What Zeke Missed on an Annual Physical

flying cadeuciiIn 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.

46 replies »

  1. This is an interesting debate; the annual health physical is worthless? That is quite a shock coming from one of the country’s foremost health experts. I thought annual health physicals were important in preventative care. I foresee that if annual health physicals become obsolete, there would be a much higher cost for diseases that could have been prevented.

  2. Bravo, Leah and Ali.

    Proactive primary care offers the chance to support health, not just respond to presenting issues. Routine care is a significant opportunity to inform and affect health. It is surprising to see the range of comments suggesting there may or may not be value in the annual. I suggest readers consider a world with no routine care, only reactive care in illness or crisis. How much of that higher cost care (often provided in the walls of a hospital) could be prevented? It is not just routine dental care that is of value.

    In infants we look at stages of development during routine physicals and proactively address developmental delays. In older adults we may look at functional and/or cognitive decline in order to respond with changes to treatment, inclusion of social supports and services, and advance care planning.

    And how else is your provider to know you have changed when they have no baseline? Is it dementia or (sudden onset) delirium, for example? There is value in routine pro-active care.

    And Leah, I wish you the very best. UW is so lucky to have you. Amy

  3. Well, we unequivocally know that it is important for some of health care to have periodic examinations. That “some” is dentistry.

  4. The physician – patient interaction will need to change due to value based payment models. Former standard practices like the annual physical will give way to more evidenced based care, with better data driven clinical content, deployed by more efficient care teams. As a physician, I can envision this leading to more productive physician-patient communication.

  5. Ali’s and Leah’s best recommendation is the notion of diffusing many (but not all) of the activities often conducted at an annual physical throughout the care process — for example, conversations between physicians and patients over such critical issues as healthful lifestyle habits, or even end-of-life; reviewing immunizations; determining the need for preventive measures or screening exams. The new care models such as Iora’s, plus regular electronic health record or registry reviews followed up by patient reminders, should allow those aspects of care to occur on a continuous basis, and outside the context of a single annual encounter.

    We can’t discount the fact that the now anachronistic annual physical arose in an earlier era before these newer technologies and approaches were available, and was at least part a way to make primary care somewhat more financially sustainable (bring the patient in whether or not he or she needs to be seen) at a time when so many other incentives were driving in the other direction. Good for Zeke for calling for change; also good for Ali and Leah for underscoring the importance of new care models.

  6. Who has quantified the value of the patient-providers relationship(s)?

  7. Physickal would have been a better match for Ezekiel, wouldn’t it? ; )

  8. William, that ‘s the failure of HDHPs . People buy them because that’s all the premium they can afford, not because they’re prepared to fork over the deductibles.

    If the huge deductible is due in the first or second year of the plan insured may not have the war chest saved to pay them – if they ever save for that hurricane day.

  9. “but I believe the ACA might allow people to combine a direct-pay primary care plan — like Doc Rob’s practice — with a high-deductible catastrophic coverage plan.”

    I don’t think it’s up to ACA is it? ACA is not an insurance plan. If an insurance carrier wants to offer this then I think they can??

  10. Has anyone noticed that “Physicial” is spelled incorrectly in the article’s title? Perhaps it’s meant to rhyme with Ezekiel, as the great Dr. Seuss would have it. 😉

  11. @Carol
    I think I was talking about an average risk person in an average risk population. How else can I talk?

    But you make an excellent point: some folks can pay more than the average as estimated in the actuarial value. So we might have Lotty paying 40% of her “covered” costs OOP even though she is in a silver plan with 70% actuarial value plan. And, of course, as you pointed out, she could pay much less than 30% also.

    Let’s hope that the folks who are really ill do not have the bronze or even the silver plans. Or hope they are rich and have brimming pockets.

  12. Thanks for responding Barry. Yes, my coverage is for single person.This year I’m on Medicare, so I squeaked through without ACA.

    Barry, I’ve talked to a couple of shocked people buying post ACA coverage and not understanding the mandated coverage additions. Even with subsidy these people are paying more than previous a-la-cart coverage, although the added pre-exist and no lifetime max is popular, I guess not when they have to pay for it.

