Notes

Is the Head-To-Toe Physical Exam Practically Worthless for Healthy Patients THAT ARE Asymptomatic?
As a health economist, I make an effort to keep up to date with new trends in medical care insurance. One trend I have found is that consumers can now purchase short term health insurance policies that will pay for doctor visits if the individual is sick, but they will not purchase the standard "complete physical" associated with an initial visit. Some primary care doctors won't see a new patient unless the physician can bill insurance for $350 - $500 for a thorough visit. If you make an online search for "head-to-toe physical" and "outdated," you will discover many web pages offering arguments and evidence that the entire physical is indeed not necessary but may be reassuring for a few patients. On the other hand, the blood tests are ten times more important than a complete physical for new patients.

We often hear the argument a good baseline physical exam with lab work is important and may help engage the patients in their own care in addition to identify those patients at risk for heart disease, diabetes, along with other problems. The individual centered medical home model is made on coordination of care, not sick care. For standard health insurance policies (those polices other than short term policies), a minumum of one annual "physical exam" or wellness visit is covered 100% by insurance and no cost to the consumer.

I am looking for a new primary care physician and will be seeing one at the end of the month. This appointment is for a fresh patient and will be coded for insurance as "wellness visit, physical exam" despite the fact that there will be little if any physical exam. Instead, I intend to use the time and energy to tell the physician what blood tests I want on this visit to establish a baseline, and along the way of explaining why I want them, he will learn about my medical history. I doubt you will see any moment remaining in the appointment for even a limited physical exam, but we shall see.

My cholesterol numbers aren't simply excellent, they are outstanding. https://anotepad.com/notes/k3cxnsy8 holds true for my C-reactive protein (a measure of coronary attack risk) and homocysteine (a measure of stroke risk). I have not had a whole physical exam in over twenty years and also have not missed them one bit. I think it is appalling that any physician would palpate my abdomen and then tell me I haven't any tenderness there, as if I did not know that. I am all in favor of preventive healthcare, but I agree with the U.S. Preventive Health Task Force that the entire physical exam has not been shown to be affordable at preventing disease. Blood testing, on the other hand, is critical to monitoring general health and critical to formulating a strategy to avoid diseases and medical ailments.

I have been asking primary care docs for quite some time now if they have ever found an abnormality on physical exam in an asymptomatic patient that was not picked up as part of standard screening (PAP smear, colonoscopy, lab testing, etc.) There have been minimal positive responses. (One doctor found an oral cancer). Standard screening could possibly be done a lot more effectively and efficiently by non-physicians as part of a public health campaign: think of the Polio vaccination campaigns of the 1940s and 1950s.

Having said that, a consultation with the patient/client for health planning purposes -- identifying what is important to him/her and the impact of health issues on those things which are important and then creating a mutually acceptable plan on how exactly to achieve those goals -- is most likely invaluable, especially if the physician has no financial interest in the choices that are made.


Yet we find an amazing lack of evidence to aid "annual physicals exams" resulting in early detection of health issues. I invite the proverbial interested reader to click on the link in the bottom of this article to find the reference for the National Institute of Health's pubmed link related to annual physicals.

In examining a population of junior high and high school student athletes who were necessary to get "participation physicals" in order to play on sports teams, one study found of 1268 students, 5% were described specialists, but only 0.2% were disqualified from playing the sports activity. The writer concludes that most those disqualified could have been discovered by obtaining a detailed health background alone. Another study of 763 student athletes found 3 positive referrals total. Factoring in the expense of all the health workers involved, each of these three findings came at a cost of $4563. In addition, a total of 16 medical problems were found during the 763 student physicals, BUT 15 of the 16 problems were, and could have been identified, from taking the patient's medical history alone.

How can you think most primary care physicians would react in case a new patient went over his health background but declined greater than a cursory physical exam and only getting his desired blood tests? Would the normal primary care doctor simply note "patient declines complete exam" and move ahead, or would he/she badger the patient into obtaining a complete physical, because that what sort of doctor always handles new patients? One problem with health care is that patients are generally obsequious and fall into lockstep patterns of getting certain exams or tests even though they will have little to no benefit on general health.

