Annual Physical Exam vs Personal Health Assessment

I read a piece in the New York Times this week questioning the usefulness of a yearly checkup with your doctor.  It cited a study from 2012 that said that people who went for an annual exam did not live longer, avoid the hospital more or visit the doctor less.  A similarly themed Op-Ed piece was written by Ezekiel Emanuel earlier this year.  With all due respect to Dr. Emanuel and the New York Times, I will disagree, although with a caveat.
The usefulness of anything depends on how you define it and the what you seek to accomplish.  A checkup that ticks off boxes on a form for an insurance discount – maybe checking blood pressure, weight, blood sugar and cholesterol may identify some people with a health issue.  A fuller exam that looks at when recommended screening exams and vaccines were last done may increase health care usage, but no one argues that a colonoscopy at the right time in one’s life can be life saving and cost-effective.  Medicare covers an annual wellness exam, designed to identify those things that cost medicare money and increase health expenses – dementia, falls and depression.  It also requires a discussion about advanced directives – what a person does or doesn’t want done if they get too sick to make decisions for themselves.  It does not cover lab work, blood pressure checks or other “problems”.  In fact, there is no “laying of hands” at all.
The argument often cited for the yearly exam is relationship building.  If you see your physician when you are well, it is a chance to know what your baseline is, and later you are not trying to establish a relationship in a crisis.  There are pros and cons to this argument – in a mobile society, when you are young, will you have the same doctor when you get ill?  Or do you view your relationship as an insurance policy?  You have the relationship, and hope not to use it.  If there wasn’t precedence for this, wouldn’t we only buy auto insurance after the accident?  Or do you view your physician as a trusted advisor, investing in your health like you might your financial portfolio, with regular review to try to optimize things?

So what do I think of an Annual Exam?

The issue with studies on physical exams are multiple – inconsistent definitions, goals and outcomes make it hard to compare results from various studies.  Besides the studies the NY Times quoted, there are several studies that show recommended screening occurs more in people who come for annual physicals, and that there are health benefits – such as identification of high blood pressure – which has no symptoms and won’t be found until it is too late.
I believe in a yearly checkup.  However, I think the definition needs to change, and it has a very specific goal.  Personal Health Risk Assessment.  All the studies are based on large populations, and when I am with a patient, the most important thing is that person across from me.  We can use population data for a discussion, but what really matters is your risk.  So I like to use the opportunity of an annual exam to go through a person’s history, family history, social history and medical concerns.  Using that information, we can use population studies and decide what studies are appropriate for you!  We can look for the things you are at highest risk for and are most concerned about.  We can decide on a risk reduction plan once we have testing data back.  Can I guarantee you will be healthier for it? No, life does not come with guarantees.  We will be able to say that we identified your risks and did our best to reduce them.  We come away with information and recommendations that are specific to you.  I know your health risks, fears and concerns, and can provide advice that addresses them.
Will you live longer for our time together?  I don’t know.  Can you live better for it – absolutely!
 The path to wellness begins with a proper diagnosis

Colon Cancer – An Ounce of Prevention….

Breaking bad news is one of the hardest parts of my job.  There are times that I have to tell someone they have a new diagnosis – whether diabetes, a sexually transmitted disease or cancer – and it is not easy.  It is even more difficult when I know that some diagnoses can be PREVENTED!  So I am a huge advocate for preventing a disease whenever I can.  March is Colorectal Cancer Awareness month – and this week’s post is an update on how to prevent ever having to hear your doctor utter the horrible words – “You have colon cancer.”

Colon and Rectal cancer will be diagnosed in over 125,000 people in the US this year.  Over 50,000 people will die from it.  Colon cancer is the 3rd most common cancer in the United States.  And the majority of cases are preventable.  So how are colon and rectal cancer prevented?  By screening for them – doing tests that look for cancer – or ideally pre-cancerous lesions, and removing them.  How do we decide when and what tests to do?  By looking at your medical history and your family medical history and determining your risk.

For those at average risk, the current recommendations for colon cancer screening is to begin at age 50.  Why age 50?  At age 50, the likelihood of colon cancer or a colon polyp – a bump in the tissue of the colon that can turn into cancer – becomes high enough that the benefit of doing a test and removing the lesions outweighs the risk of the testing and the procedure.

So what increases your risk of colon or rectal cancer?

  • Colon cancer or precancerous polyps in a first degree relative (parent, sibling)
  • Prior colon polyps yourself
  • A  history of Ulcerative Colitis
  • A family history of a hereditary colon cancer syndrome – familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

How do we screen for colon cancer?

  • Fecal Occult Blood Testing (FOBT)
  • Colonoscopy
  • Flexible Sigmoidoscopy
  • Barium Enema
  • CT Colonoscopy (also called a Virtual Colonoscopy)

 What are the advantages and disadvantages of each screening method?