  13. Peter1,

    Your quote of $565 per month in NC is for one person, I presume, whereas Lotty’s $1,400 per month (pre-subsidy) quote is for two people. That’s a 25% difference on a per person basis but it’s not unusual. It would probably cost even more in NY and NJ as premiums for the same coverage for people of the same age can easily vary by 2X or more across the country.

    Lotty probably could have purchased a policy pre-ACA that didn’t cover maternity benefits which would make a significant difference in the premium but that’s not possible now. It does sound like she and her husband are getting substantial value from their drug coverage though.

    The other issue to keep in mind is that most people don’t have high medical expenses every year. Even among seniors, for example, only 15% of them reach the Part D donut hole in any given year and two-thirds of them don’t come out the other side into the catastrophic coverage zone.

  14. Lotty, I understand your frustration. Part of these increases are due to greater coverage because of ACA. No lifetime minimums, no pre-exist as well as other coverages.

    I’m not sure why Indiana is so high. At 64 I can get a policy for $565/mth. with about a $6500 deductible – no subsidy.

    If you are a business owner you can deduct from your income tax, as an individual you can also deduct but not until a threshold of income is reached – but that doesn’t pay the bills now.

    A subsidy of $600/mth is quite high, at least the ACA provides that.

    All I can suggest is complain to your political reps.

  15. “When you have a bronze or silver plan (actuarial value 60% and 70% respectively), you are paying out of pocket 40% and 30% of the covered services yourself….in the form of deductibles, co-payments and co-insurance.”

    This is not accurate. The actuarial value percentage term means the percentage of costs likely to be paid by insurance for a standard average risk POPULALTION. A healthy individual who only needs preventive care will have 100% of his costs covered. Conversely, if your Bronze plan deductible is $6.350 for an individual or $12,700 for a couple / family and you have a catastrophe like a low birthweight premature baby with many complications that racks up a seven figure hospital bill to care for, you will only be liable for the deductible and there can be no maximum claims limit that the insurer must pay. If your healthcare needs are fully within the deductible, none of your costs will be covered.

    In comparing the cost and coverage of this exchange plan with Lotty’s former Anthem coverage, was it like-for-like in terms of the services, tests and procedures that were covered? For example, did the Anthem plan cover maternity benefits, chiropractic care, mental illness and drug and alcohol abuse treatment? Before the ACA, men and older women were often able to buy plans that excluded maternity benefits which significantly lowered the premium from what it would have been if it covered maternity benefits. They could exclude other benefits that they didn’t think they would ever need as well including mental illness and drug and alcohol abuse.

  16. John, yes! Thanks! And let patients be primary drivers of the when and the how in terms of touch points. System change required.

  17. Al, thanks so much for your response.

    Why is it so utopian to think primary care physicians should occasionally have 60 minute appointments to address multiple issues when specialists in internal medicine have 60 minute appointments routinely to discuss just one? I may just be finishing my residency and certainly have a lot to learn, but that has never made sense to me. Direct primary care (PMPM) models have addressed this and are being expanded to medicare and medicaid populations. Change payment and you have more flexibility of how care is delivered.

    Agree with the potential for the ‘wellness industry’ going overboard which takes awareness and ownership from primary care.

    And we definitely don’t think change will happen overnight, but would love to identify and encourage those who are doing it right.

  18. Another thing I should add: Policies are either national or local. I could only afford one that was “In Network” in Indiana. The Insurance company owner picked a national plan. We don’t travel much so I have to pray when we do, nothing happens. The way the plan reads “Out of Network” equals zero coverage. That’s it. Doesn’t give you a warm fuzzy when you have a husband with 3 vessel coronary heart disease…

  19. We have had health issues but you never had to worry with Anthem. Like I can no longer go to the clinic where all my other mammograms were and that specialized in breast cancer. The deductible was $3000 and payments were $200 a month. Anthem doubled my premium when the Marketplace kicked in and the deductible went up. My husband’s insurance was going up to $1000 a month. These are both individual policies. If we didn’t have subsidies, our insurance as a couple would run over $1400 a month with this same crappy insurance. We can’t afford the Anthem plans. They ran close to $2000 a month before subsidies. I am on the upper tier gold in plans I believe. The main reason I picked this plan is we have a $1000 deductible on medication and then the copay kicks in. My husband will easily pay over $1000 a month for prescriptions. Two of the pills cost over close to $1000 a month before insurance. IF you are not low income.

