Saturday, July 5, 2014

Skip the annual pelvic examination? How about the whole checkup?

An American College of Physicians practice guideline has garnered attention for recommending against clinicians performing screening pelvic examinations in asymptomatic, nonpregnant women. Although the new guideline has been called "controversial," its findings should not be a surprise to readers of American Family Physician. An editorial and blog post published in AFP early in 2013 argued that this longstanding tradition is "preventive time not well spent," since the pelvic examination doesn't actually prevent anything (screening for ovarian cancer does more harm than good and accurate testing for chlamydia and gonorrhea can be done on urine samples) and is associated with increased cost, inconvenience, and patient discomfort. With Pap smears only recommended every 3 to 5 years in most women, it also seems prudent to redirect time saved from not performing extra pelvic exams to effective preventive services such as counseling for tobacco and alcohol misuse.

But why stop at the pelvic examination? Last September, the Society of General Internal Medicine included the following item in its Choosing Wisely Top 5 List of potentially unnecessary tests or procedures: "Don't perform routine general health checks for asymptomatic adults." They cited a Cochrane review of 14 randomized controlled trials that found that the annual physical increases new diagnoses but "do not decrease total, cardiovascular-related, or cancer-related morbidity or mortality."

The physical examination may not improve outcomes in asymptomatic patients, but what about the cardiovascular risk assessment and lifestyle counseling that goes along with it? A randomized trial published this year in BMJ casts doubt on the benefits of this preventive service. In nearly 60,000 residents of Copenhagen, Denmark between the ages of 30 and 60 years, four or more sessions of individual lifestyle counseling over a 5-year period produced no effect on rates of coronary artery disease disease, stroke, or mortality after 10 years of followup. In an accompanying editorial, the Cochrane review authors state flatly: "General health checks don't work. It's time to let them go."

As the U.S. faces a worsening shortage of primary care clinicians, are today's family physicians prepared to abandon annual pelvic examinations and well-adult checkups in general? If not, why not?

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The post originally appeared on the AFP Community Blog.

2 comments:

  1. Payers gonna pay.

    Ineffective well visits are ineffective. What guidance do primary care doctors have for conducting them? The instruction I've been able to find (bygone internal medicine training experience; recent literature search) is poor.

    I'm board certified in Public Health and General Preventive Medicine, sympathetic to patients and primary care clinicians, and I want to specialize in well visits. Does anyone want to study the performance of mine? And which family physicians would be willing to refer interested patients for an effective well visit?

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  2. Today I visited a local host site of a national commercial screening company to gather info, preparing to intervene. I learned that they now offer Medicare Annual Wellness Visits.

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