Monday, April 20, 2015

Ritual, Not Science, Keeps the Annual Physical Alive

Ninety-two percent of Americans say it is important to get an annual head-to-toe physical exam, according to a Kaiser Family Foundation poll and 62% of those polled said they went to the doctor every year for their exam.

But the evidence is not on their side. “I would argue that we should move forward with the elimination of the annual physical,” say Dr. Ateev Mehrotra, a primary care physician and a professor of health policy at Harvard Medical School.

Mehrotra says patients should really only go to the doctor if something is wrong, or if it’s time to have an important preventive test like a colonoscopy. He realizes popular opinion is against this view. “When I, as a doctor, say I do not advocate for the annual physical, I feel like I’m attacking moms and apple pie,” Mehrotra says. “It seems so intuitive and straight forward, and [it’s] something that’s been part of medicine for such a long time.”

But he says randomized trails going back to the 1980s just don’t support it.

The Society for General Internal Medicine even put annual physicals on a list of things doctors should avoid for healthy adults. One problem, Mehrotra says, is the cost. Each visit usually costs insurers just $150, but that adds up fast.

“We estimate that it’s about $10 billion a year, which is more than how much we spend as a society on breast cancer care,” Mehrotra say. “It’s all a lot of money.”

And then there’s the risk that a doctor will run a test and find a problem that’s not actually there. It’s called a false positive, and it can lead to a cascade of follow-up tests that can be expensive and could even cause real harm. Dr. Michael Rothberg is another primary care physician and health researcher at the Cleveland Clinic. He generally avoids giving physicals.

“I generally don’t like to frighten people and I don’t like to give them diseases they don’t have,” Rothberg says. “I mostly tell my family, ‘if you’re feeling well, stay away from doctors. If you get near them, they’ll start to look for things and order tests because that’s what doctors do.’”

My Take:
Not only do they look for things and order tests, too often they treat things that aren’t there either.

The real problem is that the medical experience is based on finding a disease and treating it. Despite all the rhetoric, there is little or no emphasis on preventive health care. Statin drugs for high cholesterol is not preventive health care.

We have a basic model – evaluation and treatment of metabolic syndrome. If you’ve read any of my blogs, you know this term. Metabolic syndrome is a condition rather than a disease. The major signs are central obesity (weight gain around the abdomen), high blood pressure, high serum lipids, hypothyroidism, and insulin resistance. Reversal of any of these factors will prevent (or at least delay) cardiovascular disease and type 2 diabetes.

Cardiovascular disease is the number one cause of death in this country and diabetes is implicated in 7 of the top 10 causes of death.

I look for these signs in every patient and encourage them to run yearly lab work to evaluate these and other indices that might forecast potential health problems. Yes, the lab work alone is about $150, but that is infinitesimal to the dollars spent on treating any of the chronic diseases that plague our nation.

The Bottom Line:
Keep the annual physical, just make it relevant. Insist on a glycohemoglobin A1c rather than just a fasting glucose. Look at the TSH (thyroid stimulating hormone) – Is it between 1 and 2, or is it just within the medical norms. Has your blood pressure, weight or waist measurement increased in the past year? Is your general health declining?

Source: April 9, 2015 National Institutes of Health

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