The Periodic Health Exam

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The Periodic Health Exam

• R Birtwhistle MD

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Objectives

• The origins of the PHE
• The benefits and risks of PHE
• What to do in practice?
• Some cases

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The History of the PHE

• Late 18th Century
• Screening of School children, workers
• WW1
• military draft
• 1920s
• Endorsed by the AMA in 1922
• Insurance companies
• 1945
• First proposal for selective exam based on age
  and sex

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A Contrary View- D. Spence, BMJ 2009339b2973

• Tear stained reasoning should not blind us to
  the fact that screening for skin, breast,
  cervical, and prostate cancer (not to mention
  screening for high cholesterol, hypertension, or
  osteoporosis) generates overdiagnosis,
  overtreatment, and health anxiety. Doctors are
  complicit in the theft of societys most precious
  possession of all a sense of wellbeing. So,
  lets repeat screening, whatever its benefits,
  also causes widespread, real, and lasting harm.

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Do Yearly Health Examinations Improve Health?
General health checks in adults for reducing
morbidity and mortality from disease (Cochrane
Review 2013) Krogsbøll LT, Jørgensen KJ, Grønhøj
Larsen C, Gøtzsche PC
Authors conclusions General health checks did
not reduce morbidity or mortality, neither
overall nor for cardiovascular or cancer causes,
although the number of new diagnoses was
increased. Important harmful outcomes, such as
the number of follow-up diagnostic procedures or
short term psychological effects, were often not
studied or reported and many trials had
methodological problems. With the large number
of participants and deaths included, the long
follow-up periods used, and considering that
cardiovascular and cancer mortality were
not reduced, general health checks are unlikely
to be beneficial.
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Do Yearly Health Examinations Improve Health?
General health checks in adults for reducing
morbidity and mortality from disease (Cochrane
Review 2013) Krogsbøll LT, Jørgensen KJ, Grønhøj
Larsen C, Gøtzsche PC

Systematic Review of 14 RCTs (12 with data) with
almost 183,000 patients Trials Goteberg
1963 and 1969 WHO 1971 Kaiser Permanente
1965 Salt Lake City 1972 SouthEast London
1967 Mankato 1982 Northumberland
1969 OxCheck 1989 Malmo 1969 Family
Heart 1990 Stockholm 1969 Ebeltoft 1992
Inter99 1999
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Systematic Review The Value of the Periodic
Health Exam

• Screened 7039 studies between 1973-2004.
• 21 studies were included in final review
• PHE showed consistently beneficial association
  with gynecological exams and pap smears in women,
  cholesterol screening and FOBT testing. 1 study
  showed benefit on patient worry.
• Conclusion PHE improves delivery of preventive
  services
• Boulware LE et al, Annals of Internal Medicine
  2007 146289-300

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Physician Views of the Annual PhysicalAllan V.
Prochazka, MD, et al ,Arch Intern Med.
20051651347-1352
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Laboratory testing at Annual PhysicalsAllan V.
Prochazka, MD, et al ,Arch Intern Med.
20051651347-1352
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Public Expectations for Annual Physical
Examination Sylvia K. Oboler, Ann Intern Med.
2002136652-659.
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The History of the PHE
1950s and 60s Annual Physicals were common
accepted practice. Health Fairs in
US Publication of several large studies which
suggested limited benefit Kaiser-Permanente
1964 Southeast London Screening Study
1967 1976 Task Force on the Periodic Health Exam
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CanMeds FM Framework
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Considerations

• What to do?
• How often?
• How much time?
• The art vs. science of medicine?
• The laying on of hands (and stethoscopes)
• The patient as an individual?

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Recommendation grades for specific clinical
preventive actions

• A- good evidence to recommend action
• B- fair evidence to recommend action
• C- evidence is conflicting and does not allow a
  recommendation for or against
• D- fair evidence to recommend against action
• E- good evidence to recommend against action
• I- insufficient evidence to make recommendation

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Case 1
38 yr old woman, smoker who has just stopped the
BCP in order to get pregnant

• A recommendations
• Counseling on smoking cessation
• Folic acid supplementation
• Dental care
• Influenza vaccine

• B recommendations
• BP
• Pap smear
• Seatbelts
• Nutrition, physical activity
• Counseling about skin ca
• Rubella screening
• Alcohol screening

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Case 2
67 year old man with diabetes, family history of
colon cancer, lung cancer and melanoma

• A recommendations
• Blood pressure
• Nutrition, physical activity
• Influenza vaccine
• Pneumococcal vaccine
• Dental care
• Urine dip
• Colon ca screening

• B recommendations
• Alcohol enquiry
• Seatbelts
• Skin cancer counseling
• Visual impairment
• Hearing impairment
• Fasting glucose
• Lipids

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Case 3
55 year old woman with no health problems,
family history of stroke and breast cancer in
elder parents

• A recommendations
• Mammography
• BP measurement
• Influenza vaccine
• Occult blood testing stool
• Dental care

• B recommendations
• Pap smear
• Alcohol enquiry
• Diet, physical activity
• Skin cancer screening
• Fasting glucose
• Lipids