The Importance of the Annual Physical

[Rudynate]

38 minutes ago, Rudynate said:

I read the whole thing.  The bulk of your post was a melodramatic description of your recent ER experience with you screaming in agony and the docs ignoring you, which made it difficult to tease out your larger message.

I smell confirmation bias.

[NYCdadUES]

On 8/20/2023 at 11:27 AM, Unicorn said:

Well, it looks as though you seem to have found a backhanded way to get Kaiser to pay for purely cosmetic procedures, and your dermatologist seems complicit. Obviously, you know that these are skin tags, as you called them that yourself. However, let's accept for the moment your false narrative that you have no idea what these are, and that you're truly concerned they might be cancerous or pre-cancerous. In that case, it would obviously make more sense to see your PCP promptly, rather than wait 6 months to see a dermatologist. The PCP could immediately reassure you regarding the benign nature of these lesions (he could just as easily get rid of them himself if he wanted, presumably without telling Kaiser about it). Is there any wonder, with behavior like this, why it takes 6 months to see a dermatologist at your Kaiser? One can only hope this hanky-panky doesn't cause delays in diagnosis for those with truly concerning lesions, nor delays in treatment for those with serious dermatological conditions like psoriasis, who truly need to see a dermatologist. 

Most pcps  now do not even look at skin and even if they do they still refer to derm for abnormal skin growth or neoplasm of uncertain behavior. The modern physical is now labs vitals and everything OK, cscope referral, sun screen and seat belts, lock up your guns, comeback in the fall for a nurse visit flu shot. 

[Guest]

4 hours ago, Rudynate said:

I smell confirmation bias.

Factually untrue. I've been complaining about ER doctors for years on this forum, long before I was grossly mistreated at the ER where I went (which was not near any inner city place where there one might expect homeless drug addicts--though all patients should be given the benefit of the doubt unless it's pretty certain they're faking it). The 2nd ER doc I saw was fine, although there was not much for her to do, as I had pre-arranged admission/treatment with the urologist. I have had many patients recount similar stories as mine, and have received grossly incompetent referrals from ER's. 

[Guest]

7 minutes ago, NYCdadUES said:

Most pcps  now do not even look at skin and even if they do they still refer to derm for abnormal skin growth or neoplasm of uncertain behavior. The modern physical is now labs vitals and everything OK, cscope referral, sun screen and seat belts, lock up your guns, comeback in the fall for a nurse visit flu shot. 

Well, they may not examine your skin if you're in for treatment of diabetes, but they obviously will look at your skin if you come in for evaluation of a skin lesion. They will refer for anything that's suspicious. Obviously not for skin tags (hopefully). 

[+ tassojunior]

I went to my dermatologist today and he told me the two times I have had surgical removals it was Basel cancer for which he thinks an annual look by him is warranted. My two new large moles were benign as was one behind my ear. He carefully looked over my skin, especially arms and head for anything he might notice that I would not. (I cut my hair to 1/4 inch last night so he could see the scalp well). Then he burned off the new stuff and whatever he thought was called for. He said, yes, dermatologists do get many patients just wanting tags removed but in my case with two Basel cancer removals, it was prudent to have him check annually. My Kaiser has gone from 3 Dermatologists to 1. 

Edited August 23, 2023 by tassojunior

[Beancounter]

Returning to the original purpose of this thread for a brief moment…..I’d like to know the difference between a wellness check and a physical.  It’s obvious to me that they are two different things according to Medicare.   

[Rudynate]

6 hours ago, Rudynate said:

I read the whole thing.  The bulk of your post was a melodramatic description of your recent ER experience with you screaming in agony and the docs ignoring you, which made it difficult to tease out your larger message.

You should be thanking me.  I'm the only one who expressed any sympathy for your plight. 

