Using the emergency room for routine physicals

One of my patients thanked me for saving his life.  Apparently, many years ago I had told him that most men’s first complete physical is in the emergency room in the midst of their heart attack or stroke.  I have been in practice long enough to have forgotten many of the things I have told patients.  I try to capture the pearls I have learned over the last 30 years and share them with my readers.

Before I was a family physician, I was an emergency room physician.  The ER was an excellent training ground for a family physician.  Many patients use the ER as their primary source of medical care.  In a society built on instant gratification, the ER is the pinnacle of accessibility, open 24 hours a day.  The ER is the perfect “one stop shop,” making radiology and laboratory services instantly available.  The ER is falsely economical as most insurance companies cover ER visits.  What the ER is not and can never be is a family doc’s shop or a reasonable place to seek routine medical care.

One of the cornerstones of family medicine is continuity of care.  A long- term relationship between the patient and doc is essential to proper diagnosis and treatment.  Knowing patient “Q” for 25 years allows me to read between the lines.  Patient “Q” assures me that she is “fine”; she just has a little cough and has been tired.  Patient “Q” has lost substantial weight.  I noticed it as soon as I walked into the room.  Patient “Q” is pale; I noticed that fact immediately, as well.  Patient “Q” insists she is just stressed.  She minimizes everything.  Patient “Q” knows and trusts me.  At first, she balks at my suggestion that she needs blood work and an x-ray; then she gives in.

Patient “Q” has lung cancer and is anemic.  Had patient “Q” gone to the ER for care, the doc may have believed her story, not recognizing her weight loss or pallor.  Patient “Q” is alive and well.  Her cancer was diagnosed early enough to be treated successfully.

As for my patient who responded to my admonition that most men have their first physical at the time they are being seen for their first heart attack, he is doing well, being seen for yearly physicals and dealing with medical problems uncovered during those physicals.

There is almost always a time, prior to your getting sick, when the disease process is subclinical (below the radar).  Diabetes starts 10 years before it is diagnosed; doing damage at a microvascular level that is not readily visible.  Finding it in the “pre-diabetes” stage gives you a chance to stop it!

Blood pressure starts to rise over a period of time.  Identify it early; and you have an opportunity to improve and change your lifestyle and, perhaps, stop it in its tract.  If you can’t stop it, you can treat it.  Waiting for the heart attack is just foolish.

A PSA (test for prostate cancer) is relatively worthless.  A series of PSA tests taken over the years, in conjunction with a digital rectal exam (DRE), may well save your life.

While no one has a crystal ball with which to predict the future, a long-term relationship with your doc can lead to early diagnosis and improved outcomes.  The ER is the place to go in an emergency.  Ninety percent of the patients I saw as an ER doc were not emergencies.  Those patients belonged in their doc’s offices.

If you don’t have a doc, find one.  If you do have a doc, see him/her at least once a year.  The life you save may be your own.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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  • http://twitter.com/MikeGGreenberg Michael Greenberg

    Although I agree that there is no replacement for a strong relationship with a family physician, the statement:  ”Ninety percent of the patients I saw as an ER doc were not emergencies.” is not one that is backed up by any data and likely an over exaggeration.  

    • http://www.facebook.com/rob.lindeman1 Rob Lindeman

      Michael, our colleague’s statement is neither an “over exaggeration” nor a garden-variety “exaggeration”, it is the truth. Ask any ER doc.  The so-called data are deeply flawed, self-reported data from triage nurses.  These data are then propagandized by ACEP and others to justify continued and increased federal funding for emergency medicine.

  • http://twitter.com/livewellthy Stewart Segal

    To be perfectly fair, I worked in the ER 30 years ago.  Back then, there were no “Urgent Care Centers’, no pharmacy based “In and Out in a Minute” centers.  The landscape has changed a lot in the last 30 years but my local ERs still see a lot of patients who would be better served in a generalists office.

  • Anonymous

    I don’t have a relationship with my PCP mainly because I see a nurse practitioner or a physicians assistant instead of  my doctor for urgent matters and my PCP barely remembers me from last years physical.

  • Anonymous

    I left primary care long ago (back when it was still called general practice) because I could not tolerate the boring, mundane (not to mention self-limiting nature) of about 90% of what I saw and switched to ER work. There at least once in a while you would deal with matters truly of an emergency nature. However, AT LEAST 90% and probably more of visits were no different from what I had seen as a GP.

    However, the author continues to promote the myth that a physical exam is worthwhile in that it may pick up at an early stage a disease and that this results in better clinical outcomes. And by ‘physical exam’ he seems to be including routine blood tests, which are not the same thing.   Unfortunately, for the most part, the valiue of early detection of disease by routine physicals and blood tests is highly questionable, despite the fact that the mantra is quoted endlessly.  Yes, treatment of elevated blood pressure may prevent a few serious cardiovascular events.  The counterargument is that current definitions for what constitutes elevated BP are so broad that just about everyone can now be considered to suffer from hypertension, especially if you base it on BP taken in the course of a short 10 minute office visit.  And for physicians using an aneroid sphygmomanometer, how about telling me the last time you had it calibrated?  But there is a very strong argument to made for getting people (not necessarily patients) to check their BP at pharmacies and other stores where you can take your own BP using an automated device (that uses the oscillometric method that avoid the numerous inherent problems with the older auditory technique) but more importantly, avoids the very real and well known problem of ‘white coat hypertension.’

    Aside from hypertension, what else can a routine physical done by a usually bored PCP pick up?  Not much, really.
    A pap smear is probably of value, though women, given the choice, would much rather have it done by a female nurse practitioner or physician assistant than a male PCP.  Elevated cholsterol levels?  Elevated blood sugar?  As with BP, the definition of what is abnormal has become so all encompassing that it is pretty difficult to find someone who does not have one or the other values or both increased.  This is the now well known phenomenom of medicalisation, whereby patients are labelled as having a disease on the basis of blood tests based on rahter arbitrary standards or guidlines  guidelines. It goes without saying that the net result is that all such patients are declared to be in dire need of medication (usually expensive) for the rest of their lives.  Skin lesions – has been shown, I believe, that such cases are better handled by dermatologists.

    Yes, you may, if you do enough of them and avoid getting so bored that you no longer see anything, pick up things like inguinal herniae, varicose veins, bunions and so forth. But you are only kidding yourself if you think that the patient was completely unaware of them. I won’t bother with the stuff you were taught in medical school that so rarely are actually found (enlarged thyroids, spleens, livers etc.) And the number of women who present with having discovered a lump in their breast far exceeds the number whose lump is picked up during a routine exam. In terms of detection of disese, routine mammograms in appropriately selected (by age) women that need not be ordered by a physician trumps a routine physical.

    Blood tests in asymptomatic (repeat, ASYMPTOMATIC) patients are, to the least, controversial in the extreme. And at the apex of such controversy is the PSA test.  This test has rendered hundreds of thousands of men functionally impotent and a somewhat smaller number  incontinent to various degrees.  But its role in the reduction of death from prostatic carcinoma remains as questionable as ever.  What is not in question is the amount of money it has earned for urologists and the developers of the test.

    Real value of a routine physical in patients who don’t have any sysmptoms?  Not much. In my books, mostly of social benefit only. Good for those who enjoy (and have the time) to chat with their patients. Makes both parties feel better.