Sunday, January 11, 2015

The Purpose of the Annual Physical

We know, through the good graces of the US Preventive Services Task Force that the annual physical exam does not lead to less disease and does not lower mortality.  Specific elements of those exams are helpful, such as screening for hypertension in everyone and screening for breast cancer in women over 50 (and perhaps over 40).  With this in mind, Dr. Ezekiel Emanuel, started the New Year with an opinion piece in the New York Times admonishing us to “Skip Your Annual Physical.”  In it he writes,

“We all make resolutions and promises to live healthier and better lives, to make the world a better place.  Not having my annual physical is one small way I can help reduce health care costs – and save myself time, worry and a worthless exam.” 

But maybe it just isn’t that simple.  Later in the article he does note that, “the exam provides an opportunity to talk and reaffirm the physician-patient relationship even if there is no specific complaint.”  He goes on to also confirm that he will get his yearly flu shot and his routine colonoscopy.  I would also be remiss if I did not point out that Dr. Emanuel is also the author of the article in The Atlantic entitled, “Why I Hope to Die at 75” in which he points out that “creativity, originality and productivity are pretty much gone for the vast, vast majority of us.” 

Let me offer an alternative view of the annual physical with the proviso that I acknowledge that I do not hope to die at 75.  I want to live and contribute with the wisdom I accumulate and want to have a relationship with a health care professional, who will help me maximize my years even if I am not as sharp as I once was. 

The key element that I want to maintain is the relationship with a health professional who can know me, as a person over time.  In our complex health care world, the idea that a person can wait until they are sick and then have the knowledge and skill to access the right healthcare for that need is na├»ve.  It is not realistic to think that a person can effectively access and use the healthcare system without an advisor or helper who knows them as a person, and not only as a disease.  Whether the health care professional is a physician, a nurse or a new professional remains to be seen, although I suspect the model will have more possibilities than our current primary care physician approach.  The problem is that disease and illness is complex and has social and psychological elements that require a knowledge of the entire person – a knowledge that often only comes over time and with the building of trust between the professional and the person in need. 

“Human biology therefore, is indeed complex, but it is much less complex than the work done by a health care delivery system.  What’s the difference?  Why do we struggle to achieve our goals in clinical outcomes, safety and financial performance in these institutions chock full of brilliant, well-intended people?
The difference is those people….they introduce social factors into the processes and structures of health care delivery, along with emotional states and varying levels of competence and performance – all of which can have an incredible impact on results.  This is compounded by inefficient information sharing and decisions being made, at times, distant from the action.”

I worry that if we merely admonish people not to have annual physical exams, without giving them another way to have an ally in the healthcare system should they need care, we are merely creating a new problem of people flailing around the health care system, not knowing what to do.  There is still a need for a health professional who knows a person as a person, including their social and psychological issues.  This is still needed to help a person obtain the care that is right for them when they are ill, and we all get ill at some point. 

So the annual physical may not be scientifically needed, however there remains a need to have a relationship with a health professional that can get to know you over time – a health professional who can help access the right care at the right time and who knows your social and psychological issues.  At Accolade, we believe that a team approach with a professional Health Assistant as the relationship manager is one way to ensure that someone knows the patient as a person over time, and can help them access the care they need.  When this is combined with a medical home system, with a primary nurse practitioner or a primary care physician being the team member to perform the proper physical exams at the proper time, a better system of ongoing care can emerge. 

We now have Health Assistants who have had five year relationships with their clients, getting to know them and their families, knowing their social issues and the psychological hot buttons and helping them get the care they need efficiently and effectively.  We know it helps people get the most out of care delivery and saves money for both the system and those individuals.  It does not preclude the need for a caregiver to also know the patient however it assists the relationship aspects of care in an era of episodic sick care (instead of screening physicals), short appointments, and fragmented care.     

The driving force behind a yearly exam is often fostering a relationship between a single health professional and a person.  As our society moves away from this “yearly physical” model, the Health Assistant, or a similar professional, may have to move in to fill the relationship void left by this societal change.    The yearly physical exam may go the way of other non-scientific modalities but the access gained by having a knowledgeable person assisting you through the system must remain.