Annual Physical and testing may Be an Empty Ritual

[guest]

New York Times
August 12, 2003,
Annual Physical Checkup May Be an Empty Ritual
By GINA KOLATA

To the growing numbers of medical experts who preach evidence-based medicine — the discipline that insists on proof that time-honored medical practices and procedures are actually effective — there is no more inviting target than the annual physical.

Checkups for people with no medical complaint remain the single most common reason for visiting a doctor, according to surveys by the Centers for Disease Control and Prevention. In 2000, they accounted for about 64 million office visits, out of 823.5 million visits over all. At $120 to $150 per visit (and $2,000 or so for the gold-plated "executive physical" that many companies offer to top executives), that adds up to more than $7 billion a year.

Yet in a series of reports that began in 1989 and is still continuing, an expert committee sponsored by the federal Agency for Healthcare Research and Quality, an arm of the Department of Health and Human Services, found little support for many of the tests commonly included in a typical physical exam for symptomless people.

It found no evidence, for example, that routine pelvic, rectal and testicular exams made any difference in overall survival rates for those with no symptoms of illness.

It warned that such tests can lead to false alarms, necessitating a round of expensive and sometimes risky follow-up tests. And even many tests that are useful, like cholesterol and blood pressure checks, need not be done every year, it said in reports to doctors, policy makers and the public.

But if the annual physical is largely obsolete, hardly anyone has gotten the message. While the federal Medicare program does not pay for routine checkups — by law, it is limited to treating illness — many insurance companies do, saying their customers continue to demand them. Many doctors say they perform them out of habit or out of a conviction that patients expect them and that they help establish trust.

Even doctors who know all about the evidence-based guidelines for preventive medicine say they often compromise in the interest of keeping patients happy. Dr. John K. Min, an internist in Burlington, N.C., tells the story of a 72-year-old patient who came to him for her annual physical, knowing exactly what tests she wanted.
She wanted a Pap test, but it would have been useless, Dr. Min said, because she had had a hysterectomy. She wanted a chest X-ray, an electrocardiogram. Not necessary, he told her, because it was unlikely that they would reveal a problem that needed treating before symptoms emerged. She left with just a few tests, including blood pressure and cholesterol.

Dr. Min was proud of himself until about a week later, when the local paper published a letter from his patient — about him. "Socialized medicine has arrived," she wrote.

Admitting defeat, he called her and offered her the tests she had wanted, on the house. She accepted, Dr. Min said, but after having the full physical exam, she never returned.

Proponents of evidence-based medicine acknowledge that repeated tests like chest X-rays, electrocardiograms, rectal exams, pelvic exams, urinanalyses and blood work do occasionally find problems before symptoms emerge. But that does not make them necessary or even advisable, said Dr. David Atkins, the science adviser to the United States Preventive Services Task Force, an independent panel of experts that advises the Agency for Healthcare Research and Quality.

For example, Dr. Atkins said, urinanalysis can detect bacteria in the urine of 5 to 10 percent of women who have no symptoms of bladder infection. But when such patients were studied, it turned out there was no difference in the outcomes between women given antibiotics and those given placebos.

Although the bacteria disappeared in most women's urine after they began taking antibiotics, they often came back after the drugs were stopped. In the end, just as many patients in each group ended up with symptomatic bladder infections. The only difference was that the group of women who took antibiotics early on had more side effects.

