Thursday, January 17, 2013

The Annual Exam

Patients often emerge from an annual exam wishing that they had stayed home, especially after the doctor freights them with enough new findings and diagnoses to shatter the most bullet proof sense of good health.

A typical list of problems and recommendations might look something like this:

You have freckles galore, almost always innocent, but you never know, so on to the dermatologist you go.

You mentioned heart burn, probably due to simple esophageal reflux, but you never know, so off you go to the cardiologist, it could be angina. 

You have a deviated nasal septum. 

You have bilateral heel spurs.

You have a creaking of the neck (arthritis?).

No wonder many fear the annual exam more than root canal. 

Still, the idea of finding problems before they hatch, seems both important and logical.  If this were indeed true, then  maintaining good health would doubtless trump the negatives of going through the exam.

However, the Cochrane Group, the epicenter of evidence based medicine, has studied the annual exam issue extensively and concluded, in an October 2012 study, that large groups who have them regularly fare no better than those who do not.

There have of course been individuals who have benefited greatly from a screening exam.  Finding a melanoma on the back in its earliest stages or unequivocal elevation of blood pressure in an asymptomatic individual come to mind.   

It's just that if you compare large groups of individuals who take annual exams with those who do not, their health outcomes are very much the same. This applies also to illness related to cancer and cardiovascular disease, leading causes of morbidity and mortality. 

But if some people benefit from the screening exam, then, why not have one?

Traditionally, lots of information is collected during the exam (do you have gas, do you have trouble swallowing?) that takes up lots of time to gather with surprisingly little benefit. 

Since most of these patients will do no better than the unexamined, it is likely that many of the diagnoses made will actually be a form of over-diagnosis.

Over-diagnosis oftentimes leads to unnecessary tests and, even worse, unnecessary treatments.  Side effects in this scenario are especially intolerable as we ask the patient to buy risk with little prospect of benefit.

Finally, there is the matter of squandering health care dollars at a time when savings are badly needed.

So what can physicians implement to replace the current annual exam?

Let's replace the annual exam, with its painting by the numbers motif, by one that allows the patient to engage the doctor, in an unhurried way, about their concerns (it is common that the concerns of doctor and patient differ widely during exams).

So while the physician is hell bent on asking questions about every organ and body system (rarely decisive or illuminating), the patient is keen on discussing their longstanding backache or worries about memory loss.  Perhaps our exams could begin like this: "Hi Joe, what would you like to discuss today?"

In whatever form this new style exam takes it is necessary that there be ample time to discuss prevention strategies and immunizations.  

Given the research of the Cochrane group fewer people will get routine screening exams. When, how often and if to take these exams will be guided by further research on health outcomes.  For now decisions should be made on an individual basis.

What appears clear, however, is that we are putting too many patients through routine exams with little to show for it.  This is counterintuitive but supported by good research.

Whether one gets routine exams or not the following are major factors in achieving and sustaining good health:

Always notify a doctor when experiencing new signs or symptoms.  It's especially necessary when the changes are outside ones experience or when they represent an acceleration of a known problem.

Make and keep friends.

Search for intimacy.

Choose your parents and blood line wisely.

And most importantly, do all things in moderation.

OK most things.