Let’s get less physical
SITTING in a cold, sterile room in a blue paper dress, you tell yourself you’re taking care of business. That’s when the doctor listens to your heart and lungs, hits the knees with a mallet, shines a flashlight into eyes, nose and mouth -- and pronounces you fit as a fiddle. Ready to go for another year.
Don’t kid yourself. Study after study has found that the annual physical exam is almost worthless, a medical anachronism that should be buried alongside the iron lung and mercurochrome. Doctors admit they rarely detect anything by listening to the heart and lungs of a healthy adult, and when they do, the results are usually spurious. Ditto for blood work.
Even routine prostate and manual breast exams have been discounted as poor detectors of cancer, leading some experts to suggest, only half-jokingly, that there is hardly any reason for a healthy, symptom-free man or woman to ever again disrobe in a doctor’s office.
Yet the routine annual physical will not go gently into that good night. Most primary care physicians continue to perform it, and a study published last June in the Archives of Internal Medicine found widespread resistance -- on the part of both patients and doctors -- to new guidelines that recommend more selective screening based on personal and family history.
“Most of us haven’t had the guts to get rid of it,” says Dr. Fred Heidrich, a physician at Group Health Cooperative in Seattle and clinical professor at the University of Washington.
Though this is not, as Heidrich adds, just a matter of guts. Many doctors and patients see something inherently valuable to these annual meet-and-greets, a benefit not easily measured by a study. The yearly physical is a chance to forge a bond, to talk about habits and mood and get a patient to make important lifestyle changes. It’s a chance, in these days of rushed office visits, for patients to get some hard-to-come-by attention that makes them, quite simply, feel better.
Out of this debate, a more useful annual exam is taking shape. Instead of offering blood work and palpation to all comers, it provides something more pragmatic: discussion. About smoking, alcohol consumption, depression, eating habits, exercise, safe sex, even driving with seat belts.
The challenge, doctors say, is in shifting patients’ expectations -- and convincing them that they’re not just being shortchanged by a health plan’s obsession with the bottom line.
A long tradition
Preventive testing has been around since Horace Dobell, a British physician, called for regular checkups and mass screenings for tuberculosis in 1861.
By 1947, the American Medical Assn. was recommending that all healthy people 35 or older pay a yearly visit to the doctor for a battery of tests and a head-to-toe physical examination.
And by the 1960s, one of the measures of success for the American businessman was being treated to the “executive physical” -- a three-day hospital stay with work-ups on a treadmill, an electrocardiogram and X-rays.
The annual physical became even more entrenched in medical culture with the rise of HMOs and a focus on preventive care. In the 1970s, Kaiser Permanente in Oakland conducted a study in which thousands of patients received regular physical exams, packed with chest X-rays and urine, blood and hearing tests.
The study created expectation among patients, but it was simply “a giant experiment,” says one of its planners, Dr. David Sobel, now medical director for patient education and health promotion for Kaiser Permanente Northern California. “It was a great wish,” he says, “a dream that if you did these annual exams, it would actually be beneficial in terms of better health.”
The package didn’t pay off. “When we went back and looked at the data to see if these things really made a difference, the answer came back no,” he says.
But the “giant experiment” did show the benefit of tests targeted at patients by their age, family history and personal risk profiles. Those tests are mammograms, cholesterol screening, blood pressure tests and colorectal screening.
Dozens of other studies have found that the annual physical does not prolong life, prevent disability or even detect disease.
“You go in to the doctor’s office and they weigh and measure you so they can determine your body-fat index, then they sit you down and take your blood pressure. And those are the two things we know that can make a difference,” says Dr. Ned Colange, chairman of the U.S. Preventive Services Task Force, an influential panel of experts that evaluates the costs and benefits of medical screenings.
“Everything that comes after that, if you’re asymptomatic -- there’s no evidence that anything they’re doing is going to make you live longer.”
In 1999, a study found that the traditional chest exam didn’t accurately diagnose pneumonia.
Other studies have found that chest X-rays of heavy smokers make little difference in whether or not they die from lung cancer. The most recent of these, published in December 2005, found that while screening can detect early lung cancer, it also produces many false-positive test results, creating needless anxiety and further tests.
