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The Periodic Health Exam

The Periodic Health Exam. R Birtwhistle MD. Objectives. The origins of the PHE The benefits and risks of PHE What to do in practice? Some cases. The History of the PHE. Late 18 th Century Screening of School children, workers WW1 military draft 1920’s Endorsed by the AMA in 1922

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The Periodic Health Exam

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  1. The Periodic Health Exam R Birtwhistle MD

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

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

  4. A Contrary View- D. Spence, BMJ 2009;339:b2973 “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 society’s most precious possession of all: a sense of wellbeing. So, let’s repeat: screening, whatever its benefits, also causes widespread, real, and lasting harm.”

  5. 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.

  6. 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

  7. 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; 146:289-300

  8. Physician Views of the Annual PhysicalAllan V. Prochazka, MD, et al ,Arch Intern Med. 2005;165:1347-1352

  9. Laboratory testing at Annual PhysicalsAllan V. Prochazka, MD, et al ,Arch Intern Med. 2005;165:1347-1352

  10. Public Expectations for Annual Physical Examination Sylvia K. Oboler, Ann Intern Med. 2002;136:652-659.

  11. 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

  12. CanMeds FM Framework

  13. 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?

  14. 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

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

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

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

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