(MONEY Magazine) – Have you had a checkup recently? If you're like most Americans and it's been a while, you may be surprised the next time you see your doctor for a general physical. Many of the tests and procedures you've come to expect may not be performed: Instead of giving you a chest X-ray, your doctor may ask how many cigarettes you smoke and how he can help you quit. You may even be spared from giving up what often feels like half your blood supply.

A totally up-to-date annual physical is short on technology and long on talk. If you're cynical, you may think it's yet another way health providers are trying to cut costs; but that's only part of the story. The real shift is away from blind faith in screenings, a shift that reflects a sea change in the way the medical establishment views preventive medicine.

About 20 years ago, medical authorities started subjecting preventive health screenings to the same kinds of scientific trials used for prescription drugs. Among the standards required for a test to win approval: It must accurately detect early signs of a serious illness that is prevalent in the population; the illness must affect enough people to justify the cost of screening for it; there must be convincing evidence that early detection allows for effective prevention or treatment of the illness; and the test's risks must not outweigh its benefits. Using these criteria, only five screening tests have proved worthy of administering to every adult: cholesterol, blood pressure (along with height and weight), Pap smear and mammogram (for women) and a fecal occult blood test for colorectal cancer. Other tests are appropriate only when you have an elevated risk of disease, whether it is because of age, family history or lifestyle.

At the same time that this research was casting doubt on the value of some common screening practices, other studies were suggesting that changing people's negative health habits could prevent as many as half of all premature deaths in the United States. An estimated 400,000 lives could be saved each year, for example, if everyone who smoked would quit. And doctors could be surprisingly effective at convincing patients to change their behavior: One study found that 86% of women whose doctors counseled them to receive a mammogram got one, compared with 44% of women whose doctors didn't mention it. The push is on for doctors to counsel even more: The National Council on Patient Information and Education wants health-care providers to do a complete annual (semiannual for seniors) review of all of a patient's medications, including dietary supplements and over-the-counter drugs, to help prevent adverse drug reactions and interactions.

AN OUNCE OF PREVENTION

So where does that leave the individual? Caught between the appealing prospect of the more personal relationship with a physician that comes with extended conversation--assuming, of course, that doctor and patient can take the time to talk--and the unpleasant prospect of being denied the high-tech measurements we've come to expect. It's enough to leave us feeling like neglected motes in a gigantic cost-benefit equation.

The issue of prevention lies at a difficult intersection of conflicting interests. Both insurers and the federal government want to save money--so they must limit the tests they'll pay for. Disease advocacy groups want citizens to get education and screening for the particular condition they fight. Scientific breakthroughs change the medical landscape regularly: This summer, for instance, researchers discovered that giving smokers CT scans may enable doctors to find lung cancers early enough to substantially improve the odds of survival. But is it feasible to administer $300 scans to anyone who's ever smoked? Would the money be better spent on basic care for the 44.6 million Americans who lack medical insurance?

"People who come at screening from a disease focus, like diabetes or heart disease, push toward more testing and intervention, and that's perfectly reasonable," says Dr. David Atkins, preventive services coordinator at the Agency for Health Care Policy and Research. "On the other hand, there are people who say we aren't doing a good enough job on things that we know are worth it, like getting people who have had heart attacks on cholesterol medications. The reality is, prevention is difficult. An ounce of prevention is a ton of work."

But Americans believe in tests and annual checkups. We've been taught that regular doctor visits are essential to maintaining wellness. And we're right. According to Dr. Harold Sox, former chair of the U.S. Preventive Services Task Force, patients who visit their doctor for a yearly health appraisal are more likely to get the interventions they need (such as a program to reduce blood pressure) than those who go only when they have a complaint.

Yet most of us visit our physician only when something's wrong; and in the era of managed care, our medical encounters are brief--15 minutes or less, on average, according to the National Ambulatory Medical Care Survey. Two-thirds of Americans don't get yearly physicals, according to a recent survey by Consumer Reports. If every year seems too often to you, follow the guidelines of the Johns Hopkins Executive Health Program: Healthy clients from 30 to 39 are urged to return every three years; those from 40 to 49, every two years; and those 50 and over, each year.

WHO PAYS?

Since preventive care has been promoted by health maintenance organizations from the get-go as part of their marketing strategy, most insurance plans will cover a physical (though it can take weeks to schedule one), so there's no economic barrier if you're insured. Among employer-sponsored HMO plans, 98% cover adult physicals, along with 97% of point-of-service (POS) plans and 76% of preferred-provider organizations (PPOs), according to a KPMG survey. About 58% of fee-for-service plans also cover them; Medicare, however, does not. For those not covered by insurance, a physical costs, on average, $138 plus lab fees.

This $138 exam may leave some individuals wanting more--more technology, more time, more attention. A growing number of affluent consumers want to take advantage of every screening advance, whether or not it's been found to be cost-effective, and "executive health programs" are meeting the demand. Often these high-ticket exams are offered as a perk: In 1998, 13% of companies surveyed by Watson Wyatt Worldwide offered top executives a visit to an executive health program. At some, like the Mayo Clinic, two days of screenings can run to $2,000 or more.

ANATOMY OF AN EXAM

Perhaps the most important part of the new physical takes place while you're still dressed. Your doctor should take a detailed medical history, including your age, family history of illnesses like diabetes, heart disease and cancer, your medications and immunizations, and symptoms such as headaches, fatigue or a change in bowel habits. Based on this report, your doctor should tailor the basic screening tests in the chart on pages 122 and 123. For instance, colorectal cancer screening normally begins at age 50, but if a close relative has had it, you might be tested earlier. Obese men and women over 40 and people of color are among the many groups at risk for Type 2 diabetes and should be screened for the disease. At a minimum, the doctor should check your height, weight and blood pressure and, depending on your age, your cholesterol levels.

Your doctor should also discuss eating habits, physical activity and alcohol use, sexually transmitted diseases (including HIV), depression, and even seat-belt use and domestic violence. "In the past five to 10 years, physicians have become much more aware of the high prevalence of domestic and sexual abuse at all ages and the effects that can have," says Dr. Sox of the U.S. Preventive Health Services Task Force. "Patients should try their best to own up to circumstances like that in their lives so that physicians can at least help."

But this level of interaction takes time; it also assumes that a doctor and patient have developed a trusting, communicative relationship. Many Americans--even those with insurance--still don't even get the basic health screenings and interventions they need, as Surgeon General David Satcher acknowledged last year. Women aren't offered mammograms; men aren't counseled about prostate cancer. Their doctors don't talk to them about exercise and nutrition. If your doctor doesn't address these issues, you are not getting an adequate checkup no matter how many tests you have.

Medical opinion is divided on the value of the hands-on physical exam for patients without symptoms. In fact, the only hands-on exam the U.S. Preventive Services Task Force recommends is the breast exam. Many doctors believe, however, that listening to the heart and lungs with a stethoscope; feeling the lymph nodes (for signs of infection or cancer); checking the eyes, ears, nose and throat for abnormalities and palpating the abdomen (for enlarged liver, bowel tenderness and aortic aneurysm) provide valuable clues to your health. They may also help build rapport between doctor and patient.

The bottom line? An annual checkup, for most adults, is worth the effort. It's still the best way to make sure you're doing all you can to keep your health on track. But several of the tests we've come to count on--and to rely on as proof we're getting state-of-the-art care--are no longer the crucial part of the experience. It's talking with your doctor that makes the difference.