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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.

Tuesday, July 19, 2016

Preventing Cervical Cancer in Tanzania

I visited Tanzania again this summer, once again helping a group of amazing University of California, Irvine medical students with their summer not-a-vacation trip to teach bedside ultrasound and do other research projects. 
One of the projects this year sprung out of a request by a doctor we have worked with on Ukerewe Island. The island he serves is rural, primarily supported by fishing, and has a high rate of sexually transmitted diseases due to fishermen visiting prostitutes on the mainland and bringing home infections to their wives and girlfriends. This translates to high rates of HIV infection, pelvic inflammatory disease and the spectrum of disease caused by human papillomavirus (HPV). HPV can cause genital warts, which are only mildly distressing, but it can also set in motion cellular changes of the cervix that can lead to cervical cancer. Tanzania has a distressingly high incidence and death rate from cervical cancer and this Tanzanian physician asked one of the students if we could do a project that would help reduce cervical cancer.

The high mortality and incidence of cervical cancer in sub-Saharan Africa can be (and has been) addressed in many ways. Primary prevention would involve using condoms or maintaining celibacy or reliable monogamy. We have a vaccine now that can prevent persistent infection, but it is still very expensive and not used much in resource poor countries like Tanzania. Pap testing is the method we use in the US to prevent cervical cancer, and its use is widespread and effective here. It involves taking a sample of the cells of the cervix during a speculum exam, sending this to a pathologist for evaluation, and repeating that test at regular intervals. Abnormal pap tests are reported to the patient who is notified to return for further testing and eventually removal of the infected tissue if it persists. The abnormal tissue is visualized by applying acetic acid to the skin of the cervix, then using a cervical microscope or colposcope to either biopsy, cut or freeze away abnormal tissue. In most of Africa this is not even vaguely practical since women go to the doctor infrequently and speculum exams are not often performed. It is not always practical to contact people by phone, and they often come from far enough away that returning for multiple visits to deal with an abnormal pap is not likely to happen. In addition, were physicians to start performing regular pap testing, there are not enough pathologists to process the specimens.

About 10 years ago I read an article in one of the large medical journals which described an abbreviated screening test for HPV infection in which vinegar (acetic acid) was applied to the cervix, abnormal areas that looked HPV infected were identified with the naked eye and those areas were simply frozen, destroying the infected and precancerous tissue. This sounded amazing. Since then this procedure has become well accepted, though certainly not universally available, to people living in many African countries. The World Health Organization has studied it and pronounced it to be practical and recommends it for resource poor settings.

The students heard about an organization, CureCervicalCancer, which teaches healthcare workers visual inspection with acetic acid (VIA) and supplies a gun which can deliver compressed carbon dioxide (available in poor countries because it is used to make soda pop) to the infected tissue of the cervix, to freeze it off.

This year several people affiliated with Cure Cervical Cancer came to Tanzania with us, trained Tanzanian MD and non-MD healthcare workers to perform visual inspection and cryotherapy and gave them supplies they would need to make the service ongoing.

The idea of being able to provide that kind of immediate and practical service was very exciting. I just thought it wouldn't work. Doctors and nurses in Tanzania are so overworked that I doubted they would come for a few days to learn a new technique. I also thought that a pelvic exam using a speculum would be a VERY hard sell for women who have never had a pelvic exam, especially since they would be feeling fine. I thought that the doctors wouldn't have time to continue to do these exams after we left. It turns out I was wrong: health care workers were enthusiastic and attended the trainings and women lined up for testing. 

The first day we had fewer patients than the leaders felt was acceptable, about 60 patients total I think. So the students who knew Tanzania from previous trips made flyers which they handed out, used their large word of mouth network and finally hired guy in a truck with a loud speaker to drive around the streets advertising the free clinic. The next two days doubled or even tripled the number of patients screened! Several cases of HPV infection were seen and treated and a few early cervical cancers were identified and referred for likely surgery.

