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What is a good physical exam? - Preventive Medicine

Harvard Health Letter, July, 1997

The annual head-to-toe checkup has been relegated to the history books. Surprising as it may seem, nearly all experts who have analyzed the value of such an exam say that meticulous inspection of every bodily part just doesn't pay off in early disease detection or prevention.

In recent years, the yearly checkup has been replaced by the "periodic health exam," the scope and timing of which are tailored to an individual's age, risk factors for disease, and lifestyle. Much of the poking, prodding, and peering routinely done in the past has been replaced by talking. But this only confirms what physicians have long known: taking a careful history is often more important than a detailed physical examination in preventing and diagnosing disease.

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The emphasis today is on prevention. A physician who counsels a sedentary, overweight patient about diet and exercise may help that person stave off atherosclerosis and, eventually, a stroke or heart attack. This is a far less expensive and risky intervention than waiting until someone needs an angioplasty to clear out clogged arteries.

The benchmarks

There is no standard recipe for the periodic checkup, but there are some basic components that everyone should expect. The physician should:

* take a thorough history and direct the physical exam to a person's concerns or complaints,

* counsel people about dietary habits, such as cutting down on saturated fat, and recommend calcium supplements for those, particularly women, who don't get enough through food,

* ask about exercise and make specific recommendations when there's not enough,

* explore the possibility of unrecognized depression or stress that could be treated,

* ask about tobacco, alcohol, or recreational drugs and advise the use of seat belts and helmets for cyclers,

* advise regular eye exams, particularly for people at risk for glaucoma,

* caution about sun exposure, especially for light-skinned people at increased risk of skin cancer,

* inquire about sexual practices that raise the risk of AIDS and other sexually transmitted diseases,

* review all medications and how they are being taken, and

* offer screening tests and immunizations that are appropriate for someone's age and risk factors for disease.

The art of conversation

Although various guidelines place great emphasis on counseling, some physicians do not feel it is their role -- and some are simply uncomfortable -- talking to patients about sexual behavior, domestic troubles, or substance abuse. Aside from studies on smoking cessation -- which have shown that primary care doctors can be instrumental in helping people quit -- there has been little re search into whether a doctor's advice about seat belt use or reducing fat intake, for example, makes a difference in what patients do when they leave the office.

But just because there is no evidence doesn't mean the advice doesn't work. Indeed, those physicians who have chosen to counsel patients about alcohol use in the absence of data have not, it turns out, been wasting their time.

The first large clinical trial on the subject found that brief counseling from a primary care doctor helps some problem alcohol drinkers cut down. A research team led by investigators from the University of Wisconsin Medical School in Madison reported in the Journal of the American Medical Association in April that two 15-minute counseling sessions by general internists and family physicians spurred men to reduce alcohol consumption by 14% and women to cut down by 31% after one year. In addition to counseling, the doctors gave the patients workbooks and special diaries to track their progress.

Screening tests

Most healthy adults are given one or more screening tests as part of the periodic exam. Numerous groups, such as the U.S. Preventive Services Task Force, the American College of Physicians, and the American Cancer Society, make recommendations about who should be tested for what and how often. Following are the tests that doctors are most likely to encourage and the latest guidelines for adults who are generally in good health.

Colorectal cancer. A panel appointed by the Agency for Health Care Policy and Research recently concluded that the 55,000 annual deaths from bowel cancer in the U.S. could be reduced by a third if all men and women age 50 and older were screened. People who are at average risk can choose among having an annual stool test, sigmoidoscopy every 5 years, a combination of stool testing and sigmoiddoscopy, a barium enema every 5-10 years, or colonoscopy every 10 years. The recommendations state that high-risk individuals -- those with a family history of colorectal cancer or a personal history of bowel polyps, which can become malignant -- should work with their doctors to tailor an individual plan that may require more frequent screening. (For more detail on the tests, see Harvard Health Letter, October 1995.)

Blood pressure. Blood pressure should be checked at every doctor visit or at least once every two years. Even at mild elevations, hypertension can lead to stroke, heart attack, or kidney disease at any age; it is, however, a highly treatable condition. One in four Americans has high blood pressure.

What is a good physical exam? - Preventive Medicine

Harvard Health Letter, July, 1997

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