I frequently hear from foreign-born and foreign-trained physicians that "here in the united states, doctors spend too much time on treating people once they get ill rather than enough time of preventing the illness from occurring." But what does this mean in practical terms? (1) doctors ought to be ordering more blood tests to determine average sugar levels (HbA1C test) in a way that all patients know their HbA1C numbers and if they are inching towards diabetes. Other helpful blood tests would add a hormone panel for several middle-aged or older patients, and the doctors need to learn about optimal levels for these hormones, rather than ignorantly dismissing results that fall in the "normal average" range but could be sub-optimal. (2) doctors need to have staff who is able to answer patients' health questions, e.g., whether the patient should begin taking magnesium, without placing a burden on the physician to answer each one of these questions. (3) patients should be given targets for HbA1C, HDL, total cholesterol/HDL ratio, cortisol, etc., to accomplish through their own proactive, informed collection of food choices.

I can't think about any blood test that might be ordered solely to generate a patient aware. In most cases, no physician would be able to estimate the results from a blood test, e.g., no physician can estimate HDL cholesterol or total cholesterol just from speaking with an individual and getting his medical history. When insurance firms stress preventive health, they always emphasize doctor exams over laboratory tests. But again, no doctor exam can reveal 3-month average glucose, or iron deficiency, or elevated liver enzymes. It appears like some insurance companies want to do preventive health on the cheap, sufficient reason for that attitude, they ought to not be surprised that the limited kind of preventive care they support is next to worthless.

To say that the annual physical is worthless without reinforcing to the general public that some tabs on health is essential probably sends the incorrect message. After all, it is hard to argue that monitoring of hypertension, lipidemia and diabetes is not worthwhile. FDA has generally indicated by its refusal to approve OTC versions of the maintenance medications that the general public can't be trusted to monitor or manage these maladies.

I am all and only monitoring hypertension, lipidemia, and diabetes. Actually, where in fact the Affordable Care Act recommends diabetes checking for those who have hypertension, I'd go further to say everyone should know their HbA1C number (3-month average of glycated hemoglobin). But why shouldn't those values be checked in an ordinary preventive health visit, without the need for a head-to-toe physical? None of the articles have said that tests are worthless; they tend to question the value of the "annual physical" for an asymptomatic healthy adult. Indeed some doctors have recognized this fact and present patients a more limited and directed physical exam. That approach seems more sensible compared to the "one size fits all" approach with check out toe exams.

The FDA has generally indicated that the public cannot be trusted to monitor or manage these maladies. I strongly disagree with the FDA and question its motives in preventing cholesterol and hypertension medications from being accessible OTC. I hope in my lifetime they do become available. An enlightened individual may use the Internet to understand about drugs that lower blood pressure, glucose, and lipids, along with the drug's unwanted effects. At-home blood circulation pressure devices tend to be more effective in monitoring real-world blood pressure than periodic visits to a doctor's office. An enlightened patient can precisely individualize dosing of anti-hypertensive medications to bring their blood pressure to optimal levels (below 115/75 mm Hg in most people).

For an expanded version of the article, please see http://www.michaelguth.com

Michael A. S. Guth, Ph.D., J.D., directs Health Economics & Outcomes Research (HEOR) at an increased risk Management Consulting, a contract research organization based in Oak Ridge, Tennessee, where he's got successfully managed the HEOR consulting business for the past ten years. He is also a licensed lawyer having an active practice of more than 200 clients and contains developed expertise on the Affordable Care Act and its own implementing regulations.
Dr. Guth's principal research focus has been preventing the onset of age-related diseases known collectively because the metabolic syndrome. In your community of diabetes, he could be familiar with all of the drugs used to treat the condition and their potential drawbacks. Low thyroid hormones (T3 and T4) may represent the most unrecognized and under-treated causes of prediabetes status affecting some 75 million Americans.
His current research comprises the optimal design of health care insurance and total health/wellness programs including preventive health strategies and employee health engagement and resiliency. Working within a worldwide benefits team, he creates an integrated wellness-benefits strategy and executes programs aimed at changing mid- and high-risk behaviors. He positions wellness and disease-prevention as part of a larger technique for medical cost containment, and contributes innovative ideas for achieving this desired result. He demonstrates thinking "beyond your box" to rein in healthcare spending costs and reform patient usage of medical services.
A second area of current research is using Clomiphene in men for hormone modulation to avoid cardiovascular disease and other consequences of the metabolic syndrome. He could be Principal Investigator of a clinical study that compares usage of Clomiphene with external resources of testosterone directed at men; the study includes safety, efficacy, cost, and value comparisons.

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