One of my patients thought her previous doctor was "no good."
She and her husband saw the same physician, and soon after her husband had a routine physical exam, he died suddenly. At that point, the woman 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 did a fine job and conducted a solid physical exam of him. Even when doctors (and patients) do everything right, there is still no guarantee of good health.
Thinking of this 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 Get a Routine Physical Exam?
If sudden death cannot be reliably predicted or prevented, as tragically occurred with my patient's husband, what is the point of seeing a doctor for a routine physical exam 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 examinations.
First, it matters whether the visit is truly "routine." At a routine visit, there are no symptoms and the person seeing the doctor feels entirely well. But, if you set up the appointment to evaluate a symptom, ongoing problem, or concern, 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 physical exams for adults of all ages. Such visits actually have modest goals:
- To ask about health habits, undisclosed symptoms, and disease-prevention measures?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 use of bicycle helmets may encourage measures that can be lifesaving. Finding out about past vaccinations and whether you are due for boosters is also part of routine health maintenance.
- To determine your risk of disease?Before you develop symptoms of heart disease, osteoporosis, or cancer (for example), your physician may uncover risk factors (such as family history, smoking, or an unhealthy diet) that lead him or her to recommend preventive measures or screening tests.
- To examine you?It may surprise you to learn that the demonstrated usefulness of a routine physical examination is quite limited. For men between the ages of 18 and 65, the only piece of the routine physical exam formally recommended by the American Academy of Family Physicians (AAFP) is a blood pressure measurement. For women, it is blood pressure measurement and a periodic Pap smear. ThatÂ’s it for the physical exam. The other recommendations?vaccinations, counseling, or screening tests?donÂ’t require a physical exam. I donÂ’t think doctors who do more thorough physical exams are wrong to do so, but there is little evidence to support it. For example, the AAFP found inadequate evidence to recommend for or against routine examination of the skin to detect skin cancer for people at average risk.
Some health care professionals routinely recommend extensive testing for healthy people at the time of their routine physical exam. However, most of the tests donÂ’t have the proof to support routine use.
As an example, here is the short list of AAFP recommendations for a healthy 50-year-old woman without symptoms, signs, or risk factors for any important diseases (such as diabetes or cardiovascular disease):
- Periodic blood pressure measurements, at a minimum once per year.
- Regular screening tests for colon cancer (such as stool tests for blood yearly and sigmoidoscopy, colonoscopy, or barium enemas periodically).
- A Pap smear to check for cervical cancer at least every three years (if she has ever been sexually active and has a cervix).
- Cholesterol measurement (taken after fasting).
- Mammography to check for breast cancer every one to two years.
Based on the evidence, other blood tests, stress tests, chest X-rays, and other tests are not routinely recommended 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.
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 simply not true that a doctor can detect any health problem you have just by examining you. ThatÂ’s why some guidelines established in the United States and in Canada do not even recommend routine physical examinations despite the fact that most primary care physicians recommend them and their patients expect them.
If you have symptoms or are worried about a particular health issue, by all means, see your physician! But for truly routine visits, understand that there are significant limitations around the detection of disease.
Having a routine physical does help to establish a relationship with your health care professional, a process that can come in handy if you ever are sick. This may be among the best reasons to visit your doctor, even when you are feeling well.
Do you see your doctor for routine physical exams? Have you found them helpful?
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