Why a general health check may become obsolete

As every emergency physician knows, the practical exam required to provide perfect care to patients is very different than that required to effectively bill a chart. The money depends on a well-rehearsed and complex labyrinthine system of paperwork and documentation. Following national guidelines and individual expertise, evidence-based care can be rendered to complex patients; the rate-limiting factor for reimbursement resides in the documentation of an exhaustive history and physical examination. For complex patients, a 10-item physical exam is required for full reimbursement. But does this really add value to the care of the individual patient? In the context of increasingly quality-minded health care reform, is this practice outdated and misaligned with contemporary goals?

There is currently an evolving and growing body of research to suggest that the death of the general physical exam might be afoot. If you forgot your stethoscope, could you make it through your shift? Many could. How often do the physical examination findings we document actually change management? Doesn’t a problem-focused history get us 99 percent of the way in 99 percent of the patients?

A recent meta-analysis by Cochrane Reviews looked at research correlating the comprehensive general physical exam with outcomes.¹ General health checks were defined as screening examinations for multiple conditions, not just one particular disease state. (This is effectively what our existing documentation and coding guidelines require of the emergency physician for reimbursement.) A number of general findings are worth noting:

• The general health examination for adults (between 18 and 65 years of age) was not associated with improved overall mortality rates nor improved disease-specific mortality rates.
• General physical examinations did not improve the risk for major health events, such as myocardial infarctions.
• There were little data on whether the general physical examination correlated with utilization of health resources.

The authors concluded that the general physical examination among adults should focus on specific evidence-based goals of preventive medicine, not on broad system reviews and general physical examinations looking for potential disease.

Patients have expectations. They are seeking an intimate relationship with their health care providers and crave the “magical hands” that will find health care problems and restore health, which is in direct conflict with the value of the exam they expect.

Other studies have begun to create a body of knowledge that suggests the physical examination is simply obsolete. Since 1975, the contribution of the physical examination has been called into question. An article in the British Medical Journal found that the physical exam contributed to the final diagnosis in fewer than 10 percent of outpatient visits.² In 1992, a study in the Western Journal of Medicine using similar methodology found that the general physical exam contributed to the diagnosis in only 12 percent of outpatients.³