Even Medicare Wellness visits have embraced the concept of minimalistic PE. Performing a 5 minute exam likely has rapport/ satisfaction value but let’s not pretend there is much evidence based life extension or quality. BTW: agree that the lab’s ordered have similar unproved benefits.
We are all up for checkups now. We all hate them. I think they get sillier every year, and less relevant to me and my family members. We don’t do vaccines, for one, and that seems to be the primary purpose of these visits. None of drinks alcohol, smokes, or takes illicit drugs (no licit drugs either, for that matter!), and there’s no abuse in the house; we have a good family. (Though I’m not convinced that our GP office, or any related social services, would be much of a solution to problems in those areas)
Those are all the questions we endlessly get. Oh, and the stupid ones about bike helmets and smoke detectors. Is that really the job of the GP? Our GP seems obsessed with helmets and smoke detectors. Yet he never once asked me about my cycles, for example. He was there when I had my three kids, he’s exactly my age with a wife my age, I’m 59 now, and somehow through my 40s and 50s he never thought it was pertinent to ask. (When I finally brought it up to him, his response was, “well, I do ask at the end if there’s anything of concern to you.” Yeah, well, helmets and smoke detectors are NOT a concern if mine…)
He only requires we come in every 2-3 years now, and meanwhile I’ve figured out HRT on my own. I figure out pretty much everything on my own. But I choose to keep the relationship with this GP office because it’s one block from my house and I want an MD on my team, however loosely.
But I’d rather not have the charade of the “check up.” I feel annoyed the whole time. It’s just a “vax up,” really, and a review of questions not remotely of concern to me.
This year, while filling out the pre visit questionnaire for our youngest daughter before her visit, I read that this scope of work for the checkup is now explicit. It is clearly stated that any other questions or concerns will entail setting up for a separate appointment and additional charge. 🙄
I've been a very busy FM doc for over 31 years, and have seen the transition from full physicals including pelvic/rectal/etc yearly to "periodic check ups" the recommended timing of which I base on patient sex/age/comorbidities/etc. I have become a huge proponent of NOT doing much physical exam, based on the data and lack of evidence to support it, and arguably the time spent in directed discussion with a patient bears far more fruit than a routine exam when asymptomatic.
However...
There have been 2 incidents that have helped me modify/adapt the all or none approach. One was early in the career when I saw a patient for a routine check up, their only medical history was longstanding hypothyroidism, stable on levothyroxine and their labs once again confirmed well controlled TSH and no symptoms. I refilled the rx and said I'd see them again in a year. That patient lodged a complaint with the medical director about how I "didn't even examine her", so how could I have been so sure things were ok? In reviewing the complaint with me, the older and wiser clinician told me that though I wasn't actually wrong in my approach, and I can have all the salient evidence in the world with which to reassure a patient, it's the "laying on of hands" that makes them feel evaluated and cared for.
The second was much more recent, earlier this year. I was seeing a new patient with well controlled hypertension and hyperlipidemia, who wished to get some support with lifestyle change and weight loss. He reported being very active at work, enjoyed dancing 2-3 times a week, cycles regularly, and aside from some skin concerns that I addressed, really didn't have much else going on. As I was wrapping up the hour long visit (DPC rocks!), he asked if we were done, since I hadn't really examined him. I launched in to my explanation as to why we were moving away from a routine "full physical" for all the reasons elucided by Dr. Cifu in the NEJM article, but I had him get on the table and did my regular "make them feel good" exam. Well hot damn if he didn't have an irreg irreg rhythm, confirmed as a. fib on ECG. Huh. After that finding, and additional questioning, it turned out that well yes, he DID have more exertional dyspnea lately, and couldn't dance as vigorously as he may have a year ago without slowing to rest. He had chalked it up to weight so didn't mention it.
Now one could argue that I didn't really need to diagnose this, his CHADS-VASC and HAS-BLED scores were both 1, he is uninsured/not flush with cash, and my recommended cardiac work up and even the discussion of Eliquis vs coumadin(and the lab testing it entails) and their costs gave him pause. He opted for no anticoagulation, and we are seeing each other regularly for the lifestyle change support, HR evaluations, etc. Last visit he informed me that he knows he won't live forever and the risk of stroke is acceptable to him. That's a whole other discussion we could have here I guess - clot vs bleed risks and why we overwhelmingly prefer to expose patients to dangerous bleeding over risking the clot? But I digress.
Suffice it to say we will overdiagnose if we do too much examination in asymptomatic people, and we will absolutely miss some pathology by avoiding it. As with everything in this complex, maddening profession, you make the best educated decision based on the data, tempered by the patient in front of you, and hopefully most of the time the partnership of intellect/intuition will serve you well.
Agree with Adam. The patient and ourselves benefit from the interaction with a meaningful handshake, hug, and a prayer than they ever will with a nonspecific routine physical.
Hi Adam, I know that the USA loves the 'annual physical' but is there evidence for any of it. In the NEJM case, is there really any evidence that the blood tests are warranted even. I will concede the HbA1c, but everything else is screening and should be backed by evidence. They tried 'well man checks' in the UK and it made absolutely no difference because only well men turned up, but it consumed considerable resources. I'm not sure how many countries other than the US have these routine encounters but if I were to introduce them to healthcare system I would want solid evidence that they are (cost) effective.
