In January, Ezekiel Emanuel – one of the country’s foremost health experts – threw a presumptive grenade into the national discourse: the annual physical is worthless. As we watched the initial burst of reactionary fervor following hisNew York Times opinion piece, we weren’t quite sure what to think.
Then we realized why: in our training and burgeoning careers in primary care, neither of us has ever scheduled an “annual physical” for a patient. To us, the notion of such a visit – for scheduled, non-urgent care, and one not specifically for chronic disease management – is already dated. Given current trends in American health care delivery and professional training, we argue it is one that may well soon be obsolete.
But does that obsolescence change the value of that time – whether 15 minutes or 60 – with a patient, on a regular interval? Our perspective from medicine’s emerging front line offers a resounding no.
The most obvious argument for regular primary care visits is preventive care. Dr. Emanuel bases much of his argument on the validity (or lack thereof) of annual physicals. Drawing off that same evidence base, the U.S. Preventive Services Task Force sets recommendations for evidence-based screening in various populations. Even the young and healthy benefit from cervical cancer screening, initiated at 21 years of age and continued every three years provided negative results until the age of 30 (when the recommendations change slightly). Patients with higher risk earn further screenings, based on whether they smoke, their weight, their age and their family history.
As American medicine shifts away from volume-based reimbursement, we have learned – from the outset of our practice – to not order testing indiscriminately, but instead to choose wisely. Judicious application of validated preventive screens offers societal value – even though, to Dr. Emanuel’s point, we must weigh the downstream implications of that testing as we deliver care. Listening to heart sounds and checking reflexes may not have value, as he suggests – but then again, we are part of a generation taught not to reflexively order echocardiography for every aberrant noise we hear. The value proposition of preventive screening, then, may be shifting in favor of its utility.
The larger, more subtle argument, though, rests on the value of the patient-provider (and care team) relationship – one that is increasingly quantifiable. It’s true that in the 10 minute appointments so often seen in primary care, we can’t – and don’t – fit everything important into the visit. Many practices ask providers and patients to agree on 2-3 issues to discuss per visit. The important questions of alcohol use, depression, food and housing access, and other life stresses are usually deferred. Care teams’ understanding of those issues, however, is critical to providing good care. Recently, at a ‘wellness’ visit, a colleague discovered her patient did not understand why he was taking his blood pressure medications and aspirin, and also did not understand what blood pressure actually is. He has been her patient for two years. To have the time to explain that high blood pressure alone is asymptomatic and to gain increased insight into a patient’s health literacy will provide benefits longitudinally in that patient’s care, as we’ve seen from recent pilots that enable certain patients – particularly the sickest of the sick – that critical time. From both that evidence and our own experiences in novel primary care delivery models (such as the Veterans Healthcare Administration’s Patient Aligned Care Teams and the ambulatory ICU), we know this information is rarely captured in one or two visits.
The same is true when we consider planning for end of life care and setting personal goals of care – another effort best accomplished within an established, trusted relationship. Some of the most impressive end of life care may be in Shiprock, New Mexico on the Navajo reservation. Physicians there take care of their patients across the spectrum of care – from the clinic to the ICU. People die with their families around them, peacefully, and often without ventilators and aggressive interventions. This can almost fully be attributed to the indelible patient-provider relationships in that community.
Strong relationships between patients and care teams have the potential to motivate and empower individuals to better manage their health – either through preventive measures or chronic disease management. At Iora Health, each patient is assigned a health coach who works with them to meet their needs and better their health. The Iora practices have met their patients where they are in order to help them take charge of their own health. This includes “drive-by” lab checks for patients on blood-thinning medications who did not have more than a couple minutes to stop at the clinic due to work and family obligations. Patients call their health coaches with questions and clarifications and are able to access a health coach or physician at any time.
As a profession, we need to change the way we portray and practice primary care in the U.S. The notion of an “annual physical” as an appointment where a full exam is done and an array of non-specific tests ordered should be diffused. Rather, people should know their health care team and view them as partners and enablers to better health. Individuals should feel that the exams done and tests ordered are tailored to their particular needs. Work remains to be done – but the progress being made in pockets across America gives hope that we can achieve that lofty goal.
Telling the public to skip their annual physicals sends the wrong message. The upfront, unyielding investment in people and relationships – supporting topics as wide ranging as smoking cessation, housing insecurity and the struggles of raising children – will save innumerable dollars downstream. Primary care practices connected with and imbedded in communities in meaningful ways, where visits are a driver of change, not revenue, will achieve the impact that the annual physical initially aimed to effect.
In an era where we are moving the proverbial needle in reducing disparities in access to care, with millions of uninsured Americans finally entering the health care system, let’s focus on thoughtful, nuanced medical care that prioritizes relationships above all else. To attack the annual physical as low-value misses the emerging point: that the value is in the partnership created – and that that partnership is worth all the time in the world.
Ali Khan, MD, MPP is a clinician-innovator at Iora Health and a clinical instructor of medicine at Yale. He currently serves as the chair of the American College of Physicians’ National Council of Resident/Fellow Members.
Leah Marcotte, MD is a senior medicine resident at the University of Washington. As a medical student at Penn, she served as a fellow at the Office of the National Coordinator for Health Information Technology. Among her varied policy pursuits, she serves as an associate editor for the journal Health Care.
The views expressed here are those of the authors and do not necessarily reflect those of any of the affiliated organizations, including Iora Health, the American College of Physicians, Yale University and the University of Washington.