Other tests are superfluous for other reasons. Feeling the ovaries in a pelvic exam is not a good way to find ovarian cancer, according to the Agency for Healthcare Research and Quality and the American College of Physicians; by the time a tumor can be felt, the cancer is probably too advanced for treatment to help. Not finding anything is not necessarily reassuring because small tumors cannot be felt anyway, the group adds.
Nor is there any need for a doctor to take out a stethoscope every year and listen to your heart, to thump your chest each year or look into your eyes, ears and throat. Those time-honored procedures provide no medical benefit for the healthy patient with no symptoms, said Dr. Paul Frame, a member of the task force who has examined evidence for these procedures.Many doctors do a careful physical exam on a patient's first visit, to serve as a baseline, but on subsequent visits, groups like the Agency for Healthcare Research and Quality say, patients would be better off if doctors spent their time counseling them on such things as stopping smoking, eating a healthy diet and drinking moderately, using seat belts and having working smoke alarms in their houses."When we're spending time doing things that don't potentially benefit people and skipping things that may be of benefit, that's a sign not only of waste but of misplaced priorities," said Dr. Russell Harris, an associate professor of medicine at the University of North Carolina and co-director of the prevention program there.In an effort to get the message out, the federal health care research agency recently printed pamphlets for men and women, telling them what tests they need, and when.But doctors say they have yet to see a patient come in waving the guidelines and asking for fewer tests. And many doctors say that although they are well aware of what evidence-based medicine recommends, they often do much more, out of habit and tradition and out of a fear that if they pulled back they would get the sort of reaction Dr. Min did. Even some Preventive Services Task Force members who helped write the recommendations do not always strictly adhere to them.Dr. Steven H. Woolf, a task force member who is a professor of family practice at Virginia Commonwealth University, explained, "I do physical exams and I do those procedures that lack an evidence base, often because patients will think they have not gotten their money's worth if there is no laying on of hands." Others say it is hard to let go of procedures they have used for decades.Dr. Barron Lerner, an internist and historian of medicine at Columbia University's College of Physicians and Surgeons, says he asks patients to come in every year and always listens to their heart and lungs, does a rectal exam, checks lymph nodes, palpates their abdomens and examines the breasts of his female patients."It's what I was taught and it's what patients have been taught to expect," he said, although he acknowledged he would be hard pressed to give a scientific justification for those procedures. "If a patient were to ask me, `Why are you listening to my heart today?' " he said, "I couldn't say it's going to help me predict you will have a heart attack."Dr. Lerner is equally ambivalent about tests he skips. "If you ask me, `Why don't you do a neurological exam every time?' the answer is `Because I don't.' "Others say that explaining why they are not doing tests can take more time than just doing them."I still listen to everyone's heart," said Dr. Stewart Rogers, an internist at Moses Cone Hospital in Greensboro, N.C. "Why pick that fight? Why try to explain 10 years of evidence-based medicine so the patient will understand why I didn't do that test? The reason to listen to hearts is that it establishes our priestly majesty when you tell them about smoke alarms."Many say the annual visit at least gives patients a chance to establish a relationship with a doctor so they will have someone to call if they do get sick."I know that feeling of panic when someone has a real problem and they don't have an established doctor," said Dr. Christine Laine, a Philadelphia internist and senior deputy editor of the Annals of Internal Medicine. "It's that sense of who to call if you wake up in the morning and see blood in your urine." Insurers continue to pay for annual physicals because that is what their customers demand, said Larry Akey, a spokesman for the Health Insurance Association."The coverage of the physical is something companies do as a result of requests from our customers," he said.
In addition, he said, while he is not sure all the member companies would agree, there is a widely voiced belief that the people who would be attracted by an insurance policy that includes an annual physical exam are exactly the health-conscious people an insurer wants. For Medicare patients and others whose insurance does not cover even a basic physical exam, the only choice is to pay for it themselves. Many do. Dr. Mark Miller, a colleague of Dr. Min at the Kernodle Clinic in Burlington, explains to patients that Medicare will not pay for what they want. "I say, `Medicare will not pay; do you want to?' I've had the rare patient say no."The idea of the annual physical took off in the 1920's, when life insurance companies issued data widely interpreted to mean that people who had checkups lived longer. A likelier interpretation is that people who had the checkups were healthier to begin with because they took better care of themselves, said Dr. Frame, a member of the task force. Instead, doctors leaped to the assumption "that the reason for better health was the annual physical," he said. In New York City, Dr. Daniel Sulmasy, an ethicist and internist at St. Vincent's Hospital, worries about over-testing."At the very beginning there's such a fear of missing something. But with experience, one recognizes that, hey, if we hadn't found that bright object in the M.R.I. we shouldn't have done, maybe that patient wouldn't have had that catastrophic bleed into his brain for the biopsy we did to find nothing."But some patients who had what evidence-based medicine deems unnecessary tests say they are glad they did.Three years ago, Christopher Mervin, the 36-year-old director of operations at Party City of Raleigh, had an executive physical, paid for by his company, which sent him to Florida for the two-day, $2,000 exam. Everything was fine, except for one problem. The doctors saw a spot on his lung and were not sure what it was. Eight months later, after extensive testing at Duke University and the University of North Carolina, after many sleepless nights, Mr. Mervin got his answer — it was a birth defect, and of no consequence.He is not sorry he had that physical. "If I was in a car accident and something happened and they X-rayed my chest and saw the mass, who knows what would have happened? They might have taken it out. Now it's in my medical history." Mr. Mervin is still having annual physical exams.

[tazman]

As a long time pet owner, and one that strongly believes in prevention of problems, how can you, in your right mind, discount the importance of an annual physical exam for my pets. Just because people may not need one because they "feel fine", my pets can't talk. They can't tell me that something hurts, they can't tell me that they have a heart problem, etc. My veterinarian is wonderful and he thoroughly checks over my pets when they go in for their exams. He also runs a routine blood screen and checks the urine to look for early signs of problems. You may think this is all for his own pocketbook but I strongly disagree. It almost scares me to think that you, being an educated veterinarian, would condone pet owners to not have their pet's checked out annually or even more often.
I have read alot on your website and almost all of your conclusions for so called evidence based medicine is conjecture from the human side. Sorry, but I do not see how you can extrapolate from human to animal so blatantly. I really think you need to either rethink how you draw your conclusions or you need to stop "practicing".....you are putting more pets at risk for their health by advocated less involvement from a veterinarian. Didn't you agree in vet school to "first do no harm"?????

