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EDITORIAL

In defense of the annual physical exam

Noel J. Genova, MA, PA-C

Ms. Genova practices internal medicine at Mercy Primary Care, Portland, Me, and is adjunct assistant professor at the University of New England PA program, Biddeford, Me. She is a member of the editorial board of JAAPA.

What is an annual physical exam, and why is it under attack by proponents of evidence-based medicine (EBM)?¹Are they arguing against setting aside the 30- to 45-minute appointments each year that many of us use to communicate with patients about their health concerns, build relationships with them, and respond to their most intimate health-related questions? These are the aspects of the annual exam that are most important to my patients, as illustrated by two examples.

An 83-year-old woman had lung cancer. She had been booked for a "physical" before her diagnosis of terminal cancer was made. When she arrived, the patient, her daughter, and I spent 45 minutes talking about her experiences with death from cancer of her husband and sister, and how she wanted to be treated during the rest of her life. None of us needed any study to know that our time was well spent, no matter what the stated reason for the visit when it was scheduled.

A 23-year-old athlete visited the family planning clinic for her annual exam. She was asymptomatic and was in for cervical cancer screening. During the physical exam, an experienced NP detected a murmur and asked the patient to return to have the finding confirmed. Knowing my colleague's finding, I detected a fixed, split S₂ during auscultation. Remembering that this finding is always pathologic, I referred the patient to a cardiologist. Despite the excellent pediatric and adolescent health care this patient had received, an echocardiogram revealed an undiagnosed ventricular septal defect, resulting in early ventricular enlargement. The patient had a successful surgical repair several weeks after referral. I don't know how to calculate the cost of identifying this finding, but her parents found it to be worth a short but thoughtful thank-you note to our clinic.

So what's wrong with an annual exam?

In light of such experiences, which we all have had, what are the EBM experts questioning? For some patients and clinicians, the annual physical exam is a routine set of questions, diagnostic maneuvers, and advice offered by the examiner to the patient. I believe that the value of this predetermined agenda for patient encounters is what EBM proponents are challenging, on the grounds that it is not evidence based and does not lead to any meaningful findings or communication.

For confirmation, I consulted an EBM text² and the US Preventive Services Task Force (USPSTF)³ for opinions on screening tests. The EBM text asks, "Does early diagnosis really lead to improved survival, or quality of life, or both?" The USPSTF provides an exhaustive list of summary recommendations regarding screening. I believe that the major reason for EBM proponents' attack on the annual physical exam rests on questions regarding the validity of repeated, routine testing aimed at early detection, with the promise of superior treatment and outcomes.

In other words, my example of the young athlete notwithstanding, picking up a major cause of morbidity or mortality and treating it promptly rarely lead to an increase in quantity or quality of life. For instance, use of periodic ECGs or exercise ECGs is not effective in discovering asymptomatic coronary artery disease (USPSTF 1996).³ A more recent USPSTF recommendation (2003) concludes that "the evidence is insufficient to recommend for or against routine screening for dementia in older adults."³ Exceptions—that is, when widespread screening programs for appropriate populations have reduced morbidity and mortality—are screenings for breast, cervical, and colorectal cancers.

A partial list of conditions for which screening is "not recommended" by the USPSTF includes bladder, lung, oral, ovarian, and pancreatic cancers, along with peripheral artery disease and family violence (all 1996).³ Those diseases for which evidence is "insufficient to recommend for or against" screening include asymptomatic type 2 diabetes in adults and skin cancer (2003 and 2001, respectively).³ This list refers to screening, not to the diagnostic examinations and testing used when the patient has signs and symptoms.

Clinicians who perform annual physical exams must stay current on evidence-based screening recommendations and be ready to further evaluate and treat conditions identified during these encounters. The implication that those of us who are performing physical exams will follow up appropriately is important—and is explicitly included in the USPSTF's recommendations on screening for depression. This is a prevalent, treatable condition, with significant morbidity and mortality—perfect for screening. But screening is recommended only if a system is in place for diagnosis, treatment, and follow-up (2002 recommendation).³

From the patient's perspective

What do patients—who are looking for reassurance and good health advice—think of all this? Do they understand the issues that have been raised in the popular press, or might they misunderstand and stay away from appropriate exams? Do they understand the limitations inherent in screening exams to detect disease and the need for their participation if recommended treatment plans are to be implemented? Do they understand the caveats to the slogan "Early detection is your best protection"?

While listening to the radio recently, I heard that phrase. It was used in an advertisement for a facility providing total body CT. The ad touted this test as helpful to assure that the examinee would be there for his family, far into the future. No need for an annual physical exam—just have this simple, $450 test with 500 times the radiation of a standard chest radiograph, and your worries are over. The ad did not indicate whether the facility had a system for ensuring definitive diagnosis or effective treatment, nor did it mention the patient's role in adhering to a follow-up plan.⁴

A good exam requires good physical diagnosis skills

Finally, the accuracy, if not the value, of an annual physical exam has also been questioned. Do modern clinicians know how to perform a physical exam effectively?⁵ To follow through on our implied pledge to our patients that we can accurately identify asymptomatic pathology on an exam, we need to maintain our skills in physical diagnosis and not rely solely on expensive, invasive tests—the results of which may be misleading and may lead to further expensive, invasive tests.

As we go through our clinical days and as we teach students, we must keep in mind the importance of the evidence, our mission to reduce the burden of disease, and our patients' needs for connection with us, emotionally and rationally. We must emphasize interventions—whether diagnostic, therapeutic, or educational—that are proven effective, and we must maintain communication with our patients. Our time with them is too valuable to waste on anything else.

REFERENCES

1. Kolata G. Annual physical checkup may be an empty ritual. New York Times. August 12, 2003; section F:1.

2. Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone; 2000.

3. Agency for Healthcare Research and Quality. US Preventive Services Task Force recommendations. Available at: http://www.ahcpr.gov/clinic/uspstfix.htm . Accessed February 3, 2004.

4. LifeView Imaging [Web site]. Available at: http://www.lifeviewimaging.org/heart.htm . Accessed February 3, 2004.

5. Obel J. Losing the touch: as technology and medical education change, doctors may lose the ability to perform physical exams. Washington Post. June 17, 2003:F01.