The Not-So-Routine Physical

This report is published by the Food and Drug Administration

You may view the original at:
http://www.fda.gov/bbs/topics/CONSUMER/CON00156.html

by Ken Flieger

The annual medical checkup, once a cornerstone of American health care, is fading into medical history. Like Mercurochrome and the iron lung, the routine annual physical for people who aren't sick came and went in less than
a century--replaced by an approach to periodic health screening based on a new awareness of the importance of risk analysis and targeted preventive services.

That may sound like impersonal, high-tech medicine, but it isn't. Today's far-from-routine health checkup is grounded on a highly personalized concept: the idea that every individual is unique, that each of us has a medical history and lifestyle that strongly influence how healthy--or unhealthy--we are now and may be in the future.

Something Old, Something New

Today's health checkup draws on the best aspects of horse-and-buggy medicine, back when the family doctor was likely to be a long-time neighbor and friend. But it adds the product of research on factors that influence a person's risk
of serious illness--factors that range from family history to eating habits. Using that knowledge, physicians can zero in on specific preventive strategies for individual patients--selecting those, like smoking cessation or nutrition counseling, that have a good chance of helping the patient avoid serious illness or injury and omitting others, such as chest x-rays, that are of little or no benefit to healthy people.

At a time of high and rising health-care costs when health insurance providers are reluctant to cover the cost of routine checkups for people who aren't sick, moves to forego procedures of little or no value can save enormous amounts of money. At the same time, physicians are generally on the lookout for ways to make their limited time with individual patients as helpful as possible. Getting away from routine tests of dubious effectiveness and devoting more time to patient counseling that can pay off in better health have a powerful appeal for many health-care professionals.

The routine physical became firmly rooted in standard American health care almost half a century ago. In 1947 the American Medical Association recommended that every healthy person 35 or older pay a yearly visit to the
doctor to get a battery of tests, a head-to-toe physical examination, and a conference to discuss anything that might concern either doctor or patient. That was a bold move on the part of organized medicine: People were being
advised to see their doctors not just when they were sick, but when, presumably, they were well.

The idea was radical, but it wasn't new. The annual physical for seemingly well patients had been proposed at an AMA meeting as early as 1900. And a lot earlier still--as long ago as the 25th century B.C.--Chinese Emperor Huang Ti
wrote: "The superior physician helps before the early budding of the disease," not when it has already developed. The modern health checkup takes that ancient wisdom one giant step further, however. Physicians today are
able not just to offer help before disease develops, but to keep some diseases and disabilities from occurring in the first place.

For example, counseling a patient to quit smoking--better yet, persuading a youngster never to start--is a prime example of disease prevention that is now seen as a valuable part of a periodic health exam. Tobacco smoking
contributes to 1 out of every 6 deaths in the United States, including 130,000 deaths each year from cancer, 115,000 from coronary artery disease, and 60,000 from chronic obstructive lung disease.

The same kind of hard statistical evidence makes the case for physicians helping their patients cut down on fat intake, use seat belts, curb alcohol consumption, get more exercise, and otherwise adopt a lifestyle that can lower the risk of disease and injury.

But a number of questions face physicians and health organizations, as well as patients who want the periodic health checkup to be as beneficial as possible. Which tests, what sort of counseling, and what immunizations or
medicines are most effective in preventing or minimizing serious illness? Which ones are appropriate for some patients but not all, for some age groups but not others? Which should be carried out every year, every three years,
five years? How do you decide that a test is no longer needed or, conversely, that it ought to be done more often? The answers to such questions are less than certain, but patients and physicians alike have a good deal more to go on than they did a decade ago.

An Ounce (or Two) of Prevention

Two major government-sponsored inquiries sparked the reassessment of the routine annual physical. In 1979, the Canadian Task Force on the Periodic Health Examination published an evaluation of the effectiveness of preventive
services performed routinely by Canadian physicians. A similar effort was launched in 1984 by the U.S. Department of Health and Human Services, of which the Food and Drug Administration is a part. The U.S. Preventive Services Task Force, a 20-member panel of non-federal physicians, other health-care providers, and preventive medicine experts, closely followed the Canadian scheme for ranking preventive services.

The U.S. task force's report, Guide to Clinical Preventive Services, published in 1989, focused on 169 measures targeted at 60 different illnesses and conditions. It has been called "the bible" of preventive medicine. If it is, then the "gospel" is: Schedule and structure periodic health checkups to match an individual patient's individual health profile.

Given that point of departure, the list of preventive services the task force found appropriate for all symptomless patients is fairly short. The only components of the old "routine" physical exam recommended for every patient
are measurements of height, weight, and blood pressure. On the other hand, the approach to prevention envisioned in the task force report attaches great importance to screening measures to identify patients at special risk of illness or injury.

Physicians are advised to take a full, detailed medical history, to identify occupational and behavioral factors that affect health, to find out about a patient's eating habits, use of alcohol and other drugs, use of tobacco, and sexual activity--anything that may put the patient at high risk for a specific disease or disability. The physician can then make informed choices among available preventive services, emphasizing the ones most likely to benefit an individual patient. Many of these measures involve the use of devices, tests and vaccines regulated by FDA.

For example, the task force recommends periodic blood pressure testing for everyone 3 or older. High blood pressure affects close to 60 million Americans, many of whom have no symptoms. It's a major risk factor for coronary artery disease, congestive heart failure, stroke, and kidney disease. High blood pressure is easy to detect, and it can be controlled with diet, exercise and drugs, preventing serious illness and death. (See "High Blood Pressure: Controlling the Silent Killer" in the December 1991 FDA Consumer.)

