Why regular check-ups are still a good ideaAn annual "well woman" visit has important health benefits — especially the doctor-patient relationship it fosters. For most of the 20th century, the yearly "head-to-toe" physical for adults with no medical complaints was the standard of care, a way to detect disease early and reduce mortality. It typically featured blood tests, urinalysis, and screenings that included a chest x-ray and electrocardiogram. But in the late 1970s, various health groups began to re-evaluate the practice — partly because managed-care organizations wanted to bolster efficiency and reduce costs. Since then, several authoritative bodies have concluded that healthy adults don't need comprehensive physicals every year. That's the view, for example, of the U.S. Preventive Services Task Force (USPSTF), an expert panel that reviews medical evidence and issues guidelines. The USPSTF and other groups say there's insufficient evidence that such exams actually pay off in the detection and prevention of disease. Instead, these experts recommend that doctors conduct less extensive exams in the course of routine medical care and tailor them to a patient's age, sex, family history, and other individual risk factors. They also hold that procedures and tests should be limited to those of proven preventive value. For women, these include mammography; checking blood pressure, weight, and cholesterol levels; and Pap smears and colon cancer screening. Physicians can remind patients about screenings and counsel them about lifestyle and prevention during visits for various medical reasons. But efforts to kill off the comprehensive annual physical and replace it with a more prevention-focused approach have met with resistance from those most directly affected — doctors and patients. Guidelines and practice not in syncStudies conducted since the USPSTF issued its first guidelines in 1989 indicate that patients want traditional yearly physicals and physicians continue to offer them. In a study published in 2002, researchers from the Denver Veterans Affairs Medical Center randomly surveyed adults in Denver, Boston, and San Diego on their attitudes toward physical exams. Nearly two-thirds thought annual physicals were necessary and expected one, and they wanted tests that aren't officially recommended, such as a complete blood count; heart, lung, and abdominal exams; reflex testing; urinalysis; and hearing and vision tests. In a later survey of primary care physicians in the same three cities, the Denver researchers found that 65% believed that annual physicals were necessary and 88% performed them, often including non-recommended tests. Why the disconnect between official guidelines and actual practice? An editorial accompanying the study, in the June 27, 2005, Archives of Internal Medicine, suggested that physicians and patients value the annual physical because it strengthens the doctor-patient relationship, whose many benefits can be hard to quantify (see "A doctor talks about the periodic health exam"). A doctor talks about: The periodic health exam Celeste Robb-Nicholson, M.D. Most of my patients see me in the office for a checkup at regular intervals — say, every 12 to 18 months, depending on their age and medical conditions. I find these periodic health evaluations important for several reasons. Healthy women need to have several indices of health measured periodically — weight, height, and blood pressure — as well as certain preventive services (breast exam, Pap test, immunizations, and, starting at age 50, fecal occult blood testing). It's also important to reassess a woman's risk for various conditions and educate her about those risks. Family history, habits of living, and other factors affect a woman's risk profile. Knowing if and how her risk has changed helps me target my questions, physical examination, and testing, and tailor my recommendations. Seeing a patient for a periodic health exam gives me a chance to check in with her about new health concerns, many of which are triggered by news stories and direct-to-consumer advertising. The daily barrage of information — and misinformation — in the media and on the Internet can open patients to new knowledge and understanding or expose them to unnecessary fear and uncertainty. By asking questions, I learn how much a woman understands about her own health and what worries her. In turn, I help validate or assuage her concerns, and we can address them together. A "well woman" visit also helps me learn what matters most to my patients and how their health affects their daily lives. A periodic review of a woman's life context — her family, work, activities, stresses, and joys — helps us collaborate in making appropriate medical decisions. This may mean finding the best times to take needed medications, figuring out how to fit in exercise or a diet plan, or discussing how chemotherapy might affect her family and work schedule. What matters to a woman also changes as she gets older. Health goals may shift, for example, from keeping cholesterol under 200 to becoming strong enough to pick up a grandchild or walk across the street unaided. When a patient and I discuss these matters, we can work together to help her achieve her most important goals instead of spending time on concerns of no real consequence to her. Seeing patients on a regular basis when they're well also helps build a strong patient-doctor relationship, which is invaluable when serious health problems arise. It gives us an established history and a measure of trust that help my patients when they're ill and frightened. Even if there's little change in a patient's life context, medical status, or health goals between periodic health exams, there's still a lot to accomplish in a single office visit. I have a mental checklist of things I want to address in our time together: questions to ask, exams to perform, and screening and disease-specific tests to talk about and order. It's equally important for me to hear a patient describe her symptoms and voice her concerns. Here are some ways to get the most out of your visit and help foster a relationship with your doctor that works for you: Before you come to the office, jot down your concerns — whether they're about something you've read or a symptom that worries you. Also, bring a list of the medications you're taking, including prescription and over-the-counter drugs and herbal or other supplements. Be sure to mention any changes in the health of your parents, siblings, and children since your last visit: It can inform your own risk assessment. Bring up your concerns early in the office visit, so there is time to address them. Often a patient will save her biggest concern until the end of the visit, when we've run out of time. If a medication or health strategy isn't working for you, let your physician know, so that she or he can find a better approach.
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Researchers are trying to specify these intangibles. For example, a study found that the annual physical can help relieve a patient's worries about her health. The study — conducted by Johns Hopkins School of Medicine researchers for the Agency for Healthcare Research and Quality (AHRQ) — also found that the annual physical (described in the study as a "periodic health evaluation") boosts the chances that patients will get recommended health screenings (Annals of Internal Medicine, Feb. 20, 2007). Such returns, the researchers say, justify the continued use of checkups. A study of 64,288 adults in a group health plan in Seattle had similar results (Archives of Internal Medicine, March 26, 2007). Customized health careSo the annual physical — sometimes also called a "well visit" or "health maintenance visit" — isn't obsolete. Rather, it's a work in progress. There's something to be said for discarding procedures or tests with no proven preventive value and for tailoring a woman's care to her particular risk profile. For example, some women, but not all, need a thyroid function test. Moreover, any test (including those that turn out to be unnecessary) can result in false positives that lead to additional tests and possible harm. Nevertheless, official recommendations are guidelines, not ironclad rules. They neither trump a physician's experience and insight, nor overrule a patient's personal preferences. If you're used to an exam that includes non-recommended tests, you may not feel well cared for if you receive anything less. An open discussion with your physician about the evidence for and against certain tests and how it applies to you may allay your concerns. If you don't see a clinician regularly, be sure to get the tests and immunizations appropriate for your age and health situation. For a checklist of screenings, tests, and immunizations recommended for healthy women, visit the AHRQ Web site at www.ahrq.gov/ppip/healthywom.htm, or call 800-358-9295. |