The Annual Physical: Maligned and Misunderstood

In The New York Times' Sunday Review, Elisabeth Rosenthal mounted an attack on the cost-effectiveness of the annual physical, a ritual whose net value has actually been covertly questioned for decades by many health professionals, but whose sanctity has now become safe to challenge in very public view. What we’re seeing today is a seismic collision between two forces: our historic belief that deluxe healthcare, with no test or procedure spared, is an inalienable right, and our urgent need to rethink the value of every entitlement -- including the rituals of care we hold most sacred.

Forget the tricky pharmacoeconomic calculus around PSA tests and mammograms. There’s a larger picture to look at. Problems that require immediate intervention tend to be more acute and symptomatic -- and those emergent problems don’t necessarily present in accordance with the arbitrary timetable by which we set our medical appointments. Annual cycles have astronomical and cultural meaning for us, but the body doesn’t pay them much heed. Even civilians can understand that. And, in fact, the so-called annual physical is a bit of a misnomer anyway. Relatively healthy people and those who are healthcare-averse have check-ups far less often.

Rosenthal’s general perspective is sound but she conflates a few issues to make periodic “well check-ups” seem even less productive, or cost-effective, than they are. Executive physicals are surely capitalism at work, but ironically, the people who seek them out tend to be a very small minority of relatively healthy individuals. And CT scans for headaches or MRIs for lower back pain don’t tend to come about as a result of annual check-ups; they’re usually precipitated by symptoms and sick visits. We may spend way too much on medical tests for symptoms that, on average, are transitory and unimportant, but that problem can be solved by smarter protocols and more disciplined, effective MD-patient interactions. We don’t need to bash the physical to reduce unnecessary testing.

Actually, most of the testing done for annual physicals is relatively inexpensive and non-invasive blood work, and there are useful things to be learned from it, even in patients who feel quite well. The PSA, which can produce false-positives, should be accompanied by a DRE to palpate the prostate so net costs need not be unduly high. And as someone who has helped bring bisphosphonates to market (but doesn’t choose to treat her mild osteopenia with any of them), I count on a DEXA scan every few years to track the success of exercise, provide a platform for discussion about supplements, and give me greater clarity on my risk profile.

Here are some other things the annual physical does:

• It creates a more coherent picture of each patient for his or her primary care physician. If properly spent, time in the annual physical fosters the sort of MD-patient relationship that’s bound to produce more cost-effective healthcare -- for instance, by preventing very expensive ER visits, or by promoting lifestyle change and modifying risk profiles at earlier points.
• It is probably the most reliable way to diagnose and act on hypertension in patients who are otherwise healthy, in a medical culture that has clearly documented the long-term mortality benefits of increasingly tighter BP control.
• It gives physicians and patients a regular forum for discussing trends in BP, cholesterol, and blood glucose -- and for finding trigger points that persuade recalcitrant patients to embrace more aggressive pharmacologic strategies once diet and wishful thinking have truly failed.
• It allows physicians to monitor the side effects associated with all those life-extending therapies they prescribe -- drugs that we all have come to see as involving complex risk-benefit trade-offs requiring more vigilant post-market surveillance.

There are lots of ways to cut medical costs but it’s not clear that the annual physical is necessarily the greatest source of leverage -- or the right sacred cow to slaughter. We need to decide how to use those precious 45 minutes in better ways, perhaps. But we ought to work harder on figuring out how to keep insured patients out of the ER for non-emergencies than keeping them out of the PCP’s office for regular check-ups. Developing improved lines of communication (at the annual physical, perhaps?) will go a long way towards producing healthier patient behaviors, less impetuous use of testing, and more effective patient-clinician collaboration in the realm of both prevention and treatment.

So What if Statins Increase Diabetes? The Real Risk May be Patient Non-Adherence

Just when we thought we had clarity on statin safety …

Last week’s leading health headline was a startling new finding that statin use increases the risk for diabetes mellitus (DM) in post-menopausal women by 50 percent, from six percent to nine percent.

While the data source -- the Women’s Health Initiative -- is an observational rather than a prospective study, the finding persists in a variety of patient subgroups, and even after the authors adjusted for baseline patient characteristics. This makes it unlikely that the increase in DM rate is due to women’s pre-statin risks of developing DM. Since diabetes is probably the single most important cardiac risk factor -- often considered the equivalent of a first MI in certain predictive models -- this news was both unsettling and perplexing. How might physicians and their patients interpret and act on this new information?

We were curious, so last week we conducted a small survey of full-time, office-based U.S. primary care physicians (PCPs) from the Epocrates physician panel* to test our hunches. Seven out of 10 PCPs had heard the recent mass media news coverage and, as a point of interest, two-thirds of them found the coverage “sensational” rather than “balanced/informative” -- despite the fact that clinicians interviewed on NBC Nightly News emphasized that they expected to keep their patients on statins.

Certainly, the news got patients’ attention. As of our survey date, at least one-third of PCP offices had received inquiries from statin patients. Balanced coverage or not, this sort of news event raises alarms, and it’s impossible for patients to draw implications on their own. What should patients, in fact, make of it?

Plan B and Public Health: Morning-After Problems We Can’t Easily Fix

Today I signed a petition to protest Kathleen Sebelius’ decision to override the recommendations of the FDA and the American Academy of Pediatrics by banning OTC availability of Teva’s Plan B morning-after contraceptive. I say that without intent to be provocative. I simply want to acknowledge right up front that I have no moral compunction about morning-after contraception -- although I tend, dispositionally, to prefer a pound of prevention to even an ounce of cure -- and I certainly don’t believe in subjugating science to religious principles. I was surprised at the Administration’s decision because it most assuredly wasn’t in the best interest of public health -- but neither do I know how to chalk up the political wins and losses on this for Obama, who was clearly willing to ignite a controlled burn on his left in order to avoid a firestorm on his right.

The petition I signed enjoined the President “not to put politics above science” -- a credo that sounds like the right slogan for the professional (and personal) world I inhabit. Still, I can’t help but note the irony that since all regulation of public health is inherently political, this distinction is forced and artificial. The FDA came down on what I happen to think is the right side of this issue -- public health and equal protection for those young teens who have, as a practical matter, limited access to all health resources. But the FDA, like all agencies charged with health policy oversight, is an instrument of politics. Public health is just a euphemism for politics. In fact, the whole public health sphere is becoming a house built by government and merely furnished by science.

Healthcare cost savings from expanded access to preventive medicine could be dead on arrival

Enormous, and enormously unrealistic, hope is being placed on preventing illness and its complications as a means to improving health outcomes and containing healthcare costs.

A major criticism of the U.S. fee-for-service healthcare model is that it rewards the treatment of health problems over their prevention. Much of the effort at reform is aimed at revising incentives to motivate providers to deliver preventive medicine.

The logic is that if physicians and other providers are compensated for a focus on prevention, and patients have access to affordable primary care, then people will be motivated to use that care and do the things needed to stay healthy. The reality, however, may be quite different.