David U. Himmelstein, MD; Russell S. Phillips, MD
This article was published online first at www.annals.org on 5 January 2016.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2097.
Requests for Single Reprints: David U. Himmelstein, MD, City University of New York School of Public Health at Hunter College, 255 West 90th Street, 12A, New York, NY 10024; e-mail, email@example.com.
Current Author Addresses: Dr. Himmelstein: City University of New York School of Public Health at Hunter College, 255 West 90th Street, 12A, New York, NY 10024.
Dr. Phillips: William Applebaum Professor of Medicine, Harvard Medical School, Center for Primary Care, 635 Huntington Avenue, Boston, MA 02115.
Author Contributions: Conception and design: D.U. Himmelstein.
Analysis and interpretation of the data: D.U. Himmelstein, R.S. Phillips.
Drafting of the article: D.U. Himmelstein, R.S. Phillips.
Critical revision of the article for important intellectual content: R.S. Phillips.
Final approval of the article: D.U. Himmelstein, R.S. Phillips.
Collection and assembly of data: D.U. Himmelstein.
Himmelstein D., Phillips R.; Should We Abandon Routine Visits? There Is Little Evidence for or Against. Ann Intern Med. 2016;164:498-499. doi: 10.7326/M15-2097
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Published: Ann Intern Med. 2016;164(7):498-499.
Published at www.annals.org on 5 January 2016
A revolt is brewing against the tradition of periodic visits for patients without specific health concerns. A prominent colleague urged patients to “skip your annual physical” and “free up countless hours of doctors' time” (1). Even the Society for General Internal Medicine advised primary care physicians to avoid “routine general health checks for asymptomatic adults” (2).
Much of the evidentiary support for such recommendations comes from a Cochrane review that concluded that general health checks for adults “did not reduce morbidity or mortality” (3). However, we, like many colleagues, view the routine (although not necessarily annual) well-patient visit as a mainstay of the physician–patient relationship and worry that abandoning it risks undermining proven benefits of primary care, including better patient outcomes and attenuation of disparities (4). In our experience, such visits have led to new diagnoses of melanoma, colon and breast cancer, alcohol abuse, opiate addiction, and depression—diagnoses that would otherwise have been delayed or missed.
William R. Phillips, MD, MPH
University of Washington
January 8, 2016
Conflict of Interest:
Declaration of COI. I have no conflicts of interest connected with this work. <br/><br/>Disclosures:<br/>I am a member of the United States Preventive Services Task Force, but this comment does not represent the views and policies of the USPSTF.<br/><br/>I am no relation to RS Phillips, author of the piece.<br/>
No Patient is Average and No Visit is Routine
I agree with Doctors Himmelstein and Phillips(1) that calls to abandon “routine visits” misinterpret the evidence and misunderstand the context and dynamics of patient care.No patient is average and no visit is routine. Just because a patient does not need a specific test or treatment does not mean that she doesn’t deserve care. Every visit presents an opportunity for care and connection, better understanding, deeper knowledge and improved trust.Many routinely scheduled visits quickly become key encounters. Patients sometimes fail to recognize important symptoms, underestimate health risks, or need help changing risky behaviors. “Health is . . . not merely the absence of disease or infirmity”(2) and health care is not merely the reduction of morbidity or mortality.We must distinguish between periodic health exams, routine preventive services and scheduled follow-up visits. The Cochrane Center, the United States Preventive Services Task Force and other groups have developed robust methods for evaluating the net health benefits of some routine interventions. For much of clinical medicine, however, current methods and evidence is inadequate to determine value to patients. We need thoughtful research with new methods to assess the value of many aspects of patient care, including many of our routines. Even clinical rituals can offer special value, but they are not above rigorous evaluation in the rich context of patient care.Evidence-based medicine must be balanced with patient-centered care. There are more things in heaven and earth, than are dreamt of in the RTCs. In family medicine – the specialty devoted to care of the whole patient the whole time – each visit is an opportunity to activate, orchestrate and integrate. Care deserves time, both during the visit and in multiple encounters over time. The trust essential in the acute crisis or the difficult chronic illness is trust that must be earned over time and across multiple visits for various problems. This trust is also the foundation for helping patients “choose wisely” to avoid interventions of little value. “Routine visits” can, when managed by the physician mindfully managing evidence, compassion and relationship, enhance the value care.The real question is not whether routinely scheduled visits are worthwhile, but how can we make every clinician-patient encounter as valuable as it can be? More urgently, the question now may be: How do we preserve value against the triple threats of cost cutting, down-skilling and productivity pressures.1. Himmelstein DU, Phillips RS. Should We Abandon Routine Visits? There Is Little Evidence for or Against. Ann Intern Med. [Epub ahead of print 5 January 2016] doi:10.7326/M15-20972. World Health Organization. 2006. Constitution of the World Health Organization – Basic Documents, Forty-fifth edition, Supplement, October 2006.
