The Physical Exam

In July's Family practice news (OK .. so I'm just now catching up on the reading next to the toilet) is an interesting article about how physicians still do annual physical exams:

Most primary care physicians don't accept current national guidelines that recommend abandoning routine annual physical examinations in favor of a more selective approach to prevention, Dr. Allan V. Prochazka said at the annual meeting of the Society of General Internal Medicine. …

Dr. Prochazka surveyed 890 randomly selected primary care internists, family physicians, and ob.gyns. in the Denver, Boston, and San Diego areas. The physician survey was a follow-up to his earlier patient survey conducted in the same metropolitan areas, which showed that 66% of the general public want and expect an annual physical examination that includes many tests (Ann. Intern. Med. 136[9]:652-59, 2002).

Many of the surveyed physicians clearly had some of their facts wrong. For example, 56% believed that national organizations recommend a routine annual physical examination, which is no longer the case, and 63% felt that the annual physical examination is of proven value, a notion debunked in national guidelines, the internist continued.

.. and some interesting statistics:

The percentage of surveyed primary care physicians who believe that routine annual physical exams are:

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A valuable opportunity to provide counseling about preventive health services	94%
Helpful in improving the doctor-patient relationship	93%
Expected by most patients	78%
Useful in detecting subclinical disease	74%
Of proven value	63%
Covered by most health insurance plans	60%

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The percentage of primary care physicians who think that the following lab tests should be part of an annual physical exam in all patients:

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Serum glucose	46%
Urinalysis	44%
CBC	39%
Kidney function	32%
Liver function	28%
Source: Dr. Allan V. Prochazka.

.. and we know from this article in the Annals of Internal Medicine that patients expect annual physicals.

So what? 

Patients expect annual physicals because physicans are telling them that annual physicals are necessary.  There's good evidence that annual physicals are not necessary – nor are most of the blood tests in that little table above. 

I don't tell my patients that they need annual physicals.  I do tell my patients that they need periodic health evaluations.  At last week's STFM meeting, I went to an excellent talk given by Al Berg.  He's the current chair of the US Preventive Services Task Force.  There was a lot of talk about what should be "routine screening."  In the context of patients' expectations — a physician who doesn't do "thorough annual exams" and "routine bloodwork" may not be considered a good physician.  On the other hand – taking a careful social history, counseling about exercise, weight loss, screening for depression .. and really listening to our patients may be more valuable than listening to their lungs or doing that oh-so-pleasant rectal exam. We can't do both .. unless we see so few patients that we won't be able to pay the rent.  I guess that's how it was on the old days.

… And the risk of doing the physical is that it takes time away from what may be really important – like helping our patients to quit smoking, or helping them to make a decision to wear seatblets, or buy that smoke detector. 

I was told yesterday by a patient that I am "such a good doctor."  I think I need to hear that sometimes.  Most physicians do.  But when meeting patient expectations for bloodwork and annual physicals exams takes away from other important tasks … are we just meeting their perceived needs .. and not their real needs?  Ugh … too much philosophy for 8:30 AM .. I'm not a morning person.

on to the office … I see I have two "Annual Physicals" this morning.