Introduction

Good clinical practice demands comprehensive efforts in disease prevention and health promotion. A key element of this is providing appropriate preventive services to one's patient population.

Periodicity of Physical Exams

The current periodicity of physical exams for most active duty members is every 5 years until age 50, at intervals of 2 years through age 60, then annually after age 60. The exception is for all officers upon their selection to flag or general rank. A complete physical exam for these members shall be performed annually within 30 days of their birth date. More guidance on this type of exam can be found in MANMED 15-14. The routine physical exam should be tailored to a patient's individual risk factors. This is an opportunity to provide counseling on health behaviors and referral for appropriate preventive services.

Controversy and contradiction among major authorities abound regarding recommendations for screening services. Listed below are the screening examinations or services currently recommended for Navy beneficiaries. The current recommendations from the U.S. Preventive Services Task Force (USPSTF) are also given, where significant differences are present.

Skin examination should be performed annually for individuals with a family or personal history of skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions. Physicians should remain alert for skin lesions with malignant features (i.e., asymmetry, border irregularity, color variability, diameter > 6mm, or rapidly changing lesions.)

Colorectal cancer is the third leading cause of death from cancer in the United States. Screening for colorectal cancer is recommended for all persons starting at the age of 50. Fecal occult blood testing and Sigmoidoscopy are effective methods for screening. USPSTF states that there is insufficient evidence to recommend for or against routine screening with digital rectal examination, barium enema, or colonoscopy. However, some organizations (i.e. American Cancer Society) do recommend annual fecal occult blood testing and sigmoidoscopy every 5 years.

Palpation of the thyroid gland should be performed in adults with a history of upper body irradiation.

Beginning at age 18, non-fasting blood cholesterol should be obtained at least every 5 years. USPSTF states that routine periodic cholesterol screening should be performed on all men aged 35-65 and all women aged 45-65, with no recommended periodicity.

Blood pressure screening should be performed at least once every 2 years. Screening should occur annually for patients in the following categories:

• Initial diastolic pressure 85-89 mmHg.

• African-American males.

• Family history of HTN in first degree relative.

• Obesity.

• Diabetes.

For individuals requiring corrective lenses, examination of the eyes should occur at least every 2 years. Otherwise, routine vision screening is performed every 5 years. Comprehensive eye examination should be performed every 3 to 5 years in African Americans aged 20-39 years. For individuals aged 40-64 years of age, vision screening should occur every 2-4 years.

All active duty are routinely screened. Medical department personnel and personnel subject to deployment must have annual HIV testing. Other personnel are tested at their periodic physical exam. It is very important to counsel patients regarding high-risk behaviors and preventive measures.

The following subjects are expected components of good clinical practice and should be integrated into the appropriate patient visit.

Tuberculin skin testing should be performed every 3 years for individuals on active duty, and annually, if deployable, health care worker, or at high risk.

Female Specific Interventions

For women aged 40 and older, an annual clinical exam should be performed. In women under age 40, physicians may elect to perform a clinical breast examination for those who are at high risk. Most authorities recommend baseline mammogram at age 40 years, then every 2 years for age 40-50, and annually for age 50 and over. For high risk women, mammography may start at age 35, and annually thereafter. USPSTF advises routine mammography to be performed alone or with clinical breast exam (CBE) every 1-2 years in women aged 50-69 years. They further state that there is insufficient evidence to recommend for or against routine mammography or CBE for women aged 40-49 or aged 70 or older.

Pelvic examination with Papanicolaou smear should be performed annually on women 18 years and over, until three consecutive satisfactory examinations. Frequency may then be less often at the discretion of the physician, but at least every 3 years.

All women should be counseled on proper intake of calcium and regular exercise, especially in young adulthood.

Family planning, contraceptive counseling, and sexually transmitted disease prevention will be performed during every annual health maintenance examination.

Women are at high risk for both physical and mental abuse. Estimates indicate that up to 1 in 4 emergency room visits by females may be the result of abuse. All female patients should be asked about abuse.

Male Specific Interventions

A clinical testicular exam should be performed annually for males aged 13-39 years, especially those with a history of cryptorchism, orchiopexy, testicular atrophy, or those with history of testis tumor in the contralateral testis. There is disagreement among authorities whether to encourage patients to examine their testes regularly, or to screen low risk men.

Digital rectal examination (DRE) should be part of the periodic health examination of males 40 years and older, and annually for men 50 years and older. This test can be combined with the colorectal examination. Routine use of prostate specific antigen is not recommended. USPSTF now advises against routine prostate screening.

Counseling about violence and abusive behavior should be offered for all male patients.

Final notes on Counseling

Clinicians should focus counseling efforts on encouraging patients to make wise choices regarding tobacco, alcohol and drug use, physical activity, diet, and other personal behaviors. When combined, these factors account for more than 50 percent of all deaths in the U.S. Clinicians should be selective in providing preventive services. Some screening tests are more effective in a specific high-risk group and are of limited value in the general population. Consider cost, availability of follow up, and the patient's interests before performing screening.

Every encounter with a patient can be used as an opportunity to emphasize prevention (i.e. encourage quitting tobacco use or obtaining a mammogram). Apart from direct patient-physician interaction, other opportunities include posters, brochures, or videos with messages on preventive medicine practices placed in clinic and other medical spaces.

References

1. Guide to Clinical Preventive Services, 2^nd Ed., U.S. Preventive Services Task Force, 1995.

2. Clinician’s Handbook of Preventive Services, U.S. Dept of Health and Human Services 1998.

3. TRICARE Prime Clinical Preventive Services Benefits, Dec 1995. Office of the Assistant Secretary of Defense-Health Affairs.

4. Gardner, Pierce, and Schaffner, William, Immunization of Adults, New Engl J Med, 328: 1252., 1993.