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Re-thinking the Annual Physical

Please note: the following refers to routine physicals and screening tests in healthy, asymptomatic adults. It does not apply to people who have been diagnosed with diseases, who have any kind of symptoms or signs, or who are at particularly high risk of certain specific diseases.


Throughout most of human history, people have consulted doctors (or shamans or other supposed providers of medical care) only when they were sick.  Not too long ago, the “if it ain’t broke don’t fix it” mindset changed. It became customary for everyone to have a yearly checkup with a doctor even if they were feeling perfectly well. The doctor would look in your eyes, ears and mouth, listen to your heart and lungs with a stethoscope and poke and prod other parts of your anatomy. He would do several routine tests, perhaps a blood count, urinalysis, EKG, chest-x-ray and TB tine test. There was even an “executive physical” based on the concept that more is better if you can afford it. Perhaps the need for maintenance of cars had an influence: the annual physical was analogous to the 30,000 mile checkup on your vehicle. The assumption was that this process would find and fix any problems and insure that any disease process would be detected at an early stage where earlier treatment would improve final outcomes. It would keep your body running like a well-tuned engine and possibly save your life.

We have gradually come to realize that the routine physical did little or nothing to improve health outcomes and was largely a waste of time and money. Today the emphasis is on identifying factors that can be altered to improve outcomes. We are even seeing articles in the popular press telling the public that no medical group advises annual checkups for healthy adults. If patients see their doctor only when they have symptoms, the doctor can take advantage of those visits to update vaccinations and any indicated screening tests.

The Physical Exam Itself

The physical exam of a healthy, asymptomatic adult is unlikely to reveal any significant abnormality (1) that would not have been detected eventually when symptoms developed and (2) whose earlier detection and treatment would reduce morbidity and mortality in the long run.

A directed physical exam is sometimes indicated in patients with risk factors for specific conditions. A Pap smear is indicated in most women, but not every year, and the accompanying pelvic exam is likely a waste of time.

For healthy adults between the ages of 18 and 65, The American Academy of Family Physicians (AAFP) recommends only these components of the traditional physical exam:

  • For men, a blood pressure measurement.
  • For women, a blood pressure measurement and a periodic Pap smear.

They have other recommendations including vaccinations, counseling, and screening tests; but none of those require a physical exam.

Because they are so unproductive, routine physical exams are very boring to most physicians. My least favorite chore as an Air Force physician and flight surgeon was doing the required physicals. The system had some really idiotic requirements: for instance, the flight physical required a measurement of pulse rate after exercise, but there was nothing in the regulations that said what readings were considered abnormal or what actions to take if they were!

I heard about one doctor who had to do a lot of exams of healthy young men at a recruiting center and dreamed up a way to make it more interesting. He challenged himself to identify patients with situs inversus. This is a condition where the internal organs are on the wrong side (i.e. heart on the right, appendix on the left). It’s disqualifying for military service, probably because of the implications for battlefield trauma care. He soon held a record for the most diagnoses of situs inversus and was asked how he did it. He explained that he simply looked for men whose right testicle hung lower than the left and subjected those patients to a more intensive evaluation!

Screening Tests

We are increasingly questioning screening tests that were formerly recommended. The annual chest x-ray, tine test, and urinalysis are long gone. The recommended age limits for mammography have changed. Routine PSA testing is being discouraged. A recent study suggested that a woman whose DEXA scan shows normal bone density or mild osteopenia need not be rescreened for 15 years.

We don’t need to examine all the published literature on screening tests, because the U.S. Preventive Services Task Force (USPSTF) has done all the work for us.  They continually update recommended screening tests for different age and risk groups based on the latest studies. There are other organizations in the US and elsewhere that make similar recommendations but that may differ to some degree in different countries. In general, a specialty organization is likely to recommend more screening in its particular area of interest, based on a different focus in interpreting the same published evidence. The American Academy of Family Physicians, with a broader perspective, generally follows USPSTF recommendations.

The Early Detection Myth

There is a general perception, among the public and among doctors, that there’s no such thing as a bad screening test, that early detection is important, that knowing is always better than not knowing. If something is wrong with you, you need to know because, if you find a problem in time, it can be treated effectively to prevent morbidity and mortality. If you get a checkup and everything looks OK, you can breathe a sigh of relief and relax. Unfortunately this is all wrong.

A recent book explains why: Overdiagnosed: Making People Sick in the Pursuit of Health, by Drs. H. Gilbert Welch, Lisa M. Schwartz, and Steven Woloshin. It’s a comprehensive explanation of how test results make people sick and why visiting a doctor can be hazardous to your health. I reviewed it in an earlier article here on ScienceBasedMedicine.org. Please read that link and then come back.

Welch et al. commented

…some people may feel safer having their potential problems diagnosed and treated. For some, that may make the treatment side effects and hassle factors seem worth it… [but] the sense of being safer is likely an exaggerated view of the reality.

For a healthy, asymptomatic patient, the physical exam with the laying on of hands and stethoscope and other rituals is pretty much meaningless. If nothing is found, it can produce false reassurance. If something is found, it is not likely to prolong the patient’s life and it has a significant likelihood of leading to harm from unnecessary treatment or from a diagnostic cascade of tests, unnecessary surgeries, unnecessary expense, and unnecessary worry.

Re-inventing the Check-up

Doctors are not punished for overdiagnosis, but they are punished for failing to diagnose. We mustn’t let fear of lawyers interfere with our good judgment. The annual physical is obsolete.

On the other hand, there is a good argument for a periodic visit with a healthcare provider without the ritual of the physical exam. It’s helpful to have a systematic way of ensuring that the screening tests recommended by the USPSTF get done. An annual visit would be an opportunity for a preventive medicine interview and advice about a healthy diet, exercise, and other lifestyle factors. While an objective benefit has not been proven by any controlled studies, it can only be helpful for a doctor to get to know his patients before they get sick, for a patient’s history to be documented in a chart, and for patients to develop a relationship with a doctor they can trust. Instead of just rejecting the annual physical, maybe we ought to reinvent it.

Anyway, what’s so special about “annual?” The human body can’t read the calendar. A year is only a convenient way to jog the memory. Who’s to say that 365 days is better than 340 or 390 for any given purpose? In the absence of solid data, a range of suggested intervals might be more appropriate.

Welch et al. point out that health is more than absence of disease; it’s also a state of mind. They recommend health promotion efforts that lead people to feel more resilient, both physically and emotionally. Ironically, pursuing health requires not paying too much attention to it.