[Rudynate]

8 hours ago, Unicorn said:

Thanks for the correction. And yes, you are correct in stating there's also an antidote for those two as well (different from that for Pradaxa/dabigatran, which works by a different mechanism). What I was trying to impart was that, if one has to take a long-acting oral anticoagulant, it's a good idea for the patient to be aware that an antidote exists. Having worked in primary care for decades, I can state from ample experience that the quality of ER physicians can be a crapshoot at best. Just over 2 weeks ago, I was in the ER as a patient with what turned out to be a stone at the base of my ureter which was surrounded by a mini-abscess, and was causing that ureter and kidney to blow up. I was in acute renal failure, with extremely high lactic acid levels, probably close to being in septic shock. I was in complete agony, shaking in pain, with sweat pouring down my body, blood pressure 195/120, hyperventilating, yet, despite my pleas, the ER physician refused to even talk with me until the radiologist read the CT scan (which he ordered, as I said, without even talking with me). My tearful fiance even spoke with the Charge Nurse to no effect.

I can only guess why the ER physician refused to evaluate me when I came in, although my screams were probably audible throughout the ER. If he thought I was some kind of a drug addict, he could have instantly checked the state CURES database, and/or he could have done a rapid urine drug screen, which would provide a result in minutes. I was in the ER for over 3 hours before he even popped in to take a look. When I commented on this doctor's incompetence to the RN who took care of me as an inpatient, he remarked "Yes, those ER doctors are something else. Sometimes I think they all get trained at the same 'Don't evaluate the patient' residency."! When I was re-admitted for the stone removal yesterday, the ER doctor was fine, and came by promptly to speak with me. 

I would suspect that in many cases, if the patient isn't himself aware of the availability of the antidote, the patient's best bet is that whoever is consulted knows about the antidote (such as a gastroenterologist if there's a GI bleed). 

 

Your post from a few months ago:  - Stop complaining. 

[Guest]

2 hours ago, Rudynate said:

Your post from a few months ago:  - Stop complaining. 

[ICTJOCK]

On 8/22/2023 at 6:43 PM, Beancounter said:

Returning to the original purpose of this thread for a brief moment…..I’d like to know the difference between a wellness check and a physical.  It’s obvious to me that they are two different things according to Medicare.   

Thank you for the return to the purpose of my original post!     My layman's understanding is that a "wellness check"  is more direct and focused,  while a "physical"  is more general and broad.    I chatted with my physician (who I have used for years).    A great discussion about how he has reacted to things like a colonoscopy (which he put off himself,  but doesn't want me to when my time comes),  blood testing and a thorough discussion about where I'm at with my weight ,  175 and height   6'1",  blood pressure and a review of my own questions.    I call my time with him a physical.    We don't that all the blood testing every year,  but I was due.

[Guest]

6 hours ago, ICTJOCK said:

...My layman's understanding is that a "wellness check"  is more direct and focused...

A good primary care provider (PCP) will address any wellness issues which are outstanding at each visit, even if you're there for a specific problem like a sprained ankle or STD check. So if you come in for a rash, a good PCP will comment "I see you're due for a flu shot," or whatever. In fact, almost all records are electronic these days, and these records will remind the PCP of anything outstanding. Even more to the point, PCP's receive periodic "report cards" which provide statistics regarding the percentage of patients who've had their shots, pap smears, mammograms (50+), BP controlled, diabetes controlled, and so on. That's one good reason to get your rash evaluated by your PCP rather than a dermatologist (other than the 6 month wait for the dermatologist). If one has certain health conditions, there are additional flags in addition to routine ones (heart failure, diabetes, coronary artery disease, etc.). By the way, men who have sex with men need more immunizations than those who don't. 

[ICTJOCK]

Thank you for that.  I will always get my annual physical.

[+ purplekow]

On 8/21/2023 at 2:09 PM, tassojunior said:

I was told when on Pradaxa, to absolutely stop baby aspirin and when I came off Pradaxa told not to use aspirin regimen. IDK. I do know my surviving neighbor was in a big argument with his doctor over baby aspirin but I don't know if he was on thinners. He must not have been as he died of clots a few months after his partner and both had covid and recovered just before the first partner's death from clots. Both were professionals and I'm sure had excellent insurance and assumably excellent doctors. It all makes me a little "concerned" about clots.  

Hypercoaguable states are part and parcel of complications of Covid.  If both of your neighbors had Covid, they were probably subject to that increased risk.  It should be stated that anticoagulants are not fool proof.  Anticoagulant failure is a significant problem and will often lead to change in medication.  

