Annual Physical Checkup May Be an Empty Ritual

[Guest guest]

It is an great economic system but, a poor health system.

 

When the main motive for the health care system is economic rather than health,

the integrity of the whole system is in doubt. Research, solutions,

applications, medicines, treatments, etc. Evidence shows that most of it doesn't

work for health, but it is one of the major expenses in the USA. ( medical is a

large percentage of the GNP). F.

 

http://www.nytimes.com/2003/08/12/health/12PHYS.html?th

 

Annual Physical Checkup May Be an Empty Ritual

 

August 12, 2003Annual Physical Checkup May Be an Empty RitualBy 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.

 

Copyright 2003 The New York Times Company