Posted in: Diagnostic tests & procedures, Science and Medicine

Leave a Comment (85) ↓

85 thoughts on “Re-thinking the Annual Physical

  1. sarah007 says:

    What a brilliant post Harriet, the only thing missing is that the health services shoud be telling people how to stay well rather than load up with vaccines, but on the whole well done.

  2. BillyJoe says:

    sarah,

    “the health services shoud be telling people how to stay well rather than load up with vaccines”

    Except that loading up with vaccines is a very important part of staying well.

  3. BillyJoe says:

    Harriet: “In general, a specialty organization is likely to recommend more screening in its particular area of interest, based on a different focus in interpreting the same published evidence. The American Academy of Family Physicians, with a broader perspective, generally follows USPSTF recommendations.”

    In Australia, the Uological Society (USANZ) recommends PSA testing from age 40, whilst the General Practitioner organisation (RACGP) does not recomment testing at all.
    The RACGP’s recommendation is evidence-based, whilst the Urological Society’s recommendation seems to be based on self-interest.

  4. jb says:

    Great and useful post. Thanks.

    Part of rethinking the annual physical will have to be rethinking compensation. I’m pretty sure my insurance company won’t pay for anything without a procedure code and a diagnosis. That works great for tests, not so great for an annual conversation.

  5. Peter Lipson says:

    There has never been good data for annual physicals, but the one year mark makes a certain amount of sense. What other number to pick? 18 months? 34 months?

    Some sort of regular physical is still a good idea, minus unnecessary screening tests. The most important part of the physical, not including blood pressure measurement and cholesterol measurement and insuring the patient is following screening recommendations (sorry for the run on) is the chance for the doctor and patient to discuss symptoms that may or may not mean anything to the patient. The physical exam that follows the discussion can often uncover important findings such as a melanoma, an enlarged liver, genital warts, enlarged lymph nodes (sorry for the run on again).

    The data neither support nor refute the utility of a yearly physical, but it’s utility is plausible and it’s use keeps people on top of their health. Insurance companies (no one’s friend) have finally figured out that preventative care pays and (before the new health law) have been requiring patients to get yearly checks more and more. These yearly checks do not include “routine” tests that should not be routine.

    The part that we need to separate out is the question of what screening tests are more or less useful. USPSTF does a good job of this, combined with checking the recommendations of various professional organizations.

  6. constantine says:

    Harriet,

    I wonder whether it would make sense to periodically test for conditions that are quite dangerous, but do not usually produce symptoms until too late (e.g. colon cancer).

    Thanks.
    C.

  7. Janet Camp says:

    What about the physicals so often required for kids to go to camp or even to play soccer? These always seemed very silly to me and a huge waste of time and resources. They were particularly burdensome to people who did not have insurance–although in that case, it might be a good opportunity to update immunizations or spot problems that wouldn’t be picked up in an emergency room visit for a cut or broken bone.

  8. sarah007 says:

    Billy joe said “Except that loading up with vaccines is a very important part of staying well.”

    Not in my house it isn’t and guess what we are virtually no load at all to the disease management system and the family doctor who is a nice chap really allowed us to stay with him even though we moved out of are because we are such a no load family.

    Jb said “I’m pretty sure my insurance company won’t pay for anything without a procedure code and a diagnosis. That works great for tests, not so great for an annual conversation.”

    Isn’t that weird, no fee generated for talking to the patient but doing a useless test does?

  9. sarah007 says:

    Is this science based medicine or bucks based?

  10. nybgrus says:

    Dr. Hall:

    As I was reading your piece I was very excited at getting to comment, because I just had this exact discussion with my attending yesterday during clinic. As I was reading I was formulating a fine counterpoint to your post that would be interesting and yield a fruitful discussion.

    But then you went right ahead and addressed it at the end!

    In essense, my attending was discussing the necessity of an annual visit – a physical – but exactly from the perspective you wrote about at the end. The physical exam itself was not terribly important, but having a set time to sit down with a patient and discuss their health and coordinate and keep on top of (appropriate) screening tests was.

    He was giving me an example of a patient of his whom he had seen roughly 8 or 9 times in the last 3 years. However, each time was for some specific complain – sinusitis, GERD, etc – and as a result there was little time to focus on or discuss ongoing health maintainence.

    She had recently presented with a lump in her breast and the realization was made that she had not had a mammogram in 4 years (though by current USPTF guidelines, she should have). It was mentioned briefly once or twice at a problem focused visit, but never followed up on. The lump was a 6cm, centrally necrosed, inflitrating ductal carcinoma.

    The reason this discussion came up is because I had just seen a patient for a lump behind his ear (a sebaceous cyst, but he was worried it was cancer). I noted that he was slightly hypertensive and that his cholesterol had been borderline normal 5 years prior and hadn’t been done since. He was 42 and had a family history of early CAD (his father had an MI at 53). So I had presented my patient, gave my assessment, and then went on to my plan. It included doing basic labs and a lipid screen plus home BP monitoring and F/U in 3 months to see if he needed any pharmaceutical interventions for HTN or hypercholesterolemia.

    My attending said that besides the fact that doing such screening and advice giving on a completely unrelated visit would (over the long run and with lots of patients) lead to fragmented health maintainence and “dropped balls” so to speak, the insurance would not cover a lipid panel on a visit coded for a sebaceous cyst.

    So I said, “Why not code for the HTN and that will justify the labs?”

    Because he then would not get and reimbursement for the actual reason the patient came to visit.

    So why not code for both?

    Because sometimes insurance companies won’t cover the second code if it is so unrelated and then the patient can get stuck fighting a bill.

    So he coded just for the HTN and put in the order for the labs because the cyst was such a minor complaint and he agreed the screening was more important.

    So I suppose the moral of the story is that the physical should be re-invented and the insurance companies should be more willing to pay for it, even when “tacked on” to a visit for another problem. For some people a yearly works out well. For others, opportunistic screening and education is the only way to get better outcomes. Both need to be done and compensated appropriately.

  11. nybgrus says:

    Trolly troll hit on a truism:

    Isn’t that weird, no fee generated for talking to the patient but doing a useless test does?

    Yes indeed. And that is a way in which the system is broken. I’m quite happy to work towards fixing that. Happily, I can report that there is indeed a way to code for billing for time spent educating and advising a patient. However, overall it is much more difficult to get compensated adequately for just talking compared to doing any sort of test, procedure, or writing a prescription. I see it as a symptom of the “talk is cheap” mentality of America (in Australia, to the best of my knowledge, such “talking consultations” by primary care providers is compensated much better and more easily). The people who formed the majority of the opinion on the matter simply thought that a doctor isn’t “doing” anything by just talking. As I said, I’d be happy to see that remedied.

