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Wednesday, August 23, 2017

Annual physicals have been enshrined in American culture for over 70 years. However, a debate rages on as to whether they are really necessary or not. Famous bioethicist Ezekiel Emmanuel created a firestorm in January 2015 when he declared that annual physicals are pointless and a waste of time and money. Emmanuel’s argument is based on the fact that someone with absolutely zero complaints gains nothing from a complete history and physical and an associated comprehensive blood test. Emmanuel also believes that annual physicals take physicians away from patients who really need them, those who are actually ill.

As a primary care physician, I strongly disagree with Dr. Ezekiel, and in my 20 years of medical practice have rarely provided a physical that proved to be worthless. There are, in fact, many reasons to have a physical, and in the U.S. currently, only 44 million adults, or about 21 percent of the population, actually have one.

First, there are few patients who truly have zero issues or complaints. The annual physical is an opportunity to bring up all of the major or minor issues that a patient might not otherwise have a physician address. Sometimes in a minor complaint a serious issue can be identified. I once had a patient who had a simple “cold” that was pestering her and she would cough just a few times a day for several weeks. She had never smoked. Soon thereafter, she proved to have Stage III lung cancer. Another patient had very subtle headaches on and off and proved to have serious hypertension. Of course, not all minor complaints prove to be serious maladies and I don’t intend to scare everyone to rush to a physician for a runny nose, but issues that may seem benign may sometimes need attention. Be particularly wary if a symptom seems to last longer than it should. A cough, for example, is almost always benign if it goes away within four weeks. An optimal PCP (primary care physician) asks a patient numerous questions as part of the physical. We have been taught in medical school that a good “review of systems” includes as many as 30-40 questions! It may sound like this could take forever, but a good physician can reel these off quickly and get a good sense of what issues a patient may not have even considered.

Second, it is very important to establish a relationship with a primary care physician. In our age of numerous urgent care centers exploding on the scene, many patients are availing themselves of these facilities for strep tests, bronchitis, wounds and the like. I believe that these centers serve a definite purpose especially on weekends, but it would seem that the urgent care center is not the place for most medical interactions; many patients are naturally more comfortable being seen by someone they know for months or years than an urgent care physician whom they have never met and are unlikely to meet again. A physician’s familiarity with a patient and vice versa can go a long way in facilitating complex discussions and broaching highly personal topics. With whom would a 40-year-old man feel more comfortable addressing his most personal issues regarding intimacy? With an urgent care physician or a primary care physician he has known for years? This topic again jars my memory of a past patient with a complex but uncomfortable concern. A 45-year-old man came in for a physical and all seemed fine throughout the visit except that he did not provide his usual jolly goodbye when we were done and as I started leaving the room. Instead, he said, “Hope to see you again whenever.” When I turned around to ask him what he meant, he suddenly confided in me that he had severe depression and that suicidal thoughts were consuming him. Of course, he was sent for an urgent psychiatric referral and did well. Ideally, one should have a relationship with a physician who truly gets to know you and can recognize even a subtle change in mood, speech or behavior.

Next, the yearly physical is the opportunity to go over important screening recommendations and refer patients to the appropriate specialists. At age 50, for example, all patients should have a colonoscopy to screen for colon cancer, some even sooner if there is a family history of colon cancer at an early age. Mammography should be done annually in women, though some say biennially (every two years). Though controversial, a PSA (prostate specific antigen) blood test should be done in men age 40 and over to help identify prostate cancer. Why is a PSA controversial? Because some academics strongly believe that many prostate cancers will never be fatal and that PSA testing has never been proven to save lives in a randomized, controlled, clinical trial. Perhaps, but I, for one, would want to know if I have prostate cancer, God forbid, and then I can deal with it accordingly. Though I consider myself an academic as well, I think the “there is no proven clinical trial” mantra has, at times, gotten ridiculous. Is there a clinical trial that proves without a doubt that developing a relationship and talking to patients saves lives? I doubt it. Does consoling a patient on a loss of a loved one or helping them through a difficult time save lives in a randomized, clinical trial? I doubt it. Does that make it worthless? Think again, Dr. Emmanuel.

Finally, there are the silent killers. I can think of at least 10 disorders that can be ultimately fatal or seriously damaging if they are not identified early, and for which few, if any, patients will be able to recognize on their own.

1) Hypertension (high blood pressure): Few patients can actually feel their blood pressure is elevated. Hypertension can cause stroke acutely, if very severe, and lead to chronic conditions like heart disease and kidney failure.

2) Colon cancer: Few patients at the early stages of disease actually have colonic or rectal bleeding or a change in their stool pattern.

3) Brugada syndrome and Long QT Syndrome: these heart arrhythmias are particularly scary.  Fortunately, they are both rare with the former showing up in 1 of 3300 individuals and the latter in 1:2300 but both can lead to sudden death. Although these syndromes are typically familial (meaning that there is usually a family history of someone dying suddenly), some cases are “sporadic” (not familial).  What does it take to rule this out? A 5-minute EKG.  My grandfather Z”L died at 52 of sudden death so when I first learned of these syndromes, I dragged all 4 of my kids to a pediatric cardiologist to have EKG’s done.

4) Thyroid cancer: Few physicians are experts at identifying cancerous nodules, let alone patients.

5) Kidney failure: This disorder usually has no associated symptoms unless it is advanced; at a very early stage it can be easily identified by a blood test.

6) Aneurysms: Brain aneurysms are often fatal. We don’t screen the entire population with MRIs because of the cost and the possibility that we may find insignificant “spots” and the like that may lead to additional testing and procedures. However, a number of conditions that are silent, like “polycystic kidney disease,” are linked with brain aneurysms.

7) Kidney and bladder cancers: Many patients with this type of cancer do not have obvious bleeding with urination. Instead they have what is called “microhematuria,” blood that appears only on a formal urinalysis test. How long does that take? About five seconds.

8) Hypercholesterolemia: Some patients with cholesterol disorders have unbelievably high numbers, remarkably as high as 400 to 600! Usually, these cases are familial, again, but not always. How to diagnose? A simple blood test.

9) Lymphoma: Some patients do recognize abnormally large lymph nodes on their necks and underarms, to name a few locations where lymphoma shows up. However, I find that few patients actually know their bodies well enough to identify these growths. A thorough physical exam should easily find abnormally large nodes.

10) Heart attacks: Many patients know right away when they are having a heart attack. But in many patients, there is virtually no warning. As many as 50 percent of patients with heart attacks have normal cholesterol (scary again….) and as many as 25 percent of patients have no traditional risk factors.

Hmm… Dr. Ezekiel, let us see: An annual physical brings out hidden patient issues, facilitates the patient-physician relationship, provides a forum for the discussion and screening of deadly diseases and can itself identify 10 silent killers. Sounds like a pointless waste of time.

By Jeff Paley, MD

 Jeff Paley is an internist/primary care provider with offices in Englewood and Manhattan. He trained at Harvard Medical School and Massachusetts General Hospital. Dr. Paley can be reached at 201-503-0833 or 212-734-6570.