-related behaviors. Those 40 to 59 would be examined about every five years and those 60 to 74, every two years. Only at 75 would annual checkups become routine.
In a telephone interview last week, Breslow said the original proposal he and Somers made is not significantly different from many plans now being adopted by various health organizations. He said the objective of all of them is to balance sensible use of increasingly expensive medical resources with a coherent plan to effectively detect disease.
This balance should achieve a schedule of checkups "intended to reflect a rational (system of checkup intervals) and also list specific items to be included in periodic monitoring," Breslow said. "I think it's a fair statement to say that a five-year interval from ages 15 or 20 to age 65 is appropriate."
Breslow also noted that health-insurance plans have been reluctant to pay for preventive services in general--and checkups in particular. But, he said, there are signs that insurers are becoming more interested in a system of less frequent but more thorough examinations. Tests are currently under way to evaluate the effects on overall health of changes in insurance benefits that pay for occasional, aggressive checkups.
Canadian Commission Concurs
"Does a man or woman age 20 who has an examination at the point of entering work or college and has absolutely no findings of (disease) need to have an examination every single year? It doesn't make any sense," Breslow said. "It is a waste to use physician and other time to provide annual examinations for normally healthy people. But if you have specific indications of a serious illness, you don't wait five years."
The Canadian government commission, which began its work about the same time as Breslow and Somers, came to essentially the same conclusion.
"The main theme of our original report was that the annual checkup was just kind of a nondescript examination," said Dr. Richard Goldbloom, of Halifax, chairman of the commission now. Goldbloom said the Canadian task force found that--just as in the U.S.--about three-quarters of all people report visiting their doctors at least once a year for something. The checkup, he said, should become a more occasional--but more comprehensive--opportunity to assess overall health and not just deal with a specific complaint.
More recently, the U.S. Preventive Services Task Force began its own revisions of recommendations for physical examinations. The task force sparked controversy last April by suggesting that there is "no evidence" breast self-examination affects survival in breast cancer cases.
Angela Mickalide, the task force's staff coordinator, said the U.S. government effort recognizes--belatedly, perhaps--a growing "drift away from the annual checkup to a more periodic health examination." The task force, she said, will publish a series of specific recommendations in medical journals this year, following up with a book-length summary of standards for the super-checkup early next year.
The American College of Physicians, which represents specialists in internal medicine, is also preparing a major revision in checkup guidelines to be published sometime in 1988. In a 1981 report, the organization said "present data are not adequate evidence justifying annual complete examination of the asymptomatic patient at low medical risk."
But the group also concluded that there was no effective single plan to substitute for the annual checkup and left the decision about how to cope up to doctors.
The American Heart Assn.'s Grundy said the movement to reform the checkup has, in many ways, a sort of back-to-basics flavor to it. "The skills that are necessary are very simple," he said. "It's just paying attention and being aware of a problem. Not ignoring it. Not discounting an abnormality's importance.
"Patients are aware of blood pressure. That message is getting across. But we've got to get the same message out about cholesterol. And, as bad as smoking is, a lot of physicians do not do all they can to get their patients to stop.
"They don't get involved with the problem, and they should."