    I’ll also add that in every single consultation I have done to date, I make it a point to stress lifestyle, nutrition, diet, and exercise as extremely important to addressing… well, pretty much everything. My attendings do the same, btw. And drugs are to be used only as a way to bridge until the lifestyle changes occur or when they fail.

    I guess that makes me a CAM practitioner then, doesn’t it? ;-)

  12. nybgrus says:

    @constantine:

    That is precisely the question asked of all screening tests. To be a good screening test it must (amongst a few other things):

    1) Be relatively cheap and easy to use on large populations, and safe as well
    2) Have a high sensitivity
    3) Be for a disease that benefits from being caught early

    The last one is the point in a lot of cases. It is why screening mammography guidelines were changed to begin later in life – the skill of our surgeons and the chemo therapy is allowing us to have the same outcomes with cancers caught later (amongst a few other factors) which outweighs the positives of early detection because of false negative follow ups. PSA screening is more controversial, because the exact trade-offs of risk:benefit are less well understood and the negatives of a false positive PSA screen are pretty bad.

    So for things like colon cancer, as you say, yes indeed. However, the question is how often? In what population? In what way? What constitutes a negative or positive screen? What is the appropriate follow up for a negative or positive screen? Etc.

    This is all very complicated stuff and changes as our knowledge and technical skill grows. That’s why we have groups like the USPSTF.

  13. cervantes says:

    nybgrus — You forgot to mention high specificity. The downside of PSA and mammography screening is not their sensitivity, but their low specificity for lesions that will actually cause problems. That’s where much of the harm from screening tests comes from.

    Agreed with all that the payment system does not adequately compensate for time spent talking with patients. And, medical training does not adequately prepare physicians to do it well. This is the final frontier of clinical practice, and we have a long way to travel.

  14. It’s ironic that quacks and a cynical public are constantly berating doctors for over-medicalization and expensive medical red herrings, when here we have a clear case of medicine moving decisively away from that.

    I recently asked my family doctor about how our relationship should change as I cruise into the second half of life. I asked specifically about annual medical exams, and he gave me advice exactly congruent with this article. “Generally stay away” was the clear message. Suits me!

  15. tgobbi says:

    I’m posting my comment in the form of a supplement I submitted today to my monthly healthcare consumer advocate blog on TribLocal.com:

    Supplemental blog entry 21 February, 2012 by Kurt Youngmann – Healthcare Consumer Advocate

    Today my comments represent a departure from my normal modus operandi. My thrust as a healthcare consumer advocate mostly centers around questioning… well, I guess you’d call it questionable healthcare claims. I’ve challenged practitioners (and adherents) of holism, chiropractic, naturopathy, homeopathy and other scientifically unsupportable modalities to substantiate claims of efficacy for what they practice (and preach).

    Stimulated by today’s Science-Based Medicine Blog http://www.sciencebasedmedicine.org/index.php/re-thinking-the-annual-physical/#more-19352 , I’m joining its author, Harriet Hall, M.D. (known in the skeptical community by her sobriquet “The SkepDoc”) in questioning one of mainstream medicine’s sacred cows: the annual physical exam. Disclosure: Dr. Hall is my friend so I’m predisposed to accept her opinions prima facie. In fact I jokingly refer to myself as the president of the Harriet Hall fan club – which doesn’t really exist, but if it did, I’d volunteer for the position. She has a well-deserved reputation as a world-class debunker of untenable health claims and is an adherent of science-based medicine, i.e. healthcare that is supported by the tenets of good science. (See my TribLocal article of 17 May, 2011 for an explanation of the scientific method).

    In short, Dr. Hall believes that routine physical exams for the average person are unnecessary. She’s careful to explain that this “… does not apply to people who have been diagnosed with diseases, who have any kind of symptoms or signs, or who are at particularly high risk of certain specific diseases.”

    She continues, “The assumption was that [the typical or annual exam] process would find and fix any problems and insure that any disease process would be detected at an early stage where earlier treatment would improve final outcomes. It would keep your body running like a well-tuned engine and possibly save your life.” The balance of the article explains why she believes that this is not a viable concept. I recommend a careful read of Dr. Hall’s views on the subject. (See the link above).

  16. CarolM says:

    Well okay, this explains why my internist asks so puzzled when I come in for my annual. It’s really just been reassurance for the worried well, in my case, though I am high risk for breast cancer. But when I let the mammogram lapse for 18 months, I got a lump (atypical hyperplasia) and had to go through the whole needle biopsy and lumpectomy ordeal.

    I’ve had more damn false alarms, yet my mother sailed into her 90s rarely concerning herself with any of that.
    She never had a mammogram. My brother went bare of insurance for 20 years, avoiding doctors, until finally getting on Medicare at 65.

    That’s how people used to get by.

  17. This article irks me a little bit. I wonder if the readers may take this a little too literal, as if to say “doctors should only investigate current complaints and also monitor blood pressure.”

    Dr. Hall warns:

    Please note: the following refers to routine physicals and screening tests in healthy, asymptomatic adults. It does not apply to people who have been diagnosed with diseases, who have any kind of symptoms or signs, or who are at particularly high risk of certain specific diseases.

    We have to ask the question: “Well how do you diagnose the diseases in the first place?” USPSTF recommends starting screening for lipids in men at age 35. If we don’t screen for lipids, then we can’t diagnose hyperlipidemia. We should not only look for overweight patients, or those with family history of early cardiac death, or familial hypercholesterolemia. We also don’t want to wait until they develop heart disease. In this instance, this screening test in a seemingly perfectly healthy asymptomatic patient is necessary.

    Also, why isn’t sarah007 banned yet? She’s threadcrapping every post.

  18. mousethatroared says:

    HH “On the other hand, there is a good argument for a periodic visit with a healthcare provider without the ritual of the physical exam. It’s helpful to have a systematic way of ensuring that the screening tests recommended by the USPSTF get done. An annual visit would be an opportunity for a preventive medicine interview and advice about a healthy diet, exercise, and other lifestyle factors. While an objective benefit has not been proven by any controlled studies, it can only be helpful for a doctor to get to know his patients before they get sick, for a patient’s history to be documented in a chart, and for patients to develop a relationship with a doctor they can trust. Instead of just rejecting the annual physical, maybe we ought to reinvent it.”

    Interesting thoughtful article, Harriet Hall. Although, I have to admit, I was considering arguing with you until the quoted paragraph. That paragraph is a good description of how my doctor seems to handle our kinda-annual visit. I feel that it works well.

