SITTING in a cold, sterile room in a blue paper dress, you tell yourself you're taking care of business. That's when the doctor listens to your heart and lungs, hits the knees with a mallet, shines a flashlight into eyes, nose and mouth -- and pronounces you fit as a fiddle. Ready to go for another year.
Don't kid yourself. Study after study has found that the annual physical exam is almost worthless, a medical anachronism that should be buried alongside the iron lung and mercurochrome. Doctors admit they rarely detect anything by listening to the heart and lungs of a healthy adult, and when they do, the results are usually spurious. Ditto for blood work.
Even routine prostate and manual breast exams have been discounted as poor detectors of cancer, leading some experts to suggest, only half-jokingly, that there is hardly any reason for a healthy, symptom-free man or woman to ever again disrobe in a doctor's office.
Yet the routine annual physical will not go gently into that good night. Most primary care physicians continue to perform it, and a study published last June in the Archives of Internal Medicine found widespread resistance -- on the part of both patients and doctors -- to new guidelines that recommend more selective screening based on personal and family history.
"Most of us haven't had the guts to get rid of it," says Dr. Fred Heidrich, a physician at Group Health Cooperative in Seattle and clinical professor at the University of Washington.
Though this is not, as Heidrich adds, just a matter of guts. Many doctors and patients see something inherently valuable to these annual meet-and-greets, a benefit not easily measured by a study. The yearly physical is a chance to forge a bond, to talk about habits and mood and get a patient to make important lifestyle changes. It's a chance, in these days of rushed office visits, for patients to get some hard-to-come-by attention that makes them, quite simply, feel better.
Out of this debate, a more useful annual exam is taking shape. Instead of offering blood work and palpation to all comers, it provides something more pragmatic: discussion. About smoking, alcohol consumption, depression, eating habits, exercise, safe sex, even driving with seat belts.
The challenge, doctors say, is in shifting patients' expectations -- and convincing them that they're not just being shortchanged by a health plan's obsession with the bottom line.
A long tradition
Preventive testing has been around since Horace Dobell, a British physician, called for regular checkups and mass screenings for tuberculosis in 1861.
By 1947, the American Medical Assn. was recommending that all healthy people 35 or older pay a yearly visit to the doctor for a battery of tests and a head-to-toe physical examination.
And by the 1960s, one of the measures of success for the American businessman was being treated to the "executive physical" -- a three-day hospital stay with work-ups on a treadmill, an electrocardiogram and X-rays.
The annual physical became even more entrenched in medical culture with the rise of HMOs and a focus on preventive care. In the 1970s, Kaiser Permanente in Oakland conducted a study in which thousands of patients received regular physical exams, packed with chest X-rays and urine, blood and hearing tests.
The study created expectation among patients, but it was simply "a giant experiment," says one of its planners, Dr. David Sobel, now medical director for patient education and health promotion for Kaiser Permanente Northern California. "It was a great wish," he says, "a dream that if you did these annual exams, it would actually be beneficial in terms of better health."
The package didn't pay off. "When we went back and looked at the data to see if these things really made a difference, the answer came back no," he says.
But the "giant experiment" did show the benefit of tests targeted at patients by their age, family history and personal risk profiles. Those tests are mammograms, cholesterol screening, blood pressure tests and colorectal screening.
Dozens of other studies have found that the annual physical does not prolong life, prevent disability or even detect disease.
"You go in to the doctor's office and they weigh and measure you so they can determine your body-fat index, then they sit you down and take your blood pressure. And those are the two things we know that can make a difference," says Dr. Ned Colange, chairman of the U.S. Preventive Services Task Force, an influential panel of experts that evaluates the costs and benefits of medical screenings.
"Everything that comes after that, if you're asymptomatic -- there's no evidence that anything they're doing is going to make you live longer."
In 1999, a study found that the traditional chest exam didn't accurately diagnose pneumonia.