    If you go onto the Marketplace and look(at least in Indiana), you may see that $12,600 is the common deductible now per family/couple. Nothing kicks in (besides well care) until after that is met. I think its $6500 for my son on his single person policy. My son is on the same insurance and he had to pay for all his blood work from his physical.

    I called a local place that works with small businesses and individuals to help them decide on coverage. I got the owner. He said his insurance runs over $2500 a month and he had the $12,600 deductible too. So he couldn’t do any better than I with all his knowledge.

  20. “I was with Anthem (individual) for years and never had these problems!”

    You mean you never had breast cancer with Anthem, or you never had to pay deductibles? Did you not know you were signing up for a high deductible plan?

    You’ll have to be more specific about Antham’s Plan and the plan under ACA with another insurance carrier. Were you private pay with Anthem or through an employer?

    Are you getting a subsidy with ACA?

  21. Correct me if I’m wrong, but I believe the ACA might allow people to combine a direct-pay primary care plan — like Doc Rob’s practice — with a high-deductible catastrophic coverage plan.

    Some direct-pay practices charge a pretty reasonable monthly fee…just looked at Doc Rob’s site and it’s $30-60/month depending on age.

    This might be better for people than buying a “shabby” insurance product (I agree, those bronze plans do sound shabby!). And esp if you have chronic conditions or significant health risks, it’s better than skipping primary care and “paying the tax”.

  22. When you have a bronze or silver plan (actuarial value 60% and 70% respectively), you are paying out of pocket 40% and 30% of the covered services yourself….in the form of deductibles, co-payments and co-insurance. The warm fuzzy secure feeling that good insurance is supposed to give a person can hardly be felt with such imperfect insurance. In fact, you could feel less insured than if you had none. This is because you must feel on the hook for coming up with the complete deductible and all the co-pays when you are in the midst of an episode of care. If you refuse to keep feeding the cash maw, then you appear to be baulking at treatment and appear to be uncooperative with your doctor. This is a worse feeling than being without insurance altogether, when, in this circumstance, every provider is feeling sympathetic and trying to figure out ways to lessen your burden. So you feel everyone is on your same team.
    By being forced to by such a shabby product, the percentage of folks buying exchange insurance, I think, will be less and less as the years go on. You will hear more and more “It’s better to pay the tax and not get the insurance.”

  23. Here’s the fun part of an Obamacare visit. I am told I should have extensive tests to check a lump in my breast. Tests are ordered without any concern I have to pay CASH for these tests! After calling the clinic, I find I cannot afford these tests because I am paying $800 a month for a 50 yr old couple to have this wonderful insurance with a $12,600 deductible before insurance begins picking up a percentage. WE ARE ALL GOING TO BE IN WORSE CONDITION because we cannot afford testing! Even the blood work is costing us now. I was with Anthem (individual) for years and never had these problems!

  24. You want someone who can pick up the signs and symptoms of polymyalgia rheumatica and will search for dysplastic nevi and skin signs of vascular insufficiency. Do they understand IBS and the Rome criteria?

    In other words, you probably need to visit someone with an advanced nursing degee, a PA or an MD or DO.

  25. “Ideally this preventive health maintenance would all be done in the community…But not America…”

    Wholeheartedly agree, especially for at risk communities. Caregivers need to see where and how people live to fully understand their health needs.

  26. Cici, Thanks so much. Our argument wasn’t to encourage the return of ‘annual physicals’ and was certainly not to promote the traditional FFS system, but to highlight the value of primary care, particularly in non-acute care visits. (I also prefer the term ‘health review’ or ‘health check-in’ as was coined at an SGIM Town Hall on the topic.) One of the concerns we had after reading Dr. Emanuel’s article, though, was that it is rather discouraging of routine primary care in general presented to a population where there is a lot of morbidity (obesity, diabetes, heart disease, depression, etc).

