Case Scenario

Recently, a new patient in his early 40s arrived in my office asking for a “complete” physical examination. He showed me a booklet with a list of laboratory tests and services that his insurance company covered, and he requested them.

It is quite common for patients to ask me for “complete physicals.” I suppose if I were to ask why they wanted one, they'd be surprised by the question and say: “So I'll know that I'm healthy, of course.” In these instances, I usually do a reasonably complete examination, emphasizing screening modalities appropriate for the patient's age, and ordering laboratory tests if the patient has a particular problem. For example, if the patient says he has been anemic in the past, I'll order a complete blood count.

I suspect this is how most physicians handle physical examinations, but should I be doing a more aggressive job of teaching patients what a “complete” physical examination is? If so, what exactly should that examination entail? Are there legal issues to consider if, for example, a patient has had a “complete physical” and then develops an illness that was not noticed?

In the case of this patient, the results of his physical examination brought him a large bill, because he had misinterpreted what his insurance company was willing to pay for. And it brought me a headache, because his laboratory tests revealed mild leukopenia and a single elevated liver enzyme level, neither of which I could readily interpret, but which I didn't feel comfortable ignoring, either.

Commentary

The concept of the “complete” physical examination can be viewed from several perspectives. Historically, there was a time when the patient's history and physical examination were the only means of diagnosis available. While diagnostic resources have grown, the focused history and physical examination continue to be the foundation of medical diagnosis.¹ Then what should we consider the definition and role of the “complete” physical examination?

Medical students are the group most likely to obtain complete histories and perform complete physical examinations on a regular basis. Experienced clinicians generally conduct less-complete examinations and for good reason—their experience allows them to gather important details while filtering out findings that are of no consequence. To perform a “complete” physical examination does not mean returning to the ways of medical students; instead, our efforts should be directed toward maximizing the benefit to the patient.

From a healthy patient's perspective, the complete physical, or periodic health examination, should answer one or more of the following questions: (1) “Am I in the early stages of a disease that, if detected, can be cured or forestalled?” (2) “Are there lifestyle changes I can make that will increase my health and well-being?” (3) “Can I get information about my specific health concerns?” Thus, the physician must be prepared to play the roles of screener, coach, and counselor.

The patient in this scenario is engaged in what might be called “medical window shopping.” He came armed with a list of services supposedly covered by his insurance company and an expectation that medical tests are always useful and benign. “Why not run all these tests if someone else is paying?” seems to be his approach. This more-is-better attitude is common in our culture and frequently influences health care decisions. Health becomes a commodity to be purchased, and physicians are mere middlemen in the transactions. Full-body computed tomography, marketed directly to consumers, is an extreme example of this trend.² The aphorism “physicians deserve the tests they order” applies doubly in this scenario. Because the physician has to deal with unexplained abnormalities, the patient is likely to incur additional risk and expense. There is no such thing as a completely benign test.³

A recent study⁴ revealed a strong belief that certain basic history and physical examination items should be covered. More than 90 percent of a mostly well-educated, affluent patient cohort believed that they should discuss diet, exercise, and tobacco and alcohol consumption with their physician on an annual basis. A similar percentage thought that blood pressure and major organ systems should be examined. A majority favored the use of certain laboratory tests, such as Papanicolaou smear (85 percent), mammography (71 percent), serum cholesterol (65 percent), and prostate-specific antigen (65 percent). A significant minority also thought they should have an annual chest x-ray (36 percent). These results support the notion that the periodic health examination should include elements of physical examination, lifestyle counseling, and preventive care.

Another important finding was the influence of cost on the participants' opinions. The number of patients who favored an annual physical examination dropped by one half (from 64 to 33 percent) when the typical charge for this service ($150) was identified. Stated another way, only one third of the patients questioned thought that an annual examination was worth the cost of a minor tune-up for their automobile. This finding is not surprising in our health care system, where consumers are often unaware of the actual cost of services.

While it is commonly believed that “an ounce of prevention is worth a pound of cure,” this aphorism is not borne out by the medical literature. In fact, it is hard to make an economic case for most screening and health maintenance interventions. A limited number of preventive services, such as prenatal care, tests for certain congenital disorders, and childhood immunizations, are cost-effective on purely economic grounds.⁵ While not cost-effective in the strictest sense, in healthy adults, evidence supports the efficacy of screening blood pressure, annual clinical breast examinations in women older than 40 years (complemented by mammography), and periodic pelvic examinations with Papanicolaou tests in sexually active women. Beyond these three is a larger group of possibly useful services for which the optimal frequency is not known.⁶

Failure to diagnose is a common reason for medical malpractice suits. This point suggests that physicians who do not follow recommended screening guidelines are at higher risk of being sued. In practice, many of us have less than optimal rates for preventive services and screening, while others overuse certain tests in an attempt to practice defensive medicine. A considered, rational approach to the periodic health examination should lower malpractice risk and decrease wasted resources.

So how should the periodic health examination be viewed now? How can physicians provide the best care for a community of healthy people? Where should limited time and money be allocated? Three principles should guide our thinking: evidence, quality improvement, and holism.

The best way to answer our questions is to seek evidence in the medical literature. Fortunately, several sources offer current, evidence-based recommendations.^7–9 The focus should be on elements for which there is strong evidence, and those elements should be considered the core of the physician's plan. Then a decision must be made about what to leave out. The goal is to maximize the benefit that may be achieved in the time available.

The periodic health examination should be process driven, not idiosyncratic. Family physicians should make informed decisions about which preventive services to generally include in their practices. Input should be obtained from everyone involved. These protocols should be made known to patients and staff, put into practice, and monitored over time. Based on the data collected, adjustments may be needed occasionally to optimize the system. Time should be set aside at least once a year to review the “big picture.” The Put Prevention into Practice initiative from the Agency for Healthcare Research and Quality is a good place to start.¹⁰

Most patients want a personal physician who knows them. The periodic health examination may be the physician's primary contact with patients who are fortunate enough to be healthy. This examination is a great opportunity to foster the physician-patient relationship. Each physician should try to learn one personal fact about each patient or family and write it in the chart as a reminder. Examination time should be used wisely to focus on the patient's concerns. The physician should negotiate a plan for lifestyle changes as they arise but not preach to the patient.

The periodic health examination, with its “laying on of hands,” has powerful symbolic meaning and helps strengthen the bond between physician and patient. It should be used wisely.