Near the end of our visit, my new patient looked perplexed.
"Aren't you going to do a head-to-toe exam? My previous doctor always did," he said. "She was very thoughtful."
Different HIV providers have different clinical styles. Some are primary care docs, too, and some focus only on HIV. Some adopt new antiretrovirals as soon as they are presented at CROI, while others wait for the data to be published.
The annual physical examination is an area where different providers do things differently.
Many were taught that conducting a careful annual comprehensive physical examination is nearly synonymous with good care: That's how to detect hidden cancers and other lurking menaces.
Outside of HIV, this practice is being questioned. Following a skeptical 2011 Veterans Affairs review and a 2013 Cochrane review that found no benefit from comprehensive annual physical exams, a 2015 New England Journal of Medicine editorial argued, "[I]t is evidence-based prevention that's key, and the annual physical is not evidence-based…. [I]t's time to act on this evidence and stop wasting precious primary care time[.]"
Are yearly comprehensive physical exams a waste of time in people with HIV, or do higher rates of cancer and other clinical conditions merit more intense screening?
Clinical practice guidelines don't put this to rest.
Some guidelines urge comprehensive annual exams. The 2014 Health Resources and Services Administration guideline -- which guides care in all federally funded HIV clinics -- says providers should assess vitals, weight, general appearance and habitus, skin, oropharynx, lymph nodes, heart and lungs, abdomen and neurologic and psychiatric condition at least every three to four months. New York State primary care guidelines recommend a comprehensive physical every year.
By contrast, the British HIV Association recommends a targeted physical exam "guided by symptoms" every three to six months. Instead of examining every part of the body routinely, examine only the parts that symptoms suggest should be examined. For example, the abdomen if the patient has an upset stomach, the lungs if they are coughing. Additionally, the 2013 HIV primary care guidelines urge an initial comprehensive physical examination followed by proven measures such as sexually transmitted infection (STI) screens and vaccines at subsequent visits.
It's clear we need more data. Fortunately, a new study brings some.
In a retrospective chart review in PLOS ONE, Dutch authors assess the clinical value of yearly physical examinations among 299 adult HIV patients. They studied healthy, stable HIV patients: Patients seen in clinic in 2010 with CD4 counts greater than 350 cells/mm3 off antiretroviral therapy (ART) or undetectable viral loads and CD4 greater than 100 cells/mm3 on ART. Patients with hepatitis B or C; extra visits due to new complaints, pregnancy or recent ART changes; or (for unclear reasons) transgender identity were excluded. The authors recorded the new detection of malignancy or any other life-threatening abnormality on annual routine physical examinations documented by an infectious diseases physician between 2010 and 2014.
Fully 215 of 299 patients (72%) had abnormalities noted on physical examination. Two-thirds of those abnormalities were previously known or clinically expected. Examples include known lipodystrophy or high blood pressure. Some physical examination findings were new but deemed clinically minor, such as anal skin tags, incisional hernias and poor dentition.
Thirty-three patients (11%) had a new and clinically significant physical examination findings. These included a genital ulcer from syphilis and rectal condyloma accuminata. Seven of the 33 patients with new physical examination findings were newly diagnosed with an STI, only three of which were found on routine screening. None of the 299 adults with HIV who underwent documented comprehensive yearly physical examination were found to have a new life-threatening diagnosis, except (possibly) for a patient with bradycardia who received a pacemaker.
The authors summarized: "We showed that an annual routine physical examination in HIV-infected patients with stable disease revealed few new diagnoses that would not have been found without these examinations." This is true. The few significant findings the study listed would have been detected in a faster, more-targeted work up.
The authors go farther, however, writing, "a routine thorough physical examination is unnecessary." This goes too far. A larger study with more than 299 patients included might have revealed a lymphoma or heart murmur or Kaposi sarcoma, all conditions we'd be glad to detect. Also, the authors also seem to undervalue identifying non-lethal conditions such as STIs. I'm glad to cure my patients of these -- and to prevent transmission.
Back in clinic, I did a thorough examination at my patient's request. Then, we discussed how different providers are different and why I usually conduct targeted exams. We talked; we negotiated, and I'm glad we did. That's what best practice looks like when the data aren't yet clear.
Tim Lahey, M.D., M.M.Sc., is an HIV doctor at Dartmouth-Hitchcock Medical Center where he researches tuberculosis vaccines and is the chair of the clinical ethics committee. He is director of education at The Dartmouth Institute for Health Practice & Clinical Practice. Prior articles have appeared in The Atlantic, Scientific American and The New York Times.