Leaving the Annual Physical Behind

SOURCE: Mehrotra A, Prochazka A. N Engl J Med 2015;373;16:1485-1487.

Commentary that should have led us away from participating in the annual physical has been in front of us for more than 35 years. In 1979, a Canadian task force suggested that the practice of the annual physical, quite simply, be abandoned. Echoing this sentiment, the Choosing Wisely campaign (2013) voted thumbs down to annual preventive examinations in otherwise asymptomatic individuals.

Jane and John Q. Public, however, seem determined to keep the annual physical alive. Approximately one-third of adults sign up for an annual physical each year in the United States, with no sign of abatement over the last 8 years. As clinician-scientists, we must somehow evolve into one of two primary camps. First, embrace what expert reviewers have concluded based on evaluation of outcomes data — that the annual physical does not improve outcomes and expends billions of dollars that otherwise could be spent for greater benefit — and eschew further endorsement of the annual physical. Or second, admit that the annual physical (though perhaps lacking merit on the basis of measurably improved health outcomes) provides fertile ground for germination of difficult-to-quantify elements, such as improved clinician-patient relationships, while acknowledging the recognized outcome limitations.

Mehrotra and Prochazka go so far as to suggest that if the fundamental benefit of the annual physical is relationship building, then we might consider establishing contact visits with the specific agenda of relationship building, rather than anticipating relationship growth as a “sidestream benefit.” To date, the annual physical has shown minimal, if any, benefit or potential for harm. The busy clinical setting has little room for spending time frivolously. Each of us will have to balance the absence of concrete benefits from the annual physical with the rewards measured by ourselves and our patients, accrued by the acutely well patients seeking the reassurance of the annual physical.

Is Breakfast the Most Important Meal of the Day?

SOURCE: Jakubowicz K, et al. Diabetes Care 2015;38:1820-1826.

Primary education (grades K-6) teachers have parroted the mantra “breakfast is the most important meal of the day” to children and parents alike for at least 60 years. Although I’m not quite sure whether our grandparents’ teachers also had the same party line, it wouldn’t surprise me in the least. Before continuing further I must confess to my own breakfast pathology: Since my teens, I have happily consumed a 12-ounce Mountain Dew and a Chunky candy bar for breakfast every morning, eschewing coffee or anything that required more preparation than tearing open the single-layer silvery Chunky wrapper. After ingesting this carbohydrate/caffeine concert, I am happy to abstain from further calories until noon or later, after which I employ what you would call “normal” food.

It’s a good thing I don’t have type 2 diabetes (T2DM), because apparently the omission of breakfast wreaks havoc on carbohydrate metabolism later in the day in diabetics. To elucidate the phenomenon further, Jakubowicz et al compared glucose, fatty acid, and glucagon metrics in a population of T2DM patients, half of whom consumed breakfast and the other half did not. All meals were provided to subjects and standardized for caloric content. Subjects were randomly assigned to a crossover-design methodology.

Omission of breakfast was associated with less secretion of insulin and glucagon-like peptide and higher levels of free fatty acids, glucose, and glucagon. In an era where the expanding tools for management of T2DM are accompanied by a comparably expanded price, it’s nice to know that some simple lifestyle measures may enhance the opportunity for glucose control.

Confirming the Value of Total Knee Replacement

SOURCE: Skou ST, et al. N Eng J Med 2015;373:1597-1606.

Since more than 500,000 total knee replacements are performed annually in the United States, it is heartening to review a clinical trial confirming efficacy. After all, it was not so long ago that a clinical trial of knee lavage — an equally well-respected, time-honored, and commonplace orthopedic intervention — failed to show benefit when compared to sham lavage in patients with knee pain and osteoarthritis.

This prospective, controlled trial included 95 patients who were randomized to medical treatment (physical therapy, analgesia, and anti-inflammatory agents) or total knee replacement, which was also followed by medical therapy. Outcomes were measured at 12 months. As measured by the Knee Injury and Osteoarthritis Outcome Score, total knee replacement patients enjoyed significantly greater improvements than medical therapy, although both groups did improve significantly over 12 months. Additionally, because of symptom progression, 26% of subjects originally assigned to medical therapy ultimately underwent surgical intervention during the 12-month interval.

Total knee replacement provides better outcomes for pain, symptoms, activities of daily living, and quality of life than medical therapy alone.