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Thoughts on Annual Physicals and God

February 27, 2011
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A local reporter pulled another fast and loose assumption on unsuspecting readers recently, though this time I’ll cut her some slack. She was merely conveying a conventional belief shared by many other Americans.

The story was very sad. A well-loved perfectly healthy minister, the Rev. Ken Diehm, became suddenly ill and developed a severe headache. Best I can piece together, he had bleeding in his brain causing the headache that was difficult to control. Somewhere along the way they discovered he had acute leukemia causing the bleeding. In spite of aggressive treatment, he died within a day.

The reporter wrote in her story that “[t]he disease had not been detected during his annual physical two weeks earlier.”

This could be dismissed as a throw-away filler line, but it speaks of an erroneous assumption that adds to our exorbitantly expensive healthcare system. If her point was to increase the emotional impact of the story, her description that he was an “. . . avid bicyclist and sports enthusiast [who] was ‘young and physically fit” sufficed. Mentioning the annual physical didn’t make him any healthier.

It has long been recognized in the U.S. and Canada that an annual physical is useless. Specifically I’m talking about the actual physical examination. For me to spend time with a patient who has no significant symptoms probing her ears, throat, and other more personal orifices is a colossal waste of both of our time and resources (except for occasional Pap smears). I’m sure a few doctors and patients can tell stories about an abnormality that was detected in an annual physical that turned out to be something serious. This anecdote assumes early detection changes the final outcome, which is often an erroneous assumption (read the Special Interests and POEM tabs on my blog for a longer explanation). These anecdotes also discount the impact and harm of false positive findings that occur much more often.

My deeper concern is the false hope of control implied in the statement. The reporter assumed that if acute leukemia was detected two weeks earlier, the minister could have been cured even before his symptoms started. There of course is no evidence that any physical examination or blood test saves lives in asymptomatic people with leukemia.

I am not suggesting a periodic visit to a physician isn’t worthwhile. I am suggesting that much more is gained focusing the clinic visit time on talking with your doctor and targeting tests and interventions based on clear risk factors. If I were king of the medical universe I would rid the lexicon of “annual physical” and replace it with “periodic conversation.” The latter phrase is a much more accurate description of the useful part of a wellness visit. Some patients such as healthy young men have little reason to see doctors unless they have issues to discuss.

The irony of the annual physical statement is its placement in the story of the death of a Christian minister. The obituary told many stories of his inspiring works and how his faith touched others, but nothing of how his faith informed an understanding of the meaning and greater hope inherent in his death.

If I may take off my secular physician hat for a moment and offer a thought from his (and my) faith:

For I am already being poured out like a drink offering, and the time has come for my departure. I have fought the good fight, I have finished the race, I have kept the faith. Now there is in store for me the crown of righteousness, which the Lord, the righteous Judge, will award to me on that day–and not only to me, but also to all who have longed for his appearing.  2 Timothy 4:6-8

I have no idea why Rev. Diehm’s race ended a few days ago. But I do know God promises a long and healthy life to no one.

The U.S. spends 2.6 trillion dollars a year on healthcare and hundreds of billions of this total is spent trying to delay our inevitable passing from this existence to the next. We fear death as a society and spend lots of other people’s money attempting to postpone our mortality. Those resources could go to other uses.

We wish we could control when and under what circumstances we die but we can’t, and annual physicals – and many other tests and interventions that are commonly provided — change this reality extremely little, and in many cases not at all.

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4 Responses to Thoughts on Annual Physicals and God

  1. Aaron Segal MD on February 28, 2011 at 6:02 pm

    I’ve counseled so many patients that the annual physical isn’t going to detect every subclinical disease taking over their bodies. It’s (currently) the only reimbursable method for me to sit down and have a lengthy conversation about interval changes in their health, to determine which preventable diseases they are most at risk for, and to discuss measures to reduce their risk of those diseases.
    My sun-worshipers, and fair-skinned patients get a head to toe skin examination – that takes some time. If I don’t find any abnormal moles – I wouldn’t get paid for that except at a “Checkup.”
    Discussing STD prevention (rather than treating an STD) is only paid at a preventive visit.
    Since clinically important diagnoses such as “obesity” and “overweight” are never reimbursed these days, when else can I get paid to spend sufficient time counseling on calorie-counting, aerobic exercise, and weight-management? Only during a preventive visit.
    And, while there seems to be a lack of data proving that “checkups” improve health-outcomes, I think about the thyroid nodules and skin cancers that would not likely have ever surfaced in a “problem oriented” visit. How many patients would never have been properly vaccinated, or had their bone-densitometry if we didn’t have a chance to sit down and let the doctor run the visit for a change…

