“It’s time to retool the annual exam: Here’s how” by Barbara S. Levy, MD (June)
Dr. Levy’s article was excellent, and the public would be well served if her suggestions were incorporated into practice. However, I must comment on her point that a comprehensive exam has little screening value. I agree completely, but for a different reason: Few physicians have the skills to perform the type of exam that makes a difference.
They may put the stethoscope on the chest, but many physicians don’t listen as they do so, and if they did, they wouldn’t know what they were hearing. Very few ObGyns (or even younger family physicians and internists) know what to do with a tuning fork, or why we use a different one to assess neuropathy than we use for hearing deficit. They rarely look into eyes, and if they did, they would not recognize macular degeneration or cataracts. They do not know what a carotid bruit sounds like—or its significance. I could give many more examples.
There are numerous conditions that are either asymptomatic or develop so gradually that the patient is unaware when one is present. The past 35 years have proved to me that many of these conditions can be revealed through careful examination of an “asymptomatic” patient. I cannot count the many dozens of cases of skin cancer (they have their clothes off, why not look?), cataracts, macular degeneration, valvular heart disease, atrial fibrillation or atrial septal defect (which can lead to stroke), early congestive heart failure, thyroid cancer, lymphoma, neuropathy, colon cancer, and many other conditions that I have discovered during a routine physical, often in healthy younger women just needing a refill or prenatal care. Most of these conditions would have been missed by the half-hearted and cursory poke and glance that now passes as the standard of care for a physical exam. When a patient is relatively asymptomatic, it is unlikely that a diagnostic test will be ordered, so only the careful history and physical will bring the condition to light.
That said, I am in agreement with Dr. Levy’s recommendations. It is a new world, but I am not convinced that everything new represents progress.
David F. Coppin, MD