©September 2008

Many communities around the United States engage in an annual ritual called a “Health Fair.”  While such events are organized as differently as the communities themselves, they often make certain screening tests available to participants and arrange for counselors to help people make some sense of our so-called “health care system.”  However, one service that is not usually provided at Health Fairs is a physical examination, or “P.E.”  Therefore, it might be worth pondering the value of a physical exam, and taking a moment to consider its place in the preventive services armamentarium.

The United States Preventive Services Task Force (USPSTF) is assigned the task of identifying those preventive services which are recommended for the general public.  Several criteria are used to assess various preventive procedures to see if they make sense.  Such criteria include the prevalence of the illness to be prevented, the effectiveness of the detection method, the disability caused by a preventable condition, the effectiveness of disease treatment once it (or the risk of it) is detected, possible negative consequences of a preventive intervention, and finally the cost of a preventive procedure, test or treatment.  All of these criteria must be used to determine if a particular preventative step should be recommended to the public.

A physical examination requires that the patient bring his/her body to the care givers office.  It also requires that the patient’s body be looked at, touched, moved, probed and scrutinized with fairly primitive lights and lenses.  To do so requires that the patient remove his/her clothing.  Otherwise, a P.E. might be accomplished simply by sending ones laundry and a photograph to the care givers office.  Make a note of this when you are next seen for a routine physical examination.

It is now becoming popular, particularly in rural areas with limited availability of certain specialty physicians, for certain clinics to be conducted via camera, through something called “telemedicine.”  The patient is observed through a video camera and the specialist is also visible on a monitor while the patient is interviewed and visually evaluated.  Psychiatry and Dermatology are specialties for which this system sometimes works fairly well.  However, “telemedicine” is not a satisfactory method of performing a routine P.E.

While asymptomatic discoveries during a P.E. are unusual, they do indeed occur.  Whether it is a new heart murmur, an enlarged liver, a new spot on the skin or a lump that was previously undetected, with enough time in practice virtually every doctor has encountered such instances.  While it is fairly uncommon for these findings to be life saving, it is not rare that these unexpected results enhance the quality of life of the patient.  At the very least, such instances remind the patient that they are connected to the human race.  These are examples of some of the benefits of a regular physical examination.

However, one of the less celebrated benefits of a P.E. is difficult to encapsulate and even more difficult to measure.  This is the moment within the examination room when personal, confidential concerns and troubles that are encountered in every day life are shared.  These generally are items that affect our health, but sometimes include things that we may not even recognize as health concerns.  The treatments provided by the care giver may be nothing more than lending an ear, or answering questions tuned to the individual life of the patient.  However it is this moment during the exam when issues affecting the quality of life can be addressed and reflected.  It is an opportunity that the care giver recognizes as the greatest privilege of his/her profession, and it is an opportunity for the patient that should not be squandered.

The goal of a physical examination will be different, depending upon the age and/or developmental stage of the patient. During infancy, a P.E., traditionally called a “well-child exam,” is focused upon the developmental milestones, immunizations and parental education.  A physical examination during the prepubescent years will raise new questions about relationships and body changes that may have the young persons head spinning.  Young adulthood will touch on many issues that are forming lifelong objectives for the patient.  More than 50% of adult patients will have complaints that revolve around happiness and satisfaction with their lives.  And older patients often teach providers what to tell all the others.

While specific recommendations for a P.E. are not generally agreed upon by all specialty organizations, the following represents a recommended approximate frequency for routine physical exams for the general population based upon the current guidelines of the USPSTF and the California Child Health and Disability Prevention program (CHDP). You should consult your private care giver to determine the frequency of physical examination for your specific needs:

Infancy:  At birth, age 2 weeks, 2 months, 4 months, 6 months, (9months), 12 months, 15 months, 18 months, 2 years

Childhood: At age 3 years, 4-5 years, 6-8 years, 9-12 years, 13-16 years, and 17-20 years

Adult: Every three years between 20-39 years of age

           Every one to three years between 40-64 years of age

Senior: Every year from age 65 and older

A great deal of mystery surrounds the experience of hospitalization. With a little bit of luck, we will postpone for many, many years being dubbed an “in-patient.” Nevertheless, we all secretly recognize that for the great majority of us there is a hospital bed waiting somewhere in our futures. Therefore, it might behoove us to learn some of the practical facts of life as a hospital inpatient.

