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Do We Really Need The Annual Physical?

 
 
Miller
 
Reply Sun 3 Jun, 2012 11:27 am
June 2, 2012
Let’s (Not) Get Physicals
By ELISABETH ROSENTHAL

FOR decades, scientific research has shown that annual physical exams — and many of the screening tests that routinely accompany them — are in many ways pointless or (worse) dangerous, because they can lead to unneeded procedures. The last few years have produced a steady stream of new evidence against the utility of popular tests:

Prostate specific antigen blood tests to detect prostate cancer? No longer recommended by the United States Preventive Services Task Force.

Routine EKGs? No use.

Yearly Pap smears? Nope. (Every three years.)

So why do Americans, nearly alone on the planet, remain so devoted to the ritual physical exam and to all of these tests, and why do so many doctors continue to provide them? Indeed, the last decade has seen a boom in what hospitals and health care companies call “executive physicals” — batteries of screening exams for apparently healthy people, purporting to ferret out hidden disease with the zeal of Homeland Security officers searching for terrorists.

In 1979, a Canadian government task force officially recommended giving up the standard head-to-toe annual physical based on studies showing it to be “nonspecific,” “inefficient” and “potentially harmful,” replacing it instead with a small number of periodic screening tests, which depend in part on a patient’s risk factors for illness. Faced with such evidence, I have not gotten an annual physical since around the time I finished my medical training in 1989. I respect my doctors, but I see them only when I’m sick. I religiously follow schedules for the limited number of screening tests recommended for women my age — like mammograms every two years and blood pressure checks — but most of those do not require a special office visit.

“There’s a lot of inertia and unwillingness to let things go — it’s hard for doctors and patients,” said Alan Brett, professor of clinical internal medicine at the University of South Carolina, who tells well patients there is no need to see him annually. “I’ve rolled back the frequency and intensity of screening over the years, absolutely. I’m not doing lots of things now, because there’s no evidence that they help.”

There is, of course, economic impetus for American medicine’s “more is better” mode — at least when patients have insurance. In the United States, most doctors and hospitals profit more by doing more, and prices are particularly high for tests and scans. Also, we are one of the few countries where drug makers and hospitals advertise products and treatments directly to patients, creating demand from consumers who don’t actually pay their full costs.

But there are sociological reasons for America’s enthusiasm as well: an abundance of specialists, who are more likely to deploy tests and procedures, as well as malpractice fears, which leave hurried doctors inclined to order a test rather than explain why it is not necessary. And then there’s habit, said Dr. Brett, who writes extensively on the scientific basis of medical practice, adding: “If you ask gynecologists why they still do yearly Pap smears they’ll say things like: Patients expect it; It keeps patients coming back; It’s what we do in an OB-GYN visit.”

With health care costs spiraling out of control and insurance companies asking patients to pay a greater portion of bills, America may be poised to rethink its rituals. This year the American Board of Internal Medicine Foundation joined forces with Consumer Reports to compile a list of basic medical tests and procedures that are often performed but that don’t add value. The project — called Choosing Wisely — already has a list with dozens of entries, and more will be added in the fall.

“This is the right message from the right messengers — not insurance companies and government, but doctors and patients,” said Dr. Christine Cassel, president of the foundation. “The issue of confronting waste in the American health care system has grown increasingly important. But when this issue comes up in the political arena it becomes about rationing and death panels.”

The United States spends about twice as much per person as other developed countries on health care, generally without better results. A 2009 study of waste in the United States health care system pointed to “unwarranted use of medical care” — unneeded, unproven or redundant diagnosis or treatment — as the biggest single component, accounting for $250 billion to $325 billion a year.

Ateev Mehrotra, an assistant professor at the University of Pittsburgh School of Medicine, has estimated that unneeded blood tests during physical exams alone cost $325 million annually. The only routine blood test currently recommended by the United States Preventive Services Task Force is a cholesterol check every five years.

And the over-screening for some occurs in a country where 50 million people are uninsured and receive little medical attention. More than half of uninsured adults in the United States did not see a doctor in 2010. Fifty percent of Americans are not up to date with the few screening tests that are recommended — like a colonoscopy once every 10 years for those over 50 — because of high costs, said Karen Davis, president of the Commonwealth Fund.

