Letters to the Editor

Further rethinking ‘the annual’

As an internist and nephrologist, I was astounded that “Rethinking the value of the annual exam “ [ACP Internist, January 2010] would be a headline issue. Why do we need internists and all the training and exams they must undergo if there is no longer a need for a yearly evaluation? This is not only doing a careful and complete physical, but taking an accurate and detailed history, a face-to-face history that is not done by some lower-level office person or by a questionnaire that the doctor may not spend the time to read.

ACP is always espousing the need for internists, but what are they to do if not a total assessment of the patient? The general practitioner may be able to do a similar job and then shunt the patient to multiple specialists. Is this what ACP wants? If so, why do we need internists?

I've been doing internal medicine and nephrology for 35 years and I still feel that a good history and physical is important. General practitioners don't have the time for this. Specialists just do a “special” evaluation. Who will take care of the entire patient? I think that ACP should come down in favor of the annual evaluation. It's not just a physical but a connection with a well-trained physician.

The article “Rethinking the value of the annual exam “ is another example of slow progress in translating research into practice. The Canadian Task Force on Preventive Health Care concluded in 1979 that this tradition was of limited or no value, pointing the direction for the U.S. Preventive Services Task Force to focus on specific preventive services of value.

That physicians place value on this exam and that it continues to be taught in medical school reflects the power of tradition and culture over science. Even within the preventive services approach we are tradition-bound. How many providers do a pelvic exam in asymptomatic women who have undergone hysterectomy with removal of the cervix for benign disease, with the rationale being that perhaps we will detect an early ovarian cancer? We simply cannot let go.

This will persist as long as medical schools teach it. I am surprised that younger colleagues come out of training without much awareness of the evidence base for preventive medicine and its integration into routine care.

But there is another issue here. We touch on the topic of wasted financial resources in terms of unnecessary lab testing. I am deeply concerned, in this era of a shrinking primary care pool, that we are wasting human resources. We need to think very seriously about how we maximize the impact of primary care physicians on populations of people. We need our brains, knowledge and caring to be utilized in such a way that they maximize the impact of this limited resource.

The issues are organizational. We can meet the patient's needs for contact with us as well as evidence-based preventive services in visits for chronic and acute care. The Electronic Preventive Services Selector tool mentioned in the article can be a useful one to streamline this and focus discussion. We can streamline our work by delegation of tasks. Patients who have no need for follow-up care only require infrequent visits unless there are identified risk factors.

We like to say that what distinguishes us from alternative providers is our commitment to scientific evidence. Medical schools must start teaching outpatient medicine in models that are appropriate for the future based on evidence that is now 30 years old but constrained by hidebound tradition.

In “Rethinking the value of the annual exam “ Allan Goroll, MACP, said, “There's little evidence that a routine physical exam and a standard 20-30 item chemical panel improve outcomes.” If he is referring to a 10- or 15-minute history and physical done by inept laying on of hands, as is commonly practiced today, he is right. Preventive screening is good as far as it goes, but there is no screening test for the hundreds of diseases a patient may be subject to. Depending too much on screening tests bypasses the human element in medicine and leads to mediocrity of physicians who depend on tests and neglect their skills.

A periodic examination performed by well-trained physicians is the best form of preventive medicine available. When I attended medical school in the 1930s, we had intensive training in physical diagnosis and in taking a thorough history. This training was later emphasized during several years of residency at Bellevue Hospital and the Mayo Clinic. We didn't have CT scans and MRIs. We had to depend more on our own abilities. In 50 years of practice as an internist, in addition to referrals, I have probably done 40,000 annual or periodic examinations. Once, to determine if these examinations were worthwhile, I reviewed (without publishing) several thousand patient records at the Kelsey-Seybold Clinic. In addition to the usual cases of hypertension, arteriosclerosis, peptic ulcer and the like, there were several cancers (from skin to brain tumors), hypo- and hyperthyroidism, leukemia, one case of subacute bacterial endocarditis diagnosed on the initial physical examination, pulmonary tuberculosis and a few rare diseases.

Dr. Goroll, a practicing general internist, makes a good point in recommending that the internist who chooses to provide a structured annual visit should focus on cancer and other common diseases. It is also true that assistants can help. Many times my office nurse diagnosed a disease when preparing the patient for my exam and, sorry to say, pointed out after my exam a diagnosis I had missed.

Finally, I believe it would be a mistake to replace annual or periodic examinations with screening tests, even though screening is a worthwhile preventive measure.

The article “Rethinking the value of the annual exam “ summarized the lack of good evidence to support this time-honored practice. The traditional yearly “head-to-toe” examination in an asymptomatic individual has not been proven to improve health. At the same time, there are evidence-proven periodic interventions, such as screening for some cancers, obesity, unsafe behaviors, and cardiovascular risk factors, that require counseling that cannot always be added to problem-based visits. While some of these interventions can be performed by medical assistants or automated systems, others, such as reviewing the various options for colorectal cancer screening or discussing whether to screen for prostate cancer, cannot. We need to reinvent the “annual exam” into an encounter that better supports these evidence-proven interventions. The patient-centered medical home might be one way of achieving this, in addition to those discussed in the article.

Less unclear is the role of routine testing of asymptomatic patients that is rolled into the annual exam. Decades of studies and guidelines tell us that chemistry panels, complete blood counts, EKGs and urinalyses performed on asymptomatic average-risk patients are not only wasteful, but can lead to additional testing that can be harmful. While we rail against the waste of health care dollars by others, we overlook the fact that we also contribute to that waste by performing these tests in spite of evidence suggesting that we should not.

The reasons why so many of us still order yearly screening tests are well known, but they are not very compelling and should be addressed. We created patient expectations that they will undergo regular testing, so we should change those expectations, based on the evidence of what the testing does and does not achieve. We should not fear lawsuits from not doing things that are of unproven benefit. We should fondly remember the rare diagnoses that we made from such tests in the context of the many abnormals that led to additional tests, some of them risky, with the conclusion that they were false positives. For those of us who own the labs where these tests are done, we should not justify them as a way to make up for underpayment for the other services that we provide.

It has been said that the services that physicians directly provide account for a very small percentage of the health care dollar, yet physicians control a significant portion of that health care dollar. Unlike other sources of waste in the system, this one is ours to reduce.