This project may persist. They were able to train people from the city of Mwanza as well as Ukerewe Island and they promise to continue to do screening after we leave, free of charge. We shall see. There is some kind of audit planned for 6 months out. Clearly more nurses and doctors need to be trained to do this. This is clearly the right kind of screening to do in this setting and may reduce the burden of cervical cancer. In our screening clinic the host hospital also offered free HIV screening which was fantastic since treatment of HIV in Tanzania is free. Cervical cancer is more common and more aggressive in HIV infected women, so combining the screenings is really powerful.

I think this will help. I do have some reservations, though. In the US, 80% of people will be infected with HPV during their lifetimes, and the vast majority will kick it and have no ill effect. At any one time, I've read, 10% of women will have HPV infections. Only a fraction of the types of HPV that are out there are able to cause cervical cancer. The point here is that all HPV infection does not necessarily need treatment. We don't have evidence yet that VIA with cryotherapy saves lives, though it seems likely that it will and there have been mathematical models that evaluate this. VIA is, though, a sustainable method to treat HPV infection early and thus to prevent late sequelae including cancer  Clearly real prevention of infection would be the most valuable intervention in prevention of cervical cancer. This could be by vaccination, if the vaccine were affordable, or use of condoms to prevent transmission of infection.  More important even than that would be changes that allow women to have more control of what happens to them sexually. This will require improved education and economic opportunities so that women have value in the society outside of their roles as mates and mothers.




Sunday, July 10, 2016

My thyroid nodule

About 4 years ago I was examining my neck and discovered a nodule in the right side of my thyroid gland. I was examining my neck because I very rarely see a doctor and figured that I should at least cursorily examine myself to see if I could find anything of interest. My heart sounded fine, my lungs were excellent, weight was just right, pulse was nice and low, liver and spleen were fine, skin was slightly sun damaged but basically OK, blood pressure was a tad high and there was a small but definite lump in the right side of my neck.

Since I have a portable ultrasound, I looked at my thyroid nodule and found it to be about 1.8 cm, with some internal calcifications and a bright capsule. It was slightly darker than the surrounding thyroid tissue and had a few visible blood vessels.

I read about thyroid nodules and found that:

1. They are being noticed much more frequently because of increased use of CT scanning and ultrasound imaging.

2. They are very common. Nearly half of people will have significant, greater than 1 cm, thyroid nodules at autopsy.

3. About 5% of thyroid nodules are cancer, and cancer is more common in younger people, people with a family history of thyroid cancer, history of radiation to the head and neck, rapid growth of a nodule and larger nodules.

4. Experts generally recommend biopsy (taking a thin needle sample) of nodules over 1 cm in size.

5. Thyroid cancer is being overdiagnosed due to biopsies, because a needle can pick up a little bitty thyroid cancer which would never have been any problem over a person's life.

6. Some thyroid cancers will kill people. Most will not. It's hard to tell which will do what even after evaluating the tissue taken at a biopsy.

So I decided that if mine were a cancer which would cause trouble, it would almost certainly grow. I decided to follow it on ultrasound, measuring its size and watching what it looked like, and maybe get a biopsy if it grew.

It didn't seem to grow, at least not much. I was aware that it existed. I could feel it, though it didn't hurt. I was happy with my decision. Then I went to a talk about thyroid cancer at a major medical meeting. The speaker said that some thyroid cancers could grow very slowly over years and could still metastasize (spread to other areas.) Shucks. What if I got metastatic thyroid cancer? I could just imagine my family's displeasure. "It's a fool who has herself for a doctor." Also the expense, the plans forsaken. I decided to have it biopsied.

I went to a radiologist friend who said she had done many and assured me it would be painless. I scheduled it a week after my decision. I found that I needed a preoperative physical exam, which was a problem because I didn't have a doctor and hesitated to fill out my own paperwork because I figured I couldn't get away with it. So I had a physical exam which wasn't bad at all. I shuttled the paper copy to the radiology department. They still lost it, but eventually found it, and all was as it should be.

The radiology department is very familiar to me. I knew the smell and sound and paint color of the room in which I donned my hospital gown. The radiology technician gooped my neck with ultrasound gel and took about a million pictures of my nodule, measuring its length, width, height, observing its color doppler signal, looking for other nodules that might have hidden from my examining hand. My radiologist friend came in. We discussed things we agreed upon. We argued about the utility of mammography. That was probably not a good move, since she would then stick my neck with a variety of needles.