First, it is worth pointing out that these tips are not specific to any one hospital. Whether we are surrounded by the hallowed walls of the Mayo Clinic, the intensive care unit of a transplant unit, or the hustle and bustle of the medical facility on Main Street USA, human physiology behaves the same way. Complications of health care are not unusual in our “western” model of health care for the simple reason that, generally speaking, we only find ourselves hospitalized when we are already ill. Such illnesses open the door to complications and risks that make further illness more likely. One of the most important (and uncelebrated) reasons why we are in a hospital in the first place is to diminish the likelihood that complications will occur as we allow the built-in repair services under our skins to conduct their own repairs. Once the risk of managing our recovery at home is less than the risk of complications while residing in a hospital, it is time for discharge from the hospital.

Which is to say that residing in a hospital – any hospital – is not risk free. Hospital food makes excellent fodder for comedians because the therapeutic value of a home-cooked meal is generally beyond the reach of the inpatient. Hospitals are unfamiliar places with stimuli that are often not conducive to relaxation and comfort, whether emitted from a roommate, from an alarm on an alien bedside device or from the décor. It is not at all unusual for an elderly in-patient to develop some confusion during the night shift because of being confronted with disorienting surroundings upon awakening in Room 327.

More to the point, though, is the fact that hospitals are teeming with war-hardened bacteria and viruses. The organisms that we encounter in health care facilities have often been exposed to antibiotics and antiseptics that tend to encourage the surviving germs to be resistant to the more common weapons at our disposal. Infections acquired in a hospital tend, therefore, to be more difficult to control. For this reason recent legislation has focused upon preventing infections that occur while we are receiving care in a hospital – so-called “healthcare-acquired infections.” When a caregiver does not perform a washing of the hands in the presence of a patient, it is now perfectly within proper etiquette for the patient to request that the caregiver demonstrate a hand washing. This partnership between the patient and the caregiver to decrease healthcare-acquired infections is exactly the intent of these recently passed laws.

Which brings us to the four “W’s” that describe the four most common causes of fevers that may occur after or during a hospitalization. The first is “Wind,” meaning pneumonia (infection in the lungs). While confined to bed, people tend not to breathe deeply and this can cause an elevated temperature simply due to failure to inflate the lungs, or worse yet, infection in the lungs. To prevent this complication, patients are often given a Dr. Seuss-like contraption with a forgetful name which encourages deep breathing during hospitalization. The second is “Water,” which represents IV tubes and devices that provide us with fluids when we cannot eat or drink. Because these devices bypass our guts to gain access to the bag of fluids we call our bodies, they provide a doorway for infection to become established. That is why we should try to keep our IV sites as clean as possible. Thirdly, “Wound,” which stands for infection developing at sites of surgery or injuries that may have been the reasons for hospitalization. Finally, is “Waste,” which stands for urinary tract infections or complications related to constipation. Urinary tract infections are particularly a risk for patients who required the placement of a catheter, or small rubber tube, into the bladder to keep the urine drained during a hospital stay.

Being aware of these common causes for fevers during hospitalization can help patients assist their caregivers to recognize possible complications of illness early, allowing for an earlier treatment of infection. While it is difficult to know how many of the nearly 100,000 deaths due to healthcare-acquired infections that are estimated to occur each year in this country can be prevented, recent research has shown that improvements can be achieved. Preventing healthcare-acquired infections is a team effort worthy of the considerable effort that hospitals, health care providers, public health officials, legislators and diligent patients themselves are putting into improving outcomes.