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Listening For Trouble Doctors Paying Less Attention To Physical Exams And More Attention To What Patients Are Saying

Liz Kowalczyk Patriot Ledger News Service

Paul Logan has a recipe for good health: Walk two miles a day. Lay off the doughnuts. And don’t visit the doctor too often.

In fact, Logan, 46, has had only three or four complete checkups in the last 20 years. And when he walked into Dr. Paul Duggan’s Weymouth, Mass., office recently, he hadn’t had one in two years.

Duggan didn’t scold him; he congratulated him.

“You’re doing what people should be doing,” said Duggan, who has developed a gentle style during his three decades as an internist. “If your blood tests are OK, I’d like to see you in another couple of years.”

Norman Rockwell immortalized the routine annual checkup in his paintings of kindly stethoscope-adorned doctors. But in recent years, this American ritual has come under increasing scrutiny, and even attack.

More doctors are coming to believe that, for healthy younger adults like Logan, the yearly head-to-toe inspection is old-fashioned and rarely detects or prevents disease. Only patients in their 50s and older or those with serious medical problems need to get fully checked out that often, they say.

Rockwell wouldn’t even recognize the ‘90s checkup.

Doctors spend less time listening to hearts and lungs, feeling the abdomen for masses, tapping knees, peering into ears, and offering small paper cups with a knowing nod. Some don’t do physicals at all unless a patient’s symptoms warrant it.

“Patients loved the physical. It was hands-on, a true laying on of hands,” said Dr. Thomas Hawkins, an associate medical director for Harvard Pilgrim Health Care. “But there’s not much in a physical exam that’s proven to be effective. Checking the ears and doing reflexes in a healthy person is totally useless.”

Instead, doctors are doing more talking. They’re asking for complete medical and family histories and counseling patients about everything from wearing seat belts and sunscreen to cutting down on alcohol and fatty foods.

“I’m more likely to prolong someone’s life by convincing them to wear a seat belt than by listening to their heart,” said Dr. Thomas Hines, an assistant professor in the department of family medicine and community health at Tufts Medical School. “Prevention is the key.”

The name says it all. Many doctors aren’t calling it a “physical” anymore. Instead, they say “health encounter” or “periodic health maintenance.”

Doctors say the change has been slowly under way since the 1980s, but that cost-conscious managed care companies have recently pushed more physicians to streamline the checkup.

“Managed-care companies don’t want to pay for more than they need to,” said Dr. Richard Ashburn, a Weymouth internist and pulmonologist. “Some won’t pay for routine visits any more often than three years.”

Dr. Harold Sox, chairman of the medicine department at Dartmouth Medical School and a national expert on checkups, agreed: “Our time is much more limited now. We need to pass on the things that have very little value.”

Harvard Pilgrim Health Care’s recommendations are typical of managed care organizations: Healthy adults between ages 18 and 39 should have a checkup every five years; ages 40 to 49, every two years; and patients over 50, annually.

If a patient wants a checkup annually, however, Harvard Pilgrim will pay for it, spokesman Todd Ringler said. Tufts and HMO Blue say they have similar policies.

In addition to or during recommended checkups, doctors say adults should be screened for different types of cancer, high blood pressure and high cholesterol, depending on their age, medical history and family history, Duggan said. For example, women over 40 should have a clinical breast exam annually, and women of all ages should have a Pap smear every three years, says the American College of Physicians. A woman with a history of breast cancer in her family or abnormal Pap smears would need to have the tests earlier and more often.

Dr. Martin Iser, a family practitioner since 1971, is resisting the trend entirely.

He recommends that all his patients, regardless of age, receive an annual physical.

“It may not be really cost-effective and the yield is not great,” said Iser, who works as a cruise ship doctor during August.

“But for that one person on whom you discover a problem, it can be a lifesaving visit.”

Iser believes that doctors who listen carefully can detect abnormal rhythms that are warning signs for heart failure or stroke.

“If I went to a doctor and he didn’t listen to my heart and lungs, I wouldn’t consider that a physical,” Iser said.

Besides, he said, it is reassuring.

“The art of medicine is listening to patients, comforting patients and making them feel better,” he said.

“That’s not paid for by insurance companies, but people really like it.”

Hines agreed that “in the public’s eyes, the checkup is still the gold standard for health. For that reason, I don’t think anybody is on the verge of abandoning it altogether.”

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