    I’m not wild about adding other screening onto sick visits. Usually when I go in for a sick visit, it is because I am very ill. Last two times were upper respiratory infection with severe asthma cough and strep throat, not a good time to ask me to hang out for a flu or tetnus shot, run downstairs to get that cholesterol test, or discuss working more exercise into my lifestyle.

  19. mousethatroared says:

    SkepticalHealth – “Also, why isn’t sarah007 banned yet? She’s threadcrapping every post.”

    I think I’ll follow the advice that I give my kids for playmates who tease and tattle. They are usually doing it to get a reaction out of you. Don’t give them the satisfaction. Just ignore them.

  20. YaronD says:

    Doesn’t this ignore medical problems that are not a direct cause of morbidity and mortality?

    For example, take Glaucoma. By the time a person actually notices the reduction in their visual field usually a heck of a lot of damage has already been done, and is irreversible. So the occasional (e.g. annual) intraocular pressure test provides a huge benefit by being done in advanced. And it fits the sensible criteria that nybgrus mentioned.

    Sure, technically this one is only done for patients “who are at particularly high risk of certain specific diseases”, but that is when the risk factor is mainly just being over the age of ~40, which I assume wasn’t the intent here.

    And while I can’t think of other examples at the top of my head, I feel safe in making the statistical assumption (There are a lot more medical problems I’m not familiar with than there are that I am, and still I’m familiar with at least one with this character) that there are more such similar cases.

    So it seems to me that recommending to stop annual exams just because they don’t decrease morbidity and mortality… can cause an increase in other preventable medical problems that won’t kill people directly but will still adversely affect their lives and the lives of people around them.

    Sarah007, as long as you don’t get involved in a serious car accident you can also make the claim that wearing a seatbelt has no effect on your health or safety, and that driving without a seatbelt you and your kids are no load at all on the morgue system or cemeteries. Merely being lucky so far doesn’t make for a good general claim.

  21. Harriet Hall says:

    @YaronD,
    The USPSTF recommendations for glaucoma screening are here: http://www.uspreventiveservicestaskforce.org/uspstf05/glaucoma/glaucrs.pdf

    The term “morbidity” covers those other medical problems that adversely affects lives.

  22. weing says:

    One problem with dealing with the various preventative services and screens during an acute visit is time. The patient is scheduled for a short visit and I end up being late for the next patient. Another problem is the patient who doesn’t come in for a visit at all as he is healthy, and unscreened, until he drops dead.

  23. windriven says:

    Dr. Hall,

    Isn’t there more value to an annual visit with one’s physician than just a physical exam? I spent a good deal of time and effort finding an internist who was a good fit for me. At some point I may very well be trusting her with my life. Spending a few moments annually tending to that relationship seems a good investment to me.

  24. glvazquez says:

    Anyone reading this article should note the disclaimer by Dr Hall at the beginning of this post.She is writing about healthy ADULTS.
    As a pediatrician I can tell you that one of the problems we frequently encounter is patients whose parents avoid checkups and seek routine care in ER’s and Urgent Care’s. I have encountered patients with misdiagnosed problems from growth to scoliosis and everything in between. As more and more quick care centers open in our country I am sure the problem will escalate.Parents need to recognize that a visit to the ER involves diagnosing and treating the complaint you came in with and does not address developmental screenings so important in children and adolescents.
    Dr G.L Vazquez

  25. sarah007 says:

    nybugrs said “It included doing basic labs and a lipid screen plus home BP monitoring and F/U in 3 months to see if he needed any pharmaceutical interventions for HTN or hypercholesterolemia. ”

    So would you not consider asking him about his diet first and whether or not he drank enought water?

  26. Harriet Hall says:

    @windriven,
    “Isn’t there more value to an annual visit with one’s physician than just a physical exam?”

    Yes, that’s why my article included this sentence:
    “While an objective benefit has not been proven by any controlled studies, it can only be helpful for a doctor to get to know his patients before they get sick, for a patient’s history to be documented in a chart, and for patients to develop a relationship with a doctor they can trust.”

  27. weing says:

    I do a wellness inventory on my patients. The frequency depends on age. For example, I check to see if and when a colonoscopy was done, based on age and family history. I track down the results of any biopsy. No easy matter, even with an EHR. Based on all of the above, we determine the timing of the next one.

  28. sarah007 says:

    Mousy said “Usually when I go in for a sick visit, it is because I am very ill. Last two times were upper respiratory infection with severe asthma cough and strep throat, not a good time to ask me to hang out for a flu or tetnus shot, run downstairs to get that cholesterol test, or discuss working more exercise into my lifestyle.”

    What the hell are they doing to you, so when you are this ill is the appropriate ‘treatment’ steroids, antibiotics?

  29. sarah007 says:

    Yaron D said”Merely being lucky so far doesn’t make for a good general claim.”

    But I don’t believe in luck because I am not a doctor, my health status is a planned action.

  30. LovleAnjel says:

    “…my health status is a planned action”

    What, precisely, does that mean?

  31. Narad says:

    What, precisely, does that mean?

    It’s rank Natural Hygiene. The system, however, is so dumb that it’s usually advanced with the utmost coyness, just as Th1Th2′s opening gambit is always to conceal the fact that the words have been silently redefined. The obnoxious haughtiness is part and parcel of the NH game, as it is presumed to be based on unarguable “Law(s) of Life.”

  32. tanha says:

    This is an important topic but i see a few reasons FOR annual physicals:

    1) So your doc can make money since each adult physical can generate a good chunk of change

    2) Patients don’t always know if they are healthy and asymptomatic. They can’t see that weird mole on their back or know if there blood pressure has been high, etc. At some point even those that have chronic disease were once healthy and asymptomatic, until a doc diagnosed them with a problem.

    3) Patients desire preventative medicine

    4) Refilling prescriptions in patients who don’t have chronic disease and wouldn’t otherwise see their doc; like birth control pills, etc

  33. mousethatroared says:

    Off topic, beyond something that is an annual event.

    Happy Paczkis Day Everyone!

  34. Harriet Hall says:

    @tanha,
    “reasons FOR annual physicals:
    1) So your doc can make money since each adult physical can generate a good chunk of change
    2) Patients don’t always know if they are healthy and asymptomatic. They can’t see that weird mole on their back or know if there blood pressure has been high, etc. At some point even those that have chronic disease were once healthy and asymptomatic, until a doc diagnosed them with a problem.
    3) Patients desire preventative medicine
    4) Refilling prescriptions in patients who don’t have chronic disease and wouldn’t otherwise see their doc; like birth control pills, etc”

    1) This blog is about science-based medicine, not about economics-based medicine.
    2) A patient who is not aware of a mole is by definition asymptomatic. The USPSTF gives us screening recommendations based on evidence. For skin cancer, there is not enough evidence to assess the balance of benefits and harms of skin surveys by doctors or by patients themselves. Those with chronic diseases usually develop symptoms, and treatment in an asymptomatic stage usually doesn’t change overall outcomes.
    3) Effective preventive medicine does not require a physical exam other than taking BP.
    4) Rx refills don’t require physical exams.

