Wednesday, July 4, 2012

The "Annual Physical": Screening, equity, and evidence

Three articles in the NY Times over a two-day period addressed the circumstances of a person’s (or, in medical parlance, “the patient’s”) visit to the doctor and their expectations. On Sunday, June 3, “Let’s (not) get physicals” by Elizabeth Rosenthal called into question the American habit (?) belief (?) that there is something called an “annual physical” that everyone should get to maintain their health, even if they are not having any symptoms. Rosenthal says that they are not necessary, and can even be harmful, and that the US is virtually alone in the world in perpetuating this idea.

She supports her argument by going through a list of tests frequently done at these visits that are not recommended by the US Preventive Services Task Force (USPSTF) and many other expert bodies. These include screening for prostate cancer with prostate-specific antigen (PSA) tests, routine electrocardiograms (EKGs, or sometimes more correctly, ECGs), Pap smears (should be done for most women every 3 years, and not at all for women under 21, or for those over 65 if they have had 3 previous normals). She doesn’t specifically address the actual physical examination part of the “physical” but there is little to no evidence to support this either. (And that is pretty much true of pre-participation physicals for school and sports also.) She indicates that the Canadian government recommends against these exams, noting that they are “potentially harmful,” and discusses the “Choosing Wisely” campaign of the American Board of Internal Medicine Foundation, which I recently discussed ("Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing,” April 14, 2012).

“Potentially harmful”? Yes, of course. When a screening test is positive, it is then necessary to do a confirmatory test (usually more difficult, expensive, uncomfortable, risky or all of the above than the screening test, which is why it wasn’t done in the first place) and this may lead to other procedures – biopsies, surgery, etc. We tend to think of this as good if we have the disease, but if we don’t we incur cost, risk, and sometimes actual harm in looking for it. Indeed, sometimes even if we do have the disease, the complications of the investigation can lead to worse outcomes that the disease we are looking for. Which is why no test should be ”routine”.

The right term is “screening,” which means testing for something for which you have no symptoms, and it should be reserved for conditions that are potentially serious, can be identified by testing before symptoms appear, and for which there is an intervention that is not only effective but is more effective when done before the symptoms appear. None of this relates to tests done when you have symptoms, or have a diagnosis, and are being tested to follow up on treatment. For example: a screening blood count (CBC) to look for anemia in asymptomatic people is not indicated, but it might be if you are tired and pale. And if you are anemic and are treated (say, with iron), further testing to see if it worked – if you are no longer anemic – is appropriate.

The next day (June 4) two pieces appeared in the paper. In “The trouble with ‘Doctor knows best’”, Peter Bach also discusses screening tests that are not indicated and the puzzling fact that many doctors do them anyway. He attributes this to a combination of 1) this is what they learned from their teachers, 2) their concern because of “bad things” they have seen before in their practices, and 3) our instincts that make us “apply these [cancer screening] tests as if they were treatments, as if getting a mammogram were somehow like prescribing an antibiotic.” He shows how all of these are, or can be, wrong. The first should be obvious to all of us: the state of the art and of medical knowledge has often, indeed likely, changed from when we learned from our mentors. We need to keep up with current information, based on the most recent data available.

The second and the third are maybe a little harder to understand. With regard to #2, we, even doctors, remember what is unusual, not what is usual, and we tend to think that “had we only done that test, the bad outcome might have been prevented” when it usually would not have. #3 has to do with the difference between treating a condition that we have diagnosed and screening asymptomatic people. For almost all conditions, the percent of people who actually have them is so low that a majority of the people who have positive screening tests will actually be false positives. The physician’s anecdotal experience, never a substitute for the actual population data, may have value in the treatment of a condition she sees frequently, but virtually none with regard to screening.

The third article, “Afraid to speak up at the doctor’s office” by Pauline Chen, which was published also on June 4 but originally appearing earlier on Dr. Chen’s blog, talks about the reticence of people (even, as she describes, intelligent, successful, and generally empowered people) to not only not question their doctor’s recommendations, but to not even ask questions. This is something I have seen over and over again with friends and relatives, who don’t want to bother the doctor, or, worse, have gotten the message that Dr. Chen’s friend did that “’I don’t really feel comfortable bringing it [her concern about her symptoms] up,’…While her doctor was generally warm and caring, ‘he seems too busy and uninterested in what I feel or want to say.’”  Dr. Chen cites an article from a recent Health Affairs, Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making[1]which shows this is a really common problem.

How much this is due to doctors being “authoritarian” rather than simply “authoritative,” or due to the physician being very busy (despite being “caring”) and wanting to cut short potentially time-consuming conversations, I do not know, but it is not a good thing. Nor, of course, is it good for patients to be hostile or to treat the physician as if she were a retail store where you just put in an order for what you want. Shared decision making requires collaboration, but, as in all situations with unequal power (student-teacher, employee-employer, etc.) it is primarily the responsibility of the party with greater power – in this case the physician – to take primary responsibility for ensuring that they are open to and welcoming of sharing. This is not the same as becoming a rug for a demanding patient to walk on, just as a patient being aggressive is not the same thing as being assertive. But as this study shows, the absence of shared decision making is much more often a failure on the part of the physician to encourage it.

Annual exams are more complicated. Dr. Rosenthal is absolutely right in pointing out the lack of indications for many of the screening tests that we often do, and in the incorrectness of the myth of the “annual physical”. On the other hand, such visits, whether annual or less often, serve another purpose. They offer the physician a chance to talk to the patient, to ask questions about real or potential health risks that the patient may not have bothered to bring up because it didn’t seem “worth bothering the doctor about” or because they weren’t sure that they could talk to the doctor about it. The latter includes “sensitive” topics such as domestic violence, abortion, sexual health, drugs, etc. It also is a time that doctor and patient can discuss health risks and what the patient can do for themselves to minimize their risks, from smoking and alcohol and drugs to safe sex and bicycle helmets and healthful foods.

Indeed, this is the main use of a “school physical” for sports – not to really identify physical problems that put a student at risk, but as an opportunity to talk to adolescents, a group that doesn’t often come to the doctor, about their health behaviors. Dr. Rosenthal says I respect my doctors, but I see them only when I’m sick.” But she adds “I religiously follow schedules for the limited number of screening tests recommended for women my age — like mammograms every two years and blood pressure checks — but most of those do not require a special office visit.” However, she is a doctor; a lot of people don’t know what is indicated without guidance, and may not be so “religious” about doing those things without encouragement.

The biggest problem, as I have said many times, is that do these unnecessary-and-potentially-harmful tests for patients with good insurance, going to extremes with even more and more expensive and more un-indicated tests for “executive physicals” when a company is paying, but not do even the most strongly-recommended tests for poor and uninsured people. These people may never get to the doctor until they are very sick.

This absurd inequity, too much testing for some and too little for others, based not on patient preference but class, income and insurance status, is the true scandal. While there is clearly much else to do, a universal health insurance program is the obvious first step.

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