The Physical Exam

What is the utility of doing an annual physical exam on an otherwise healthy and asymptomatic person? Currently, it's standard practice; you listen to the heart and lungs, check the ears, eyes, and throat, etc. But is there evidence for or against routine physicals?

This is an interesting question, and I don't know a lot about it other than one paper we got on the subject. The program director here suggests that the efficacy of the physical exam should be compared to that of lab tests. What's the sensitivity and specificity of listening to the heart? What's the positive predictive value that an abnormal heart sound the average clinician finds turns out to be a cardiac defect?

He argues that most of the physical exam is useless. The average clinician isn't good enough at listening to heart sounds to warrant doing it. Both the sensitivity and specificity of catching a heart problem are low (perhaps <50%). The benefits of pursuing a workup of an abnormal cardiac exam on an otherwise healthy person don't necessarily outweigh the risks and costs. So he suggests that the cardiac exam is only good for building the patient-physician relationship; it is not a cost-effective tool to identify heart defects in a healthy person. Interesting.

On the other hand, pediatric cardiologists are extremely good at identifying heart sounds. Their sensitivity, specificity, and positive and negative predictive values are really high (>90% I think). They are good at differentiating between innocent benign murmurs and ones that need further workup. This suggests that listening to a newborn heart is worthwhile.

This was the first time I heard much on the utility of doing a physical exam on a healthy person, and I think it's very interesting and merits some more thought. Indeed, if some exam maneuvers have a high rate of false positives or false negatives, it might not be cost-effective to even do that maneuver. We think the same way for lab tests, why not apply it to the physical?