The Death of the General Physical Exam

Best Evidence Review of General Health Checks in Adults

The Study

Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

Introduction

The general health examination may be a staple of outpatient medicine, but the current study suggests that it does not improve important patient outcomes. At a time when the cost of healthcare is under intense scrutiny, it is clear that the goals and structure of the general health examination need reform if it is to continue to survive. The current review examines the results of an important systematic review of the general health examination and offers ideas on a way forward.

Background

"I have a 58-year-old woman here for a general health exam," the resident reports. It is early in the clinic day, an optimistic time before complicated cases and last-minute patients upset the rhythms of teaching and patient care. My assignment is to shepherd this patient safely through her clinic visit with one of our senior residents, and teach the resident a thing or 2 in the process.

The resident's presentation schusses forward, like a competitive skier navigating the gates in the giant slalom. HPI (history of present illness), PMH (past medical history), PSH (past surgical history), meds, allergies...all moving along. Everything is going just as planned.

The last finding in the resident's 18-item review of systems is painless vaginal bleeding for 3 months. And then he is off to the physical examination.

OK, I'm thinking, hang in there. The resident will circle back to the bleeding issue. Surely it will be featured during his presentation of the examination. Maybe something really important is coming.

The resident performs a head-to-toe physical examination but, amazingly, a highly incomplete one. When presenting the assessment and plan, he has a thorough understanding of the patient's hypertension, her mild left lateral epicondylitis, and her insomnia.

Last, the resident mentions this patient's vaginal bleeding. He recommends a women's health screening examination at her next appointment 1-2 months from now. She can have a proper examination and evaluation at that time.

This resident queried shortness of breath in this patient with no risk factors. He examined her tympanic membranes. He will order laboratory testing that includes her serum chloride and bicarbonate levels. But he did not acquire further history regarding her vaginal bleeding. He did not perform a pelvic examination.

"What is the number-one concern regarding this bleeding?" I ask.

"Cancer," he responds correctly.

"So why not perform a better evaluation of this patient's cancer risk right now?"

"I guess I thought that the patient was here for a general exam, so I focused on that. That form is really long."

It is. And it could have delayed the prompt diagnosis of cancer in this patient (thankfully, her work-up, completed within 1 week of this visit, was negative). Moreover, it was not the first time I had seen a physician miss doing the right thing because the goal for a patient visit became the completion of a form or algorithm.

The general health examination has been with us for generations, and it is widely accepted as part of the standard of medical practice. The Affordable Care Act embraces this standard, for the first time paying for an annual wellness visit for older adults.

But what can be expected regarding health outcomes of the annual wellness visit? The current systematic review evaluates this issue.

Medscape Family Medicine © 2013  WebMD, LLC

Cite this: Charles P. Vega. The Death of the General Physical Exam - Medscape - Mar 05, 2013.