This article came across my desk, if you are brushing up on your healthcare reform policy before the election take a look - Enjoy!
TIME TO CHECK IN ON THE CHECKUP:
Thirty million additional Americans may have access to health insurance in 2014 // New care models are changing the doctor-patient relationship // America may face an extreme shortage of physicians by 2020 // Will the annual physical survive another decade?
The End of the Physical?
By Linda Keslar // Photographs by Brian Finke // Fall 2012
As the head of a Florida advertising and public relations firm, Colleen Chappell, 46, has long viewed her health as a company asset. She exercises regularly, eats nutritiously, keeps her weight down—and always has an annual physical examination. “I’m religious about it,” Chappell says. The head-to-toe exam is supplemented by blood work and screenings including a Pap smear and a mammogram.
One in five American adults takes Chappell’s approach, seeing a physician every year, and an annual exam remains the most common reason for consulting a primary care doctor. Yet there’s little evidence to demonstrate the value of a yearly checkup, and no major U.S. health organization recommends one. “Many people just embrace this belief that seeing your physician every year is a good idea,” says Ateev Mehrotra, assistant professor of medicine at the University of Pittsburgh School of Medicine and a policy analyst at RAND Corp.
One reason for regular visits—to make sure patients get health screenings—has become less important in recent years as expert groups conclude that many tests can be skipped or done less frequently. The U.S. Preventive Services Task Force, which reviews evidence and issues guidelines, now recommends that mammograms for most women begin at age 50, and then be done every other year. (Others, including the Mayo Clinic and American Cancer Society, call for mammograms every year or two for women in their 40s and annually for those in their 50s and older.) The task force and professional societies such as the American College of Physicians have endorsed discontinuing several other tests and procedures typically done with an annual physical.
Still, to many physicians, the annual checkup has a value beyond detecting illness, helping them bond with patients while updating health histories, determining what screenings are needed and providing counseling. “It’s a way for physicians to gain the trust of their patients,” says Barron Lerner, a professor of medicine at New York University Langone Medical Center. “When I do a complete exam, I know my patient inside and out.” Studies have shown that patients also appreciate having a thorough examination.
While arguments about the annual physical are nothing new, the debate will become more urgent in 2014, when the U.S. Patient Protection and Affordable Care Act is slated to add an estimated 30 million insured patients to the nation’s roster. That influx, when many primary care doctors are stretched to capacity, could further alter where and whether people receive yearly exams. Many may opt for retail clinics, typically staffed by nurse practitioners, or they could become part of a “medical home,” a team approach that also makes extensive use of non-physician caregivers.
“What we think of as the annual physical lies at the intersection of all of this,” says L. Ebony Boulware, associate director of the Welch Center for Prevention, Epidemiology, and Clinical Research at the Johns Hopkins University School of Medicine in Baltimore. “There are a lot of unanswered questions about what aspects of it are useful, including the frequency.”
The notion of an annual physical goes back at least to ancient Greece and Rome, and though it fell out of favor for some 400 years beginning in the late Middle Ages—physician-scholars then felt that poking and prodding a patient was beneath them—it made a comeback in the late eighteenth century. Aided by scientific theories of disease and new technologies such as the stethoscope, physicians sought to learn as much as possible about the internal state of the body, and in 1861, British physician Horace Dobell identified components of a physical—a patient’s personal history, a meticulous exam and lab tests for detection and diagnosis—that persist today.
In the United States, medical historians generally point to June 7, 1900, at the American Medical Association’s 51st annual conference, as a turning point. George Gould, a Philadelphia physician, offered a new, enduring definition of a doctor’s role—as someone who can tell patients they have a problem before they know they’re sick—and he cast the comprehensive periodic exam as the mechanism for uncovering medical issues. “It is in the catching sight of the forerunning indication of disease, the symptom of a symptom, the functional beginning of organic abnormalism, that a large deal of progress lies,” he said.
In 1922, the AMA officially endorsed the idea of regular exams, and other medical societies across the country soon offered support.
Corporations began advocating annual exams for workers, and after the Second World War, an increasing focus on health screening, particularly for cancer, made a yearly checkup seem all the more crucial.
Yet just as the popularity of the annual physical was rising, doubts about its effectiveness were heard. In 1975, a study in the Journal of Family Practice noted that there was scant scientific basis for a yearly exam and recommended that it be replaced with less frequent visits tailored to age, gender and risk factors. A Canadian task force came to a similar conclusion, and major medical groups revised their guidelines.
Healthy adults under 40, according to the AMA, could safely go five years between exams; older patients, every three years.
Soon, the U.S. Preventive Services Task Force weighed in. In 1989 (with an update in 1995), after reviewing more than 6,000 studies of more than 200 interventions often performed with an annual exam, the task force graded each test or procedure. The group found little value in routinely ordering blood work, thyroid checks, urinalysis, electrocardiograms and treadmill tests. According to the USPSTF, an annual comprehensive history and head-to-toe physical were no longer strongly recommended for healthy adults.
