Q: “What is a well person?”
A: “A well person is a patient who has not been completely worked up.”
As I enter the exam room, a smiling 10-year-old boy greets me. Pete, my last patient of a long day, is here for his annual well visit. I chat with him about his life — home, school, nutrition, exercise, sleep, etc. — and I’m struck by something. Pete is really well. He’s well-fed (but not too much), active and well-rested, and, most importantly, he’s happy. He has not been to see me in an entire year, and only comes in for preventive health counseling. I think back on my entire day… and on my whole week. Pete is different from every other child I have seen this week. He is, in fact, the only truly “well” child I have seen in a long, long time. And I wonder — is he the last?
I’ve begun this post with a short riff on Dr. Clifton Meador’s satirical masterpiece, “The Last Well Person,” published in the New England Journal of Medicine in 1994. Meador profiles a 53-year-old man he imagines to be the last known truly “well” person in the U.S. in 1998. The patient is subjected to every known evaluation and found to be basically undiagnosable. I reflect on this story each day as I enter one examination room after another, visiting with patients (and their families) in my pediatric practice.
Sadly, the story of “Pete” is real. I no longer see many well kids even though I am a primary care pediatrician, dedicated to keeping kids healthy. Yes, I devote much of my time to counseling parents about lifestyle choices (e.g., nutrition, exercise, play, rest, sleep) to promote wellness and prevent disease. Still, each and every encounter must be “coded” with a numerical set of instructions based on diagnoses (associated with disease states) so that I can get reimbursed for the care I deliver. My ability to keep my office open (so that I can continue to try and help families keep their children healthy) is predicated on my skill in playing this diagnostic code game.
Are there “well child” codes? Yes, thankfully. But they do not pay as well per block of time as my “sick visit” codes. I am better off financially if I see more sick kids per day — assuming I assign the most appropriate high-level codes to these visits — than spending my time focusing on preventive counseling. Not that these children are better off. In the long run, they will be subjected to more and more medical care for their asthma, diabetes, ADHD, or whatever chronic illness they develop.
Meador’s thesis — that the practice of medicine has become consumed by creating and labeling conditions that do not truly reflect illness — is a cautionary tale, more true today than ever before. This epidemic of overdiagnosis and overtreatment, created by a disease-treatment system dressed in health care system’s clothing, is a self-perpetuating Mobius strip leading to a sicker America. What are the costs — real and opportunity — of a system in which everyone is, well, “un-well”?
Doctors from the Center for Child and Adolescent Health Policy at Boston’s MassGeneral Hospital for Children wrote:
The number of children and youth in the United States with chronic health conditions (a health condition that lasts >12 months or at time of diagnosis is likely to have a duration of >12 months) has increased dramatically in the past four decades … Health and social welfare systems are unprepared for the rapid growth in demands that will arise from these epidemics, and major increases in public expenditures should be planned for in the near term. For the longer term, the epidemic growth of childhood chronic conditions calls for major efforts to understand causation and means of prevention.
The debate rages as to why more children are diagnosed with chronic health conditions. Better diagnosing? More ill kids due to environmental factors? Both? While I do not agree we are “better” at diagnosing, I do think we are better at labeling. There’s a subtle difference.
Over the past 20 years, we have shifted the curve to include more children in certain diagnostic categories. Why? Because more diagnoses equal more money. More for hospitals and physicians who diagnose and treat, more for insurance companies who can charge higher premiums based on covering a sicker population, and more for pharmaceutical companies who make the drugs we increasingly use to treat. We are spending more money per child to perform diagnostic tests and treat health ills due to chronic conditions that could have been prevented in the first place.
Some of these conditions are not necessarily illnesses, in fact. I took issue with an article published last year in Pediatrics, my guild’s preeminent scientific journal, regarding the treatment of elevated cholesterol in children with statin medications. Before we start advocating the prescription of these heavy-duty medications for young children, shouldn’t we first establish that the benefit of the treatment outweighs its risk? Or even that the risk of the disease is outweighed by the risk of the treatment? My colleagues will argue there are cases of children with genetically-predisposed extreme elevations in cholesterol, placing these kids at tremendous risk for premature catastrophic cardiovascular events (heart attacks, strokes). Agreed — but these cases are really rare. Most children with cholesterol numbers higher than a given number (used to be 200, now it’s 170: more shifting the curve) are diagnosed with “hypercholesterolemia.” But is this diagnosis actually correlated in most cases with any true disease? And if it is — if it’s a risk factor for early heart disease, for example — shouldn’t we first consider safer, more effective and more cost-efficient alternatives, such as dietary change and exercise? This one example exemplifies the mess we’ve created by economically and morally incentivizing a disease-treatment system.