tazman

[whistle blower]

http://evidencebasedvet.com/forum/viewtopic.php?t=202

[guest]

Screening is an important subject and is a source of misunderstanding as
well as fraud. Remember when we used to get annual chest x-rays and
urinalyses? The traditional annual physical exam has been discarded as a
waste of time. We are constantly re-assessing the evidence and changing the
recommendations for what routine tests should be done when on whom. No test
is perfect. There will always be false positives and false negatives, and
there will always be "normals" who test outside the "normal" range - as an
analogy, there are some very tall people who are perfectly normal and must
be distinguished from people who are tall due to a disease such as
acromegaly. If you do 10-20 lab tests on the healthiest person, at least one
is likely to register outside the normal range due to the laws of statistics
and probability and the way the normal range is defined. Then you waste time
chasing your tail to prove it doesn't really mean anything.

To be effective, a screening test must meet these requirements: it must get
positive results in most of those who have the condition, and negative
results in most of those who do not, it must find a treatable condition, and
the treatment must do something to improve life span or quality of life. The
harm from the test itself (radiation, for instance) should not outweigh the
benefit of the findings, and the cost should not be ridiculously high. The
prevalence of the condition in the population to be screened is important: a
treadmill test may be useful in a population of those with symptoms or risk
factors of heart disease, but if it is used in low-risk patients or
unselected young people, it will only result in lots of false positive
results and unnecessary alarm.

Screening CT scans on healthy people were never a good idea, and they were
never endorsed by any medical organization. The radiation is significant,
negative findings give a false sense of security, there is a high rate of
worrisome but benign findings requiring further evaluation, sometimes with
invasive tests, and most of the diseases that are picked up would have been
found eventually by other means, and the earlier diagnosis may not actually
prolong survival. The consensus of all the authorities has been that routine
scans will do more harm than good.

The trend among family physicians today is to do limited, directed screening
tests based on risk factors, and to perform health maintenance chores as
patients come in for other reasons rather than to do annual physical exams.
The recommendations change constantly, and some tests are dropped as others
are added.

Of the tests you mentioned, blood pressure screening has proven its value,
cholesterol screening involves a number of pitfalls, PSA is controversial,
and I don't know of anyone who recommends routine tests for blood calcium.
Note: I'm talking only about routine screening tests for everyone - there
are plenty of indications for testing people with symptoms, family history,
risk factors and other considerations.

Harriet Hall, MD

[guest]

Promotion of unproven medical care in the market place is a heathfraud
practice. It's inappropriate, irresponsible, and against the public interest for
the AVMA to condone the general employment of any medical care until and
unless its efficacy has been clearly and unequivocally established by means of
rigorous, objective science. AVMA promoted Twice-a-year wellness examinations
for pets "Guidelines" have, to date, clearly failed to met this criterion.

_informed consent annual and biannual medical care_
(http://evidencebasedvet.com/forum/viewtopic.php?t=202)


_AVMA and vet school professional organized doctor crime_
(http://evidencebasedvet.com/forum/viewt ... light=avma)

[guest]

[Guest]

None of those responses addressed the concern of Tazman. Aren't animals and people different? People know when there is something wrong with them (sometimes), pets can't tell us when they don't feel good, we have to see something out of place. I want my vet to check to see of there are developing problems that I am not qualified to do. Also, I believe that dogs and cats age at a much more frequent rate than people so the comment about going every year in people doesn't translate either.
Is there a vet monitoring the responses to this board or not? It doesn't seem like anyone answered Tazman's questions and I have the same questions.

[malernee]

Study examines unnecessary medical testing.

Routine office visits for preventive health exams are intended to
identify treatable diseases before symptoms occur and to promote
healthy behaviors. However, a study has concluded that more than 40%
of such visits result in physicians ordering unnecessary laboratory
tests and procedures. [Merenstein D and others. Use and costs of
nonrecommended tests during routine preventive health exams. American
Journal of Preventive Medicine 30:521-527, 2006]
http://www.ncbi.nlm.nih.gov/entrez/quer ... med_docsum
The researchers examined data from the National Ambulatory Medical
Care Survey from 1997 to 2002 for office visits for a general medical
examination with no apparent illness. The outcome was compared with
the recommendations of the United States Preventive Services Task
Force (USPSTF), which recommends against the routine use of
urinalysis, electrocardiograms, and x-rays. The researchers concluded:

**At least one of these three tests was ordered 43% of the time

**The estimated waste related to these tests totaled at least $47
million to $194 million per year in direct costs plus additional
expenses for follow-up tests done in response to false-positive
screening tests.

**The three tests are relatively inexpensive. Unnecessary screening
tests that are very expensive were not included in the study.

**The factors contributing to unnecessary testing are (a) ignorance
or rejection of the USPSTF guidelines, (b) patient demand, and (c)
fear of malpractice suits.