We have gradually come to realize that the routine physical did little or nothing to improve health outcomes and was largely a waste of time and money. Today the emphasis is on identifying factors that can be altered to improve outcomes. We are even seeing articles in the popular press telling the public that no medical group advises annual checkups for healthy adults. If patients see their doctor only when they have symptoms, the doctor can take advantage of those visits to update vaccinations and any indicated screening tests.
The Physical Exam Itself
The physical exam of a healthy, asymptomatic adult is unlikely to reveal any significant abnormality (1) that would not have been detected eventually when symptoms developed and (2) whose earlier detection and treatment would reduce morbidity and mortality in the long run.
A directed physical exam is sometimes indicated in patients with risk factors for specific conditions. A Pap smear is indicated in most women, but not every year, and the accompanying pelvic exam is likely a waste of time.
For healthy adults between the ages of 18 and 65, The American Academy of Family Physicians (AAFP) recommends only these components of the traditional physical exam:
For men, a blood pressure measurement.
For women, a blood pressure measurement and a periodic Pap smear.
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We are increasingly questioning screening tests that were formerly recommended. The annual chest x-ray, tine test, and urinalysis are long gone. The recommended age limits for mammography have changed. Routine PSA testing is being discouraged. A recent study suggested that a woman whose DEXA scan shows normal bone density or mild osteopenia need not be rescreened for 15 years.
We don’t need to examine all the published literature on screening tests, because the U.S. Preventive Services Task Force (USPSTF) has done all the work for us. They continually update recommended screening tests for different age and risk groups based on the latest studies. There are other organizations in the US and elsewhere that make similar recommendations but that may differ to some degree in different countries. In general, a specialty organization is likely to recommend more screening in its particular area of interest, based on a different focus in interpreting the same published evidence. The American Academy of Family Physicians, with a broader perspective, generally follows USPSTF recommendations.
The Early Detection Myth
There is a general perception, among the public and among doctors, that there’s no such thing as a bad screening test, that early detection is important, that knowing is always better than not knowing. If something is wrong with you, you need to know because, if you find a problem in time, it can be treated effectively to prevent morbidity and mortality. If you get a checkup and everything looks OK, you can breathe a sigh of relief and relax. Unfortunately this is all wrong.
A recent book explains why: Overdiagnosed: Making People Sick in the Pursuit of Health, by Drs. H. Gilbert Welch, Lisa M. Schwartz, and Steven Woloshin. It’s a comprehensive explanation of how test results make people sick and why visiting a doctor can be hazardous to your health. I reviewed it in an earlier article here on ScienceBasedMedicine.org. Please read that link and then come back.
Welch et al. commented
…some people may feel safer having their potential problems diagnosed and treated. For some, that may make the treatment side effects and hassle factors seem worth it… [but] the sense of being safer is likely an exaggerated view of the reality.
For a healthy, asymptomatic patient, the physical exam with the laying on of hands and stethoscope and other rituals is pretty much meaningless. If nothing is found, it can produce false reassurance. If something is found, it is not likely to prolong the patient’s life and it has a significant likelihood of leading to harm from unnecessary treatment or from a diagnostic cascade of tests, unnecessary surgeries, unnecessary expense, and unnecessary worry.
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