November 10, 2015
More than two years ago, the Society for General Internal Medicine (SGIM) released its list of Choosing Wisely® recommendations, which included advising against performing routine general health checks for asymptomatic adults. The rationale behind the recommendation was that “regularly scheduled general health checks without a specific cause, including the ‘health maintenance’ annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.” Unsurprisingly, controversy ensued among primary care physicians who feared that the patient-physician relationship would be harmed by the lack of an annual physical.
I recently had a routine physical with my physician whom I have been seeing for more than 20 years. Although I suffer from the minor aches and pains of being 63 years old—which I suppose could classify me as a symptomatic patient for some ailment—I like to think that I am mostly in “perfect” health.
As I had not seen my physician in several years, I provided her with an update on my medical history (two detached retinas, and tendonitis of the elbow and arthritis of the neck that were treated by physical therapy). I provided the details of two deaths in the family and gave a rundown on current health issues and the need for a flu shot. The visit lasted about 30 minutes and waiting time was less than five minutes.
I received the minimum number of lab tests: I made sure that a PSA test would not be done, per the recommendations of the American College of Preventive Medicine, the American Academy of Family Physicians and the American Urological Association, and my physician did not run a routine CBC. Per the Society of Cardiovascular Computed Tomography’s recommendation, she didn’t ask for a coronary tomography angiography for screening. The physical exam, which included listening to my heart and checking my blood pressure, took five minutes.
In light of the lack of evidence that they are effective, I think the SGIM got the recommendation against annual physical exams right. This recommendation falls in line with the aim of the campaign – to promote care that is supported by evidence. Unfortunately, practices are going to continue to recommend annual physicals and find symptoms to justify them. (Who doesn’t have symptoms of something?) On the bright side, many practices are developing innovations to these regular visits to a primary care physician – they are reviewing the screening tests to see if they are really needed, they are providing more preventive care visits, they are using remote/telemedicine and they are making use of other clinicians in the practice, such as NPs and PAs.
Perhaps, though, it’s not an “all or nothing” choice. Perhaps Choosing Wisely can contribute to a conversation around what the right elements for the annual physical are – what tests and procedures should and should not be performed. Tests that have the lowest probability of yielding positive findings should be eliminated from the portfolio of “possible” tests to perform. My recent visit represented a “lean,” less-wasteful physical; it focused on high-yield tests and the most beneficial exam. Eve Kerr, et al., in a recent blog post on The Conversation.com titled, “Sometimes less is better – so why don’t doctors ‘deintensify’ medical treatment?” introduces the concept of less intense treatment and being aware of the duration of a treatment. By applying the concept of “deintensification,” we can build a more appropriate set of tests and procedures for any physical exam.
Daniel B. Wolfson
EVP and COO, ABIM Foundation