Let's Get Physicals
By Dr. Alan FreshmanDear Dr. Lanny: My daughter is 12 and has to get yet another physical, this time for a sports team. What’s the purpose of all of these doctor’s visits when a child is clearly healthy?
A: Physical exams, camp physicals, school physicals, sports physicals, well-child checks. What does it all mean?
As Shakespeare might have said, a physical by any other name would smell as sweet. Well, maybe not after sports.
Although they may be for different purposes, ultimately all these exams are to determine if the patient is doing well from the perspectives of growth, development, and physical and mental health. Sports physicals are to determine, within reasonable likelihood, if the patient is fit and safe for a chosen activity.
Although there are no absolute rules, the American Academy of Pediatrics (AAP) has established a recommended schedule of exams for the healthy child. These recommendations are heavily weighted toward frequent exams during infancy, and then annually by the third birthday. The recommendations suggest seven visits by age 1, generally coinciding with immunizations and blood work.
The frequent visits during the first and, to a lesser degree, the second year of life reflect the dramatic changes occurring in all aspects of development during this time period. Although a baby may seem fine right after birth, problems that are not immediately obvious may be developing. Significant changes in the circulatory system after birth may result in the development of an important heart murmur in the first weeks of life. Similarly, there can be development of significant hip problems that did not appear in the nursery. Routine office visits should reveal these and other problems.
Measuring and charting an infant’s growth can reveal or suggest problems well in advance of clinical symptoms. Simple growth charts remain an example of low-tech at its cheapest and best.
Routine lab work remains minimal. Infants have a complete blood count (CBC) at 1 year and lead tests at 1 and 2 years of age. The AAP Bright Futures program presently puts the lead tests in the category of “risk assessment” and appropriate reaction. This simply means that the AAP is allowing the physician to make a determination if there is sufficient concern to do a lead test. New York state has a higher level of concern and mandates that lead is tested at 1 and 2 years. Any other lab work depends on the physician’s assessment of risk—an example being evaluation of cholesterol and related compounds in children with strong family history of sudden cardiac death.
While it is true that most physical abnormalities are first noted by the patient or his family, this is not always the case. Visual or hearing problems, chronic ear problems other than infection, genital abnormalities, and high blood pressure are just a few examples of what may be found on a simple exam. Routine review of development may reveal problems with speech, large motor functions (sitting, walking) or interpersonal relations at a time when early intervention may be very beneficial.
Difficulties in school may also be related to physical problems. The child, for example, who can’t seem to focus, or who falls asleep in class may have a sleep disturbance due to allergies, or huge tonsils, or obesity. Not all problems with focusing are attention deficit disorder (ADD).
Routine exams in childhood help establish a relationship with the doctor that can pave the way for personal questions in adolescence. If both parents and child know and feel comfortable with the doctor, honest answers may be given to questions regarding sex, drugs and other issues.
In an ideal world, the doctor would check the breasts and genitals of male and female children, the same as he examines the rest of the body. This is, however, not an ideal world. Understanding the anxiety of “tweens” and adolescents and recognizing the potential for liability, many physicians will “defer” such exams in females to the gynecologist. Although problems prior to sexual activity are infrequent, they can occur, and we are clearly missing an important opportunity to intervene.
When should a female first see a gynecologist? As with the AAP recommended schedule for routine exams, there is no absolute answer. Pediatricians tend to recommend seeing a gynecologist if there are problems with menstrual periods, if the adolescent is sexually active, or by the end of high school. In 2006 the American College of Obstetricians and Gynecologists (ACOG) recommended a first gynecology visit between 13 and 15 years of age. I spoke with two local gynecology offices and found one practice seeing increasing numbers of healthy mid-adolescents, stating, “Times have changed.” The second office was clearly surprised at a recommendation of 13 to 15 years and saw few adolescents for routine exams in that time period.
I believe that routine exams provide an opportunity for discovering problems, cementing relationships, answering questions from parent or child, and providing preventive guidance. I believe that a good exam is time and money well spent.
Dr. Alan Freshman, father of two grown sons, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family’s health care. Send e-mail to him at firstname.lastname@example.org.