[Rudynate]

On 8/26/2023 at 12:47 PM, purplekow said:

Hypercoaguable states are part and parcel of complications of Covid.  If both of your neighbors had Covid, they were probably subject to that increased risk.  It should be stated that anticoagulants are not fool proof.  Anticoagulant failure is a significant problem and will often lead to change in medication.  

Yes - my hemo switched me from Xarelto to Eliquis for that reason.

[Guest]

1 hour ago, Rudynate said:

Yes - my hemo switched me from Xarelto to Eliquis for that reason.

Strange switch, since Xarelto (rivaroxaban) and Eliquis (apixaban) both work by the exact same mechanism (they're Factor Xa inhibitors). If one really wanted to go with the direct oral anticoagulants (DOAC's), there would at least be some sense in switching to dabigatran, which works via a different mechanism (direct thrombin inhibitor). Depending on the indication or circumstance, especially if one needed something that really had to work, one might have to go with warfarin. It's a pain in the ass to prescribe, and a pain in the ass to take (requires frequent monitoring, has lots of drug interactions, and unpleasant dietary restrictions), but sometimes it's the only thing that works. For example, it's the only anticoagulant that works for those with artificial heart valves and certain "over-clotting" (hypercoagulable) disorders. In the large healthcare facility where I worked, we had a group of specially-trained RN's whose sole job it was to counsel and adjust doses of those taking warfarin (they worked in "warfarin clinics"). As unpleasant as it is to prescribe, some patients absolutely need it. 

Mnemonic hint: the ending "xaban" indicates the medication is a Factor Xa inhibitor. The main reason I usually prescribed Eliquis rather than Xarelto, and the reason Eliquis is the #1 prescribed oral anticoagulant in the United States, is Eliquis's shorter half-life. If the patient has bleeding problems, or if the medication needs to stopped for surgery or major dental procedures, stopping Eliquis can be fast and easy (as is going back on it). 
 

Within 3 years of its being introduced, apixaban overtook rivaroxaban as the #1 prescribed anticoagulant:

Oral Anticoagulant Utilization in the United States and United Kingdom - PMC

WWW.NCBI.NLM.NIH.GOV

 

"...As of 2017, apixaban was the most commonly dispensed DOAC, accounting for 25% of all oral anticoagulant utilization, followed by rivaroxaban (21%)..." 

Edited August 31, 2023 by Unicorn

[+ purplekow]

19 hours ago, Unicorn said:

Strange switch, since Xarelto (rivaroxaban) and Eliquis (apixaban) both work by the exact same mechanism (they're Factor Xa inhibitors). If one really wanted to go with the direct oral anticoagulants (DOAC's), there would at least be some sense in switching to dabigatran, which works via a different mechanism (direct thrombin inhibitor). Depending on the indication or circumstance, especially if one needed something that really had to work, one might have to go with warfarin. It's a pain in the ass to prescribe, and a pain in the ass to take (requires frequent monitoring, has lots of drug interactions, and unpleasant dietary restrictions), but sometimes it's the only thing that works. For example, it's the only anticoagulant that works for those with artificial heart valves and certain "over-clotting" (hypercoagulable) disorders. In the large healthcare facility where I worked, we had a group of specially-trained RN's whose sole job it was to counsel and adjust doses of those taking warfarin (they worked in "warfarin clinics"). As unpleasant as it is to prescribe, some patients absolutely need it. 

Mnemonic hint: the ending "xaban" indicates the medication is a Factor Xa inhibitor. The main reason I usually prescribed Eliquis rather than Xarelto, and the reason Eliquis is the #1 prescribed oral anticoagulant in the United States, is Eliquis's shorter half-life. If the patient has bleeding problems, or if the medication needs to stopped for surgery or major dental procedures, stopping Eliquis can be fast and easy (as is going back on it). 
 

Within 3 years of its being introduced, apixaban overtook rivaroxaban as the #1 prescribed anticoagulant:

Oral Anticoagulant Utilization in the United States and United Kingdom - PMC

WWW.NCBI.NLM.NIH.GOV

 

"...As of 2017, apixaban was the most commonly dispensed DOAC, accounting for 25% of all oral anticoagulant utilization, followed by rivaroxaban (21%)..." 

