The Prescription for Your Annual Physical Exam
"Brand medically necessary -- generic substitution not permitted."

      The days of one-size-fits-all annual physical exams are gone. Just as many states have passed prescription drug laws regarding the substitution of generic drugs for brand name products, savvy health care consumers need to ensure their prescription for an annual physical exam is marked "No Generic Substitution."

Background

      The annual physical exam is an American tradition that dates back to the 1920s. Physicians and patients alike, feared that the body housed silent time bombs, just waiting to explode. We began testing for whatever we knew how to find, looking for the silent killers stalking us. At that time, there were few tests, and most of them were not expensive. Now, our knowledge of the physical body and risk factors has expanded greatly, as well as our love of and reliance upon tests. The practice of medicine transformed from a spiritual calling to one of the major revenue generating industries in America.

      Unfortunately, our fear that killers hide silently in our bodies has not diminished. We want to shine the light in every nook and cranny, and the business of medicine is more than happy to help us do so. How do we realisticaly identify problems and tame our fears, without putting ourselves at unneccesary physical risk and financial cost?

      There are countless task forces, educational groups, non-profit organizations, and for-profit companies that publish guidelines and recommendations regarding preventive medicine practices. The U.S. Preventive Services Task Force is considered the most credible, with the least amount of pharmaceutical company money support and political motivation. It was was formed in 1984, to evaluate whether there was valid scientific evidence to support the many preventive medicine practices routinely used in standard health care, including the annual physical exam and associated blood tests and x-rays.¹

      In spite of numerous national educational campaigns by a variety of health care organizations, in 2005 over 65% of primary care physicians continued to conduct old-fashioned, standardized annual exams on symptom-free adults. Often, these providers ordered laboratory tests that have proven useless as cost effective disease screening tools, and neglected ordering the tests or procedures that are specific to the person's family history and lifestyle choices.²

      You probably have a tailor-made financial plan for your retirement. You also deserve a custom-made plan to optimize your personal health, so you can enjoy your retirement. Go to your next health maintenance appointment fully prepared, and you can gently push your providers into 21st century evidence-based health care, if they aren't already here.

The Basics

       To be worth doing, a screening test needs to be able to detect problems before symptoms occur, and a positive test should lead to an outcome than is better than would have happened if treatment began after any symptoms appeared. Unnecessary tests - those that don't accurately detect problems or don't change the outcome -- are not only a waste of money, but usually cause needless worry and lead to more unnecessary tests.

Recommended Screening Tests & Procedures

      For healthy people, the majority of screening tests and procedures are most cost-effective and beneficial when done based on specific, personal risk factors such as an individual's lifestyle choices, body compositon and size, ethnicity, and genetics.

      The passing of chronological time (age) is an independent risk factor for many diseases such as heart disease, diabetes, and certain cancers. The table below was created using a wide variety of government and non-profit organization sources. It lists the tests and procedures that should be discussed with your health care provider, once you turn 50, regardless of any other risk factors you may have for developing these health problems.

      In addition, as a preventive medicine physician, I recommend calculating your Body Mass Index (BMI), and assessing your level of physical activity using the Rapid Asssesment of Physical Activity (RAPA) tool. A sedentary lifestyle can be as damaging to your health as smoking a pack of cigarettes a day, and carrying extra body fat increases your risk for a multitude of health problems.

      Remember, only you and your health care provider can write your personal prescription for health maintenance accurately, after reviewing your personal risk factors, known medical conditions and medications, and use of over-the-counter medicines, including preventive ones like daily aspirin, nutritional supplements and vitamins. Quality is often better than quantity. Take the time to understand why a test or procedure is needed or not needed, and if it will truly help you. You might be better off without it, if you're not at significantly higher risk than the average 50+ year old. If a screening test turns out positive, you often have to undergo several more invasive and/or expensive procedures to make sure it is not a false positive result. Often these follow-up procedures carry significant health risks.

Screening Tests & Procedures Known to be Useless or Under Debate

         Surprisingly, procedures such as listening to hearts and lungs, yield few, if any, valuable medical findings when someone comes to the doctor's office with no symptoms or complaints. Global testing of body fluids is also unproductive. Laboratory tests such as a routine urinalysis, chemistry profile, complete blood count (CBC), and kidney function tests, have no value as screening tests in people who do not have any symptoms of disease. More often than not, positive results are false positives, creating a chain of expensive testing just to prove the test result was false.

      Screening for prostate cancer in men with no symptoms is hotly debated. Although there are tests to detect early-stage prostate cancer, there is mixed and inconclusive evidence that early detection of prostate cancer improves quality or quantity of life. False-positive results are frequent, and create unnecessary biopsies, and potential complications from treatment of cancers that might not have affected the person's well-being. If early detection is shown to improve health outcome at a future date, men aged 50 to 70 who are at average risk, and men older than 45 who have risk factors will benefit most from screening tests.

Be Prepared!

1. Know your family history.
   
   Which diseases are important? A disease that occurs at an earlier age than expected (10-20 years before the typical age), or the same disease in more than one close relative - you, your children, brothers, sisters, parents, aunts, uncles, cousins, nieces, and nephews.
   
   For instance, women who have a family history of heart disease or diabetes, who had diabetes during pregnancy or who gave birth to an infant weighing at least nine pounds are at higher risk of insulin resistance, a type of prediabetes. Making healthy lifestyle changes could prevent the need for taking medication, with all its side effects, later on in life, and screening earlier or more often might be appropriate for you.
   
   Remember that just because a disease runs in a family does not mean it is genetic. Poverty and malnutrition tend to run in families, as well as religious, educational, and other cultural beliefs and practices. Your family may have higher rates of heart disease or diabetes because family members lived in a similar geographic or socioeconomic environment, not your family's DNA.
   
   
2. Know your personal risk factors.
   
   What about you puts you at a higher or lower risk compared to others? Health risks are specific to your age, occupation, lifestyle behaviors, food choices, ethnicity, genetics, medications and supplements used, and physical environment.
   
   For instance, do you or have you used tobacco products, alcoholic beverages, chemicals at work, lived primarily on a high-fat or high-calorie diet, spent hours baking in the sun? Have you exercised regularly, increased your fiber intake, meditated daily, taken vitamins or food supplments?
   
   
3. Be hands on with your health.
   
   The thought of finding a lump, bump, or strange looking spot on your skin is scary, as is the idea of needing professional emotional or psychological support. Unfortunately, in the case of your health, ignorance is not bliss. Everyone has some risk for cancer. Cancer is likely to affect 1 in 3 women and 1 in 2 men at least once in their lifetimes. The risks for depression, anxiety and substance misuse are significant among older adults. Go beyond your fears, and become an A+ student of your own mind and body.
   
   Do your monthly self checks and periodic mental health screening quizzes, and record the dates and results in your health journal to take with you to your next health maintenance appointment.
   
   

      For the most part, our bodies take care of themselves, and let us know when something isn't right - if we are willing to sit still and listen. While it is normal to want reassurance that everything is perfect, no test or procedure is 100% accurate and sensitive. Our release from angst comes with a high financial price tag, as well as false positive test results and false reassurrances.

      Ramp up your self-knowledge, find time to be still and listen quietly to your body's messages, and talk openly with your primary health care provider about not wanting unproductive tests. Candidly discuss your family history and personal risk factors, and together, you can determine which tests and exams are right for you.

      Rejoice! Medicine is becoming a custom-made world, tailored just to you.

© Joy Koenig, MD 2008 All Rights Reserved. Originally published on October 11, 2008.