The Assault On Screening Tests And Annual Health Assessents (AKA Annual Physicals): Is Ignorance Bliss?

As I have mentioned in recent entries, there has been what seems to me a rather urgent effort to show that we as health care professionals care about the high cost of health care in the U.S.  How much of this is the result of political correctness, how much of this is an effort to stave off efforts to encroach on health care industry profits, how much of this is good people taking advantage of “the moment,” I can’t say.  But, I do know that much of what I have been reading in the media and professional communications is crazy stuff.  Maybe not crazy as in insane, but misguided and misleading in some instances.  Case in point: an article that appeared recently in the New York Times (June 2, 2012).  The article was entitled, Let’s (not) get physicals,” and was written by Elizabeth Rosenthal, a physician.  Basically, the opinion piece addressed what the author called “the ritual (annual) physical examination” and its evils.  The evils were related to the mostly useless, expensive, and even potentially harmful consequences of the various screening studies the examining doctor might order.

Are annual  “head-to-toe”  physical examinations actually performed often in the U.S.?

I have been a physician for quite a while now and I even see physicians sometimes for my various health care issues.  I would argue that physicians rarely (if ever) perform comprehensive physical examinations on patients without some specific reason and in that circumstance, physical examinations are very sign/symptom directed and not comprehensive (I am not saying if that is or is not a good thing).  I suspect that what the author meant to address was the question of an annual health care assessment, which is not the same thing as a comprehensive physical examination.  I suspect that many modern-day physicians wear stethoscopes curled around their necks as part of their uniform rather than as a necessary tool of the trade (perhaps, I exaggerate a bit?).

Are annual health care assessments a waste of time and money and potentially dangerous?

My take on Dr. Rosenthal’s opinion piece is that she is mostly concerned about needless screening tests performed that could lead to more tests that may lead to unnecessary treatments.  Who would disagree with her?  The author cites PSA screenings and mammograms as examples that can lead to mayhem.  In my opinion, Dr. Rosenthal may be a little bit off target.  I do not see the annual (or whenever) health care assessment by a patient’s primary care doctor/nurse practitioner, etc. as the problem, but rather, the way information gleaned at the visit might be used.  For example, the argument goes that we should not do routine PSA screenings because we might be tempted to subject patients to unneeded biopsies and surgeries, etc.  Isn’t the problem mostly bad decisions about what to do with information, not about having the information?

Responses to the opinion piece

I was surprised to find quite a large number of responses from readers about the article.  A few were in agreement with Dr. Rosenthal, but most jumped all over her case, citing the benefits of maintaining regular contact with one’s primary care doctor.  I must say that I tend to agree with the critics.  It would be nice if each of us actually had a primary care doctor and if that doctor actually knew us reasonably well.  Having a meaningful ongoing relationship between patient and doctor makes it easier to sort out things when a problem does arise.  It may not be a perfect analogy, but I look at a regularly scheduled health assessment with one’s primary care doctor sort of like the every 5000 miles oil change for my car.  I expect the mechanic to do more than just change the oil-  to make sure everything is “looking good” such as the hoses, fan belt, antifreeze, battery fluid, etc.  Those checks take only a few minutes and cost little or nothing but can save me big problems down the road.  Of course, people aren’t automobiles and physicians and nurses are not mechanics but……?  Let’s not forget that routine health care assessments do not automatically require any testing and that best clinical practices should guide the physician not tradition (or even the expectation of the patient that such and such useless tests will be ordered).  Above all, physicians should take the time to communicate with their patients and explain why such and such test was ordered or why it was not and what might be done with the test results.  Also, it shouldn’t be a “my way or the highway” attitude by the physician.  Medical care should be a cooperative effort between the patient and health care provider.  Finally, every physician should have a system in place that allows test results to be communicated in timely fashion to patients with information regarding the meaning of the results.  This isn’t rocket science.

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