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Tuesday, July 26, 2016

The "Yearly Physical"


"I'm going to the doctor next week for my yearly physical."

So normal. Of course you are. Everyone should do that.

But the concept of a yearly examination of one's whole body to see if everything checks out fine is a relatively new invention and whether or not it is necessary is a very controversial question.

I just read an article by Abraham Verghese, an internist and champion of physical diagnosis, professor at Stanford University, inspired writer, about the history of the physical exam. The idea that physicians could know more about a person than he or she could know about him or herself has only gained traction in the last century and comes partly from the invention of gadgets such as the stethoscope, the reflex hammer and the blood pressure cuff which reveal truths only to those of us skilled in their use. Enthusiasm for these has waned a bit as we have become enamored of our ability to see the shadows made by bones and such during an onslaught of electrons (x-rays), or the ability to check the levels of molecules and minerals in the fluids of our bodies, among other technological miracles. This evolution which takes us away from the bedside has also made us less confident in and also less dependent on the information we get by physically examining our patients.

We love what we can measure and correlate, and the physical exam is part of that process. If we can feel an enlarged spleen or liver, that is correlated with certain disease states, but certainly not always. If we can feel lumps in the breasts, testicles or thyroid, there may be something life threatening going on. Or not.

As doctors, we are trained in the nuances of the physical exam. I learned how to examine every orifice and surface, looking for specific abnormalities, and then developed skills over many years in understanding the wide variation in normal people. My physical exam is a conversation with my patient's body which happens simultaneously with a verbal conversation, which in itself is a kind of physical examination. How a person speaks, what interests them, how they follow the conversation are part of the neurological and psychiatric examination. As the physical exam unfolds, my understanding of a patient and my relationship with him or her deepens.

Does a physical exam save lives? I'm not sure. The definitive study will never be done. Only a small subset of what we do at the time of a physical exam has been rigorously studied and found to be of benefit. What a physical exam should entail has never been adequately worked out and there is no consensus. A pelvic and rectal exam, synonymous for some people with a "complete physical" have not been shown to have value in a patient with no symptoms in those areas. These and other parts of a "routine physical" may lead to overdiagnosis: finding something wrong that leads to more testing or treatment that does not improve or lengthen life. Nevertheless, it seems likely that a physical exam, done well and mindfully, is substantially valuable.

If it is valuable, shouldn't we all be getting one, yearly at least? Not necessarily. Plenty of people are healthy and will remain healthy without a doctor doing anything at all to them. "Health checks" were studied by the Cochrane Collaboration and found not to improve morbidity or mortality. There are a few things that would be good to check if you are feeling healthy, just to make sure all is well, though.  It would be good to measure blood pressure  or screen for HIV or hepatitis C for people at risk. If a patient somehow hasn't heard that it is unhealthy to smoke and be inactive and morbidly obese, ride a motorcycle without a helmet or drink and drive, it may make sense to impart this wisdom.

Medicare does not cover a general physical in the sense that most people think of it. What it does cover is a "Welcome to Medicare Physical" right after becoming insured under Medicare, which involves some screening that is important for determining risks and needs, and a yearly "Wellness Visit" which involves only vital signs and some screening tests along with advice on what is presently being recommended, stuff like mammograms, pap smears and colonoscopies. Patients are often put off by this because they don't like scripted interactions with their doctors, and doctors are put off by it because we have usually not memorized the script and some of us are not sure we agree with it.

Is a physical exam a good idea then? And should it be performed yearly on everyone? I, personally, would prefer that I have a chance to have unstructured time to physically examine and interview my patients yearly, in other words to do a physical. I would like them also to get information about what the evidence says about various screening tests and I would like that to be easily accessible in the medical record, but I don't necessarily feel strongly about being the person to offer that information. Perhaps a nurse or a health educator could do that better. I recognize that insurance companies may not cover a complete exam for a person who is healthy.  For this reason, a physical exam may need to be scheduled as a prolonged visit to discuss multiple health issues. Taken as a whole, and not because it is based in scientific evidence, I favor the physical exam. I also would completely forgive anyone who preferred to skip it.

2 comments:

Stacey Murray said...

I agree that the annual exam is an opportunity to provide recommendations/screenings and for creating a database for this patient. It can also diagnose high cholesterol, early diabetes, breast, colon and prostate cancer, before they have symptoms. However, I think a lot of what we do is illogical and may be more focused on keeping the medical money machine churning than actually creating a healthier population. If our goal is early diagnosis, we need a revolution in patient access, and innovations in testing and information dissemination. We have a system that is inefficient, fragmented, inconvenient and expensive. It typically takes four office visits for the average female patient for an annual exam. That's four days of time off of work, or of finding a babysitter, or borrowing a car or having to take public transportation; inconveniences that doctors often don't realize. The first visit is with the doctor, then a visit to the lab, then the visit for the mammogram, then the visit back with the doctor to review the results. This is ridiculous, yet I rarely read articles discussing innovative changes to the system, just work-arounds. Patients should be able to order their own lab and diagnostic studies after-hours and get results directly from the lab and radiologists. They should be able to pay with healthcare debit cards with their premiums determining the balance or the choice (and incentives) to pay cash. If there was physician/facility price transparency, this could truly drive the market. How about more community health centers with multi-specialties, labs and radiology centers within the same structure so patients can get everything done in one day. Allow patients to pay yearly fees to belong to these centers and get rid of fee for service. Patients should have one reliable resource to refer to online for health information created by a new healthcare organization paid for by the taxpayers. Patients shouldn't need to see a doctor for certain medications or vaccinations (which should all have registries) and the role of pharmacists could be further expanded. Understanding health conditions and how to read a lab report could be taught before one graduates high school. Wouldn't it be amazing if people actually knew something about the one thing they say they value most? Sorry to take up so much room. I just think there needs to be more articles, blogs and focus on asking for ideas to truly revolutionize our healthcare system and start recognizing what a mess it is.

Janice Boughton said...

Your points are excellent. I favor the physical exam as a time to create a connection with a patient and build a relationship in which I can help them with what they feel is important. We need to value efficiency and question the wasteful ways we make more money but we also need to slow down and be with our patients because that is what makes our profession wonderful.