Intensive screening can prove useless for a number of reasons, experts say: Tests can have high rates of “false positives,” signaling that there may be disease, when further tests and procedures reveal none. Likewise, they can screen for conditions where early detection does not alter the course of the disease, either because the body might heal itself or because there are no effective remedies. In either case they can lead to aggressive procedures to clarify the diagnosis or provide treatment, which themselves can be harmful.

In a report released last month, the Commonwealth Fund pointed to a heavy reliance on specialists in the United States as a central factor in driving up costs. Americans have far fewer doctor visits on average than patients in places like Japan and Denmark. But they see more specialists and get more tests.

Specialists are generally inclined to use the tools — and newest toys — of their trade. Surgeons operate. Radiologists conduct scans. Interventional cardiologists do angiograms and stent placements to hold open arteries. “When you go to Midas you get a muffler,” we said when I was in medical training.

“If you have back pain, maybe a primary care doctor says take a muscle relaxant and do these exercises,” Ms. Davis said. “But in the U.S. you might say ‘my friend went to this doctor and had surgery and it’s better.’ So you make an appointment with a back surgeon but before you see the surgeon, you must have a scan. There’s less of what doctors call ‘watchful waiting.’ ”

Many of the screening tests are developed, evaluated and then promoted by specialists and specialty societies — and some prove unhelpful when more widely studied. Specialists are often the last to give up a procedure.

Dr. Brett estimated that 80 percent of urologists still order the prostate specific antigen tests, compared to only 20 percent of primary care doctors. That test is no longer recommended by the Preventive Services Task Force because prostate cancer is most often an extremely slow growing disease that does not kill, while prostate cancer surgery comes with frequent complications, like incontinence.

“The last patient you saw can influence you more than the study of a huge population,” said Dr. Cassel, an internist who was previously an official at several medical schools. “Urologists see the people who have serious advanced prostate cancer, which is a devastating disease. And they have a tool — surgery — that addresses it. So they want to do it.”

DOCTORS emphasize that in moving away from aggressive screening, they are not endorsing less care for the ill or proscribing preventive care that is helpful. “If you can afford it, there’s a tendency to say ‘why not?’ ” said Dr. Cassel. “Well, there are a lot of reasons: CT scans are very high radiation. Every test comes up with little incidental findings. So you have a cardiac stress test and that will lead to catheterization, which has risks, and it turns up just a normal variant. There’s a therapeutic cascade that follows each test.”

A recent study in the Annals of Emergency Medicine found that 10 percent of Americans get CT scans each year and that the use of CT scans in emergency departments has increased sixfold in little over a decade. The Choosing Wisely program recommends against the common practice of conducting X-rays or scans on patients with simple back pain that is less than six weeks old. Virtually all people over 50 will have abnormalities on such tests, and most back pain gets better without surgery.

Consciously or subconsciously, experts say, commercial interests foster unneeded tests. Studies show that doctors who invest in radiology machines are more likely to order X-rays, for example.

As of today, only a few screening tests are recommended as useful for healthy, asymptomatic people by the Preventive Services Task Force and some of those — like blood pressure checks — don’t require a doctor visit and could be performed in a pharmacy. “If you follow their recommendations you hardly do anything to patients,” said Dr. Brett, adding that the most important intervention doctors perform on healthy patients may be counseling about habits. For new patients, he still does the full head-to-toe medical exam — though he does not routinely order blood work — and regards some parts as more or less playacting.

Doctors have become accustomed to performing this ritual in years of training, and “patients come to expect it,” Dr. Cassel said.

“Patients say, ‘hey, why didn’t I get my CXR?’ So many docs say O.K., and order one. You don’t really need all those tests and probably most of the physical exam.”

A medical doctor and an environmental reporter for The New York Times.

