Response to CMR Revisions
January 30, 2017
My name is Tom Groblewski. I am an Osteopathic Family Medicine physician from Beverly, MA, and I am currently the Statewide Medical Director for Massachusetts Partnership for Correctional Healthcare.
I am both an administrator and a practicing physician. I began practicing in 1995; I have focused on correctional healthcare since 2005. My patients and my practice are affected by 105 CMR 205.000.
First, I want to extend my strong general support for the proposed amendments which, in my opinion, represent a logical, evidence-based upgrade to this very important set of standards.
With the exception of the Complete Blood Count (CBC) blood test (205.200 (D) (1)), I agree with the proposed amendments.
Incarcerated patients come into our security system with a wide range of medical histories and problems. Some are acutely ill, some have labile chronic diseases, and some have no active medical issues.
To provide the safest entry for each individual patient in the group of thousands which comes into our system each year, the Intake Physical Exam has to be both thorough and flexible. Thorough to capture and focus on pertinent positives and negatives, and flexible to allow variation, as clinically appropriate, from one patient care plan to another.
This balance is best struck by using a Targeted Assessment approach, as is proposed in the amendments.
Physical examinations of asymptomatic patients should consist of those elements shown to have an impact on mortality and morbidity. Based on recommendations of the American Academy of Family Physicians, (AAFP), these include:
a. Blood pressure
b. BMI
c. Age appropriate screening for cervical cancer, colon cancer, and breast cancer.
Summary of Recommendations for Clinical Preventive Services, January 2017, AAFP Policy Action November 1996, January 2017· Order No. 1968
Patients with specific complaints or problems, such as abdominal pain, musculoskeletal pain, and/ or chronic disease(s), should have an appropriate detailed examination targeted to the relevant area(s) and documented similarly. Ancillary basic evaluation of areas of the body related to the area of complaint may be appropriate. Positive findings must be documented completely and followed to successful resolution during the period of incarceration. Examination of areas totally unrelated to the area of patient complaint is discouraged, and may even be harmful.
Similarly, as reported by Kenneth Lin, MD, in American Family Physician, “screening CBCs and urinalyses waste time and money, interfere with providing worthwhile tests, and may end up doing more harm than good.”
KENNETH W. LIN, MD, Agency for Healthcare Research and Quality, Rockville, Maryland., MARGUERITE R. DUANE, MD, MHA, Columbia Road Health Services, Washington, D.C., Am Fam Physician. 2007 Aug 1;76(3):351-352.
A 2012 Cochrane Review of General Health Checks in Adults for Reducing Morbidity and Mortality from Disease found:
“General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.”
Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD009009. DOI: 10.1002/14651858.CD009009.pub2.
In summary, I strongly support the proposed amendments, with the notable exception of the Complete Blood Count (CBC) blood test (205.200 (D) (1)), for which I can find no published, evidence-based support, and which can be easily obtained when clinically indicated.
The rest of the proposed amendments represent a thoughtful, evidence-based approach to the Intake Physical Exam.
Respectfully submitted,
Thomas A. Groblewski, DO
Statewide Medical Director, Massachusetts Partnership for Correctional Healthcare
110 Turnpike Road, Suite 308, Westborough, MA 01581