The Annual Rip-Off?

No health measure is as widely accepted by the American public as the annual or semiannual physical checkup. Doctors and hospitals promote it. So do major health organizations. Many labor unions and corporations agree that periodic employee examinations serve everybody's interests. Even Presidents dutifully submit to them, as did Gerald Ford last week on his 63rd birthday. Yet an increasing number of physicians have begun to question whether the ritual trip to the doctor is really necessary or practical.

The Annals of Internal Medicine, many of whose physician subscribers derive considerable income from checkups, recently published a critical diagnosis of the routine examination. Among other things, it suggested that the periodic exam may be just one more instance of "a tendency of the health professions to oversell prevention ... and to overvalue the benefit of their care to patients." Acting on the advice of medical consultants, the Chicago board of education is scrapping annual chest X rays for all employees. Even leaders of the American Medical Association have joined the doubters. A.M.A. President-elect Dr. John Budd, a Cleveland general practitioner who boasts that he has not had a routine physical since he joined the Army in World War II, regularly asks patients who demand checkups: "What do you want one for? Who says you need one?"

Obvious Symptoms. Good questions, other doctors agree. Though regular checkups are important for spotting health problems in youngsters and the elderly or in people with obvious symptoms of illness, they appear to be largely unproductive for the vast majority of the population. For most adults, write Drs. Donald M. Vickery and James F. Fries in a health guide called Take Care of Yourself (Addison-Wesley; $9.95, hardcover; $5.95, paperback), "even the most elaborate checkups ... do not detect early and treatable diseases with any regularity." Dr. Russell Roth, a longtime Erie, Pa., urologist and former A.M.A. president, concurs. In 35 years of routine rectal examinations, he reports, he has discovered in only one patient an ailment that lent itself to treatment. Even if diseases could be easily detected in checkups, adds Dr. William Keith Morgan of West Virginia University's School of Medicine, "patients are probably better off not knowing they are going to die of Huntington's chorea or multiple sclerosis 15 or 20 years from now."

Annual checkups are also under attack because they are time-consuming (some stretch over several days) and expensive (up to $400). Fries estimates that as much as $15 billion to $20 billion of the U.S.'s annual $118.5 billion medical bill is spent on routine examinations.

Despite their broadsides against annual checkups, doctors do not criticize regular examinations for certain types of illnesses; some tests, in fact, do make economic and medical sense. For example, Vickery and Fries recommend routine blood-pressure tests for hypertension, inexpensive skin tests to spot tuberculosis, Pap smears for women over 25 to detect cancer of the uterus and cervix, and glaucoma examinations for people over the age of 40 if their families have had a history of the eye disease.

On the other hand, they do not advise X rays, electrocardiograms (EKGs) or blood analyses as a matter of routine, unless there are compelling reasons for them: persistent hoarseness or chest pain in a smoker, say, might warrant a chest X ray or EKG, and a family history of breast cancer in a woman over 25 would justify periodic mammograms (breast X rays). In general, they insist, Americans should not waste their precious health dollars on annual checkups but rely instead on easy-to-perform tests that can often be done inexpensively by a nurse or paramedic.

Sensible as such advice may be, doctors concede that the annual checkup will remain an American institution for years to come. For one thing, patients will continue to demand it. Also, says Dr. Ralph Greene, a Chicago pathologist, others have a vested interest in its survival: "There is tremendous money involved; internists, hospitals and many clinics derive a lot of income from this myth in American medicine." West Virginia's Morgan, who in 1969 wrote a debunking article, "The Annual Fiasco (American Style)," is even more blunt. Says he: "The investment pays off for the doctor, not for the patient."

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