On the other hand, the Preventive Services Task Force found no scientific basis for routine urine testing of all asymptomatic patients. (See "Urinalysis: Looking into the Void" in the October 1989 issue of FDA Consumer.) Instead, the task force recommended periodic "dipstick" urinalysis for pregnant women and people with diabetes. Urine testing, the task force suggested, may also be appropriate for preschool children and people over 60.

Serious urinary tract disorders are uncommon, urinalysis is not especially reliable as a screening test for such disorders, and the effectiveness of early detection and treatment of urinary tract problems is unproved. Hence, doing a urinalysis routinely and repeatedly among symptomless people can't be justified.

By the same token, electrocardiography (ECG) to screen for unsuspected coronary artery disease is recommended only for certain high-risk groups and for people, such as airline pilots, whose sudden heart attack could endanger
public safety. "High-risk" in this instance means people who have two or more risk factors for coronary artery disease--cigarette smoking, high blood pressure or high serum cholesterol levels, diabetes, or a family history of coronary disease before age 55. The task force found no basis to recommend routine ECG screening of all individuals with no hint of coronary artery disease.

Again, the reason for the recommendation is straightforward: Studies have shown that routine screening of symptomless people in whom the probability of coronary artery disease is low has been found to generate a large proportion
of false-positive results. Studies of the more reliable stress ECG (or "stress test"), in which the patient is tested while exercising to raise the heart rate toward its upper limit, indicate that most symptomless people with abnormal test results don't have coronary artery disease. According to the task force report, neither the regular nor stress ECG is recommended for children, adolescents, or young adults who show no evidence of heart disease and plan to start a strenuous athletic program.

Not Another Cookbook

While there is broad consensus among health authorities that an annual, more-or-less uniform checkup of symptom-free, presumably healthy people is inappropriate, experts and professional organizations don't entirely agree about exactly what should take its place.

In 1991, the American College of Physicians, whose members are specialists in internal medicine, published a lengthy report comparing its own preventive service and screening recommendations with those of the U.S. Preventive
Services Task Force, the Canadian Task Force on Periodic Health Examination, and other organizations. There was general agreement on routine blood pressure screening and on counseling adults about tobacco use, nutrition, exercise, sexual behavior, substance abuse, injury prevention, and dental care. All groups also recommended tetanus-diphtheria booster shots every 10 years and influenza immunization for persons 65 and older. U.S. organizations also recommended pneumococcal immunization at age 65.

The groups generally agreed that women should have an annual Pap smear beginning at ages 18 to 20 and every third year from age 20 through the mid 30s. They did not entirely agree on how often and for how long older women with no symptoms of or risk factors for uterine cancer (including a family history of uterine cancer or a succession of abnormal Pap test results) should continue to have periodic Pap tests. However, the U.S. groups recommended Pap tests at least every three years through age 65.

An annual mammogram to screen for early breast cancer was uniformly recommended for women from age 50 on, but not all the organizations surveyed agreed on how often women under 50 should have mammography screening. The
American Cancer Society (ACP) specifically advises women between 40 and 49 to have a mammogram every one or two years. All agreed, however, that women should have a clinical breast exam annually beginning at age 40.

A check of serum cholesterol every five years was recommended for all men between the ages of 20 and 70 (the Canadians narrowed that to between 30 and 59). The U.S. task force suggested that cholesterol screening of women,
younger men, and the elderly was "clinically prudent," meaning that the physician should base a decision on factors such as a patient's fat consumption, known high cholesterol problem, or other coronary artery disease risk factors.

After age 50, ACP recommends yearly stool screening for occult blood, but the U.S. and Canadian task forces said there was insufficient evidence to recommend for or against this test.

Also after age 50, ACP recommended procedures to check for diseases of the colon: sigmoidoscopy every three to five years or air-contrast barium enema every five years. Again, neither the Canadian nor the U.S. task force
recommended for or against these tests.

A Vote for Low Tech

Many experts think the new face of the periodic health examination is at least as important as new medical technology in safeguarding people's health. Americans seem to agree. A recent Gallop poll conducted for the Pharmaceutical Manufacturers Association Foundation found that 28 percent of heads of households thought that of all health-related efforts, lifestyle modifications, such as diet, exercise, and smoking cessation, had benefited them most. Diagnostic tools--x-rays, CAT scans, and heart monitors, for example--were judged most beneficial by 25 percent of those surveyed, and 25 percent placed drugs and vaccines at the top of the list. Improved surgical techniques scored best with only 16 percent of the sample. All of which supports the idea that active participation by patients and health-care
providers has a critical role in efforts not just to treat, but to prevent, human illness.

Ken Flieger is a freelance writer in Washington, D.C.

A Physical Glance

-An annual overall physical for healthy adults of all ages is no longer recommended by most medical experts.

-Counseling about lifestyle and health is now considered an important part of a periodic exam.

-During a periodic exam, depending on your age and gender, your doctor may suggest one or more of the following tests and immunizations:

-blood pressure
-cholesterol level
-occult blood in stool
-sigmoidoscopy or air-contrast barium enema
-clinical breast exam
-mammography
-pap smear
-tetanus-diphtheria booster
-flu immunization
-pneumonia immunization

You may view another report by The National Library of Medicine here.