Routine physical exams aren`t what they used to be in much of the medical world.
For most of the worried well, the head-to-toe annual physical is out. Instead of a chest X-ray, exercise electrocardiograms, barium enemas and dozens of lab tests, the visit to a clinic or a doctor is more likely to consist mostly of talk.
The trend away from batteries of tests seems to be everywhere.
Doctors still take what they describe as ”careful histories.” They ask how you have been feeling, if you`ve had unusual pain, if you smoke, how many drinks you have a week, what diseases run in your family.
They still offer advice they consider lifesaving: Don`t smoke, eat less fat, get regular exercise, wear your seat belt, and don`t keep firearms handy. ”I may save your life by getting you to get rid of the handgun in your house that your wife may grab someday when she`s mad at you,” said Dr. Thomas Kottke, a Mayo Clinic heart specialist.
But when tests are performed, the emphasis is on specific tests at specific ages for specific people. There are Pap smears and breast X-rays for women considered at risk of cervical or breast cancer, prostate exams for older men, blood-pressure checks for many, eyeball-pressure tests for glaucoma for the middle-aged and older. There is counseling to encourage healthier lifestyles.
Some institutions develop guidelines; others have no formal policy but generally follow recommendations of health organizations such as the American Cancer Society and the American Heart Association.
Though for many years the chest X-ray was supposed to be a key element of the routine physical, most health experts now warn against it for general use, saying that it doesn`t do any good and that the radiation, over a lifetime, could do some harm.
And the value of such standbys as resting and exercising electrocardiograms, proctoscopic exams, colon X-rays, computerized multiple laboratory tests of blood and urine, and diabetes screening has been questioned by the U.S. Preventive Services Task Force, a national panel of experts convened 3 1/2 years ago by an assistant health secretary.
The panel has concluded that many of the elements of the routine physical are unreliable, that some of the reliable ones don`t improve a person`s chances of survival and that lifestyle advice (improving diet, increasing exercise, giving up smoking) can do far more to ward off the major killers, heart disease and cancer.
Kottke, who has served on the task force since its inception, says that overeager doctors who insist on doing full-scale exams of the healthy ”are dangerous people.”
”Every time they start doing tests (on a healthy person without symptoms of disease), they empty your billfold, and they can hurt you,” he said.
He cites as an example a marathon runner from Madison, Wis., who was turned into a hypochondriac by a doctor who misinterpreted the man`s test results.
The runner had gone to the doctor because of peculiar heartbeats. The doctor put him in a hospital and ran tests indicating the man had an enlarged heart.
That, combined with the man`s resting heart rate of 40 beats per minute, about half the average, made the doctor suspect that the man`s heart was deteriorating.
”He told him there was nothing that could be done and that someday he would need a heart transplant,” Kottke said.
The ”symptoms” (slow heart rate, enlarged heart) are normal findings in marathoners, Kottke said. Kottke put the man on a treadmill, monitored his heart and found no evidence of heart problems.
”He was in the top percentile (for heart performance) for men his age,” Kottke said.
The reassurance didn`t work.
”It`s several years later now and his life has changed for the worse,”
Kottke said. ”He gave up his job (he thought it was too stressful for a man with a bad heart). Every time he catches his breath he is frightened. He has stopped exercising.”
”The problem with the regular physical, besides the fact that some findings can hurt you,” Kottke said, ”is that some of these things are worthless.”
Even the routine chest X-ray is of dubious value, he said.
”There`s not enough tuberculosis around anymore to make it worthwhile to X-ray everyone, and if what you are looking for is lung cancer, well, if you find it, there is very little evidence that what happens after that is going to affect the outcome.”
There is strong evidence that in the right circumstances many tests do help.
Blood-pressure measurement can spot and monitor hypertension. Cholesterol measurements can spot people at high risk of heart disease who ought to change the way they eat. Pap smears can detect cervical cancer when it is curable, and mammograms sometimes pick up unsuspected early breast cancer in women past 35 or 40.
Dr. Jeffrey Croke, a preventive-medicine specialist at Stanford University, wrote in the 1988 winter edition of ”Stanford Medicine” that most of the 40 million routine physicals done each year detect nothing.
As early as 1979 a major study published in the Canadian Medical Journal, analyzing the results of periodic health exams, recommended that the annual physical exam be dropped in favor of specific tests to detect specific illnesses at certain times in patients` lives.
”But patients and doctors are slow to give up old practices,” Croke wrote.
Dr. James Craig, medical director for General Mills, said the company provides a head-to-toe exam only once for employees younger than 35, every five years from 35 to 45, every two years from 45 to 55 and annually after that. ”And we tailor the exam to the individual-it`s not the same for everybody.”
He said the company replaced most of the routine physicals with a three-pronged program centering on physical, mental and social health.
The program encourages leanness, a low-fat diet, exercise, healthy ways of dealing with stress, moderate drinking at most, increased fiber in the diet and safety habits such as using seat belts.
Dr. Melvin Amundsen, head of preventive medicine at the Mayo Clinic, said the clinic still provides regular executive physicals, largely at the behest of corporate officials or the medical directors of the corporations.
Amundsen said, however, that one of the main purposes of seeing patients is ”to change their behavior so they stop doing things to themselves that cost society so much in terms of early mortality and chronic disease that requires high technology late in life: strokes, heart disease and cancer.”
