Blogfinger

By Paul Goldfinger, MD, FACC.  2020. (Re-post from 2012, but still valid.)

In the N.Y. Times Sunday Review on June, 3, 2012, a physician presents an article entitled: “Let’s (Not)  Get Physicals.” The subtitle is: “We cling to the ritual of the annual exam, despite evidence that it isn’t needed.”   She is talking about the traditional yearly exam that many doctors recommend for people who seem to be healthy .  We are, of course, not talking about office visits for patients who actually have medical conditions.

Dr Elisabeth Rosenthal says, “…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.” She begins by slamming PSA blood tests for prostate cancer detection.

She goes on to blame “economic impetus for American medicine’s ‘more is better’ mode.” In other words, doctors do it for the money.

Then she presents a list of  “tasks to jettison.” These are “a sampling of routine screening tests and medical procedures that research has suggested are not necessary: annual physical, annual ECG, annual routine blood work, annual cholesterol test, annual Pap smear, and PSA test.”

In general, I am sympathetic with Dr. Rosenthal’s message because I have been a long-time critic of waste and greed in the medical profession. But I think her glib article about “physicals” is off the mark and might discourage patients from getting needed healthcare.

The problem here is that the premise is wrong. She equates the annual “physical” to performing unnecessary screening tests. Although it may be true that such tests may be done during an annual exam  (such as the yearly ECG, for example), she fails to mention that those “physicals” also include important healthcare services other than the  tests which she condemns.

To begin with, everyone should see their doctor once in a while (we can debate the frequency) for no other reason than to assess and counsel patients regarding disease prevention: weight, diet, exercise/fitness, smoking, flu shots, blood pressure, mental health, and adherence to recommended tests, such as colonoscopies, which are proven to save lives. So while she denounces  yearly health maintenance visits to a doctor, she has made no provisions in her negative analysis for prevention—the number one health challenge, by far, in the U.S.

There is also a valid concern in medicine regarding early detection of diseases which may be manifested by unimpressive symptoms or by physical findings, before the person actually gets sick. It’s not unusual for doctors to actually find something during a yearly “physical.” That’s one reason why med students study history taking and physical examination. I also believe that a yearly visit with a dermatologist is a good idea, especially as one gets older–they sometimes find things like curable melanomas.

In addition, if a physician is prescribing some preventive medication, such as a cholesterol drug or a birth control pill, he is not only justified to ask for a periodic office visit, but it will be malpractice not to do so since he is accountable for the efficacy and safety of those prescribed drugs.

Similarly, if a doctor is to take on the responsibility of accepting you as his patient, making his office available to refill prescriptions, responding to your phone calls, seeing you if you get sick, providing coverage at night, and being your personal advisor regarding consultants and other medical inquiries, then he should make sure that he sees you at least once per year so as to maintain the time-honored “doctor-patient relationship.” This is good medicine.  All sorts of health maintenance  services can be accomplished during a yearly “physical.” And the visit brings the doctor up-to-date and provides a new baseline in case the patient should call on him subsequently.

As for her list of unnecessary tests, you will notice that it is mostly the yearly timing rather than the test itself that is criticized.  All the tests on her list, such as blood work and Pap smears, are essential when used properly. The only one which is truly controversial is the PSA blood test to screen for prostate cancer. At a yearly physical exam, the doctor can use his judgement about ordering certain tests, and no practice guidelines can replace the art of medicine. The decision about the PSA test is important because it might save someone’s life–ie to identify the risk of dying of metastatic prostate cancer.   Your doctor must individualize your need for that test.

Unless Obamacare, or whatever system we get, provides some mechanism for healthcare maintenance, then I believe the annual physical exam still has a purpose—it just needs to be redefined and renamed. Let’s call it the “see your doctor once-in-a-while to go over your health status visit.” It makes sense. Somebody needs to be in charge, and the NY Times doctor won’t be there for you.