In the years since the medical community first got revved up on the idea of “value-based care” — the conceptual antithesis of the “more is better” fee-for-service model — a common target of criticism has been the routine physical, one of the most time-honored traditions in medicine.
The attacks come from all angles: The annual check-up isn’t cost-effective, it doesn’t lead to better outcomes, it actually might lead to worse outcomes, it’s a waste of doctors’ time, it’s a waste of patients’ time.
Such is the hostility toward the yearly physical that the Society of General Internal Medicine, as part of the Choosing Wisely campaign, recommended against routine check-ups for asymptomatic patients.
And just last year the New England Journal of Medicine published a pair of point-counterpoint pieces on the issue, with well-articulated arguments for and against.
What to think? Are we witnessing the twilight of the centerpiece of the doctor-patient relationship? In the future, will the primary care office come to resemble something akin to an urgent care, with a waiting room full of coughing, sneezing, aching people?
One of the arguments for the model of symptom-driven appointments — going to the doctor only when you’re sick –is that the physician can just squeeze preventive care measures into these visits. Since they’re already prescribing antibiotics for that UTI, they should be able to throw in a referral for a colonoscopy at the same time, right?
Wrong.
Doctors have precious little time with their patients as it is. Addressing one acute problem in 15 minutes is challenging, but there’s rarely only one thing that’s ailing patients. More often it’s a sore throat and knee pain and a side effect of their medication and … you get the point. And with visits that are solely focused on symptoms, it’s reasonable to assume some patients will wait to “accumulate” several complaints before they come in, and then expect the doctor to address them all at once. This scenario gets overwhelming fast.
A physical affords doctors a chance to catch up on the ever-expanding list of guideline-based preventive measures that are due each year; review the patient’s medications; perhaps do a more thorough physical exam than usual. Who knows, there may even be time to chat about the patient’s grandchildren for a minute or two. These small touches are hard to measure when researchers study value-based care, or when they assert that there is “no evidence” of benefit for the annual physical.
It’s also worth considering the physician’s well-being. This mentality that doctors can just “squeeze” another element into an already packed visit is part of what makes primary care unpalatable for so many. Primary care providers are overburdened, and now we’re demanding that they compress two visits into one? That’s a big ask.
There are many broken pieces of health care that require fixing, but this is not one of them. Patients are no less deserving of our care and attention in the absence of illness. In fact, seeing them when they’re well is an opportunity to encourage and reinforce efforts to maintain their good health. This, I think, is the reward that drives doctors who love primary care: Keeping people healthy, not just treating them when they’re sick.
Eric Beam is an internal medicine resident who blogs at The Long White Coat.
Image credit: Shutterstock.com
