Who Needs a Physical?

Last week I saw an elderly woman whose daughter brought her in with a long list of symptoms, including palpitations, chest pain, fatigue, forgetfulness, dizziness, headaches, chronic leg swelling, abdominal pain and irregular bowels.

“She needs a complete physical,” the daughter said.

I disagreed. In my opinion, she needed a thorough evaluation of her symptoms and concerns, starting with her most urgent symptom of chest pain. She was simply not well enough for a routine physical.

This is no joke: A routine exam is essentially for healthy people. Patients with alarming symptoms need to have them evaluated promptly in a focused way, and not wait until their next routine physical, where the urgent issues would have to be dealt with in conjunction with immunization advice and all kinds of health maintenance issues.

Not everybody believes in the annual physical. Medicare doesn’t cover it, and most of the things doctors do during such an exam are of little or no proven benefit, as the proponents of evidence-based medicine remind us.

Those routine tests that are supported by the evidence are not usually recommended on an annual basis, but rather at different intervals for different age groups.

As far as the old-fashioned head-to-toe physical, there is simply no scientific support for it if you listen to the U.S. Public Health Task Force or the big insurance companies.

I have always shied away from the term “complete physical”, because there really is no such thing in clinical practice. There are always more things you could do, but don’t – we all have to budget our time as well as all other resources in our profession.

For many years now I have preferred the term “Annual Review”, because, in preventive medicine as in clinical diagnosis, you can usually accomplish more by simply talking to your patient than by delving into examinations and procedures right away.

In my practice, I see the Annual Review as my opportunity to ask patients things that they may not have thought of bringing to my attention. It is my opportunity, just like in the “well child visit,” to offer what we call anticipatory guidance – addressing things that might become problems in the future, and how to avoid that happening.

I am more likely to find a patient with angina by asking him how he feels when he splits and stacks firewood than by auscultating his heart or doing an annual resting EKG in my office. I also think I am more likely to spot a depressed patient if I have a chance to ask a few open-ended questions about how things are going than if I only rely on questionnaires.

There is no doubt that certain parts of the routine physical exam are valuable. I tend to talk my way through the exam, asking questions while I touch the patient, explaining what I am looking for, and encouraging the patient to do their own breast exam, lymph node or testicular exam. 

And, getting back to auscultating the heart, it is necessary to do. A physical without listening to the heart is like a dinner without a main course. People expect it, and you never know what you’ll hear if you stop and listen for half a minute or so.

I didn’t need an EKG to diagnose my elderly chest pain patient with atrial fibrillation.

A Hero’s Pain

“I don’t know if you understand, Doc, what kind of man this is.”

The man who spoke appeared to be a few years my junior. He was speaking of his father, who is one of my patients at the local Veteran’s Home, where I am a relative newcomer.

“This man fought in two wars and earned two Medals of Honor. He is not going to tell you how much pain he is in, even when you ask him, because he isn’t even going to admit to himself how much he hurts.”

He made a point I actually hadn’t considered before during my tenure at the Veteran’s Home. My patient has metastatic cancer, and the nursing staff asks him every day to rate his pain. His answer is always 2 on a scale from 0 to 10.

As doctors and nurses we estimate our patients’ discomfort through their words and also through their vital signs, facial expressions, posture and other nonverbal clues. But when it comes to treating war heroes, do our usual instruments fall short?

I remember thinking when I admitted the ailing veteran that he seemed so humble and plain spoken. The words “true hero” came across my mind then. I didn’t consider that I might not be able to accurately assess his cancer pain or his level of distress over his terminal diagnosis.

There is a lot of talk about cultural competency in this country. Today I even read in one of the publications of the American Medical Association that several states are mandating that physicians take courses to improve their skills in dealing with patients from cultural and ethnic minorities.

Somehow I think we oversimplify the issue of cultural competency if we focus on only those we think of as minority groups. Our challenge in caring for all our patients is to meet them where they are, to step out of our own world long enough to at least get a glimpse of theirs. We must first meet as human beings before we can begin our medical assessment.

War heroes are a minority, too.

A Real Pain

Why would a toothache bring Ted Larson to the emergency room when he already takes half a dozen morphine tablets per day for his chronic back pain?

Why did Bridget Hall’s fibromyalgia pain seem to escalate after her last doctor gave her long-acting oxycodone?

Is Bob Bachman really in that much pain from his arthritis, or is he sharing or even selling his pills?

Taking care of patients with chronic pain is difficult. Physicians are at the same time told to recognize and treat pain better, and also to be more stringent with pain prescriptions to avoid drug diversion. Our understanding of the physiology and psychology of pain is evolving, as well as our knowledge of the science behind addiction.

As often before I see that some of the things I learned from my clinical professors in medical school were forgotten or even dismissed, only to come back into focus years later.

Thirty years ago I was taught that patients with ordinary low back pain would get better pain relief from modest doses of conventional pain medications if they were also prescribed a low dose of the antidepressant amitriptylene. The reason, as I remember it, was thought to be that amitriptylene made the brain interpret incoming pain signals differently.

Later, other authorities made a big distinction between mechanical low back pain and neuropathic or radicular pain, commonly referred to as sciatica. The focus shifted away from the brain’s interpretation of pain signals in general to whether a pain originated in the musculoskeletal system, like low back pain or arthritis, or in the peripheral nervous system, like sciatica.

When fibromyalgia was first recognized as a disease, there was a lot of confusion about where the pain came from. The name itself suggested that the pain originated in the musculoskeletal system. With the understanding at the time that such pains could be treated with narcotics, many fibromyalgia patients ended up on strong pain medications. We still used medications like amitriptylene and the more modern antidepressants with success, but the thinking was that these drugs worked mostly by improving sleep or treating unrecognized depression. Today we recognize fibromyalgia as a disease involving increased pain sensitivity of the nervous system, and we now have several medications targeting this mechanism.

We have also learned that patients who receive opiates for any kind of pain can develop a fibromyalgia-like intensification of nerve pain associated with ordinary touch, allodynia, or otherwise moderately painful stimuli. This phenomenon is called opioid-induced hyperalgesia. Paradoxically, decreasing such a patient’s pain medication dosage reduces their pain level.

More recently, even chronic musculoskeletal pain of arthritis has been shown to cause a nerve-mediated general pain sensitivity of a similar type. Patients with severe arthritis often experience aching and pain in areas without joint disease, such as skin or muscle tissue.

The practice of my early teachers, who treated most chronic pain as if it were at least in part nerve pain has found new respect and acceptance after many years of neglect as science has finally caught up with their clinical wisdom.

So when Ted Larson, already on chronic narcotics, complains of severe, nerve-mediated tooth pain, his pain is real and may actually be more severe than the same toothache in a person not on narcotics.

Bridget Hall’s fibromyalgia pain may actually have been made worse by the narcotics she was prescribed.

And Bob Bachman’s long-standing arthritis may indeed have made him increasingly pain sensitive. He has never failed a random urine drug screen or pill count. With the new data on neuropathic pain sensitization in patients with longstanding arthritis, it may be time to try him on something specifically for nerve pain, rather than increasing his regular pain medications.