Instead, the group now suggests periodic checkups tailored to a patient’s risks. Guidelines call for blood pressure screening that begins at age 18, cholesterol screening for men starting at 35 and for women at 45, and ongoing monitoring of patient weight. Colon cancer screening should start at age 50, and physicians should also screen patients for tobacco use, depression, alcohol misuse and obesity.
Younger women should be screened for chlamydia, and breast cancer screening should start by age 50. And USPSTF guidance continues to evolve. “Our recommendations are based on science, not expert opinion,” says Michael LeFevre, vice chairman of Family and Community Medicine at the University of Missouri and USPSTF co-vice chairman—and when new evidence is found, guidelines may need to be changed.
There has been growing concern, for example, about false positives, erroneous test results that worry patients and may lead to expensive, unnecessary treatment and radiation exposure. That’s why the task force called for later, less frequent mammograms, and why it announced that PSA testing, for prostate specific antigen in men, does more harm than good. The USPSTF cited a lack of evidence that the test reduced prostate cancer mortality and noted that high readings often resulted in needlessly aggressive treatment and side effects such as impotence and incontinence. Yet insurance companies continue to pay for the PSA test, and the American Urological Association still recommends a first-time test at age 40, with the schedule of follow-up testing to be determined on an individual basis.
While the expert consensus may be that the annual exam isn’t needed, many patients still want one, and doctors are happy to oblige. In a 2005 study published in the Annals of Internal Medicine, the majority of physicians surveyed in Boston, Denver and San Diego continued to perform the exams, in part because exams helped build relationships with patients. Many physicians also said physicals helped them detect illness before symptoms appeared, and that they often ordered blood tests, urinalysis and other tests primarily because their patients expected them.
The physical does seem to help ensure that patients receive cholesterol screening, gynecological exams, Pap smears and fecal occult blood testing, a test used to diagnose colorectal cancer, according to a review by Ebony Boulware and other researchers in the 2007 Annals of Internal Medicine. Looking at two dozen studies of the annual exam, the researchers also found that seeing the doctor regularly seemed to ease patients worries about their health, though it had less impact in encouraging patients to lose weight, get blood pressure under control and go for mammograms, or in helping physicians detect disease.
Whatever benefits the physical does provide may come at too high a price, however. In another 2007 study, in the Archives of Internal Medicine, Pittsburgh’s Ateev Mehrotra and other researchers analyzed a national sample of 8,413 physician visits that took place from 2002 through 2004 with patients who received annual physicals or gynecological exams. Extrapolating from that sample, they estimated that yearly exams account for 8% of all physician visits and cost $7.8 billion a year in the United States. The tab for unneeded blood work and other lab tests was $325 million annually, according to the study.
Meanwhile, the researchers found that 80% of preventive care was actually delivered outside of a routine physical, and that during the previous year, three out of four patients who got annual exams had visited their doctors for another reason—an occasion that could have been used to order preventive tests, says Mehrotra, who notes that the growing use of electronic health records should make it easier to flag patients who need screenings that can be done whenever they come to the office.
But do physicians really have time to talk about the need for a mammogram or a colonoscopy when a patient has a sore throat? More and more responsibilities are being shifted to primary care doctors, and by one estimate, there could be a shortage of 149,000 physicians by 2020.
One study has suggested that for doctors to deliver just the half dozen recommendations the USPSTF considers most helpful might take about two hours a day—hours most physicians don’t have, says LeFevre. “I have a hard enough time getting through my patients’ medical complaints,” he says.
Under the Affordable Care Act, patients will get free access to preventive services ranked highest by the USPSTF, including colonoscopies for anyone over 50 and bone density tests for women over 65. The health care law also requires coverage for a new annual “wellness” visit for Medicare beneficiaries that includes a health history and counseling about prevention (though not a physical examination).
How can an overstretched system handle that flood of new patients and responsibilities? Much may depend on new models for care. For example, something known as the patient-centered medical home coordinates care from a team of providers and asks nonphysician team members, such as nurse practitioners, to talk to patients about preventive tests. That frees doctors to concentrate on the hands-on examination and on formulating a treatment plan.
Yet there remain many questions about this model of care, including how often healthy patients need to be seen. Medical home reimbursement depends on patients receiving vaccinations and recommended screenings and procedures, and the financial pressure could encourage frequent exams. There’s a complete lack of evidence about what interval of care is appropriate, says Boulware.
The growing popularity of retail clinics in drugstores and supermarkets also may have something to say about the future of the yearly physical.
The clinics had some 1,200 locations in 2010, and patients can get treatment for upper respiratory infections, sinusitis, sore throats and ear infections, among other complaints. But the clinics also provide exams to meet employer requirements and sports and college physicals, as well as blood tests and immunizations. Typically, nurse practitioners and physician assistants staff the clinics and refer more complicated cases to patients’ primary care physicians.
