On one hand, the 2013 “Choosing Wisely” campaign sponsored by the Society of General Internal Medicine recommended against preventive examinations in asymptomatic patients (that is, those showing no symptoms). This is old news because the
Canadian Task Force on the Periodic Health Examination recommended “that the annual checkup, as practiced almost ritualistically for several decades in North America, be abandoned.”
About one-third of adults receive an annual physical currently. The content of the “annual” physical is not standardized. Even considering the heterogeneity of periodic exams, two large reviews of physical exams showed no reduced morbidity or mortality. Surprisingly and disconcertingly, annual physical exams may be harmful. “False positives” arise in asymptomatic people which when further explored or treated create problems. Asymptomatic thyroid nodules are an example of this false positive phenomenon.
On the other hand, people’s desire to form a trusting relationship with a physician—which has been shown to benefit functional status, patient satisfaction, and compliance—is very real as more and more patients seek concierge physicians. The growth of concierge practices locally supports this assumption.
Also supporting the patient-physician relationship is a progressive Medicare policy that covers (under Part B) an annual “Wellness” visit with your physician. The visit includes a health risk assessment, personalized health advice, and a screening schedule for appropriate preventive services.
There is a challenge facing primary care physicians who are time-pressured. One answer is to use a multidisciplinary team-based approach, exemplified by the patient-centered medical home model. In this approach, many of the time-consuming tasks (such as medication renewals, immunizations, screening tests, and basic documentation) are completed by non-physician team members and free up the physician to build and sustain a trusting relationship with the patient.
In this improved team-based annual or periodic visit, the physician would review all the information collected by team members, inquire about the patient’s life status as pertinent to health and well-being, and then review all the findings. The summation of the visit would include plans for the coming year with objective and measurable goals.
In young healthy adults with health-conscious lifestyles, the interval between such visits might be longer than a year but still short enough to maintain a trusting relationship. Non-physician providers could be very effective in maintaining these relationships. For older patients with multiple medical problems, the team headed by a physician, and a shorter interval between visits would be more appropriate.
Payment and practice reforms directed by Medicare, Medicaid, and most of the large commercial insurers have the shared federally mandated goal of having most payments for value and eliminating the current fee-for-service system which has been in place for decades. This profound change will surely alter the way primary care is practiced.
Turning the annual physical exam into a team-based annual health review represents an opportunity to migrate from a repair shop mentality to prevention. Prevention is clearly better for patients, society, caregivers, and even the payers as quality of life improves and costs decrease.
At the end of the day, the traditional annual exam performed by a physician should change with a focus on building and sustaining a relationship, prevention, and employing a team with each team member practicing at his/her highest level of training and competence.
Helping everyone live a longer, happier, and healthier life is a goal with which we all agree. We are simply debating how best to achieve it.