  35. mdstudent says:

    Fascinating article with radical implications. It reminded me of a meeting I had with a family physician a few years ago who refused to see me regularly because I was deemed “young and healthy”.

    I’m beginning to gain a much deeper understanding of the clinical value of routine screening tests.

  36. Connor says:

    @sarah007

    “…my health status is a planned action.”

    Please could you let me know what exactly that plan involves?

  37. Lytrigian says:

    Please could you let me know what exactly that plan involves?

    Why, not getting sick, of course!

    It’s impossible to argue with the anecdotally convinced when they are their own anecdote. Sarah will never accept that the reason she finds her methods effective is that she happens to be healthy, not that she’s healthy because her methods are actually effective. Some people lived into their 90s in the Middle Ages too, despite the utter lack of useful health care and incorrect understanding of disease, but we would hardly take that for a general rule.

    My own annual “check-ups” have been pretty much as Dr. Hall described in her conclusion. Routine screenings have, in my case, turned out to be very useful and I’m glad I’ve had them.

  38. BillyJoe says:

    I have never had a physical and plan never to have one.
    My logic is simple.
    I would never take medication on a regular basis simply to decrease the risk of disease.
    I am addicted to exercise which keeps me in the healthy weight range regardless of what I eat.
    I do know my BP is fine because I have a friend who plays nursie with me :)

  39. mousethatroared says:

    @BillyJoe, Do you have a relationship with a doctor who you feel is competent, that you can communicate with, that you can trust?

    I’ve known people that rarely visited the doctor, who became seriously ill or injured. Finding out your doctor (who you maybe saw once a few years ago for a sprained ankle) is a complete quack, incompetent, etc when you’re seriously ill is not a desirable experience.

  40. mdstudent says:

    @ Billyjoe,

    I don’t think Dr. Hall is arguing that healthy individuals like yourself completely avoid seeing doctors until it becomes absolutely necessary (ex due to serious injury or infection). Rather, my understanding is that she’s advocating for a new paradigm in the regular “check-ups” between physicians and asymptomatic patients that avoids reading too heavily into seemingly abnormal findings from a number of questionable screening tests.

  41. DW says:

    I think that’s a really good point – patients need to screen their doctors, too. It isn’t one-way. Hope this doesn’t sound too placebo-y, but in addition to credentials and experience, you need a doctor you have some rapport with. Part of the point of having an established relationship with a doctor is that if/when you do need them – and most of us will at some point – you have some basis for believing what they say, or at least trusting that they have your best interests in mind and will work hard on whatever problem you come in with. (I’m not a doctor; I know doctors all assume all of you are trustworthy and competent etc., but that isn’t the case, and patients have to take some responsibility for finding the right doctor.) The only way I can think of to establish the relationship is to see them on at least a somewhat regular basis.

  42. sarah007 says:

    Conner said “Please could you let me know what exactly that plan involves?”

    Staying well, avoiding flu vaccines and palliative attempts to displace homeostasis and not depending on a doctor to ‘screen’ me for non diseases and suggest fire fighting.

    Of course if I get run over by a truck then emergency services have total value.

    Lytragian said “Sarah will never accept that the reason she finds her methods effective is that she happens to be healthy, not that she’s healthy because her methods are actually effective. Some people lived into their 90s in the Middle Ages too, despite the utter lack of useful health care and incorrect understanding of disease, but we would hardly take that for a general rule.”

    But surely we should be studying the groups of people who live into their 90′s without ‘effective health care’ and try to understand why they are so well.

    Harriet said “3) Patients desire preventative medicine”

    No they don’t really, they desire the knowledge to stay well without taking medication and this is totally possible generally, unless one has been combatively traumatised. They require preventative knowledge and this is largely absent from medical consultations for some reason.

  43. DW says:

    “Staying well,”

    So your first strategy in staying well is to stay well.
    A little circular reasoning there?

    Reminds me of the bumper stickers that say, “I’m planning to live forever. So far so good”

    Sarah, I hate to break it to you, but we’re all planning to stay healthy. It doesn’t work out that way for everyone. There is more than a little “blame the victim” in your aggressive ideology.

  44. nybgrus says:

    @sarah:

    Indeed. I was a bit curt in my response re: the F/U visit, but as I said in a few other posts around these parts, diet and exercise are the first and primary interventions. Drugs are used to bridge the time between diet and exercise having an effect and/or if diet and exercise fail to have the necessary magnitude of effect.

    Despite what you clearly believe, as DW has been pointing out, you cannot simply will yourself to being and staying healthy. There are myriad pathologies that can come your way despite every best possible effort – even the ones you are about to say are better than what us silly doctors know. In cases like these, drugs are invaluable in prolonging and improving life. But even when on medications, I still counsel patients on the synergistic effects of good diet and exercise, advocating for the minimum amount and dosage of meds necessary to bridge that gap (the same gap which I reckon you don’t believe exists).

  45. Harriet Hall says:

    @BillyJoe,

    “I would never take medication on a regular basis simply to decrease the risk of disease.”

    Never? Why not?
    Let’s imagine a hypothetical example: genetic testing advances to where it can predict you have a 99% chance of developing a certain fatal disease. There is a pill you can take once a day that will reduce your risk to 1%. It is a safe pill with no serious side effects and only a 1% chance of minor side effects. Would you take that pill?
    Where would you draw the line?

    Do you insure your house and car?

  46. Chris says:

    I suspect BillyJoe is being sarcastic. It is hard to tell since his statement is less outlandish than someone else.

  47. Harriet Hall says:

    I missed the sarcasm, because as Chris says, people really believe far more outlandish things.

  48. Narad says:

    No they don’t really, they desire the knowledge to stay well without taking medication and this is totally possible generally, unless one has been combatively traumatised.

    Is that a whiff of Ryke Geerd Hamer that I’m detecting?

  49. sarah007 says:

    nybgrus said “Drugs are used to bridge the time between diet and exercise having an effect and/or if diet and exercise fail to have the necessary magnitude of effect. ”

    This is bonkers logic. Let’s say someone has high blood pressure because they are dehydrated, taken meds to dilate when the patient needs to rehydrate makes no sense. The triage for high BP doesn’t take into account the why from the medic but from a good alternative practitioner doing an audit of why is at the top of the list.

