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For decades physicians have been recommending that all patients see their doctor at least once a year for their annual physical exam. But, now with the help of evidence-based medicine, the data is very clear that this practice does not change patient outcomes. This means that there is no scientific evidence to suggest that undergoing a yearly physical exam will cause patients to ultimately feel better or live longer1. In fact, the problems that patients worry the most about – heart attacks, strokes and cancer – were not affected one way or the other by a yearly physical exam. Asymptomatic patients who undergo yearly physical exams were as likely to have a heart attack or die from cancer as asymptomatic patients that did not undergo a yearly physical exam.
Why is this?
Let’s look at what actually kills people in America. The top 3 killers of Americans are2:
- Heart Disease (Heart attacks, heart failure)
- Cancer (Lung Cancer, Breast Cancer, Prostate Cancer, Colon Cancer, etc)
- Chronic lower respiratory diseases (COPD from smoking, Asthma)
Let’s focus on the number one killer – Heart Disease.
Heart disease develops silently by causing plaque build-up in the arteries that supply the heart muscle with blood. Plaque begins with cholesterol deposition in the walls of the arteries, the leading cause of this phenomenon being the over-consumption of saturated fats (found in red meat, dairy products, etc) in our diet. Once the cholesterol begins to build up in the arterial wall, the inside lining of the artery tries to wall it off by thickening and growing up around it. Immune cells also come in and try to eat up the cholesterol (though are unable to effectively to do so), causing inflammation in the wall of the artery. This then causes platelets to form a clot around all of this, leading to a growing mass of cholesterol, arterial wall thickening, inflammation and clot called an “atherosclerotic plaque”.
As this plaque grows it can become unstable once it reaches a point where it is blocking up 30-40% of the arterial lumen. At this point a patient will not be symptomatic (i.e., no chest pain) because enough blood is still getting around the plaque to perfuse the heart muscle and not cause any damage. And, even if such a patient were to undergo a stress test, the stress test would not pick up this blockage because, again, enough blood will be getting around the plaque to keep the heart muscle perfused and happy. Thus, the EKG even under stress (running on a treadmill) will appear normal. Even the echocardiogram pictures of the heart (stress echo) and nuclear imaging of the heart (nuclear thallium stress testing) will appear normal.
But, unfortunately, it is at this 30-40% blockage stage that a plaque can suddenly rupture (especially in smokers and diabetics). The break in the plaque left by the rupture will quickly clot over (called a “thrombus”), causing 100% blockage of the arterial lumen very quickly. Blood will not be able to get to the heart muscle downstream from the blockage and the downstream heart muscle will therefore begin to die from oxygen deprivation. This is what is colloquially called a “heart attack”.
Such 100% blockage can be fixed with a stent, placed by a cardiologist on an emergency basis. But, at 30-40% blockage before anything has happened yet, stents do not help – i.e., there is nothing procedurally that can be done. So, even if we knew about the presence of such a plaque, no procedural intervention would be beneficial. Rather, this is when a patient really needs to start a statin drug (like Lipitor or Crestor), which have been shown to stabilize (thereby reducing the likelihood of rupture) and shrink the size of plaque, greatly reducing the chance of ever progressing to a heart attack.
Now, take the asymptomatic patient who walks into his doctor’s office for an executive physical with plaque blocking up 30-40% of a coronary artery. He is walking in with the number one killer of Americans hiding deep inside, waiting to strike. He doesn’t know this plaque exists, nor does his doctor. The physical exam will not reveal its presence. An EKG will not reveal its presence either, and it is for this reason that routine EKGs are NOT recommended for asymptomatic patients.3 If this patient was then subjected to an exercise treadmill stress test, it is unlikely that the presence of this lesion would be picked up either.4
Thus, in the case of screening for the #1 killer of Americans – a physical exam, EKG and routine stress testing of the asymptomatic patient will not pick up the presence of relatively advanced disease that is waiting to strike and cause a heart attack. Unfortunately, this means that much of what happens in an “executive” or even routine yearly physical exam for an asymptomatic patient doesn’t accomplish anything of actual value for the patient. Most of what goes on in that setting has no evidence-based scientific data to support it and, in fact, the scientific data generally contradicts these practices.
So, what is the alternative?
Clearly, we need to get away from the idea that one exam, once a year for the asymptomatic patient is sufficient for the detection of disease and, in particular, risk for deadly disease. I have utilized heart disease as the primary example today, but, most illnesses that people fear and think that a yearly physical will detect if present fall into the same category as heart disease. The disease can be hiding and yet still remain undetected.
Rather, the asymptomatic patient needs – first and foremost – to have an established relationship with a primary care physician that he trusts and that he consults with on a regular basis. Whether the symptoms are sudden or subtle, any appearance of symptoms needs to be addressed as early as possible with a primary care physician, before they progress to the point that an ER visit is required. This then allows for a regular and routine review of symptoms and risk factors (which can change over time), with quick and easy access to the physician in the event that any concerning symptoms appear. The key is early detection at the first sign of symptoms, for, the presence of symptoms then narrows the testing and isolates the problem much easier, avoiding extra and expensive testing that is ultimately of no value. This is especially true of ER visits, where the main job of the ER is to get the patient out of the ER – either via admission to the hospital or, referral back to the primary care physician to ultimately figure out what is going on.
Thus, ERs are generally to be avoided in favor of a rapid-responding primary care provider.
The problem this creates is that rapid primary care responses are hard to come by nowadays when primary care doctors are often inundated with 20-30 patients a day and are unable to respond to individual patient needs as quickly as they would like. It can often take 2-3 days for a patient to hear back from their physician after placing a call with the office, where getting in to be seen can sometimes then take a day or two more. By that time patients have often visited an ER or urgent care clinic to have their issue addressed, though usually in a suboptimal and less satisfying manner.
A “concierge” type practice is an alternative way to meet these patient needs, where access to a physician is much more rapid given that such physicians allow patients to access them via cell and email and only see 6-8 patients a day on average, rather than 20-30 patients a day in a traditional practice. In a perfect world, this style of practice would eventually replace the yearly physical, and patient outcomes would be greatly improved. There are already studies beginning to demonstrate this, where patients that are part of more personalized practices like this have far fewer ER visits and far fewer hospitalizations.5 Diabetic patients were shown to have better blood pressure control, better cholesterol control (i.e., improved risk factor modification for heart disease) and better eye exam compliance rates, when compared to national health plan rates.6
In conclusion, both patients and businesses should strongly consider changing their thinking on this, moving away from the yearly executive physical which has been proven to be essentially useless, and moving toward something like “concierge” or personalized medicine which can put the patient in contact with his/her physician 24/7 so that ER visits and further complications can be avoided and disease can be caught early and managed in a more effective manner before the patient experiences serious consequences. Furthermore, executive physicals can often cost between $3000-$5000 dollars for one day of testing, while most personalized medicine plans that offer 24/7 physician access year-round will cost around $2000 annually.
There is a better way to do things and personalized patient care for an affordable fee is proving to become the preferred way to do it.
Author: Christopher Hughes MD
North Texas Preferred Health Partners
3417 Gaston Ave, Dallas TX, 75256
- BMJ2012;345:e7191 (Conclusion: General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes)