WHAT IS A PHYSICAL?
Sanaz Majd, MD
Did you know that insurance plans are mandated to cover an annual “physical exam” without a co-pay for patients? Have you had yours within the last 12 months? What do doctors evaluate at this visit and what can you expect?
Note that a physical exam isn’t necessarily all “physical.” That is, it is not as much about the exam portion of the visit as it is about prevention, which is a key component of your health. It is the opportunity to obtain an overall general assessment of your health and make certain that you have completed the pertinent, age-appropriate preventive measures and screenings in order to maintain good health.
Expert physician groups, such as the US Preventive Services Task Force (USPSTF), help set these guidelines for physicians nationwide. They carefully review the latest research and literature in order to set recommendations after careful evaluation of the tradeoffs between benefits, harms, and costs of each screening throughout time. Of course, patient preference is always vital when making recommendations. Your physician can review the risks/benefits of certain tests with you and then a united decision whether to screen or not can be made.
Below is a breakdown of some of the most common preventive screenings that doctors typically address at these visits. Keep in mind that this list pertains only to the average-risk healthy person, and not those with other risk factors, such as a personal or family history of certain conditions.
CERVICAL CANCER SCREENINGS
Cervical cancer screening is recommended starting at age 21 until age 65 for most women. For those less than age 30, the recommended screening frequency is every 3 years, and for those aged 30 and above every 5 years—as long as it is performed along with a “Human Papillomavirus (HPV)” co-testing. HPV is a sexually-transmitted virus and the underlying cause of over 99% of cervical cancer. This is the reason why younger women are screened more frequently—they are more likely to change partners and therefore be more exposed to HPV.
BREAST CANCER SCREENINGS
The various expert groups that set guidelines currently do not agree on when to start and how often to screen for breast cancer, especially for women in their 40s. However, most health plans do cover an annual mammogram for women in this age group, so make sure to discuss when to initiate screenings with your doctor for an individualized recommendation in your 40s.
Most expert groups do agree, however, that women in their 50s should obtain a mammogram about every 1-2 years, and continue screening until at least age 74 or as long as the patient has a life expectancy of at least 10 years.
COLORECTAL CANCER SCREENINGS
The colonoscopy is the gold standard for detecting colorectal cancer, with a detection rate of 95%. Precancerous “polyps” (small clumps of tissue that form on the lining of the colon) called “tubular adenomas” are removed during this procedure, which is the only cancer screening test that can remove the source of the problem. For the average-risk adult, screening starts at age 45 and lasts until the age of 75, or until life expectancy is at least 10 years. After a completely normal colonoscopy, the recommended screening interval is 10 years. But if certain polyps are found, the interval could be shorter. Those with a family history of colorectal cancer or certain other inherited conditions may require earlier or more frequent screenings.
An alternative to the colonoscopy is the Cologuard test, which analyzes the stool for blood and certain DNA markers that increase the risk for colorectal cancer. It detects 92% of colorectal cancer, but only 42% of large precancerous polyps. A kit is mailed to your home and is mailed back to the lab after completion, with results sent to your doctor within a few weeks. If the test is “positive” (aka abnormal), a colonoscopy is then necessary for further evaluation. Note that there is a 13% false positive rate, so 13% of people will have an abnormal test result when it really is not. If it is “negative” (or normal), then you are off the hook for 3 years.
PROSTATE CANCER SCREENINGS
Most expert groups recommend screening with a blood test called the Prostate Specific Antigen (PSA) starting at age 50 for most average-risk men until age 75, or until the patient has at least a 10 year life expectancy. African Americans and men with family history of prostate cancer may need to be screened earlier.
OSTEOPOROSIS SCREENINGS
Osteoporosis screening via a bone density scan (aka “DEXA”) begins at age 65 in postmenopausal women, or in women less than age 65 who have certain risk factors (family history, previous pathologic fracture, chronic glucocorticoid therapy, smokers, those with excessive alcohol consumption, etc.). Screening is repeated every 2-5 years depending on the results.
ABDOMINAL AORTIC ANEURYSM (AAA) SCREENINGS
This is recommended for certain men ages 65 to 75 who are current or former smokers or who have never smoked but have a 1st-degree relative with AAA. The screening is performed via a one-time ultrasound.
MENTAL HEALTH SCREENINGS
This simply includes a health questionnaire in which:
Adults and adolescents ages 12 and above are screened for depression. Adults and adolescents ages 13 to 64 are screened for anxiety.
IMMUNIZATIONS
A physical exam is also the time when most physicians update patients on immunizations.
BLOOD TESTS
Hepatitis B and C, and HIV screenings: These screenings are recommended in all adults age 18 or higher as a one time universal screen as part of routine blood work. However, any further screening after that can be done upon request/need/symptoms.
Cholesterol screening: A blood test screening is recommended once between the age of 17 and 21, and then starting at 35 for men and 45 for women. It can be earlier for those with certain risk factors, such as diabetes, hypertension, smokers, and those with a family history of cardiovascular disease.
Diabetes screening: Screening for Type 2 diabetes is recommended for adults with hypertension or high cholesterol, in addition to those aged 35 to 70 who are overweight. This is often measured via a blood test called a “hemoglobin A1c,” which provides the average blood glucose levels for the last 3 months and does not require fasting.
Chlamydia screening: Routine chlamydia screening is recommended for all sexually-active women age 25 or less, or men at higher risk. It is often included in a routine pap smear for this age group, but it can also be completed via a urine test.
PEDIATRIC SCREENINGS
For children, doctors closely track growth—this refers to height, weight, and body mass index. For infants, head circumference is also closely tracked. Development is also monitored, including vision and hearing screenings at certain ages, along with an assessment of a child’s milestones, nutrition, sleep, stooling, screen time use, dental care, mental health, and so much more. Appropriate recommended vaccines are also administered. Therefore, these “well child” visits are vital to ensure that growth and development are on target.
OTHER SCREENINGS
Again, the above information pertains to the average healthy person. Certain other patient populations may require further screenings/testings, including:
• Diabetics
• HIV-positive people
• Pregnant women
• Older adults
• Gay men, transgender men/women
• Cancer survivors
WHAT A PHYSICAL IS NOT
With all that being said, it is important to also keep in mind what a physical is not. It is not meant to be a visit in which acute or new symptoms or concerns are discussed.
For instance, it is not a good time to discuss a new chest pain, abdominal pain, headaches, low back pain, etc. Think of the physical as an opportunity to help prevent disease and conditions, and not a visit to discuss other symptoms—this requires a more thorough investigation, deserves more time and attention, and is often not covered by health plans during a physical because it is not preventive. If you have other health concerns, it would be wise to schedule an office visit first to address them and then reschedule your non-urgent physical exam for a later, more opportune time.
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REFERENCES:
USPSTF: https://www.uspreventiveservicestaskforce.org/uspstf/
American College of Obstetricians and Gynecologists (ACOG): https://www.acog.org/
American College of Physicians (ACP): https://www.acponline.org/
American Cancer Society (ACG): https://www.cancer.org/
American Academy of Pediatrics (AAP): https://www.aap.org/