    Harriet said “Let’s imagine a hypothetical example: genetic testing advances to where it can predict you have a 99% chance of developing a certain fatal disease. There is a pill you can take once a day that will reduce your risk to 1%. It is a safe pill with no serious side effects and only a 1% chance of minor side effects. Would you take that pill?
    Where would you draw the line?”

    This is genetic fantasy and there are no safe pills so the only data you are going to get from this is hypothetical.

    I insure my house and car because it is not possible to have a mortgage or drive without insurance legally. If I told you that eating no processed food, avoiding newspapers and vaccines would be good for your health would you do it?

    Narad said “Is that a whiff of Ryke Geerd Hamer that I’m detecting?” I have no idea but I suspect you don’t really understand what I said.

    DW said “but we’re all planning to stay healthy. It doesn’t work out that way for everyone.” Yes but if your plan is to fear pandemics, take toxic meds to stay healthy and give responsibilty to third party medical insurance schemes the outlook isn’t that good.

    Litragian said “It’s impossible to argue with the anecdotally convinced when they are their own anecdote. ”

    So the yearly medical isn’t for the anecdotally convinced? If research is now showing it had little value it must have been established cos someone thought it was a good idea, correct me if I am wrong but that’s an anecdotally convinced event. By the way most surgery has no EBM and it is routinely done every day in every country.

  50. Scott says:

    The triage for high BP doesn’t take into account the why from the medic

    Utterly false.

    This is genetic fantasy and there are no safe pills so the only data you are going to get from this is hypothetical.

    Well gee, maybe that’s why she said “Let’s imagine a HYPOTHETICAL example.”

    If I told you that eating no processed food, avoiding newspapers and vaccines would be good for your health would you do it?

    If you told me that 1+1=2, I would ignore you.

  51. nybgrus says:

    Let’s say someone has high blood pressure because they are dehydrated,

    I’m the one with bonkers logic? You are aware that dehydration would make you hypotensive, right? What am I thinking. Of course you don’t.

    Chris, why did I bother even remotely engaging this troll? First Thingy tries to tell us that vaccines can’t work because they don’t stimulate the immune system like a “natural infection” does and now Sarah is trying to tell me that decreased plasma volume leads to increased blood pressure.

    There is no point further conversing with the new Trolly Doll.

  52. Chris says:

    Live and learn. ;-)

  53. cloudskimmer says:

    I enjoyed the article. Dr. Hall, I wish you could sell this to the FAA, which requires airline captains to have a physical every six months and an EKG every year, while copilots require an annual physical… by a designated FAA examiner. This typically is a cash-raising endeavor for doctors who get a patient who doesn’t want anything found to be wrong with them, and who writes a one hundred dollar check (two hundred with the EKG) for a 15 minute visit featuring an eye exam, urine check for sugar, blood pressure, looks into eyes, ears and nose, listening to heart and lungs, and maybe abdominal palpation. After age 60, the EKG is required every 6 months. Is there any evidence that this weeds out pilots who may have a problem in flight? Overall it seems expensive, inconvenient and unnecessary. And most pilots have another primary care physician to whom they can freely discuss their medical concerns. (Company medical departments have been discontinued because the airlines no longer want to spend the money.) It seems to me that data from these exams could be a treasure trove of evidence of the uselessness of annual or semi-annual physical exams, if we could only get the FAA to pay attention. I’m ready to be persuaded one way or another; I’d really like to see results of that database search.
    A couple of good things about the annual physical: First, you get to interact with your physician in a non-threatening situation, so that when something bad happens, your physician is not a stranger. Second, it can provide reinforcement in attempts to lose weight, stop smoking, or maintain an exercise program. My personal doctor always checks my weight and asks about my eating and exercise habits. In T.R. Reid’s book, The Healing of America, he mentions that the Japanese are far heavier users of medical care and live about five years longer than Americans. Average visits are very short, getting blood pressure readings or medications, but it provides a comforting interface with someone who cares about your health. I fear that reducing doctor visits will have an adverse effect on confidence in how medical care is doled out in this country; mine is already at a low ebb.
    And while Doctors find annual physicals boring, they also don’t like patients with difficult problems that aren’t subject to clear diagnoses and treatments. And when a patient is perceived as dying, elderly, or difficult, Doctors often avoid them; not always, but often enough to be very disturbing.

  54. rork says:

    You knew what to do already, were reminded about it to boot, but feed the insane troll anyway.
    Control, you must learn control.

    May I now move on to point to what is making news for me that is mildly related:
    http://www.ncbi.nlm.nih.gov/pubmed/22312138

    Too much screening for ovarian cancer (transvaginal ultrasound or serum CA-125 assay), against recommendation, by docs that we would have liked to say are participating in scientific medicine.
    “One in 3 physicians believed that ovarian cancer screening was effective, despite evidence to the contrary. Substantial proportions of physicians reported routinely offering or ordering ovarian cancer screening, thereby exposing women to the documented risks of these tests.”
    There’s a bit of “they wanted it so I did it” in there, but we are anxious that “they just don’t get it” about over-diagnosing and such – cause it really is a bit counter-intuitive if you haven’t been over that territory a few times. I wonder if PSA tests might be going this way too. Will insurance companies not notice the worst offenders?

  55. DW says:

    “Yes but if your plan is to fear pandemics, take toxic meds to stay healthy and give responsibilty to third party medical insurance schemes the outlook isn’t that good.”

    What?

  56. mousethatroared says:

    @Chris- I don’t think that BillyJoe is being ironic in stating he’s not willing to take medication to prevent illness. I’ve seen him say something similar before. But I believe he was talking about something like statins, not any hypothetical drug that might exist in the future. Since he is having his blood pressure checked, I assume he might consider some sort of blood pressure intervention.

    Of course he can speak for himself, though. Just thought I’d put my bet in before he responded.

    @DW- I suspect you have to speak Sarah Palinese to understand S-007

    cheers, formerly M in M

  57. sarah007 says:

    Scott said “If you told me that 1+1=2, I would ignore you.”

    You must be a believer then.

    Nybgus said “dehydration would make you hypotensive, right? ” Ok so thick blood is easier to pump!

    “decreased plasma volume ” no, increased density, so bend the rules to fit your answer!

    DW said or didn’t “What?” Well I suppose the idea that that pandemic was a scam is hard to grasp and all that useless medicine that did nothing constructive, well that’s a guess actually because Roche lost all the Tamiflu data as reported in the BMJ so I assume it was a total failure or they wouldn’t have “lost” it would they?