Warfarin was one of the first anticoagulants and it was the standard of care for years.  However, it was also the drug that caused the most side effects and the most medication related deaths, so despite its effectiveness it was always a difficult drug to monitor.  Changes in diet, especially of Vitamin K containing foods would often require changes in dosing.  Missing a dose or taking an extra dose could cause issues.   Overall, it was effective and difficult to manage. That they have gone so far as to have a warfarin clinic speaks volumes of the risk of this beneficial drug. 

Edited August 31, 2023 by purplekow

[dbar123]

The”Wellness exam” is a bit of a charade for sure. My PCP experience would be far more useful if he was able to give me patient specific advice on how many calories I should be eating and what kinds of diet plans I should be following. When I ask these questions I get more of a blank stare.

[ICTJOCK]

1 hour ago, dbar123 said:

The”Wellness exam” is a bit of a charade for sure. My PCP experience would be far more useful if he was able to give me patient specific advice on how many calories I should be eating and what kinds of diet plans I should be following. When I ask these questions I get more of a blank stare.

Perhaps your "wellness exam"  could be conducted in the office of a Registered Dietician

[jeezifonly]

So many things that start out small and become huge, expensive, debilitating during treatment might have been caught ahead of the first sign of the worst.
For anyone over 45, it’s risky to ignore basic preventative care, even if out of pocket 

Medicare covers annual wellness checks, but not annual physicals. Don’t know why.

Check w Drs office how they bill it and how the exams/tests differ. (For HIV treatment I get blood work 4x year billed as follow-up visits for which there is no copay)

We seniors also benefit from routine specialized visits for heart, skin, feet, gut, teeth, eyes…
Like Roxy Hart, I’m older than I ever intended to be

 

[Guest]

12 hours ago, jeezifonly said:

...Medicare covers annual wellness checks, but not annual physicals. Don’t know why...

We seniors also benefit from routine specialized visits for heart, skin, feet, gut, teeth, eyes…

Mystery solved for the first sentence here: because going over many healthcare maintenance issues (including BP, BMI, cancer screening, immunizations, etc.) improves health outcomes, and annual physicals do not.

You're mostly wrong when it comes to the second sentence. Yes, everyone (not just seniors) should see a dentist twice a year, but that's not a medical issue. Those visits should certainly be done by dentists, not physicians. Although most seniors probably have some sort of visual symptom which needs attention, in the absence of symptoms, routine visits are not recommended by public health experts. Perhaps surprisingly, there is no evidence that even glaucoma screening is helpful:

Recommendation: Primary Open-Angle Glaucoma: Screening | United States Preventive Services Taskforce

WWW.USPREVENTIVESERVICESTASKFORCE.ORG

"The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma in adults."

Same for skin cancer screening:

Recommendation: Skin Cancer: Screening | United States Preventive Services Taskforce

WWW.USPREVENTIVESERVICESTASKFORCE.ORG

"For adolescents and adults who do not have signs or symptoms of skin cancer:
The USPSTF found the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer."

Anyone who disagrees simply shows the arrogance of thinking he knows better than the public health experts who've actually taken the time to review all of the studies and evidence relating to these issues. 

[Guest]

16 hours ago, ICTJOCK said:

Perhaps your "wellness exam"  could be conducted in the office of a Registered Dietician

Well, a dietician can certainly spend more time than a physician (or NP or PA-C), but primary care providers should certainly be able to answer questions in the dietary realm, and should definitely not respond to those questions with a "blank stare" or similar brush-off. Electronic medical records easily allow physicians to include some routine advice in their written discharge summaries which accompany any visit. One can even tailor one's own "dot phrases" which instantly print out lengthy routine advice, such as advice on how to avoid saturated fats (with ".satfat") or simple carbs (with ".smplc"), for example. Obviously, the PCP can't go into lengthy meal preparation advice, but should be able to recommend easy substitutions, such as switching to whole grain pastas and brown rice, and replacing coconut and palm oils with canola and/or olive oil.