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Mini-Medical Lecture May 2012

Mini-Medical Lecture May 2012

Our second Mini-Medical School was Saturday, May 19th at 12:30, at our usual location, Chautauqua Hall in Pacific Grove.

Here is a copy of the handout with many useful resources.

What is the annual medical exam? It is much more than ordering a pap and a mammogram.

This is what happens at your annual examination for a low risk person (depends on age):

Screening procedure:

Interview:Recent personal medical history, surgeries, new family history; dietary and nutritional assessment; physical activity; use of complementary medicines and practices; tobacco, alcohol and drug use; domestic issues.

Physical Examination: Height/weight/BMI/BP. Physical exam and pelvic examination (usually at >21 years of age).

Laboratory Testing: Pap smear, STD screening, HIV Screening, Blood tests for diabetes and heart disease, mammography, colorectal cancer screening.

Evaluation and Counseling: Sexuality, fitness and nutrition action plan, family, work, lifestyle and sleep, cardiovascular risk factors, injury prevention, sun exposure.

Immunizations: Diphtheria/Pertussis/Tetanus (every 10 years) , Herpes zoster(shingles) (one dose at 60), Pneumococcal Vaccine at 65, Influenza annually beginning at 50, HPV Vaccine (<26 years). There are many additional tests and screenings for individuals with risk factors, a problem or an illness! You can only decide what is right for you by having an in depth discussion with your personal physician. This summary provides you with a basis for your discussion.

Who sets the standard of care and what are they?

US Preventive Services Task Force http://www.uspreventiveservicestaskforce.org

The American College of Obstetrics and Gynecology http://www.acog.com

Am. Society for Colposcopy and Cervical Pathology http://www.asccp.org

The Pap Smear: Summary: When to start Screening: After age 21. Screening intervals: Every 2-3 years. May screen every 3 years with a history of 3 negative tests. With HPV co-testing (after age 30) every 3-5 years. When to stop screening: Women over 65. With a history of dysplasia screen for 20 years after diagnosis. Screen women over 65 if they are sexually active with multiple partners.

Mammography- Start at age 40 depending on situation. ACOG states every 1-2 years in 40-50 age group and annually thereafter. USPSTF states screening every 2 years. Insufficient evidence of benefit after age 75. Check radiation dose and track exposures at http://www.xrayrisk.com.

Bone Density Screening- Start at age 65, except for high risk groups. High risk is by the FRAX tool ( http://www.shef.ac.uk/FRAX/tool.jsp?country=9 ) defined as smoking, alcohol intake, low body mass, parental fracture history. There are other risk factors, such as amenorrhea, premature menopause, exposure to high risk medications such as steroids.

Other issues- Advanced risk assessment tools (Coronary calcium score, LDL particle count). These may not be covered benefits on your insurance because they are considered “experimental”. This means the insurance company, not the physicians, have decided it is not ready to be used as a screening test.

The professional organizations set the standards based on published and peer reviewed research results. This is considered to be “evidence based medicine”. The decision to pay for testing is usually in the hands of the payor. In the United States, most Americans below the age of 65 are covered by private insurance. Each insurance company has their own approval system and standards for payments. Most private insurance companies are for-profit corporations who are responsible to stock holders. This places the physician between the standard of care and the payor. I believe most patients think their doctor is a representative of their insurance company because they have a contract, whereas the reality is that the physician labor force is simply contract labor.

I choose to step away from that inherent conflict of interest when I cancelled my provider contracts with all the health insurance companies. I do not accept insurance for office visits. Patients pay at the time of service and I courtesy bill their insurance for any out-of-network benefits. It is not easy to be independent, but I can tell you it certainly is honest.