I remember a conversation I had with a patient who thought her previous doctor was "no good."
She and her husband received care from the same physician, and soon after one of his visits, her husband suddenly died. At that point, she 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 provided excellent care. Even when doctors (and patients) do everything right, there is still no guarantee of good health.
Thinking of my 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 a Routine Visit?
If sudden death cannot be reliably predicted or prevented, as tragically occurred with my patient's husband, what is the point of seeing the doctor 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 examination.
First, it matters whether the visit is truly "routine," meaning there are no symptoms and the person seeing the doctor feels entirely well. On the other hand, if you set up the appointment to evaluate a symptom, ongoing problem or concern, everything changes: 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 physicals for adults of all ages. Such visits actually have modest goals:
- To ask about health problems 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 a bicycle helmet may be helpful to encourage some simple measures that can be lifesaving. Finding out about past vaccinations and whether you are due for boosters falls into this category.
- To determine your risk of disease — Before you develop symptoms of heart disease, osteoporosis or cancer (as examples), your physician may uncover risk factors that lead to prevention or earlier detection of disease. Examples include questions about family history, smoking or exercise
- To examine you — It may surprise you to learn that the demonstrated usefulness of a routine physical examination is quite limited. For example, the American Academy of Family Physicians (AAFP) recommends blood pressure measurement and periodic measurement of height and weight for adults age 18 or older. But there is little evidence to support other routine examinations. 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.
Keep in mind that even if you do have an abnormality detected on physical examination, it is often of little importance. For example, just as a freckle is technically not completely normal skin, minor abnormalities are often detected that have no bearing on your health. A lipoma (a benign tumor made up largely of fat) can cause a lump under the skin almost anywhere on the body. To be sure it's not something serious (like cancer), it may be important to have it removed, but an examination that detects a lipoma is an example of how an abnormal examination does not always mean you have a disease.
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Some health care professionals routinely recommend certain tests for people who are healthy at the time of their physical examination. In fact, very few tests have been shown to be helpful. For example, for a healthy 50-year-old woman without symptoms, signs or risk factors for important and diseases (such as diabetes or cardiovascular disease), the AAFP recommends:
- Regular screening tests for colon cancer (such as stool tests for blood yearly and sigmoidoscopy or colonoscopy periodically) until age 75
- A Pap test at least every 3 years (or a pap smear with human papillomavirus (HPV) testing every 5 years) until age 65. (This screening is not necessary if the woman had previously had a hysterectomy.)
- Mammography every two years between the ages of 50 and 74(Screening before age 50 was left to each doctor and patient based on indivual risk factors and values regarding the benefits and harms of screening.)
Based on the evidence, other tests, such as EKGs, chest X-rays and blood tests, are not routinely recommended for anyone without symptoms or risk factors for a particular illness.
Updating immunizations for the healthy adult is also important. For example, influenza vaccination is recommended yearly, and tetanus and diphtheria vaccinations are recommended every 10 years. Other vaccinations, including rubella, zoster and hepatitis B, may be appropriate for people in certain age and risk groups.
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Putting It All Together
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 a myth that a doctor can detect any health problem you have just by examining you.
Your doctor may ask you to come back yearly for a routine physical, but the real impact of such visits may be limited. It's best not to rely on routine doctors' visits to provide a guarantee of health. On the other hand, at your visit you may learn of risk factors for disease you did not know you had, or discover that what you thought was "just getting old" was really symptoms of arthritis or depression.
If you have symptoms or are worried about a particular health issue, see your physician. But for truly routine visits, understand that there are significant limitations for the detection of disease. In fact, some guideline authors and medical societies (such as the Society of General Internal Medicine, do not recommend routine physical examinations. That's despite the fact that many primary care physicians continue to schedule them and many patients expect to have them.
It's unfortunate, but true: A normal examination does not mean you are absolutely healthy. Conversely, even if you have an abnormality on your examination or testing, many findings turn out to be unimportant.
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.
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Robert H. Shmerling, M.D., is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.