    I don’t believe that a 5 minute examination and a set of labwork is a “physical.”
    We try to tailor our preventive recommendations to each patient, and that often requires additional counseling (“Let me explain why I don’t think we should do a screening stress-test/whole-body-MRI/ankle-ultrasound-bone-density/etc…”)

    So, if I could actually get paid to review the chart and provide a little preventive care and counseling at other visits, then MAYBE some of my patients could go without an annual checkup.

    But it’s unfair to expect physicians to provide tailored preventive care at every visit (or between visits) without paying us for that work. And since I’m very skeptical that all this “medical home” talk will really lead to fair payment for “background” services, the annual physical remains important to me.
    visits.

    It’s interesting to me: When I see a sick or injured patient in the office, there are very specific documentation guidelines that dictate what I must record in order to get paid.
    I’ve been unable to find any guidelines at all to define a preventive visit.
    I suspect that instead of the 60-minute visits we currently schedule for preventive exams, I could probably chat with my patient for 15 minutes about something “preventive” and still bill for the same visit.

    So, if we could lay out better expectations of what a check-up is intended to do, I think we could better demonstrate the utility of these visits – both to patients and payers.

    • Richard Young MD on February 28, 2011 at 10:13 pm

      Aaron,

      Thanks for your thoughts. Once again we are discussing work family physicians provide that goes unpaid unless we play games with the existing system. However, as we think about what a better payment system would look like, we should support being paid for spending time with patients that lead to something effective and relatively cost-effective such as explaining to an anxious high-risk patient why a flu and pneumonia shot is a good idea. But we shouldn’t support being paid for time not well spent, such as brief counseling for weight loss (Cochrane review found it to be worthless).

      One concrete change in the current Medicare E/M billing rules should be that we can be paid without doing any physical exam (though let’s recognize we do examine our patients just by making eye contact, shaking their hand, listening to their speech, and watching them walk in and out of the room).

  2. Dr Synonymous on March 2, 2011 at 8:44 pm

    Great post and important comment from Aaron. I’m a family physician. We indeed have the wrong business model for a relationship based specialty such as family medicine. The title Annual Physical has to be replaced in the brains of our patients to something like periodic health re-alignment or premature demise prevention visit for physicians to have satisfaction helping people to align with a better future (or less often, celebrating their good health and choices with them). We’re trapped again with something, wrong terminology for what we really perceive to be helpful, possibly of our own doing. The “Payment” Centered Medical Home isn’t going to deliver the best for the patient either.
    The message of the Bible verse, or similar faith statements in other religious writings, however, is huge in patient understandings . I find that part of the post the most helpful. As people (at least our seniors who receive a lot of the $2.6T referred to by Dr Young) align with their perceived ultimate life/spirit trajectory, the end of life component of the periodic conversation, when appropriate, may allow patients to teach us about a different kind of hope and outcomes that they desire; outcomes that preclude the last couple visits to the ER and the last few CT scans or the last two doses of chemotherapy that were futile. Let’s remember to peer beyond Cochrane and see our patients and our nation asking for something better than just more numbers and more technology. God does seem to have something to say about it. Our patients might already be listening. We might be helpful if we listen, too, and clarify how the patients physical and spiritual expectation aligns with our (non)system.

    • Richard Young MD on March 6, 2011 at 8:25 pm

      Dr. Synonymous,

      Thanks for the kind words. The Bible verse was a stretch for me. I’ve never tried that before. I’m not trying to push my religious views on anyone else, but anyone interested in meaningful healthcare reform in the U.S. must acknowledge the powerful role religion plays in our healthcare system that is not nearly as prevalent in Europe. Any U.S. healthcare reform proposal that does not factor in the role of religion is doomed to failure.

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