The Annual Physical Exam, that yearly ritual of organized indignities and medical doublespeak, followed by a huge bill for a lot of tests identified only by indecipherable codes, may become extinct.
At least as we know it now.
For some years physicians in internal medicine and family practice have had the feeling they were not providing the kind of health care they wanted for their patients. At the same time, many patients were finding that establishment medicine wasn't necessarily making them feel better.
So called "holistic" or "wholistic" movements, along with a burgeoning health-food industry (sometimes with dubious scientific value), were attracting hordes. Often it was well-trained medical personnel seeking new ways of augmenting health care who were encouraging each of us to be responsible for our own health. Skepticism -- even hostility -- toward establishment medicine kept on growing.
And to top it off, costs were soaring.
One of the areas most vulnerable to attack was the poke-stick-squeeze-thump-X-ray routine every year.
Physicals, the physicians themselves have admitted, didn't really give a clean bill of health: Up to half of all heart attacks occur in patients with no previous symptoms, for example, and by the time a lung cancer shows on an X-ray it usually has advanced beyond much help. Even when something turns up that can be helped -- like hypertension -- the patient isn't always motivated to do the things the doctor suggests.
In the past five years, a number of alternative suggestions have been published -- mainly a 1977 study in the New England Journal of Medicine, a 1978 report from the National Academy of Sciences and another report the following year from the Canadian Task Force on the Periodic Health Examination.
More recently a group of life and health insurance carriers has set up a nonprofit organization called INSURE, based in New York, to conduct a scientific comparison of doctors and patients functioning under the annual physical regimen, and another group adopting what they call "Lifecycle Preventive Health Services" (LPHS). About 100 doctors and 2,250 patients so far are participating in Wisconsin, Pennsylvania and Florida, with another 2,250 patients under traditional care.
Under LPHS, according to INSURE director Dr. Donald N. Logsdon, "packages" of recommended tests, questions, treatment approaches and periodic examinations have been devised for specific groups of patients. Excluded is the routine, annual physical for healthy people without any special symptoms, age 18 to 75.
Pregnant women and children are examined pretty much according to schedules recommended by the American College of Obstetrics and Gynecology and the American Academy of Pediatrics. "Young adults" (up to 40) have examinations every five years. Over 40, there may be specific tests at shorter intervals depending on individuals -- whether they smoke, for example.
The content of adult examinations also is changed under the LPHS program:
* The routine chest X-ray and electrocardiogram (EKG) have been eliminated.
* Mammograms have been added for women age 50 and over.
* Physicians in the program counsel patients about risk factors in their life styles.
The last is more complicated than it sounds. Internists typically have not been trained to "counsel" patients, nor, in many cases, have they learned to connect certain environmental risks with their patients' health.
INSURE has prepared a series of teaching aids for physicians designed to communicate to their patients the effects of diet and exercise (or lack of it), and to motivate patients to stop smoking, moderate drinking, even fasten seat belts on themselves and child restraints on their youngsters. Elderly patients are advised on accident-proofing their homes.
Initially designed for three years, the study is just entering its third year. Part of its early mission was to interview physicians and patients about the most effective ways to transmit information and motivation.
Early results, says Logsdon, tell us "that it is very clear that physicians are very receptive to eliminating the routine physical and changing their approach if you can provide them with some skill training regarding preventive services, especially patient education . . . and pay them their customary charges. Reaction from patients has been very positive regarding changing health-related behavior, and satisfaction levels are very high."
The study, of course, is also designed to measure cost-effectiveness and this too appears to be positive in the short-run studies. (Patients are paying only for the medical care they actually need.) More will be known during subsequent "longitudinal" studies, says Logsdon, which will follow participants over a few years to compare lasting health effects.
The first scientific reports on the project -- reaction of physicians, effect on their practice patterns and most effective techniques -- will be presented starting this month. Physicians have been given manuals and video tapes showing examples of doctor-patient dialogues and suggestions for improving rapport. Participating patients have guides and pamphlets, along with individualized risk-factor inventories.
Meanwhile, many internists and family practice physicians have already amended their physical examinations to trade off, for example, chest X-rays for mammography, and are devoting more time to exploring life styles of their individual patients.
Although the elimination of certain tests has been recommended by major health organizations, there is still "considerable controversy in the medical profession" about the changes, says Dr. Carol Scatarige, of the Office of Disease Prevention and Health Promotion, Department of Health and Human Services.
Part of the discussion, she says, involves the "lack of a scientific base." That is, of course, the purpose of the INSURE project.
But what could be even more important than elimination of the annual physical is the training of doctors to talk -- and listen -- to their patients.