Routine visits are disease mongering and wasting resources
Himmelstein and Phillips’ opinion about routine visits deserves comment as it is confusing.(1) Krogsbøll et al’s review is well confirmed by two recent studies.(2,3,4) Routine visits neither reduce morbidity nor mortality - overall, for cardiovascular or cancer causes! No doubts the U.S. Preventive Services Task Force would recommends against the service (grade D) if needed.Good intentions preferring common sense to evidence have killed many, even for prevention (e.g. prone sleeping position for infants …). One can understand Himmelstein and Phillips’ concern for the low-income persons. Indeed, Medicare—seniors and adults with permanent disabilities are significantly more likely than others to need health care services. However, good access to health care means being able to schedule timely appointments. Routine visits can’t help: a) it is transforming healthy people in patients needing a medical surveillance, which is disease-mongering; b) it is ignoring stories of doctors not taking Medicare patients by threats of payment cut.(5) Routine visits are wasting resources, time and money might be better focused: the deprived need education, social support and better living condition.(6)1 Himmelstein DU, Phillips RS. Should we abandon routine visits? There is little evidence for or against. Ann Intern Med 2016. Online. doi:10.7326/M15-20972 Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.3 Saquib N, Saquib J, Ioannidis JP. Does screening for disease save lives in asymptomatic adults? Systematic review of meta-analyses and randomized trials. Int J Epidemiol 2015;44:264-77 4 Jørgensen T, Jacobsen RK, Toft U, Aadahl M, Glümer C, Pisinger C. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. BMJ 2014; 348.5 Boccuti C, Swoope C, Damico A, Neuman T. Medicare patients’ access to physicians: A synthesis of the evidence. The Kaiser Family Foundation 10 Dec 2013. Avalaible at http://kff.org/medicare/issue-brief/medicare-patients-access-to-physicians-a-synthesis-of-the-evidence/ Accessed 8 Jan 2016.6 Ludwig J, Sanbonmatsu L, Gennetian L et al. Neighborhoods, obesity, and diabetes-a randomized social experiment. N Engl J Med 2011;365:1509-19.
Thomas J. Poulton, MD
Alaska Native Medical Center, Anchorage, and The Creighton University School of Medicine, Phoenix, Arizona
April 7, 2016
We Must Provide Value, Not Good Intentions
Drs. Himmelstein's and Phillips' exhortation to continue thoughtful "routine" visits arrived in the mail, appropriately, on the same day I received three reminders to attend to necessary care in my own life. My optometrist wants to see me: it has been one year since my last visit. My auto repair shop wants me to bring my car in for a "routine checkup to prevent problems before they happen". My dentist helpfully reminded me that it has been six months since my last visit and that I should "invest in a great smile by scheduling a checkup before little problems become big ones". How thoughtful they all are.Each of those three advertisements has the same scientific foundation as the urgings of Himmelstein and Phillips: none whatsoever. The available evidence is clear that unnecessary "routine" healthcare visits certainly serve to make humans dependent on their physicians, lead at times to unnecessary and even harmful interventions, and add cost without adding value. And therein lies the rub: these presumed good intentions come with costs: all those costs are borne by every party of interest excepting the helpful physician.Our intuitions and bare opinions are biased and flawed; that is why we believe research is so important. Let me suggest that for those physicians who are convinced, based only upon their own biases, that "routine" conversations with patients add value, they can shape their practices to achieve their goals while avoiding unethical behaviors. They need merely to invite the targeted patients to enjoy a free lunch with them. The typical month provides about 22 workday lunchtimes for this activity. By extending this practice to Saturdays and Sundays, each physician so motivated can provide a free, extended, confidential, therapeutic, investigative conversation to thirty patients per month, 365 souls assisted every year. Of course, such lunches should fairly and ethically be preceded by an informed consent discussion that allows the prospective diner to understand the risk that she will be infantilized, made dependent, and may well receive unnecessary and injurious diagnostic and therapeutic interventions as a consequence of that grilled cheese and soup.
