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Sunday Jan 18, 2015

Annual Exams? Tailor Visit Frequency to Patients' Needs

Ezekiel Emanuel, M.D., recently offered some interesting advice to the more than 2 million readers of The New York Times. Emanuel, who is an oncologist, said Americans should skip their "worthless" annual physicals(www.nytimes.com).

This message -- conveyed via our nation's largest metro newspaper -- has caused a great deal of concern among primary care physicians, as well as confusion among our patients. As with so many things, significant aspects of this issue are overt, but many more are nuanced.  

One of the issues Emanuel raises is the increasing evidence that doing a complete annual physical exam does not improve morbidity and mortality. This correlation is actually fairly well proven. In fact, significant data, including the book Overdiagnosed: Making People Sick in the Pursuit of Health, by Dartmouth professor H. Gilbert Welch, M.D., M.P.H., suggest that reliance on routine complete physicals and indiscriminate use of various labs and screenings actually confer more harm than benefit. Such evidence is the basis of Choosing Wisely, the AAFP-supported initiative that identifies overused tests and procedures and encourages physicians and patients to discuss those options before incorporating them into a treatment plan. The Academy has identified more than a dozen tests and procedures that have questionable value for certain groups of patients.


© 2014 Sheri Porter/AAFP
Here I am listening to a patient during an office visit. A recent New York Times editorial against annual exams minimized the importance of the physician-patient relationship.

And although the AAFP does not have a guideline recommending annual exams, we certainly aren't recommending that patients stay home until they have an acute illness. The frequency of visits should be tailored to the patient, based on recommended screenings and conversations between the physician and patient.

It's worth noting that much of Emanuel's argument against annual exams is built on a 2012 Cochrane Collaboration review(onlinelibrary.wiley.com) that considered only asymptomatic patients. According to the CDC, half of U.S. adults have at least one chronic condition(www.cdc.gov), and 25 percent have two or more. Now ask yourself, "What percentage of my patient panel would I feel comfortable not seeing until they had an acute illness?"

Every patient deserves individualized care. Family physicians don't treat the "average" patient. We don't treat diseases, and we don't treat labs. We treat people and families. Accordingly, we have to take the evidence and put it into the context of that specific patient and his or her needs. This can include a patient who feels strongly that he or she should have a screening test or a complete physical even with the awareness that it may lead to a cascade of labs or evaluations that might not be otherwise indicated. Being patient-centered means having these conversations and supporting our patients in their choices even if they go against the evidence.

Emanuel briefly, and grudgingly, acknowledges that an annual exam provides an opportunity to "reaffirm the physician-patient relationship." But in dismissing the exam as having no benefit, he minimizes the importance of that ongoing physician-patient relationship. The annual exam is an opportunity for primary care physicians to strengthen this bond by speaking with our patients and getting to know them better. This helps us provide better care when they ultimately need it and enhances their trust in us.

Establishing this relationship early is critical to yielding the best dividends when people become ill. This trust and caring can only be created in the setting of an ongoing and growing relationship that requires face-to-face visits. The relationship also facilitates the primary care physician's role as a cost-effective coordinator of the patient's health services by making early detection of problems possible.

So what about frequency? Patients should be seen based on their age, their gender, their health care philosophy and needs, their problems and diseases, and multiple other factors. The ultimate goal should be to maintain and nurture the relationship. We should focus on appropriately addressing the patients' concerns, as well as on formulating an agenda based on our understanding of where that patient is in achieving health and minimizing disease. So, not only do we consider what an appropriate screening protocol is for each patient, we also address the all-important behavioral and lifestyle aspects that impact morbidity and mortality.  

What we need isn't reliance on an annual physical. Instead, we need to continue to push for changes in our health care system that ensure the care we deliver is focused on prevention and evidence-supported measures that are individualized for each patient. Family physicians are ideal for this role. We must continue to move health care delivery in this direction, and physician payment should reflect the value and power of this relationship and what we provide.  

Reid Blackwelder, M.D., is Board chair of the AAFP.

Posted at 11:11PM Jan 18, 2015 by Reid Blackwelder, M.D.

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