Will A Routine Physical Uncover Every Problem?

Will a Routine Physical Uncover Every Problem?

I remember a conversation I had with a patient who thought her previous doctor was “no good.”

She and her husband received care from the same physician, and soon after one of his visits, her husband suddenly died. At that point, she decided to change doctors, believing that her doctor should have been able to detect a problem that could cause sudden death and done something to prevent it. Perhaps she was correct — I did not know the details of her former doctor’s care or her husband’s health problems. But it is also possible that her husband’s doctor provided excellent care. Even when doctors (and patients) do everything right, there is still no guarantee of good health.

Thinking of my patient, it struck me that there may be misconceptions about what a routine doctor’s visit can accomplish and what its limitations may be.

Why a Routine Visit

If sudden death cannot be reliably predicted or prevented, as tragically occurred with my patient’s husband, what is the point of seeing the doctor at all? It turns out that many conditions can be readily detected or prevented, while others are simply beyond the limits of screening tests or examination. First, it matters whether the visit is truly “routine,” meaning there are no symptoms and the person seeing the doctor feels entirely well. On the other hand, if you set up the appointment to evaluate a symptom, ongoing problem or concern, everything changes: The visit is no longer “routine,” and what goes on in the office may be focused on the complaints or medical conditions that you have.

Even in the absence of symptoms, many physicians recommend routine, yearly doctor visits and physicals for adults of all ages. Such visits actually have modest goals:

To ask about health problems and disease-prevention measures. Even if it is not the reason for the visit, routine questions about exercise, alcohol use, depression, domestic abuse, and hearing problems, for example, may lead to treatments or interventions that make major improvements in your health or quality of life. Questions about smoke detectors, use of seat belts or a bicycle helmet may be helpful to encourage some simple measures that can be lifesaving. Finding out about past vaccinations and whether you are due for boosters falls into this category.

To determine your risk of disease. Before you develop symptoms of heart disease, osteoporosis or cancer (as examples), your physician may uncover risk factors that lead to prevention or earlier detection of disease. Examples include questions about family history, smoking or exercise.

To examine you. It may surprise you to learn that the demonstrated usefulness of a routine physical examination is quite limited. For example, the American Academy of Family Physicians recommends blood-pressure measurement and periodic measurement of height and weight for all adults age 18 and older and breast examination for women aged 30 or older. There is little evidence to support other routine examinations. For example, the AAFP found inadequate evidence to recommend for or against routine examination of the skin to detect skin cancer for persons at “average” risk.

Keep in mind that even if you do have an abnormality detected on physical examination, it is often of little importance. For example, just as a freckle is technically not completely normal skin, minor abnormalities are often detected that have no bearing on your health. A lipoma (a benign tumor made up largely of fat) can cause a lump under the skin almost anywhere on the body; to be sure it’s not something serious (like cancer), it may be important to have it removed, but an examination that detects a lipoma is an example of how an abnormal examination does not always mean you have a disease.

Necessary Tests

Some health-care providers routinely recommend testing for people who are healthy at the time of their routine physical. In fact, very few tests have been shown to be helpful. For example, for a healthy 50 year old woman without symptoms, signs or risk factors for important and diseases (such as diabetes or cardiovascular disease), , the AAFP recommends:

1. Regular screening tests for colon cancer (such as stool tests for blood yearly and sigmoidoscopy, colonoscopy or barium enemas periodically)

2. A Pap smear at least every three years (if she has ever been sexually active and has a cervix)

3. Cholesterol measurement (with fasting lipid profile)

4. Mammography every one to two years

That’s it for people who report no health problems, symptoms or risk factors for specific diseases. Based on the evidence, other tests, such as EKGs, chest X-rays and blood tests are not routinely recommended for anyone without symptoms or risk factors for a particular illness.

Updating immunizations for the healthy adult is also important. Tetanus and diphtheria vaccinations are recommended routinely, with boosters every 10 years. Other vaccinations, including rubella, hepatitis B and influenza may be appropriate for people in certain risk groups.

Putting It All Together

Physicians integrate the information you provide from your symptoms, past health problems, physical examination and testing to detect disease or a risk of disease. If you feel well and have a normal exam, it’s likely you are healthy. Unfortunately, many conditions can escape detection even with the best medical care. Sudden death may occur from heart disease or a burst aneurysm (among other reasons) despite a recent normal physical examination. It’s a myth that a doctor can detect any health problem you have just by examining you.

Your doctor may ask you to come back yearly for a routine physical, but the real impact of such visits may be limited. It’s best not to rely on routine doctors’ visits to provide a guarantee of health. On the other hand, at your visit you may learn of risk factors for disease you did not know you had, or discover that what you thought was “just getting old” was really symptoms of arthritis or depression.

If you have symptoms or are worried about a particular health issue, see your physician. But for truly routine visits, understand that there are significant limitations for the detection of disease. In fact, guidelines established in the United States and separately in Canada do not recommend routine physical examinations; and that’s despite the fact that most primary care physicians and their patients want and expect them. It’s unfortunate, but true: a normal examination does not mean you are absolutely healthy. Conversely, even if you have an abnormality on your examination or testing, many findings turn out to be unimportant.

For many, having a routine physical helps establish a relationship with their health-care providers, a process that can come in handy if you ever are sick. Establishing a relationship with a health-care provider may be among the best reasons to have a visit to your doctor, even when you are feeling well.