    Could not agree more re: misaligned incentives, reforming payment and refocusing on person-centered care.

    Ultimately, very happy this is generating rich discussion including the role and delivery of primary care in the U.S., which I imagine was also the intention of Dr. Emanuel’s piece.

  27. Gosh, where to begin with this one! I fear this discussion has got apples, oranges, peaches, grapefruit and watermelons all mixed up together. A clinician can learn a patient has gained weight without an annual physical. A doctor can develop a solid, trusting relationship with a patient without an annual physical. And who says it has to be a doctor? What if a patient develops that bond with a nurse practitioner?
    It’s not that it is “bad” to visit someone periodically with expertise in medicine and health. It’s that the system’s misaligned incentives are more about items to code (tests, procedures, medications) than our well being. And then there are all of the false positives!
    Dr. Kernisan’s concept of an “annual review of your health” is an appealing one. This is less about the traditional ffs visit that generates $X in revenue and more about fostering a culture of health that puts consumers at the center.

  28. I think it’s certain better to think of an “annual review of your health” rather than annual physical. It’s good to make an effort to review the big picture of a person’s health, and also to make sure that clinician and patient are on the same page as to prevention, management of chronic disease, etc.

    Incidentally I do these reviews in my geriatric consultation practice because the beleaguered PCPs are not getting around to it and many frail older people have very fragmented care.

    In my experience these kinds of meetings are most productive when done face-to-face, AND when everyone’s done a little prep and data review beforehand. If not face-to-face, at least by phone. Why? Because some things are much easier via conversation, like problem-solving, or picking among a variety of options, or understanding someone’s values so that a clinician can provide the right advice.

    Does it have to be done with a doctor? Probably not, if your health isn’t complicated. But if it is complicated, you need a regular review with a doctor AND a good primary care relationship too.

    Re Rob’s model, I don’t know that we’ll go this route but you certainly could give people vouchers to go get their care from direct-pay providers. I believe some Medicaid programs do this for support services and they call it Cash & Counsel. Those patients who don’t want this responsibility can stick w Kaiser or with conventional insurance.

  29. I think what the authors are saying is that we should come up with an alternative, an approach that gives people a chance to regularly have a face to face where they confront any issues that are being missed …

    As it stands right now, patients are being systematized.

    And the system doesn’t work.

  30. Ideally this preventive health maintenance would all be done in the community, with family doctors / nurses who live near the patient… that’s how it’s done in some places in the world. But not America…

  31. You might enjoy Cory Franklin’s response (Is it smart to skip your annual physical?).

    They claimed that the value of the patient-providers relationship(s) is quantifiable, then introduced anecdotes.

  32. How can it be bad to visit with someone who knows more about physiology, medicine and pathology than you do?…periodically?

    Ideally, such a person should be in our own family and we could talk to them every day. You don’t have to call these visits a “physical” if that term is too scary.

    Now, if that expert is too proactive and costing you too much money or time or hassle or adding too much risk to your life, that is a different problem. These faults can be corrected, but having too much knowledge about your own body or mind seems impossible, unless one is a self-injurious hypochondriac, in which case that problem should also probably be discussed with the wise one.

  33. Peter – I am not convinced yet that this is the way to go, but after doing it for 2 years I am becoming more convinced. There is a long way to still. The first step – building a low-cost self-sustaining model – is proven. But if I get up to 1500 patients (which is a LONG way), then this becomes much different. The key is that new practice models need to be considered because the old one is so terribly broken. Changing to a single-payor system or doing other gyrations with the current system without radical change won’t fix things.

  34. “If this practice model becomes attractive enough to physicians, then the current exodus from primary care will stop..”

    Certainly more money less work always attracts. But does it block out those who can’t afford the monthly membership fee and access to needed treatment? Does it create a stampede to good PCPs just to lock up your spot before the door closes leaving others out in the cold?

    I’m not convinced yet Rob, that your career path is the path medicine should go.

