Notes

May be the Head-To-Toe Physical Exam Practically Worthless for Healthy Patients Who Are Asymptomatic?
As a health economist, I make an effort to keep abreast of new trends in health care insurance. One trend I've found is that consumers is now able to purchase short term medical health insurance policies that will purchase doctor visits if the individual is sick, but they will not pay for the standard "complete physical" connected with an initial visit. Some primary care doctors won't visit a new patient unless the doctor can bill insurance for $350 - $500 for a comprehensive visit. If you make an online search for "head-to-toe physical" and "outdated," you will discover many web pages that provide arguments and evidence that the entire physical is indeed not necessary but may be reassuring for some patients. In contrast, the blood tests are ten times more important when compared to a complete physical for new patients.

We often hear the argument a good baseline physical exam with lab work is essential and can help engage the patients within their own care and also 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 medical 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 searching for a new primary care physician and will be seeing one at the end of the month. This appointment is for a new patient and will be coded for insurance as "wellness visit, physical exam" even though there will be little or no physical exam. Instead, I intend to use the time and energy to tell the physician what blood tests I'd like on this visit to set up a baseline, and in the process of explaining why I want them, he will find out about my health background. I doubt there will be any time remaining in the appointment for even a limited physical exam, but we will see.


My cholesterol numbers aren't simply excellent, they are outstanding. The same holds true for my C-reactive protein (a way of measuring heart attack risk) and homocysteine (a measure of stroke risk). I've not had a complete physical exam in over twenty years and have not missed them one bit. I think it is appalling that any physician would palpate my abdomen and tell me I don't have any tenderness there, as though I did not already know that. I am all and only preventive health care, but I agree with the U.S. Preventive Health Task Force that the complete physical exam is not shown to be affordable at preventing disease. Blood testing, however, is crucial to monitoring overall health and critical to formulating a technique 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 within an asymptomatic patient that has been not picked up within standard screening (PAP smear, colonoscopy, lab testing, etc.) There were minimal positive responses. (One doctor found an oral cancer). Standard screening could 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, an appointment with the patient/client for health planning purposes -- identifying what is important to him/her and the impact of medical issues on those things which are important and then creating a mutually acceptable anticipate how exactly to achieve those goals -- is probably invaluable, especially if the physician has no financial fascination with the choices that are made.

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

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

How does one think most primary care physicians would react in case a new patient went over his medical history but declined more than a cursory physical exam and only getting his desired blood tests? Would the typical primary care doctor simply note "patient declines complete exam" and move ahead, or would he/she badger the individual into obtaining a complete physical, because that the way the doctor always handles new patients? One problem with health care is that patients are generally obsequious and belong to 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 medical doctors that "within the united states, doctors spend a lot of 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 find out average sugar levels (HbA1C test) in a way that all patients know their HbA1C numbers and whether they are inching towards diabetes. Other helpful blood tests would add a hormone panel for all middle-aged or older patients, and the doctors need to learn about optimal levels for these hormones, instead of 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 start taking magnesium, without placing a burden on the doctor to answer each one of these questions. (3) patients should be given targets for HbA1C, HDL, total cholesterol/HDL ratio, cortisol, etc., to achieve through their very own proactive, informed selection of food choices.

I can't think of 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 the blood test, e.g., no physician can estimate HDL cholesterol or total cholesterol just from speaking with an individual and getting his health background. 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 insufficiency, or elevated liver enzymes. It sounds like some insurance companies wish to accomplish 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 necessary 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 cannot be trusted to monitor or manage these maladies.

I am all in favor of monitoring hypertension, lipidemia, and diabetes. Actually, where in fact the Affordable Care Act recommends diabetes checking for those who have hypertension, I would go further to say everyone should know her or his 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 lab tests are worthless; they tend to question the worthiness of the "annual physical" for an asymptomatic healthy adult. Indeed some doctors have recognized this fact and present patients a far more limited and directed physical exam. That approach seems more sensible than the "one size fits all" approach with head to toe exams.

The FDA has generally indicated that the general public can't 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 am hoping in my lifetime they do become available. An enlightened individual may use the Internet to learn about drugs that lower blood circulation pressure, glucose, and lipids, along with the drug's unwanted effects. At-home blood circulation pressure devices are more effective in monitoring real-world blood circulation 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 Risk Management Consulting, a contract research organization based in Oak Ridge, Tennessee, where he has successfully managed the HEOR consulting business for the past ten years. He could be also a licensed lawyer having an active practice greater than 200 clients and has developed expertise on the Affordable Care Act and its implementing regulations.
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His current research comprises the optimal design of medical care insurance and total health/wellness programs including preventive health strategies and employee health engagement and resiliency. Working within a global benefits team, he creates a wellness-benefits strategy and executes programs targeted at changing mid- and high-risk behaviors. He positions wellness and disease-prevention within 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 health care spending costs and reform patient usage of medical services.
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Website: https://www.tebbyclinic.com/dot-exam/required-dot-physical-forms/