  58. Lytrigian says:

    Nybgus said “dehydration would make you hypotensive, right? ” Ok so thick blood is easier to pump!

    Sarah, look it up. There’s a reason diuretics are commonly given for high blood pressure. You could not have better illustrated that what might seem to make “common sense” is commonly wrong.

    But surely we should be studying the groups of people who live into their 90′s without ‘effective health care’ and try to understand why they are so well.

    This cannot be done ethically. It probably can’t even be done practically. But it’s probably not necessary: in any large population there are going to be outliers. If most people are dead before they reach age 40, you would still expect a certain number to be alive 30, 40, or 50 years later purely by chance, as long as you were within reasonable limits of the organism.

    The fact is, though, that thanks in part to modern health care, it is no longer uncommon for people to live into their 90s where it was VERY uncommon even 100 years ago. Perhaps you feel this is a bad thing, but I can’t share the sentiment.

  59. Narad says:

    Nybgus said “dehydration would make you hypotensive, right? ” Ok so thick blood is easier to pump!

    I was so hoping it would double down. Let us grant the “thick blood at constant volume” proposition. What does Poiseuille’s law tell us? Pressure is inversely proportional to viscosity, you gormless tiddler.

  60. Narad says:

    … or I just put my foot in it. Let me do that again.

  61. Narad says:

    Yah, high viscosity = low flow = low pressure doesn’t quite work out in practice. I’d like to stick with “gormless tiddler” all the same.

  62. Harriet Hall says:

    Hyperviscosity, in conditions like polycythemia, can sometimes raise blood pressure. In the vast majority of people with high blood pressure there is no hyperviscosity. Dehydration does not cause hyperviscosity. Dehydration lowers BP; it doesn’t raise it. Diuresis (a kind of dehydration) is an effective treatment for HBP.
    The idea of dehydration causing HBP comes from Batmanghelidj’s “water cure” quackery.
    http://www.sciencebasedmedicine.org/index.php/the-water-cure-another-example-of-self-deception-and-the-lone-genius/

  63. DW says:

    Sarah, the idea that “that pandemic” was a scam isn’t at ALL hard to grasp. It’s moronically easy to grasp that. It’s the kind of shallow thinking that characterizes most conspiracy theories. They’re always attractive to people who have trouble thinking about complex topics. It is much easier and less threatening to declare something a scam or conspiracy than to wrap one’s mind around the notion of an actual pandemic.

    Lots of people have been recommending coursework for you. I’d like to add Psychology 101 to your courseload. Read about some basic psychological mechanisms like projection, displacement, and denial. These are mechanisms that protect us psychologically from distressing thoughts, like the idea that we actually can get sick even if we do everything “right,” and epidemics and pandemics ARE possible, they actually aren’t invented by mean governments.

  64. this post is awesome.

    here is a possibly valuable idea to throw into the discussion (ignoring the true-believer thread and troll thread):

    for the benefits noted of the ‘annual exam:’ advice to exercise, admonitions to do USPSTF screenings:

    is a physician needed?

    SRSLY

    a trained monkey could do those things.

    even the CBE and the KY jelly thing. i have been a trained-observer of primates, and I will tell you that they can do these things.

    in the country song, the exasperated young woman says, “i shaved my legs for THIS??!!”

    I went to med school for this?

    physicians are super duper at a lot of things.

    and they are in limited supply.

    let’s not burden them with tasks that could be handled by a trained monkey.

    someone else needs to do this. someone who could be good at this, and needs a job. there is plenty for the docs to do. we have a ‘physician shortage.’ even if we subtract the need devoted to asking people if they eat right.

    a lower-level professional needs to do the symptom-seeking and screening-encouragement.

    a behavior-change person needs to provide direction on quitting smoking, eating right, and exercising.

    each of those needs to know enough to detect a red flag and let that signal rise up to the physician.

    great post. heretical, but great.

  65. Harriet Hall says:

    @MedVsTherapy,

    “someone else needs to do this”
    I totally agree. Lower level professionals should be utilized, as well as computer-based tools. Medical care should be a team effort, with the doctor in charge of the team.

  66. Calli Arcale says:

    Very interesting and provoking post, Dr Hall! I like it. I get an annual physical; I have asthma, and I have some prescriptions that require refilling on an annual basis. But I don’t really need the physical itself. After observing eight years of bringing my daughters to well child visits, I have come to the opinion that we need something analogous to the well child visit. The well child visits are much quicker than the physicals, even with a lot of the old tests eliminated. Rather than attempting to create a full baseline of the patient’s health at that particular moment in time, they mostly screen for developmental problems and such, interview the parents to explore risk factors and answer any concerns, and provide whatever vaccinations are indicated. I would think the adult physical could be generally replaced by a well-patient visit. It would be a win-win all around, I suspect.

  67. Harriet Hall says:

    @Calli Arcale
    “I would think the adult physical could be generally replaced by a well-patient visit.”

    This is actually being done. As a military retiree, I get my care from the military medical system. Every year I get a letter telling me what routine screening tests I’m due for and reminding me to make my annual appointment for a “health maintenance” visit, sometimes with a doctor but more often with a physician assistant or nurse practitioner.

  68. sarah007 says:

    lytragian said ” But surely we should be studying the groups of people who live into their 90′s without ‘effective health care’ and try to understand why they are so well.

    This cannot be done ethically. It probably can’t even be done practically. But it’s probably not necessary: in any large population there are going to be outliers. If most people are dead before they reach age 40, you would still expect a certain number to be alive 30, 40, or 50 years later purely by chance, as long as you were within reasonable limits of the organism.”

    Well this is a critisism you aim at CAM, “it can’t be studied” Utter bollocks, you put an advert in the paper for anyone who is 90 and avoided their doctor, never had a vaccine or even been to hospital etc. and collect the data. I know loads of parents who don’t vaccinate their children, none have atopy or chronic ill health and their med bills are non existent.

    So if we are well in your world into our 90′s it’s because medicine helps us live longer, in my world it’s because of chance, what a load of septik tank nonsense, are you making this up or singing off a song sheet?

    Harriet said a pile on BP, what does the CDC say May is High Blood Pressure Education Month? “Nearly 68 million people have high blood pressure, which is also called hypertension, in the U.S.”

    That says to me that ‘proper doctors’ don’t have a blind clue what they are doing!

  69. Sarah you can’t possibly be that stupid. A patient is said to have hypertension even when it is well managed with hypertension. It’s not that we know they have hypertension but can’t treat it. Fuck, you’re dumb.