She numbed the left side of my neck with a lidocaine injection. I asked her if she knew that the nodule was on the opposite side and she reassured me that she hadn't been born yesterday and had performed this procedure before and knew exactly where my nodule was. She introduced a long needle from the wrong side of my neck into the nodule on the other side so as to avoid poking my carotid artery which was really quite close to my nodule. The bright shiny capsule turned out to be incredibly tough, requiring rather vigorous stabbing to get a sample. She then informed me that she recommended we do a core biopsy as well, since the pathologist appreciated a larger piece for evaluation. This was done through a type of coaxial cable. The core was taken with a gun which made a disconcerting thump as it removed tiny pieces of my thyroid. She showed me the little bottles with chunks of tissue it them. The hardware came out of my neck. Blood was mopped up.

It didn't hurt very much. Maybe a little like being strangled without the can't breathe part. Maybe not that bad, since I've never actually been strangled and wouldn't know. There isn't much numbing, just at the place where the needle goes into the skin because the thyroid itself has only dull pressure sensation. Swallowing is rather sore for a few days, however, because the thyroid moves up and down with every swallow.

Weeks later the bills began to arrive. I have medical insurance these days, through the hospital where I work. The total charges were $2,361. About half of this was for the ultrasound, about $300 was for the pathologist to read the slides. Another approximately $300 was to the radiologist, with free update on the utility of 3-D mammography and $500 was for supplies such as needles and coaxial cable. "Adjustments" due to using the hospital, which provides the insurance, for the whole procedure reduced the cost by a bit over $1000. So insurance paid $820 and I paid about $500.

The results came back "non-diagnostic." There was not enough thyroid tissue to be sure it's not cancer. Up to 20% of thyroid biopsies are non-diagnostic.

My initial reaction was that I was looking for cancer cells and they didn't find cancer cells and so I'm fine. It turns out that this is about right. There is a study from 2014 in which patients with non-diagnostic results on fine needle aspirate had a repeat biopsy (which I would not do because ouch, in so many ways). These patients almost never had cancer diagnosed, and almost all of those who did have abnormal repeat biopsies turned out to have false positive results. This means that they had a significant surgery removing a part of the thyroid and there was no cancer.

What I learned from my thyroid biopsy:

1. They are very expensive and the cost to even a well insured consumer is not small.
2. A thyroid biopsy is not painless. It is also not horribly painful. I do not want another one.


In the big picture, there is not a lot of value in routinely evaluating thyroid nodules with biopsy. There are 240 million adults in the US. About half of them probably have thyroid nodules greater than 1 cm. Performing an uncomplicated biopsy on all of them would cost about 240 billion dollars, assuming no repeat biopsies, diagnosing 6 million of them with cancer. Thyroidectomy and further treatment and followup of these diagnosed patients could easily cost that much again, adding up to nearly half of the US's yearly healthcare spending. A not insignificant number of people would suffer damage to their recurrent laryngeal nerve, limiting their ability to speak and sing, or lose the function of their parathyroid glands which regulate calcium balance. Of the cancers discovered, quite a few (hard to know the number) would never cause harm if untreated. Only about 1900 people die of thyroid cancer each year in the US and some of these are due to very aggressive cancers that will be fatal regardless of when or whether surgery is done. Despite an increase in detection and surgery for thyroid cancer in the last decade, there has been no change in death rates for this disease.

In the smaller picture, specifically the picture of an individual person with a lump in the thyroid, it is difficult to know what to do. Thyroid cancers can metastasize and kill a person. They just don't do that very often. Reassurance is valuable. Being diagnosed with cancer that would have caused no harm could be devastating. Being diagnosed early and avoiding death is priceless but extremely unlikely. As a doctor my practical approach should probably be to avoid searching for thyroid lumps in patients with no symptoms and to try to help those patients whose lumps come to light navigate the dangerous waters of further medical evaluation.