Even the once highly touted breast self-exam appears unhelpful. The American Cancer Society now calls it “optional” after a rigorous 2002 study of Chinese women found that such exams made no difference in the early detection of breast cancer or in reducing deaths.
The Preventive Services Task Force has since concluded that a manual breast exam, even when performed by a trained health professional, is also ineffective.
As early as 1984, the U.S. Department of Health and Human Services called for one-size-fits-all physicals to be dumped in favor of periodic checkups that matched each patient’s individual health profile.
None of this stops patients from wanting a full-blown physical. Studies have consistently identified strong patient demand for routine and unproven blood tests, such as for glucose and hemoglobin levels, and renal, liver or thyroid function.
Doctors appear keen on the physical too. Last year’s Archives of Internal Medicine survey found that 65% of primary care doctors believe in the validity of the physical exam, 78% say patients expect it, and almost all -- 94% -- believe it improves the physician-patient relationship.
The result? Many primary care doctors continue to perform tests that seem to impart little benefit. “There’s this disconnect between evidence-based medicine and how it’s practiced,” says the study’s lead author Dr. Allan Prochazka, an internist at the Denver Veterans Affairs Medical Center.
That disconnect can harm.
For one thing, physicals take up money and time. As much as one-third of all U.S. health care dollars is estimated as wasteful, and as medical costs continue to spiral skyward, the annual exam is attracting attention as one place to save money.
“The physical exam takes time that could be better spent, especially if a doctor only has 20 minutes before the next patient,” says Dr. Harold C. Sox, editor of the medical journal, Annals of Internal Medicine.
In addition, “If you run enough tests on virtually any healthy person, you’re going to find something out of the norm,” says Sobel. “Then you have to do a lot of re-tests and assure the person that nothing is wrong.”
Sobel relates how one of his patients insisted on paying $900 out of pocket for a whole body CT scan, which came back with several questionable findings that never would have been detected without the scan. The patient eventually got a clean bill of health, but not before more tests and anxiety.
Heidrich, meanwhile, recalls a perfectly healthy man in his early 40s who was given a treadmill test before starting a new exercise regimen. That test indicated a need for further testing: a coronary angiogram. Unfortunately, the dye that’s routinely injected into the heart during this test precipitated a clot that resulted in a stroke.
The mere act of acing a physical could even be misleading, according to some doctors. Tests may not be sensitive enough to show subtle precursors to disease in a patient’s body -- such as a buildup of arterial plaque or the faint, precancerous changes to lungs from smoking.
The patient could get a clean bill of health and leave the office with false reassurance.
But some doctors say the annual physical might help in ways not easily captured by studies.
For one thing, it imparts psychological comfort and helps establish a connection between physician and patient.
“I think all doctors think they confer some benefit by the laying on of hands,” says Sox. “If I have an extra five minutes, I will do a cursory examination because I think the patients want it and feel better about their doctor if he does that.”
The physical also carves out a time for counseling on important lifestyle choices.
“If it increases the likelihood that a person will exercise, stop smoking and lose weight, it’s a trade,” says Elizabeth McGlynn, a medical researcher and associate director of Rand Health, a Santa Monica think tank. “If the laying on of hands is not invasive, establishes a relationship and gives a doctor the chance to talk to the patient and give advice, then I’m not sure it’s a bad deal.”
Indeed, simply talking and counseling have been shown to influence patients: Some studies have found that 5% of smokers quit on a doctor’s advice.
Paula Golden is one. The 58-year-old L.A. businesswoman credits her internist with helping her stop smoking 2 1/2 years ago, coaxing her into action where friends and family had failed. “There’s some ancient stuff going on when you sit down with your doctor, it’s kind of like a modern-day shaman,” she says. “And if you’re a responsible patient, you will confess to them your sins.”
Golden began observing the once-a-year rite soon after her 40th birthday. These days, she schedules it with almost religious devotion, always in the first week of the new year.