  70. nybgrus says:

    lol. you know the troll is bad when the commentariat here begins resorted to incredulous profanity.

    not that I am offended mind you. I second the thoughts entirely. From my POV it is merely a reflection of the degree of trollish inanity.

    Be proud Sarah. You have reached troll level: Master.

  71. weing says:

    I frequently forget this advice: “Never argue with an idiot. They drag you down to their level then beat you with experience.”

  72. Lytrigian says:

    Well this is a critisism you aim at CAM, “it can’t be studied” Utter bollocks, you put an advert in the paper for anyone who is 90 and avoided their doctor, never had a vaccine or even been to hospital etc. and collect the data. I know loads of parents who don’t vaccinate their children, none have atopy or chronic ill health and their med bills are non existent.
    I’d be very surprised if there were enough people in their 90s for whom this is true for there to be a large enough population for a good study. Sure, there are places where modern medicine is a rarity, but in those places people almost never live into their 90s. THIS is why I think such a study would be hard to do by ethical means, not because longevity is a thing that per se can’t be studied as is the claim for CAM. If there were it might be worth doing — but collect what data? That’s a bit of a conundrum too.

    I’m glad you weren’t advocating actually withholding medical care from a population deliberately. Frankly, you’ve been irrational enough that I couldn’t put it past you, and indeed that’s how I took your meaning.

    Of course you know loads of parents who neglect their children’s health, and the kids are just fine. Given modern sanitation and the herd immunity conferred by nearly everyone else being vaccinated, most such kids are going to be just fine most of the time. Hard to get polio, whooping cough, or measles if you’re never exposed to it. Tell me something surprising. Hell, before I was in my late 30s I could have done without a single doctor visit ever. Not that I didn’t but I could have; I’d never had a serious health issue. Then my gallbladder became diseased, and here I was without a single risk factor. (I lacked all of the classic “three Fs” of gallbladder disease: I was neither fat, nor female, nor 40.) Good thing I wasn’t afraid of doctors *then*, huh?

    And then, there are kids who are only alive because of intensive, frequent medical intervention. Maybe you’d consider the species improved if they were allowed to simply die, but I suspect their parents would differ.

    So if we are well in your world into our 90′s it’s because medicine helps us live longer, in my world it’s because of chance, what a load of septik tank nonsense, are you making this up or singing off a song sheet?

    Medicine among a host of other factors, yes, sanitation, clean water, safe food, and good hygiene not least among them. We understand these things as contributing to good health because of — I’m sorry to inform you — modern medical research. You benefit from them even if you never set foot in a doctor’s office, just as your children benefit from nearly everyone around you having been vaccinated. Lacking those things, then yes, you’d better be damned lucky if you want to make it to 70, never mind 90.

    Or why do you think long life was so very rare in earlier centuries?

  73. The troll’s dumbness is rubbing off on me. I meant to write: ” A patient is said to have hypertension even when it is well managed with *medication*.”

  74. darwin says:

    Even the argument that visiting a doctor to get to know him while you are well is lost in these days of hospitalists. Few primary care docs or internists treat their patients in hospitals. When you have a massive trauma, you’ll see ER docs and surgeons unfamiliar to you. When you come down with cancer, you’ll be tossed into a world of oncologists.

    Don’t worry about Sarah spy; time will have her relying upon the mercy she likes to belittle. If she’s human.

  75. sarah007 says:

    Ilitragian said “Of course you know loads of parents who neglect their children’s health, and the kids are just fine.”

    Well that’s a lot of medical sense, tell us how you neglect your health and you’re fine. OH take statins I forgot.

    “ooooh look, another medical anecdote hiding in a fact “the herd immunity conferred by nearly everyone else being vaccinated”

    The only study done on herd immunity was on natural herd immunity, ie not vaccinated. Artifical herd immunity is a fantasy construct, all those vaxxed kids on steroids for their asthma are more of a risk to my kids, the nut allergies, my kids can’t take peanut butter to school.

    “Then my gallbladder became diseased” What by magic! Spontiseparetist! voodoo?

    “just as your children benefit from nearly everyone around you having been vaccinated” OOOh look another medical anecdote, points means prizes.

  76. sarah007 says:

    “When you come down with cancer, you’ll be tossed into a world of oncologists.”

    Perhaps this statement sums up why so many people are sick to whatever with the kind of people you are, you have contempt for everyone that won’t suck you off, even patients.

    Well done.

  77. mousethatroared says:

    darwin “Even the argument that visiting a doctor to get to know him while you are well is lost in these days of hospitalists. Few primary care docs or internists treat their patients in hospitals. When you have a massive trauma, you’ll see ER docs and surgeons unfamiliar to you. When you come down with cancer, you’ll be tossed into a world of oncologists.”

    One of the things that you can look for in a primary care doc is one who does a good job coordinating care with specialists, one who’s office staff is good at record sharing, when needed, and has good processes and computer system in place for reporting test results and checking patient records on care from other providers. Of course, if you are perfectly healthy and never see a specialist, you won’t have much opportunity to evaluate the PCP on these criteria.

  78. lilady says:

    @ darwin: I think you might find this article interesting:

    http://www.health.harvard.edu/fhg/updates/When-your-care-involves-a-hospitalist.shtml

    I love my G. P., but if I went to an emergency room following a traumatic injury, I want to be treated by an Emergency Medicine specialist. If I need treatment for cancer I would seek treatment provided by an oncologist.

    I think I would stand a better chance of recovering from a traumatic injury and recovering from cancer by going to specialists…

  79. Harriet Hall says:

    Hospitalists are a great idea, but the goal of a good primary physician is to visit the patient in the hospital, communicate with the hospitalist or specialist, and provide continuity of care.

  80. Chris says:

    Though, Dr. Hall, that is not always feasible. Our family doctor is next door to a small community hospital, and he did visit me each time I was there having a baby. But he could not go across town to Children’s Hospital when my son was transferred there, nor his subsequent hospitalizations at Children’s. Though he did call us when we were at the hospital, and at home.

    It is getting even more complicated with two other specialists, and being referred to surgery in another state.

  81. thatguybil81 says:

    These types of “healthy check ups” are now mandated by Humana if you want to save $360-1000 a year in premiums.

    A large insurance company like humana would not be throwing good money away. They must have done a cost benifit analysis and be gaining more then they are spending by maindating these yearly health check ups.

  82. Scott says:

    If they can’t mandate the necessary communication any other way, then it would make sense even if none of the actual benefits are due to the ritual of the “physical.”

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