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. 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:
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. Some health care professionals routinely recommend testing for people who are healthy at the time of their routine physical. 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:
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. 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 guidelines established in the United States and separately in Canada do not recommend routine physical examinations. That's despite the fact that most primary care physicians and their patients want and expect 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. 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.
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