On the morning of her annual physical, Judy Dohany sat on the edge of the examining table at Thomas Jefferson University Hospital with the happy anticipation of a good student waiting for a favorite professor's feedback.
"I couldn't wait to see Dr. Ziring," Dohany said. "I like to keep tabs on my blood pressure. I'm 50 now. Things start to happen. I've lost friends to heart attacks. My best friend has diabetes. It scares me."
For nearly 20 years, her internist, Barry Ziring, has been giving her annual physical exams, a ritual that for just as long has been deemed unhelpful and even harmful.
Reviewing the data, health economists and medical groups including the American College of Physicians and the Centers for Disease Control and Prevention, have concluded that the standard checkup and battery of routine tests waste money, do not prolong life, and often result in overdiagnosis and unnecessary treatment.
"For the asymptomatic, nonpregnant adult of any age, no evidence supports the need for a complete physical examination as traditionally defined," Sylvia Oboler wrote in a pivotal paper published in the Annals of Internal Medicine in 1989.
In 2012, the Cochrane Review, which provides evidence-based research in health care and health policy, reached virtually the same conclusion.
"This systematic review of randomized trials suggest that general health checks in adults may not reduce morbidity or mortality from disease. . . . Current use of general health checks is not supported by the best available evidence."
The number-crunchers undoubtedly have a point, said David Nash, dean of the Jefferson School of Population Health. Nevertheless, he said, "I think we really should reject that."
Nash, who was deputy editor of the Annals in the late 1980s when Oboler's paper appeared, said the premise has changed.
"How do you define an annual physical?" he asked. "It used to be to try to find evidence of disease. A roll of the dice to find the cancer early."
No longer, Nash said.
"Today, it is a conversation about wellness and prevention. An opportunity to ask your patient about smoking, nutrition, and personal relationships. Are you wearing a seatbelt? Do you own a gun? What is your stress level?"
Furthermore, he said, there is plenty of evidence that tests such as colonoscopies do save lives. "Without a doctor," he reasoned, "how are you going to get a colonoscopy?"
Nash agrees that the old habit of ordering routine electrocardiograms and blood tests on healthy patients should be abandoned.
"But in the modern era, the physical is a check on social determinants of health. On crime, socioeconomic status, education. We can offer counseling, reinforcement, help with smoking cessation. Even if the visit is only to calculate the BMI, it is worth it. Patients commonly do not own a scale. They come in and say, 'Wow! Ten pounds in a year?' "
During her annual checkups, Dohany said, she has grown to trust Ziring's judgment.
In turn, Ziring said, he has developed a familiarity with Dohany's medical history so that when he discovered changes in her weight, blood pressure, and stress levels, he was able to discuss them frankly and help her make appropriate changes.
After changing to a more sedentary job several years ago, she started gaining weight. In August 2011, when she saw Ziring, the scale tipped at 218 pounds. Her blood pressure, which had been a consistent 120/82, had crept up to 140/96.
"We had a talk about diet and exercise," Dohany said. She took his advice, joined a gym, and reduced her portions. When she returned the following August, Ziring congratulated her. She had lost 70 pounds and her blood pressure was back to normal.
"So," Ziring began, "How have you been?"
Dohany told him shsue had developed varicose veins and painful swelling in her legs, and was wearing support socks and taking an herbal supplement.
"What sort of exercise do you do?" he asked.
"I walk on the treadmill and do Zumba."
"You're a nonsmoker, right?"
"I hate smoking!"
Ziring nodded with approval.
He asked her about her relatives' health and the results of her last mammogram.
"No chest pain?"
"Shortness of breath?"
"You haven't had a colonoscopy, right?"
"No," she said. "I know I'm due for that."
Given Ziring's family history of diabetes and her leg swelling, several blood tests had been ordered, including a cholesterol screening. Ziring used a calculator to determines her risk of a heart attack over the next 10 years.
"Your HDL is 90. Your LDL is 88. Your blood pressure is 120 over 77," he said, entering the numbers into the app on his iPhone and holding it so she could see. "You're looking better and better!"
Dohany broke into a grin. "I think the exercise is paying off!"
Ziring, who is 57, has had to adapt the way he conducts physicals, but doctors who have completed their training in the last five years started out with a different approach to the annual exam.
"The annual physical shouldn't be just a checkup, but a check-in," said Felecia Sumner, 28, an internist in Newtown Square who works in the Crozer-Keystone network. But rapport is not instant, she said.
"Just like any relationship . . . it will be difficult to bring up confidential issues if you don't know someone well," she said.
She agrees that doctors need to be restrained about testing, but also says studies that criticize the value of annual exams are "based on information that is a little outdated.
"We're practicing medicine and wellness in a very different fashion," she said.