There has been much debate over primary care for everyone raising the cost of health care. The main reason is because in the traditional medical model testing begets more testing. This is the reason executive physicals are so expensive and often times inconclusive.
The problem with many of these tests is there has not been a clinical utility demonstrated with many of the findings. Also, many of the tests reveal things that have no treatment. The idea of testing for something without having a workable plan in mind from the outset is bad medicine. Often findings on these extensive and expensive tests reveal things that may never progress to a disease state. These tests also allow the doctor to give up on critically thinking about you as an individual and often times sets off a cascade of red herrings.
The hype in the media of course does nothing to help this rush for massive testing. The Bio-Physical 250 or the latest manufacturer of CT scanners hyping the benefits of a total body scan as the gold standard in disease prevention is does nothing to decrease mortality. There is a rhetorical comment in medicine that refers to CT scanners as the diagnosis machine. This comment is made tongue-in-cheek. Just because something abnormal appears on the scan does not mean that it is what is causing the current problem. Another problem with unwarranted scanning and testing is the fear that becomes inspired in many patients.
Is there any benefit to the advances of modern science and medical testing? The plus side of testing is that sometimes these findings may motivate patients to do major healthy lifestyle changes. This assumes those changes will have an effect on the abnormal finding.
Is there an executive physical that can actually motivate behavior change and not cost thousands of dollars? Yes. The way this is done would be by a health care provider that takes the time to get to know you. One whom you establish a relationship with. It is very important for your primary care provider to get to know you in the context of your daily life. This yields a far better picture of your health rather than a one time snap shot that leaves us all guessing at how you got to this point. The best executive physical should focus on current lifestyle habits and state of health. Patients should complete a detailed history which includes a screening for alcohol abuse, domestic violence and sexual history. Also included should be a depression screening, anxiety screening, and quality of sleep screening. Finally no health review would be complete without an extensive nutritional and diet review. Ideally a 3 day diet recall/ journal should be kept in advance of the actual meeting with the health care provider.
Another important component of an executive physical which is often overlooked is a health education session in which patients learn how to navigate the health care system with respect to their current and future health problems. Patients should be taught how to speak to health care providers to get the answers and the care they need.
In an effort to perform a better physical exam and health survey a new trend has started emerging in the New York City area. Patients are being seen in their homes. The comprehensive physical exam consists of the health surveys previously discussed. This is becoming particularly attractive to men who state the main reason they do not go to the doctor is because of time wasted. Another advantage to being seen in your own home is the less likely chance of catching a infection in a standard medical office or hospital. How many times have you gone in for a physical and then three days later gotten sick?
Conducting a physical exam in the patients home consists of the following measures that yield the most informative data:
height on a door jam
blood pressure in both arms in 3 positions
screening men for testicular cancer (and teaching them how to do this on their own)
as well as digital rectal exam for prostate cancer.
These test combined with a through skin exam and review of the major systems can yield far more useful data than a whole body CT Scan that picks up obscure findings that have no clinical correlation. The home based executive physical exam also allows for a look in the refrigerator, bathroom, and common living area for quality of food, hygiene, and potential hazards.
What about testing?
Blood tests should be done with a plan of what you hope to do with the results in mind. Random and massive testing can have some very serious and expensive consequences.
This is a list of tests that will yield the most useful data that can actually be addressed without causing further harm or alarm:
* complete blood count (CBC)
* comprehensive metabolic panel (CMP)
* Serum Insulin
* thyroid profile
* urine analysis and micro albumin
* Hep A and B antibodies
* Varicella and MMR titers
* Syphilis titer (RPR), Herpes titers and HIV
These test give insight to the major body organs and systems as well as highlighting risk of infectious diseases. The results can be greatly improved with lifestyle modifications. Other tests can be added on if clinically indicated.
What about imaging?
In an effort to spare patients needless radiation and to maintain biggest bang for the buck much of the imaging should done by ultrasound. This adds no radiation and allows for a sufficient evaluation of blood flow. Insufficient blood flow is typically what kills most people.
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