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  • Yearly physical

    We were recently told about a slew of complaints from patients that they are disappointed in several providers physical exams. Specifically with the lack of certain testings including psa, ekg, urine screening, and a few others. The advice handed down was these items should be addressed and explained why they are not necessary. "it will only take a minute"

    My personal opinion is if someone brings up PSA screening and would like to continue doing it even without good reason I will go along with it. But I do not open that door unless they open it first. And I'm talking pure screening. Of course if there's symptoms or concerns that the whole other matter.

    Am I crazy? Should I just be doing these things routinely to avoid medical legal issues and to prevent complaints? What do you other pcps do?

    I generally use the physical exam as a chance to catch up on routine health maintenance and put in a plug for a healthy lifestyle changes. The examination part I feel is actually a minor role of the visit. I've talked with lots of other physicians who mention doing a for show exam but I try to keep it to just the useful and practical evaluations.

    Again these were general complaints across the board so I don't have anybody specific in mind to bring up but I would bet the person complaining that somebody didn't look in their ears also came to their physical exam with nine unrelated complaints.

  • #2
    Patients have unrealistic expectations on the value of an annual. Medicine does nothing to dissuade this notion.

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    • #3
      Is an outpatient screening EKG a real thing?

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      • #4
        The only way I could convince my crazy uncle to get prostate screening was by going to see his female PCP for a physical on 2/14. I wonder how many of those patients they get.

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        • #5
          Um- sort of like screening MRI. Sometimes the lack of specificity of a test can be detrimental to the patient. Whether it be anxiety, added cost, unnecessary procedures. There is a reason why they're not in the favor of routine screening anymore.

          CT CAP- the new annual physical for many going through the ER.

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          • #6
            Originally posted by CordMcNally View Post
            Is an outpatient screening EKG a real thing?
            When I went for a general check up at age 28 or 29 they hooked me up for an ekg. I had never had one and didn’t see why it was needed but complied. My wife was pissed afterwards and said that was totally unnecessary and the physician was just running unnecessary tests to get more from insurance. I didn’t go back.

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            • #7
              Originally posted by CordMcNally View Post
              Is an outpatient screening EKG a real thing?
              Medical industrial complex>>>Military industrial complex+Tech complex+Wedding complex+Baby industrial complex+Religious industrial complex

              Probably not totally true, but you get the scale.

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              • #8
                -'physical' I routinely use the words annual preventative visit; make a point that bulk is spent on making sure the wheels don't fall off and the actual exam is a small part of that. Typically don't even have them undress unless a specific issue either.

                Some old school retired docs mention it especially first time, but quickly tail off unless they self-attrition because they believe that we're Paladins with magical healing hands.

                Immunizations
                Medrec
                Screening

                Prostate: discuss pro/cons of screening PSA - people typically want it as academia folk are data driven. Then decide from the data.

                MMG - same thing discuss; especially 40-50 range pro/cons

                EKG - Welcome to medicare. That's about it. Point toward executive exams do it for their $3000 annual Cadillac mayo clinic type exams if they ask and offer up our Concierge service.

                PAP age outs

                STI screening


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                • #9
                  A real physical exam once a year seems very reasonable. Look for skin cancer, murmurs, bruit, etc. At the very least document what you actually did accurately so acute care physicians have a better idea what patients baseline exam actually is. I don't think a screening ECG in healthy patients at some point is unreasonable at all though repeating them annually as a matter of routine seems excessive. You could catch a long QT, brugada, HCM, etc before patient has a bad outcome from them. Additionally, it gives a baseline to compare to when the show up at the hospital with chest pain.

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                  • #10
                    Originally posted by CordMcNally View Post
                    Is an outpatient screening EKG a real thing?
                    My seniors still think so, and most get mad when I explain to them that they’re not getting one.

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                    • #11
                      Originally posted by CFEonline View Post
                      A real physical exam once a year seems very reasonable. Look for skin cancer, murmurs, bruit, etc. At the very least document what you actually did accurately so acute care physicians have a better idea what patients baseline exam actually is. I don't think a screening ECG in healthy patients at some point is unreasonable at all though repeating them annually as a matter of routine seems excessive. You could catch a long QT, brugada, HCM, etc before patient has a bad outcome from them. Additionally, it gives a baseline to compare to when the show up at the hospital with chest pain.
                      Eh? UC/ED folk look at our notes?

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                      • #12
                        I do a fuller exam than most peds folks, I think. I do essentially the same exam on everyone 4 and up, so some parts are less relevant and in that sense it's partly for show.

                        But it's also because, especially with little kids, I get a lot of buy in by having them do UE active resistance strength testing.

                        Also, I try to get them to tell me any concerns way ahead of time so it's not an "Oh BTW". I can usually guess the mental health OBTW soon as I sit down.

                        I'd say about 60% of the time I'm covering things aside from a the full peds physical, vision, hearing, and hemoglobin.

                        Things I can't stand are when some mom tries to give me a rash history. Show me or shut up. ALmost as annoying is "I have (type 2) diabetes and I want to make sure my skinny 4, 8, 10, 17 year old doesn't." They don't - they're not fat like you.

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                        • #13
                          I tried to get my PCP to not do a PSA every year, and that was ok for a while. Back then I had to sign a form that stated that I understood the risks and benefits of my choice not to repeat it annually. I think they got tired of the time sink that those discussions took up. Now they just do PSA every year. I just go with the flow.

                          And they do urinalysis annually as well. I went in for my annual labs in a fasting state after a rigorous mountain biking workout early one morning. I had a few red cells in my urine and got sent to the urologist for further work up. The evaluation came out fine and the urine was normal when performed in a well hydrated state.

                          She also does a traditional physical exam. My doc is very careful to follow up on everything. Although I have no risk factors, she insisted I take 10 mg per day of atorvastatin based on the 10 year risk of an MI. It’s based on plugging every patient into the risk calculator and once you are a male that gets older, basically every male needs to be on a statin based on age. It sometimes feels a bit like overkill, but she’s very detail oriented. I resisted the statin decision knowing that the number needed to treat to prevent one non fatal MI is something over 100, but 10 mg per day of atorvastatin is my only med so I go with it. I frame it as a “supplement” since I don’t like the idea of taking medicine because I have an “illness” when I do not.
                          Last edited by White.Beard.Doc; 02-27-2022, 12:28 AM.

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                          • #14
                            I haven't personally seen my PCP in about 6 or 7 yrs. I only went once to establish care. He did a pretty quick visit and spent most of the visit fat shaming* me (BMI then was 23) and said that was the most important thing for me to keep an eye on at the time. He was absolutely right about all of it and it was probably one of the best encounters as a patient that I have had. Unfortunately he moved, and now I need to get someone else at some point.

                            *not literally, of course. It was all appropriate medical advice.

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                            • #15
                              How many of you perform a complete skin exam as part of the annual physical? Is it recommended? That actually seems important if the number of skin cancers I as a psychiatrist have diagnosed (3, all on their faces) is any indication. But I don't think any of my pcps have ever done that on me.

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