The Death of the General Physical Exam

Commentary: Personalized Care in a Cost-Cutting Era

We are promised an age of personalized medicine. Diagnostic procedures and even drug therapies should be tailor-made to maximize their positive impact on individual patients. Yet, the general health examination runs counter to this principle. We as physicians often spend precious time checking off the same boxes for a 22-year-old woman as for an 82-year-old man.

Meanwhile, important health prevention goals may actually be inhibited by the sheer comprehensive nature of the general examination. Adolescent vaccination rates lag well behind the goals for coverage, with less than 50% of adolescents being up to date for some vaccines.^[1] Similarly, a study of 708 physicians found that only 47% of this group was providing chlamydia screening for sexually active adolescent girls.^[2]

Health maintenance adherence among adults is not much better. The rate of colorectal cancer screening among individuals aged 50 years or older has improved, but the overall rate of screening remains only 55%.^[3] The rate of influenza vaccination among adults is a paltry 36%, and only one half of older adults receive routine vaccination against pneumococcus.^[4]

How do we improve these important health milestones in an era of both expanding technology and a focus on cutting costs? The answer seems to center on the use of technology and decision support. Multiple studies have demonstrated that interventions to remind health practitioners when to use preventive services are effective in improving the delivery of these services.^[5,6,7] Even more exciting is the possibility of involving patients more actively in the decision-support model, thus empowering them toward wellness.^[8]

To be fair, the current systematic review did not include research focused exclusively on general health checks among older adults. These patients may be more likely to benefit from a health maintenance visit because they have a longer list of preventive health goals and also are more likely to have undiagnosed and serious chronic illness. It will be interesting to witness whether the new provision for a routine health examination for seniors not only increases the rate of screening tests and vaccinations, but also has real clinical benefits.

In the larger sense, however, the routine physical examination can only survive by incorporating technology and shared decision-making to emphasize evidence-based goals of preventive medicine. All healthcare professionals should be practicing preventive medicine, and significant deviations in practice patterns should be resolved through the use of incentives.

If the routine general examination instead continues to feature a broad review of systems with unnecessary additional testing, such as complete blood counts and chemistry panels, it is time to leave it behind as a medical anachronism. We have more important things to do, and our patients will be healthier for it.

Clinical Pearls

In the current study, the general health examination for adults between 18 and 65 years of age failed to improve overall or disease-specific rates of mortality.
General health examinations failed to improve the risk for major health events, such as myocardial infarction, but they were associated with an increased incidence of previously undiagnosed chronic disease.
There were few data on whether the general health examination affected the use of healthcare resources or rates of disability.
The general physical examination among adults should focus on specific evidence-based goals of preventive medicine, and not broad reviews for potential disease. Decision-support technology can help make these visits more effective.