  • FOBT  – done yearly; a small amount of stool is placed on a card, and a chemical added to see if there is any blood in the stool.  Best done with 3 consecutive bowel movements at home and returned to the doctor.  This helps detect cancer because polyps or cancer often bleed.  If blood is detected, a colonoscopy is required.
  • Colonoscopy – this a procedure,  done under anesthesia or sedation, where a flexible tube with a camera is inserted in the rectum and passed through the entire colon.  It directly visualizes the colon and any polyps can be removed (preventing them from becoming cancer).  It should be done at least every 10 years (if totally normal) and more frequently depending on risk and findings.  The 10 year interval is based on studies that show it takes about 10 years for a polyp to turn into cancer.  It requires a “prep” – emptying the colon of any stool the day prior to the procedure.  This is the “gold standard” for colon cancer prevention.
  • Flexible Sigmoidoscopy – this is a procedure, where a flexible tube similar to a colonoscopy tube is inserted in the rectum, and the first two feet of the colon are looked at for polyps or cancer.  If they are detected, they can be removed.  It requires a prep to clean the colon.  It can miss any polyps beyond the two feet of colon closest to the rectum.  If any polyps are found, either a colonoscopy or a barium enema to look at the rest of the colon are recommended.
  • Barium Enema – this is an X-ray test where barium is inserted into the rectum and outlines the inside of the colon.  An X-ray is taken to see the outline, allowing polyps that change the outline to be seen.  It requires a prep before the procedure to empty the colon.  If the study is abnormal, a colonoscopy is required.
  • CT Colonoscopy (Virtual Colonoscopy) – a study using a CT scan and computer reconstruction to see the inside of the colon, looking for polyps or cancer.  It takes less time than a traditional colonoscopy.  There is radiation exposure. It does require the same prep as a colonoscopy, and a small tube is inserted in the rectum to pump air into the colon to allow for better imaging.  If the study is abnormal, a colonoscopy is required.

How does this affect my practice?

I recommend a colonoscopy for all my patients over 50 years old.  If there is a family history of colon cancer I recommend starting 10 years before the relative’s age when they had colon cancer or age 50 – whichever is sooner.

Most people dread the prep – cleaning out their colon more than the procedure itself.  Most people sleep through the actual procedure.  The preps have gotten better in that you don’t need to drink as large a volume of liquid as in the past.  It could be considered the most useful cleanse ever!  

I also recommend FOBT yearly between colonoscopies, though current guidelines to not require this.  I make this recommendation because FOBT is easy, and people may delay their colonoscopy or a polyp may develop a little faster than the usual 10 years.

As far as flexible sigmoidoscopy and barium enema, I only recommend them if there is a reason a colonoscopy can not be done.  CT colonoscopy gives a great image of the colon, and if totally normal gives good reassurance that there is no colon cancer.  However, if there is an abnormality, a colonoscopy must be done, requiring a second prep and procedure.

Colon cancer is preventable – and if diagnosed early, curable.  The important thing is to talk to your doctor about your risk and get screened – any method of screening is better than nothing!  I recommend colonoscopy as it allows the best visualization of the colon – and removal of polyps at the same time – one stop shopping.  Telling someone we prevented them from getting cancer is much more fulfilling than telling them they have colon cancer!

The path to wellness begins with a proper diagnosis

Some useful links:

CDC colon cancer screening guidelines

American Cancer Society colon cancer detection guidelines

American Cancer Society colon cancer overview


Vaccines for HPV – Lies, Damn Lies and Statistics

In 2006, a new vaccine was introduced in the US – a vaccine for the Human Papilloma Virus (HPV).  This virus is responsible for most cases of cervical cancer, some throat, penile and anal cancers, as well as genital warts.  The vaccine is effective against the 4 strains of HPV that cause the majority of cervical cancer and genital warts.  It is given as a series of 3 shots over a 6 month time period, and is approved for females and males, ages 11-26.  There are two brands of vaccine, Gardisil and Cervarix, currently FDA approved in the US.  Recently, there has been a lot of media attention to HPV vaccines, leading to a lot of confusion about what the vaccine does and how safe it is.  As the father of a 12 year old girl, I thought I’d share my views and research.

What is HPV?

Human Papilloma Virus is the most common Sexually Transmitted Infection and responsible for most cervical cancer, as well as genital warts in both sexes.  It can also cause throat, penile and anal cancer.  The 4 strains of the virus that cause the most harm are 6,11,16, and 18, which are the strains in the vaccine.  HPV causes almost 34,000 cancers a year, with about 2/3 of them in women.  Almost 12,000 of the cancers are cervical cancer, which is usually treated by removal of the cervix and uterus (hysterectomy) which makes it impossible for a woman to have children.  Over 14 million people per year get infected with HPV.
HPV can be tested for in women during a PAP smear, hopefully identifying lesions before they become cancer.  However, there is no reliable test in men, other than doing a biopsy on a wart or other visible lesion.