This article has been revised to reflect the following correction:

Correction: June 3, 2012


An earlier version of this article misspelled the surname of Dr. Christine Cassel

NYTimes
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Type: Discussion • Score: 2 • Views: 2,279 • Replies: 21
No top replies

 
Miller
 
  0  
Reply Mon 3 Dec, 2012 04:23 pm
Can the computer replace the physician?
0 Replies
 
ossobuco
 
  2  
Reply Mon 3 Dec, 2012 04:40 pm
@Miller,
Me, I am for screenings.

I assume the author is against cross the board checks, including with those who have been fine on those reviews for years; I still think people should be checked from time to time, and the checking is not that hard, relative to other expenses.

ossobuco
 
  1  
Reply Mon 3 Dec, 2012 04:59 pm
@ossobuco,
My doctor at my clinic is, last saw her, hefty. She is very smart.

We are societally different, she is there as boss, which I'm fine with.

One time, a couple of years ago, she was interested in my burritos - breakfast to freeze. I'm the one who has gotten rid of weight.
Miller
 
  1  
Reply Mon 3 Dec, 2012 05:27 pm
@ossobuco,
Many of the Doctors seem to be overweight. The nurses who don't do FLOOR DUTY also seem to be on the heavy side.
0 Replies
 
Miller
 
  1  
Reply Mon 3 Dec, 2012 05:28 pm
@ossobuco,
With the rise today in incidence of diabetes , I think periodic blood work is needed. Maybe every year, or every other year.
ossobuco
 
  1  
Reply Mon 3 Dec, 2012 05:34 pm
@Miller,
You and I are different some times, but I'll agree on that.
0 Replies
 
ossobuco
 
  1  
Reply Mon 3 Dec, 2012 05:53 pm
but wait, all need to read further.
0 Replies
 
georgeob1
 
  1  
Reply Mon 3 Dec, 2012 05:57 pm
A free market for medical services would eliminate most of these issues. Unfortunately once we start putting government band aids on the problem we are condemned to an endless series of unanticipated side effects; more band aide to correct them; more unanticipated side effects .....

Cycloptichorn
 
  2  
Reply Mon 3 Dec, 2012 06:04 pm
@georgeob1,
There's no 'free market' for health care possible without much greater transparency as to costs on the part of the providers of said HC; and, good luck with that one.

Cycloptichorn
georgeob1
 
  1  
Reply Mon 3 Dec, 2012 06:11 pm
@Cycloptichorn,
It's entirely possible and - as indicated in Miler's post above - it's growing and will likely get larger still.

Good luck seelking transparency and patient-oriented service in a government- managed program.
Miller
 
  1  
Reply Wed 5 Dec, 2012 02:35 pm
@georgeob1,
georgeob1 wrote:

... patient-oriented service in a government- managed program.


The government has recently stated that medicare bills for any hospitalized patient will not be paid, if the patient is unhappy with the care they received.

Anyone who's worked in a hospital knows that some patients will never be happy...
georgeob1
 
  1  
Reply Wed 5 Dec, 2012 03:01 pm
@Miller,
That's precisely the sort of bureaucratic grandstanding that will stimulate worse side effects on the behaviors of both patients and service providers, side effects that will ultimately doom the system.

Advocated of government managed health care are quick to point out the supposedly low overhead of Medicare compared to the insurance iundustry, without any evident understanding of the profound differences in government accounting, compared to the real world in which Doctors and insurance companies operate.

Medicare doesn't pay it costs for office facilities, employee retirement, legal support, enforcement or even the cost of money (which in this area is huge), while insurance companies do. Recent revelations about Medicare fraud should give us all concerns about the future trajectories of that element of cost. Indeed most of the examples of obnoxious behavior by insurance companies have to do with their actions to abide by the insurance contract and eliminate fraud. While there's little doubt that insurers are sometimes unfair anf greedy, it is very likely that the majority of the stories one reads have much more to do with just sticking to the insurance contract.
0 Replies
 
JPB
 
  2  
Reply Wed 5 Dec, 2012 06:30 pm
@Miller,
Miller wrote:

georgeob1 wrote:

... patient-oriented service in a government- managed program.


The government has recently stated that medicare bills for any hospitalized patient will not be paid, if the patient is unhappy with the care they received.

Anyone who's worked in a hospital knows that some patients will never be happy...


