The Relationship: Medicine Is Both Art and Science
The Question: Questioning the value of the annual physical exam for “healthy,” or asymptomatic, adults is nothing new, but the issue assumes greater significance in the current era of limited resources and the growing status of evidence-based care. Last month, The New England Journal of Medicine’s “Perspective” was devoted to the pros and cons of eliminating this time-honored, but poorly evidenced, practice. Before discussing these pieces, it seems only fair to tip my hand and admit I am (empirically, subjectively, limbicly) in favor of the annual check in with one’s PCP – whether one “needs” it, or not.
The authors of both articles agree that the lack of standardization in the annual exam makes the epidemiological research weaker, i.e., lack of evidence does not mean there could not be a benefit from the well-considered, “periodic health examination.”
The Arguments: The “evidence” is certainly on the side of eliminating this ritual, an annual, highly variable event that seems directed and driven by payment structures and has shown no effect on morbidity or mortality. While not the most costly, it is the most frequent type of visit in the US, costing in excess of $10 billion per year and using up about 10 percent of all primary care outpatient visits. Given the scarcity of primary care access and health care dollars, eliminating this practice would seem a “no-brainer” – right?
What about the relationship? What about preventive care and screening? What about health counseling? What about routine labs and tests? It couldn’t hurt – right?
There is no evidence for the annual exam improving or establishing a therapeutic relationship. It is also not conclusive that screening leads to treatable, previously unsuspected diagnoses in the asymptomatic, or that annual exams lead to more preventive measures, such as smoking cessation or appropriate immunizations. And, it is well established that if you do enough tests on the asymptomatic, some will be positive, and most likely those will be false positives, leading to further tests or procedures and greater risk for iatrogenic disease. So it seems like we should protect healthy adults from inappropriate contact with the healthcare system – right?
Well, not exactly. How do we define “inappropriate?” Here’s where the mechanical argument turns more organic – more “behavioral,” if you will.
Facing a lack of evidence, go with reasoning
The authors of both articles agree that the lack of standardization in the annual exam makes the epidemiological research weaker, i.e., lack of evidence does not mean there could not be a benefit from the well-considered, “periodic health examination.” While the suggestion is put forth that general health issues could be addressed during problem-focused visits, this approach is countered by the time constraints and the many guideline-driven (pay-for-performance) demands for these chronic or episodic visits.
I would also offer the concern that the “asymptomatic” may not have any episodic visits; rather than serve up a list of questions at the annual visit, should they have to make multiple appointments to address concerns as they arise? Or, should they wait until they have symptoms even they cannot deny? How do we know who is asymptomatic? The Alzheimer’s Association feels strongly that routine cognitive testing in older adults is important to address cognitive issues early on. [In my practice, I try to see my asymptomatic patients with bipolar disorder on a regular basis “whether they need it or not,” because when they feel too good to come in, it’s a problem!] Another example of “asymptomatic” is the active, middle-aged male with a family history of coronary heart disease and a weight gain of roughly 10 pounds a decade. Should he just wait until he has his heart attack? It may seem obvious, but the power of caring and serious advice or comments from one’s physician cannot be overestimated.
The article by Dr. Allan Gorroll, in favor of keeping the periodic visit, is pragmatic, humanistic and beyond nostalgic. He offers a number of actionable items, in keeping with the movement towards patient-centered medical homes, medical care teams, integrated care, etc. It is a concise, two-page read that promotes the involvement of a team of providers, each contributing at “their highest level of training and certification,” with the physician freed from “providing the more commoditized elements of care,” able to access all the gathered information (in an electronic medical record), and focus with the patient in a more in-depth and comprehensive review. He also notes that the interval might be longer than a year for the young and healthy, but frequent enough to maintain the relationship and hone in on age-specific life events and stresses.
This approach would meet the needs of health care maintenance, prevention, screening, and relationship-building. It’s well worth reading.