What is the controversy?

Mark Twain once said, “There are 3 kinds of lies: Lies, Damn Lies and Statistics.”  All three have been used in the argument for and against vaccines.  Vaccines in general provoke very strong reactions from many people. Vaccines have been blamed for many conditions and reactions completely separate from the diseases the vaccines were meant to prevent.  There have been vaccines that have been recalled and discontinued because the risk of side effects was higher than the disease rate – a vaccine for Rotavirus and for Lyme Disease have both been discontinued.  There are immune reactions that are possible that can have serious health consequences, but these are not very common.  Allergic reactions to a vaccine are possible, just as they are possible with other medications or foods.  These reactions need to be considered and a good medical history obtained before they are administered.  However, I think that as medical science has progressed, we have lost sight of the devastation these preventable diseases  caused.  
I want to be very clear and state that there is NO LINK BETWEEN VACCINES AND AUTISM.  There was one scientist who made that claim and published research making that claim.  His research has been shown to be falsified, the journal that published the study issued a retraction and the scientist has had his medical license revoked.
Out of 57 million doses of HPV vaccine given through March of 2013, there have been 22,000 reactions reported.  Of those, less than 1800 have been considered severe reactions, mostly headache, nausea and fainting.  Enough people fainted that it is recommended that people wait 15 minutes after the vaccine before leaving the doctor’s office.  There have been about 30 deaths reported after the vaccine – but  none of those deaths have been shown to be directly related to the vaccine.  For example, if someone died in a car accident after receiving the HPV vaccine, it is reported.
Much of the recent controversy regarding HPV vaccine comes from 2 events in the past year.  In one, a physician submitted a case report of a 16 year old girl with irregular periods and eventual ovarian failure – with the symptoms beginning a few months after receiving the vaccine.  There was no evidence linking her condition to the vaccine, and it is known that in cases of early ovarian failure a cause is only found 10% of the time.  In addition, the reporting physician had strong personal beliefs that may have biased her reporting of the case.
The other event was when Katie Couric had a physician on her talk show who was involved in the development and testing of the HPV vaccine.  This doctor in several interviews did not question the safety of the vaccine or it effectiveness, but rather called attention to the fact that it is not yet known how long the vaccine lasts, and a booster may be needed.  She also questioned the need for the vaccine when PAP smears could detect the cervical cancer early.  However, HPV causes 20,000 cases of non-cervical cancer per year which would be missed.  Her statements also assume a much higher rate of women going for PAP smears than is likely to occur.  Ms. Couric did not give equal airtime to her own medical expert, her comments supporting vaccination were on the show’s website.  Ms. Couric did issue an apology after the show aired acknowledging that not enough airtime was given to talk about the benefits and safety of the HPV vaccine.

How does this affect us?

Our ability to treat disease has advanced tremendously in the past 100 years.  The rate of mothers dying during childbirth was reduced dramatically by having doctors and nurses wash their hands prior to delivering the baby… simply by preventing infection!  Today, it is accepted that by not smoking, maintaining a healthy body weight, normal blood pressure and cholesterol, we can prevent heart disease.  If we stop preventing disease, a healthy life and life expectancy would be very different from what it is today.  The CDC estimates that if we stopped preventing diseases with vaccines:
  • 13,000 – 20,000 people a year, mostly children, in the US would contract polio, requiring braces, crutches, wheelchairs and breathing machines
  • Almost everyone in the US would get measles, 20% of whom would need to be hospitalized, and 450 would die per year in the US, and 2.7 million worldwide
  • Haemophilous Influenzae (Hib) would cause 20,000 cases of meningitis or epiglottis in the US, killing 600 people per year.  About 1 in 200 children under 5 would be infected, and those that survive are often left deaf, with seizures or mental impairments
  • Almost all children would contract whooping cough, with about 9000 deaths per year
  • Pneumococcus would infect 63,000 Americans yearly, killing 10% of those infected
  • Rubella, while mild in most children and adults, causes birth defects in 90% of children whose mothers got infected while pregnant, causing heart defects, deafness, cataracts and mental retardation
  • Mumps would infect 300,000 people a year, and causes deafness in about 6% of cases.  It also caused miscarriages in women infected while pregnant
  • Hepatitis, Diptheria, Tetanus and Chickenpox are all diseases with potential long term consequences that we are preventing with vaccines
Vaccines are some of the most closely monitored treatments in medicine, both because the diseases they prevent are serious, and the consequences of not getting it right are real as well.  This is a great conversation to have with your physician during an Annual Physical.  My daughter will be getting her vaccination shortly.
The path to wellness begins with a proper diagnosis