“It gives me a very strong sense of well-being,” she says. “Like, ‘Yeah, I can go another year.’ ”
The annual physical is morphing into a different kind of meeting ritual between physician and patient. Experts in the healthcare industry are trying to refocus the checkup to a discussion of family medical history, calcium and vitamin D needs for older women, and screening tests tailored to the individual.
Almost all tests recommended by the U.S. Preventive Services Task Force (such as Pap tests, colorectal screening and cholesterol tests) are age-specific.
For some tests, there is still debate -- for example, about the value of annual mammograms for women between 40 and 50 years old. For most women the recommended age is 50.
Doctors also debate the value of prostate testing for men with no prostate cancer symptoms.
On one side sits the American Cancer Society. It recommends that two tests be given to all men beginning at age 50: the PSA blood test, which measures the level of a protein in the blood, and a digital rectal exam.
On the other side sits the Preventive Services Task Force. It says there’s no strong evidence that the benefit of such tests outweighs potential harm. That’s because current prostate testing is unable to distinguish between aggressive and slow-moving cancer, often leading to unnecessary treatment.
“What I tell my patients is that it’s controversial whether a man should have it at any age,” says Seattle physician Heidrich. “For every one man who is saved from prostate cancer, there are 10 who are rendered impotent or with a leaky urinary tract.”
In recent years, the health care industry has sought to alter patient expectations by tweaking the name and nature of this annual ritual. Many HMOs now refer to it as the “wellness visit.”
The shift poses a delicate issue for HMOs, which are concerned that their attempts to introduce more targeted checkups will be perceived as just another way to cut skyrocketing medical costs. In 2004, Group Health, the largest HMO in Seattle, stopped performing routine manual breast exams on women when they went for their mammograms. Several women objected and sought visits with their doctors to have it done.
Given the long waits, co-pays, and abbreviated visits, many healthy patients may wonder why they should even bother going to see the doctor in the first place. And, in fact, some doctors predict that the annual exam may one day be replaced with a questionnaire, a follow-up phone call and a postcard reminder -- like the kind that veterinarians send to dog owners -- that it’s time for your next Pap smear.
“Myths fall hard,” says Sobel. “Patients come in to see me and they’re smoking, they’re overweight, they’ve got a poor diet. But what they want is some chest X-rays, a complete exam: ‘Reassure me.’
“We sometimes ignore the most obvious things,” he says. “They may not have the magic of medicine but they have the biggest impact on health.”
(BEGIN TEXT OF INFOBOX)
Tests that hit their target
Instead of receiving a standard battery of tests, adults should be given more targeted health screenings, according to preventive health authorities. Here are the main tests they should have, and when:
* A cholesterol check at least every five years, starting at age 35. Those who smoke, have diabetes or a family history of heart disease should start having their cholesterol checked at age 20.
* Blood pressure, at least every two years.
* Colorectal cancer screening, starting at age 50 and then every 10 years.
* Depression screening, if a person has felt “blue” or hopeless and taken little interest or pleasure in things for two weeks straight.
* Diabetes testing every five years. People with high blood pressure, high cholesterol, who are overweight or have a family history of diabetes should be tested more often.
In addition, a woman should have:
* A Pap smear every year or every two years after having two normal tests in a row. Some experts recommend having both a human papillomavirus (HPV) test and a Pap test every three years as long as both tests are normal.
* A mammogram every one to two years, starting at age 50. She should talk to her doctor about whether to consider mammograms earlier, between ages 40 and 50. The decision will depend, in part, on the age at which she started her period, whether she has a family history of breast cancer and whether she has ever had a breast biopsy.
* An annual chlamydia test, if she is 25 or younger and sexually active. If older, she should talk to her doctor to see whether further testing is warranted. She should also discuss testing for other sexually transmitted diseases.
* A bone density test for osteoporosis, beginning at age 65. If she weighs 154 pounds or less, she should talk to her doctor about beginning as early as 60 years old.
And a man should:
* Talk to his doctor about the possible benefits and harms of prostate cancer screening if considering a prostate-specific antigen (PSA) test or digital rectal examination (DRE).
* Discuss with his doctor whether he should be screened for sexually transmitted diseases such as HIV.
-- SARA SOLOVITCH