These challenges are not insurmountable. I prefer to think of them as opportunities for sustainable change. We must look to our own communities and study small-scale prevention models that are working. There are numerous integrative, intergenerational, ground-up programs that break down traditional silos and involve multiple segments of the community. I’ll be profiling these models in future posts, hoping that their stories motivate others to take notice. I sincerely hope that we, as a society, wake up and recognize the costs of the problem-based disease culture we’ve created. It’s not too late. I don’t really believe my patient Pete is unique. But we must resist labeling and treating our children for conditions resulting from ill-fated attempts to shoehorn them into increasingly stressful and restrictive environments. What will it take to move to a strength-based model of care, in which we promote and celebrate what’s right with each child? Imagine that.
Next week, each and every time I enter an exam room, I’m going to look for more “Petes.” Me: “Good morning, Mrs. Jones. Can you tell me what’s right with your child today?” I’m going to lead with that, because I don’t really believe that I’ve seen the last well child.
 Perrin JM, Bloom SR, Gortmaker SL. “Increasing childhood chronic conditions in the United States.” JAMA. 2007;297:2755-2759. Link.
Dr. Rosen is an integrative pediatrician based in Oradell, NJ. This article previously appeared in the athenahealth blog.
I would also add, as a long-time specialist in EMR systems design evalaution, that there is a strong perverse incentive against finding well patients, designed into most EMR screen prompts. These modules are built to remind the practitioner to fill in enough codes, data points, follow-up plans etc. in many EHR systems. Leaving fields blank and writing a note that “this kid is happy, healthy, and well”, will often get you multiple screens asking you to confirm that you’re leaving all of the coding and escalation fields clear, on purpose.
I just gave birth to my second daughter and was amazed at how little preventative care was given and how the expectation was that there would be pathology. I was scheduled for a c-section “just in case” when there was no real reason not to deliver vaginally. I was prescribed Zofran for nausea, but was not told about the benefits of acupuncture, which in the end was the only thing that helped me keep food down. What was noticeable to me was when I got PUPPP, a skin irritation near the end of pregnancy that is highly annoying, but not harmful. I was told to take Benadryl by the doctors to just alleviate the symptoms and let me sleep. I had 5 weeks of pregnancy left and would likely be on the Benadryl that whole time. Online I learned that a particular soap from Whole Foods would clear it up and it worked like a charm. When I shared this news, nurses were highly interested in finding out the name of the soap, what was in it, writing down all the information. The doctors didn’t seem to care at all.
And the most educated, wealthiest women are often choosing to birth at home now as a result of over-medicalized hospital births. A friend of mine who is an OB, but believes in low intervention births, says that this is tragic. She has worked in places like Afghanistan and Guatemala. she says that the women in these places would give their right arm in order to give birth in a hospital setting. And yet our hospitals here in the U.S. are pushing people away.
I’m not sure what the policy solutions could be, but I agree with you completely.
Allison – thanks for sharing your story. Sadly, it’s a common one these days. In addition to advocating for true preventive/wellness care, I also practice integrative medicine and just wrote a book (Treatment Alternatives for Children) discussing safe and effective natural solutions for common issues. Acupuncture is very effective for nausea/vomiting and headaches.
Great post. this should be required reading for kids coming out of med school.
Parents too …
Peter1 – you would think, and maybe ultimately this will happen via PCMH models but for now, no. What we’ve seen is simply this: patient has no copay for well visit but insurance co. pays us same amount. translation: we get paid LESS for same visit now. good for families, bad for primary care docs.
Dr. Rosen, This should happen now. You should contact your contracted payers and find out why they are not paying the full amount on the claim (perhaps you are not using the correct CPTs…).
The ACA law regarding preventive care is a prohibition on payers to impose any cost-sharing for certain services, not an imposition on physicians to wave the patient responsibility portion for the same.
Margalit – We are using the correct CPT’s but despite the complete drop-off in well visit copays, our payers are not paying a different fee schedule for well visits. I am having my staff sift thru data this yr vs. last to compare but do you have resources/links for me as I contact payers?
Doesn’t the ACA pay more for preventive – assuming that would mean “well” patients?
Thank you for this.