  35. This is all very sensible but seems to make the opposite point, meaning Zeke’s point. All the examples given are for people with issues–blood thinners, EOL etc. Obviously those people should go to the doctor. (Navahos have poor health status and short life expectancies, so I’m not sure I would use them as an example of good health practices. I’m just sayin’…)

    What people like Zeke (and I) are reocmmending is exactly the opposite of what the wellness industry does. Whereas wellness vendors want a one-size-fits-all solution — eveeyone should go every year. What both Zeke and these authors are advocating is go to the doctor if you need to go to the doctor. The difference is these authors are using a more expansive definition of “need.”

    And there is also one fallacy in this posting, about “building a relationship.” To that I say, you can’t be serious. I’ve been going to the same practice for 30 years, and have cycled through 4 PCPs. Maybe in the Marcus Welby era you kept the same doctor for life, but large practices now hire and fire doctors, and doctors (especially PCPs) quit, move etc. It’s a complete was of time for people in the 20s and 30s without health risks to get annual wellness visits or physicals or whatever you call them, on the hopes of buidling a relationship.

    There is also a certain pollyannish quality to the assertion that doctors are suddenly going to dispense with all the tests they always do and spend up to 60!(!) minutes chatting about health risks? Maybe on their planet…

    But in general there are some good points here IMHO. I’m just not sure they lead to the conclusion that the authors say they lead to.

  36. Difficult to say. The actual number of “active patients” was usually a guess. Somewhere between 2 and 3 thousand. The underlying question, which is quite reasonable: is how big a practice like mine needs to be for this model to be a viable system-wide alternative? Certainly over 1000 patients. If this practice model becomes attractive enough to physicians, then the current exodus from primary care will stop, and perhaps it will become a favored destination instead of specialities. It certainly has a much better atmosphere for both patients and their caretakers. My hope is to continue to expand this and develop processes and efficiencies to keep the good atmosphere while growing into something that is something that can be adopted by docs without destroying the system. 600 is not enough yet, but I’m nowhere near full.

  37. I changed the system because the old one made me do things like “Physicals” to give decent care. I am presently up to nearly 600 patients, have only 2 nurses, am not near full capacity, and give far better care. My point is that the “physical” is not the answer, fixing the system is.

  38. Here’s why the annual physical is, in my view, an anachronism:
    1. The name: it emphasizes the examination and testing over what really matters – history taking, updating the records, and education.
    2. The location: if the real importance of an annual physical is to update records, get better (or more in-depth) history, then it doesn’t necessarily have to be done in the office. The ideal care would happen on an ongoing basis and these things would happen as a matter of course. Unfortunately, our payment system forces the office visit to be the place where care must be done.
    3. The way it’s usually done. For most physicians, the “physical” results in the ordering of lab panels, getting EKG’s, ordering stress tests, etc. It is a place where 22 year olds (like my son) who are healthy, low risk (nonsmoker, exercises 4+ x/week) get lipid profiles and chem panels. This leads to overtreatment and often to further unnecessary testing.

    In my old practice I liked doing physicals because they were the main time I’d go over the chart and make sure we were up to date. Implicit in that rationale is the fact that I would never go over people’s charts or go after services in the regular course of care (because I was too busy meeting MU requirements, overdocumenting for E/M, and keeping the office full of sick people). I don’t do that anymore. I interact with people between visits and we try to reach out to people when care is do.

    So, I’d say while your argument is sound, it is based on accepting that we can do no better than our current system. Nobody should take blood pressure meds if they don’t understand it. That is our failure, and to do a “physical” to compensate for our previous failings is a flawed rationale.

  39. completely agree. We still need patients to come into the office. During an office visit, we catch 25 pound weight gain, prediabetes, medications being taken incorrectly, smoking, unsafe sexual practices with the need for screening for STDs, etc, etc. When patients bounce between PCP to PCP and don’t get regular care, they end up with late presentations of diseases– advanced diabetes, ESRD from untreated hypertension, etc. When they are in the office, we need to avoid harm, and don’t do unnecessary diagnostic procedures