The Dizzying, Deceiving Doctor’s Visit
No wonder the annual physical is giving way to 'wellness exams'
Remember that in-person, regular check-up by your doctor?
If it’s only a vague memory or an unpleasant imaginary idea, you’re not alone. A variety of models are emerging for better patient care, and in the future, we can expect it to be far different than it is today (and was yesterday).
“There’s clearly still a role for the physical exam,” a doctor said.
“The traditional physical examination could benefit from significant revitalization and re-engineering to make it more effective,” authors from Johns Hopkins University School of Medicine and Kimmel Cancer Center, Baltimore, Maryland, said in a JAMA report.
A physical exam includes the collection of a person’s medical history and a review of vital signs. Then it’s on to an exam of the patient’s body. The authors explore different ways that exams could be more effective and accurate, which they say could transform medical care from a “disease-responsive endeavor to a health-promoting enterprise.”
Dr. Bruce Landon, a health care policy professor at Harvard Medical School who practices internal medicine at the Beth Israel Deaconess Medical Center in Brookline, Massachusetts, agreed with the report. He noted that physical exams are different from annual preventive exams; a physical exam is done at nearly every doctor visit, but an annual preventive exam goes beyond to include details on patient history and risk factors — and it can include lifestyle counseling.
Physical exam skills have been eroding because doctors do not complete some components and have relied solely on technology to gather information.
"Medical schools need to do a better job of teaching it," Landon said.
The physical exam can still be instrumental in good patient care. For instance, an electrocardiogram gives a doctor more information than listening to the heart alone, but the doctor may not need to order it if he or she thoroughly listens to a patient's heart and doesn't find abnormalities. Ordering the test when it is not needed can pass unnecessary costs to patients.
"There's clearly still a role for the physical exam," he said.
Health care has shifted from a reactive to proactive stance, Dr. Mike Sevilla, a family doctor from Salem, Ohio, told LifeZette.
"Even the term 'annual physical' has fallen out of favor in the past few years," he said. "The new terminology now is 'annual wellness exam,' and I think that's more accurate."
The Not-So-Annual Annual
Recently, the medical community has debated whether or not a preventive exam should be done annually. The United States Preventive Task Force doesn't have a recommendation on whether or not we should have annual exams. There are guidelines for when men and women should have different tests, however.
It should be up to each person and his or her doctor to determine the frequency of office visits.
Periodic exams are adequate for most patients, Landon said.
A 2015 report in The New England Journal of Medicine suggested a visit to establish a doctor-patient relationship that would focus on medical and social history, and less on a physical exam or laboratory tests. In lieu of an annual exam, primary care doctors should proactively monitor their patients via tools such as online risk assessments. Authors of that report also suggest that health plans and government programs no longer pay for annual visits or use regular checkups as a measure of health care quality.
Twila Brase, a former nurse and co-founder of the Citizens' Council for Health Freedom based in St. Paul, Minnesota, said it should be up to each person and his or her doctor to determine the frequency of the visits.
Due to costs and time constraints, she believes many people do not want to go for an annual checkup and prefer only to see the doctor when needed.
Brase is leading an initiative that would not only change the frequency of visits — it would revert health care back to the way it was prior to managed care. In those days, doctors did not accept insurance; patients saw the doctor and paid for the service, then submitted a claim to their insurance company. This eliminated the conflict in using a third party, as well as other factors, such as how many patients a doctor is required to see. Relationships were direct and more personal, "exactly the way the doctor-patient relationships should be," Brase said.
Visit of the Future
Landon believes checkups, whenever they may occur, need not include trips to the office. Telemedicine can make it possible for patients and doctors to connect when a physical exam isn't needed, or to follow up on a visit.
"Not everything that a physician does with a patient requires a face-to-face visit," Landon said.
Dr. Eva Aagaard, an internal medicine professor at the University of Colorado Anschutz Medical Campus, said there is more of a shift to team-based care, where patients also see other professionals such as nutritionists and nurse educators in the office.
"Rather than one-on-one relationships between doctors and patients, patients will have relationships with a team of people who care for their needs both in clinic and out," she said.
Sevilla believes visits in the future will be largely based on data.
"The wellness exam of the future will involve so much more data that we cannot even imagine, including phenotypes, genomic information, and datasets that we haven't even thought of yet," Sevilla said. But patients will still need physicians to interpret all the data — so that relationship isn't going anywhere.