There are some things that should be checked at an annual physical, including the stool for blood and listening for a carotid artery
Even Medicare Wellness visits have embraced the concept of minimalistic PE. Performing a 5 minute exam likely has rapport/ satisfaction value but let’s not pretend there is much evidence based life extension or quality. BTW: agree that the lab’s ordered have similar unproved benefits.
We are all up for checkups now. We all hate them. I think they get sillier every year, and less relevant to me and my family members. We don’t do vaccines, for one, and that seems to be the primary purpose of these visits. None of drinks alcohol, smokes, or takes illicit drugs (no licit drugs either, for that matter!), and there’s no abuse in the house; we have a good family. (Though I’m not convinced that our GP office, or any related social services, would be much of a solution to problems in those areas)
Those are all the questions we endlessly get. Oh, and the stupid ones about bike helmets and smoke detectors. Is that really the job of the GP? Our GP seems obsessed with helmets and smoke detectors. Yet he never once asked me about my cycles, for example. He was there when I had my three kids, he’s exactly my age with a wife my age, I’m 59 now, and somehow through my 40s and 50s he never thought it was pertinent to ask. (When I finally brought it up to him, his response was, “well, I do ask at the end if there’s anything of concern to you.” Yeah, well, helmets and smoke detectors are NOT a concern if mine…)
He only requires we come in every 2-3 years now, and meanwhile I’ve figured out HRT on my own. I figure out pretty much everything on my own. But I choose to keep the relationship with this GP office because it’s one block from my house and I want an MD on my team, however loosely.
But I’d rather not have the charade of the “check up.” I feel annoyed the whole time. It’s just a “vax up,” really, and a review of questions not remotely of concern to me.
This year, while filling out the pre visit questionnaire for our youngest daughter before her visit, I read that this scope of work for the checkup is now explicit. It is clearly stated that any other questions or concerns will entail setting up for a separate appointment and additional charge. 🙄
I've been a very busy FM doc for over 31 years, and have seen the transition from full physicals including pelvic/rectal/etc yearly to "periodic check ups" the recommended timing of which I base on patient sex/age/comorbidities/etc. I have become a huge proponent of NOT doing much physical exam, based on the data and lack of evidence to support it, and arguably the time spent in directed discussion with a patient bears far more fruit than a routine exam when asymptomatic.
However...
There have been 2 incidents that have helped me modify/adapt the all or none approach. One was early in the career when I saw a patient for a routine check up, their only medical history was longstanding hypothyroidism, stable on levothyroxine and their labs once again confirmed well controlled TSH and no symptoms. I refilled the rx and said I'd see them again in a year. That patient lodged a complaint with the medical director about how I "didn't even examine her", so how could I have been so sure things were ok? In reviewing the complaint with me, the older and wiser clinician told me that though I wasn't actually wrong in my approach, and I can have all the salient evidence in the world with which to reassure a patient, it's the "laying on of hands" that makes them feel evaluated and cared for.
The second was much more recent, earlier this year. I was seeing a new patient with well controlled hypertension and hyperlipidemia, who wished to get some support with lifestyle change and weight loss. He reported being very active at work, enjoyed dancing 2-3 times a week, cycles regularly, and aside from some skin concerns that I addressed, really didn't have much else going on. As I was wrapping up the hour long visit (DPC rocks!), he asked if we were done, since I hadn't really examined him. I launched in to my explanation as to why we were moving away from a routine "full physical" for all the reasons elucided by Dr. Cifu in the NEJM article, but I had him get on the table and did my regular "make them feel good" exam. Well hot damn if he didn't have an irreg irreg rhythm, confirmed as a. fib on ECG. Huh. After that finding, and additional questioning, it turned out that well yes, he DID have more exertional dyspnea lately, and couldn't dance as vigorously as he may have a year ago without slowing to rest. He had chalked it up to weight so didn't mention it.
Now one could argue that I didn't really need to diagnose this, his CHADS-VASC and HAS-BLED scores were both 1, he is uninsured/not flush with cash, and my recommended cardiac work up and even the discussion of Eliquis vs coumadin(and the lab testing it entails) and their costs gave him pause. He opted for no anticoagulation, and we are seeing each other regularly for the lifestyle change support, HR evaluations, etc. Last visit he informed me that he knows he won't live forever and the risk of stroke is acceptable to him. That's a whole other discussion we could have here I guess - clot vs bleed risks and why we overwhelmingly prefer to expose patients to dangerous bleeding over risking the clot? But I digress.
Suffice it to say we will overdiagnose if we do too much examination in asymptomatic people, and we will absolutely miss some pathology by avoiding it. As with everything in this complex, maddening profession, you make the best educated decision based on the data, tempered by the patient in front of you, and hopefully most of the time the partnership of intellect/intuition will serve you well.
Agree with Adam. The patient and ourselves benefit from the interaction with a meaningful handshake, hug, and a prayer than they ever will with a nonspecific routine physical.
Hi Adam, I know that the USA loves the 'annual physical' but is there evidence for any of it. In the NEJM case, is there really any evidence that the blood tests are warranted even. I will concede the HbA1c, but everything else is screening and should be backed by evidence. They tried 'well man checks' in the UK and it made absolutely no difference because only well men turned up, but it consumed considerable resources. I'm not sure how many countries other than the US have these routine encounters but if I were to introduce them to healthcare system I would want solid evidence that they are (cost) effective.