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A Piece of My Mind
May 5, 2020

The $50 000 Physical

Author Affiliations
  • 1Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
JAMA. 2020;323(17):1682-1683. doi:10.1001/jama.2020.2866

Recently, I was discussing the physical examination with some of our house staff after a conference on evidence-based medicine. I asked whether there was evidence to support performing an annual physical examination on a healthy patient. They did not know. “It couldn’t hurt,” one resident offered. I countered that it might, and then challenged them to come up with an example. Blank looks. Embracing the power of anecdote, I related the following story:

About ten years ago, when my father was 85 years old, he and my mother sold their house and relocated to an assisted-living facility in Pittsburgh. Shortly after their arrival, my father visited his new primary care physician for a “checkup.” He had a longstanding history of hypertension, glaucoma, and some mild mitral regurgitation, but was otherwise in good health. As part of his evaluation, the internist performed a complete and thorough physical examination. He palpated my father’s abdomen and thought that the aorta was too prominent; he suspected an aortic aneurysm. My father had never smoked, and there were no recommendations for aortic aneurysm screening at the time. Nevertheless, his physician ordered an abdominal ultrasound. The test revealed a normal aorta, but the ultrasonographer noticed something suspicious in the head of the pancreas. It was recommended that he have a CT scan. The CT revealed a normal pancreas, but there was now a solitary lesion in the liver, strongly suggestive of hepatocellular carcinoma. My father, who had worked in the chemical industry his entire life, had extensive exposure to numerous solvents, including benzene, and after consulting the Merck Manual, he concluded that it was, in fact, liver cancer. Based on his reading, he understood that the treatments were not very effective and that he was going to die; he would not pursue the diagnosis further. He was philosophical about it—the chemical business had put his six children through college and graduate school. He had had a good life.

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