Rhode Island-based MinuteClinic has targeted the 3.5 million professional drivers regulated by the U.S. Department of Transportation.
Every two years, drivers must have a physical checking vision, hearing, heart health, weight, blood pressure and respiratory status, among other conditions, and they must show that they’re receiving treatment for medical problems. With more than 600 locations in 25 states, the clinics are positioned to care for this mobile work force, says Nancy Gagliano, MinuteClinic’s chief medical officer. The nurse practitioners who consult patients collaborate with physicians at the Cleveland Clinic, Henry Ford Health System, Emory Healthcare and others, and MinuteClinic has an electronic health record system that’s being integrated with those of its affiliated hospitals. “We can hook up patients with primary care physicians and follow them along the road, to monitor blood pressure and other vital signs,” says Gagliano, who notes that the retail clinic model could use other technologies to deliver additional kinds of care without an office visit. “Depression screening might be delivered through telemedicine, using something like Skype for the visual interaction,” she says.
But retail clinics and medical homes aren’t alone in using nonphysician clinicians to help deliver care that has traditionally been part of an annual physical. Massachusetts, whose reforms have resulted in a surge of newly insured patients, has faced a growing shortage of primary care doctors, according to a study by the state’s medical society, and at Massachusetts General Hospital’s Revere HealthCare Center, many more patients wanted physicals than there were available time slots. That meant, for one doctor in particular, a wait of as long as nine months for a physical. Three years ago, Amy Wheeler, physician chief of the adult medicine unit, and Joan Niles, adult medicine practice manager, spearheaded a project that uses “lean process improvement” techniques borrowed from manufacturing plants. Medical assistants monitored the time a dozen primary care physicians spent on each component of an exam—from the minutes doctors took to greet patients to how long they spent updating patient histories, medication lists and prevention tests, and providing a hands-on exam.
Taking into account variations among physicians, the group developed and implemented several changes that have led to vast improvements in productivity and the satisfaction of both physicians and patients.
Medical assistants and the nursing staff now take larger roles—for example, by sending electronic checklists to physicians weeks ahead of an exam to remind them to order needed tests. Patients get letters about the tests and help in scheduling so that results are ready prior to exams. Before physicians enter the exam room, medical assistants have talked with patients about their medications, arranged for refills or health screenings and made sure the room has everything the doctor will need.
Another change has been to schedule annual physicals during dedicated blocks of time. “That has really allowed me to focus on my patients and do the exam more efficiently, because I’m not distracted by the patient next door who needs immediate attention,” says Wheeler. She finds that she can now complete eight to 10 physicals during a four-hour period, whereas before she got through just three. The wait time to schedule a physical with a Revere physician has shrunk to two or three months.
A different approach to streamlining the annual physical is coming from the American Board of Internal Medicine Foundation and a coalition of medical societies. In a program they call Choosing Wisely, the groups are compiling lists of tests and treatments that doctors judge are being done too often. For internists, that includes stress tests for heart disease, brain scans, and bone density scans for women. “We’re not saying these should never be done, but they need to be personalized to patients’ needs,” says Christine Cassel, ABIMF president. Later this year, 16 other specialty groups will release their own top five lists of overused tests and procedures.
Yet even as these groups and others look for ways to limit unnecessary care, there’s a growing demand for uber-physicals, which may cost from $1,000 to $5,000, and take more than a day to complete. LeFevre of the USPSTF notes that such exams tend to include many things for which there’s little evidence of effectiveness—such as a computed tomographic scan of the heart to screen for heart disease.
But proponents are drawn to the notion of leaving no stone unturned.
That’s the same reason many patients and physicians are reluctant to give up an annual exam—as costly and inefficient as it may be. And sometimes doctors will uncover a dangerous condition just in time. Last year, Colleen Chappell, the Florida advertising executive, signed up for an executive physical at the University of South Florida Monsour Executive Wellness Center. It took nine hours, cost Chappell $5,000, and included not only an extensive blood panel but also a treadmill stress test, an abdominal ultrasound, a brain scan, a mammogram and a contrast-enhanced breast ultrasound, which produces more detailed images than the normal test.
The special ultrasound detected an abnormality; a biopsy revealed cancer at its earliest stage, and a genetic test showed that Chappell has the
HER2 protein, associated with particularly aggressive tumors. After chemotherapy and radiation treatment, she is now cancer free. “If I hadn’t had the executive physical, it might have cost me my life,” says Chappell. That’s a sentiment physicians and policymakers will have to weigh as they continue to assess the value of an annual exam.
The rest of the audience liked the Ronzoni Smart Taste (which is my favorite of the 3 as well). It is the same color and texture as regular pasta, though it can be overcooked more easily then regular pasta can be. The people who did not like the Smart Taste, said that it was to soft, thus they must be true aldente pasta lovers!
