Why the hell did I go to medical school?
That's the question I asked myself after reading the New York Times this weekend. On the front page of the Sunday Review there was an article entitled "Let's (Not) Get Physicals," in which Elisabeth Rosenthal listed the pointless and dangerous reasons why a routine physical exam -- and many of the screening tests that routinely accompany them -- are useless.
I spent most of my 20s in medical school and then in residency. I took a class called Physical Diagnosis and spent the last two years of school working in a hospital and a clinic. Prior to graduation, I had to perform a full physical exam on an actual patient in front of my medical professor in order to graduate. Like me, medical students around the country are brainwashed every year into thinking that preventative health care and annual physical exams will not only uncover some hidden illness, but also potentially save and prolong the lives of our patients. As a board certified internist, I have been performing routine annual physical exams nearly every day of the week for the past 22 years. Then in one full swoop Elisabeth Rosenthal, a medical doctor and environmental reporter for the New York Times, crushed everything I believed to be true with her two-page article.
But in all honesty, this was not the first time I had heard this.
For many doctors, the physical exam is a perfunctory exercise we perform on our patients because that's what we were taught to do. Rarely, have I discovered something critically wrong with one of my patients during a well visit. Yes, I did find a melanoma the size of a grapefruit on one young man, and I did detect blood in another gentleman's urine, which led me to discover he had a kidney tumor. Just this year I diagnosed two men with invasive prostate cancer during their routine physical when I drew blood to measure their prostate specific antigen (PSA). Both men went on to have radiation therapy and are now cancer-free. They were fortunate to have come in when they did. Just last month the Preventative Service Task Force stated that they no longer recommend screening men over 50 years old with PSAs. As a doctor I'm suppose to strongly discourage my male patients when they ask for a PSA to be included in their annual labs. Just like I'm not suppose to perform an EKG, routine blood tests, annual cholesterol, annual Pap smears on my females and pre-operative chest X-rays (can't wait to fight with surgeons about that one).
So is that all the annual physical comes down to? A dog and pony show of palpation and auscultation, superfluous blood tests and unnecessary recommendations to specialists my patients shouldn't see?
I don't think so.
Annual physical exams are also reminders to discuss diet and exercise. Routine weights and measurements allow us to track trends to monitor for obesity, a huge problem in America. I also use the annual physical exam to discuss smoking, alcohol consumption and recreational drug use. The annual physical exam is an opportunity to initiate a conversation about sexual practices and depression. Doctors couldn't possibly be expected to cover all this in a 15-minute visit.
Of course I understand the U.S. spends nearly twice as much per person as other developed countries on health care. Unneeded blood tests during a physical exam alone cost $325 billion a year. Perhaps that's why managed care limits which prescription medications doctors can order. Most insurance companies will only allow doctors to pick from their list of medications that appear on their formularies. And all because doctors spend too much money, choosing the latest designer drugs and ordering the coolest and newest tests. But is that completely true? What other country allows direct-to-consumer marketing? I can't watch CSI or Grey's Anatomy without being inundated with commercials for prescription drugs. How could any patient resist taking a pill to kill that horrible gastroesophageal cartoon character that's causing peptic ulcers, or feel sympathy for that poor little Pristiq wind-up doll that just can't make it through her day because of depression? Walking to work, I see billboards and posters on train stations and bus stops urging people to "Ask Their Doctor About..."
Now, I don't disagree completely with the article in the New York Times. When patients come in with back pain or knee pain and demand an MRI, I try my best to discourage them, saying it's not a first-line test. I also know that I run the risk of losing that patient, like many others, when I don't give them what they want. Not so shocking when you really think about it. Just as the article suggested that surgeons are inclined to operate and radiologists inclined to order scans, patients will also find a new doctor if they don't get their prescription for Xanax or that MRI. Yes, that's right; Patients will leave a physician who does not accommodate their needs.
But more than anything, shouldn't we be focusing on preventative health care instead of discouraging patients to see their doctor annually? Aside from the unnecessary blood tests, over-prescribed medications and needless radiological scans, what's so wrong with fostering this basic human interaction?
But I'm an old-school physician, one that harkens back to the days of Marcus Welby. I like the concept of a small-town doctor who knows everyone in the community by name and has their medical histories memorized and not stored away in an iPad. Then again, it's not 1950 and I don't practice medicine in Port Charles or some other mythical town.
Then in the same issue of the New York Times there was another article entitled "Salt, We Misjudged You." Sitting there at the breakfast table drinking my protein shake and coffee with soy milk, I thought, "My things are changing."
If there's no need to touch a patient then perhaps I could just stay at home in my apartment and see patients virtually through Skype on my iPad?
Maybe that's where this is all headed.
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