Source?
JPB
 
  2  
Reply Wed 5 Dec, 2012 06:32 pm
@Miller,
IMO, the answer to the question in the title is, "No!" and ,"Hell NO!". I've stopped going to doctors. The concept that something found early can be treated easily is all well and good until it results in a medical history that makes you uninsurable.
Miller
 
  1  
Reply Thu 6 Dec, 2012 01:50 pm
@JPB,
It may have been a statement I read about in either the NYTimes or the WSJ.

After my last Doctor's visit, about 3 months ago, I received in the mail a form from a company representing the group practice that provided my medical care. This form stated the interested of the group in my evaluation of the care that I had received, both in terms of the Doctors and the office staff.

A question was also asked about the use of sterile conditions by the MDs, RNs and the medical assistants.

The form was then sent to an out of State company for evaluation.

You could sign the form or leave it unsigned.

I signed it.

We were also asked to give the Doctor a grade on a scale of 1-10, with 10 being the highest. I gave the Doc an 8.

The whole survey was about 4 pages long.

This form was not a product of the US Government..as least directly. I do suspect that the form(s) are used when the Feds evaluate the group practice at the time of funding.
0 Replies
 
Miller
 
  1  
Reply Thu 6 Dec, 2012 02:03 pm
@JPB,
JPB wrote:

I've stopped going to doctors. The concept that something found early can be treated easily is all well and good until it results in a medical history that makes you uninsurable.


This is an ongoing problem with the issue of breast cancer in women. Several studies ( some reported in the New England Journal of Medicine ) conducted outside the USA on the use of mammography in women of different age groups have come to the conclusion that the use of mammography in the prevention of breast cancer and death from this disease is of limited, if any use, in the female population older than 69 years of age.

I don't think many American MDs follow the above guidline relative to age.


Another topic reported in the New England Journal of Medicine concerned the treatment of UTI mainly in women. The conclusion of the American authors was that an assay by plate count ( on agar) of collected urine from the patient with the UTI was a waste of time and money, as most UTI patients will have neg microbial growth. Only the most severly infected patients will yield heavy microbial growth in the collected urine.

The authors conclude that UTI patients ( in general ) should be given an Rx for an antibiotic such as Cipro over the phone to a pharmacy. This procedure would reduce the cost of one of the most common problems that affect American women.

It is NOT the usual procedure followed, however.

JPB
 
  2  
Reply Thu 6 Dec, 2012 02:13 pm
Quote:
The authors conclude that UTI patients ( in general ) should be given an Rx for an antibiotic such as Cipro over the phone to a pharmacy. This procedure would reduce the cost of one of the most common problems that affect American women.


That's amazing considering that the labeling for Cipro states that it should be used only in difficult cases of UTI and is not to be used as a first-line treatment for UTIs.

A couple years ago my then-19 yo daughter was prescribed Cipro based on symptoms and prior to culture results (which ultimately came back negative) as a first-line treatment. A week later she was hospitalized with a severe CDiff infection resulting from the Cipro. It was then that I read the labeling and discovered she was over-prescribed the antibiotic. The CDiff infection has left her with chronic IBS. All for a UTI she didn't have.
JPB
 
  1  
Reply Thu 6 Dec, 2012 02:18 pm
@Miller,
Quote:
This is an ongoing problem with the issue of breast cancer in women.


Yes, the number of women diagnosed with BCA that are no longer insurable based on what many in the field now consider an over-diagnosis of cancer in women with early stage tumors is staggering.
0 Replies
 
JPB
 
  1  
Reply Thu 6 Dec, 2012 02:27 pm
@JPB,
Quote:
To reduce the development of drug-resistant bacteria and maintain the effectiveness of CIPRO Tablets and CIPRO Oral Suspension and other antibacterial drugs, CIPRO Tablets and CIPRO Oral Suspension should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.


Actually, she was over 17 at the time
Quote:
Pediatric patients (1 to 17 years of age):
Complicated Urinary Tract Infections and Pyelonephritis due to Es- cherichia coli.
NOTE: Although effective in clinical trials, ciprofloxacin is not a drug of first choice in the pediatric population due to an increased incidence of adverse events compared to controls, including events related to joints and/or surrounding tissues. (See WARNINGS, PRECAUTIONS, Pediatric Use, ADVERSE REACTIONS and CLINICAL STUDIES.) Ciprofloxacin, like other fluoroquinolones, is associated with arthropathy and histopathological changes in weight-bearing joints of juvenile animals. (See ANIMAL PHARMACOLOGY.)

Cipro product insert
 

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