Daniel Pomerantz MD MPH
Montefiore New Rochelle Hospital, Albert Einstein College of Medicine
April 18, 2016
Finding time for relationship-building
In “Should We Abandon Routine Visits? There Is Little Evidence for or Against,” Himmelstein and Phillips acknowledge that the evidence against “routine health checks” is old and outdated (1). They also recognize that there may be other good reasons to continue having visits that are not based on the need for evaluation or treatment of a specific health condition. As both a practicing primary care internist and a palliative medicine specialist, I see a great need for an ongoing series of visits with my patients, both for following up on their health and well-being, but also to facilitate an ongoing conversation with them about what is important to them. Some of these are explicit conversations which are triggered by events in my patients’ lives, either their own illness or something that happened to a friend or family member. Some conversations are more implicit. I get to know how a patient handles health care decisions by working with them over time to try to make the many healthy changes that we physicians frequently recommend to our patients, both adherent and otherwise. I get to learn who values advice, and who values evidence. I get to learn who cherishes ease, comfort and simplicity, and who prefers to struggle for independence, no matter how difficult or inconvenient. Over time, I get to learn who trusts their children and who has no one they can depend on. All of this takes time, and time is in short-supply. In their analysis of more than 31,000 primary care visits, Bruen, et al, found that the average length of each visit was about eighteen minutes (2). If we eliminate visits with no immediate problem on the agenda, where will we find the time for relationship-building?More and more time is devoted to gathering information for a variety of value- or quality-based reporting programs. Where is the “quality time” for physicians and patients simply to get to know one another, and develop the trusting partnership that is not only vital to helping to cope with serious illness, but necessary for encouraging adherence with potentially distasteful but beneficial measures like colon cancer screening? Physicians need time to talk to patients, who “don’t need a flu shot,” as well as patients who may not “need” anything right now, but who will undoubtedly need a trusted adviser or confidant at some time in the near or distant future. Trusting relationships develop over time through visits for both routine and urgent conditions. The periodic health exam (PHE) itself may not be beneficial, but by creating a structured time to consult a physician and talk about health care, the PHE facilitates the development of the therapeutic relationship.1. Himmelstein DU, Phillips RS. Should we abandon routine visits? There is little evidence for or against. Annals of Internal Medicine 2016 April 5;164(7):498-9.2. Bruen BK, Ku L, Lu X, Shin P. No evidence that primary care physicians offer less care to medicaid, community health center, or uninsured patients. Health Affairs 2013 September 01;32(9):1624-30.
Stephen J. Gluckman, M.D.
Perelman School of Medicine of the University of Pennsylvania
April 24, 2016
Morbidity and mortality outcomes devalues the benefit of annual examinations
Himmelstein and Phillips make several excellent arguments in their opinion piece on annual physical examinations . Putting emphasis on trying to determine if the literature supports a morbidity or mortality benefit to annual examinations is not the best way to judge benefit.
Annual examinations accomplish much more than attempting to uncover a potentially life threatening latent disease. They are opportunities for reinforcing and congratulating patients who have successfully lost weight, decreased excessive alcohol intake or stopped smoking. For patients less successful it offers the opportunity to discuss and strategize to achieve these goals. Discussing topics that many patients might not make an appointment for such as complementary therapy, advanced directives, life satisfaction issues, less than expected sexual contentment, updating immunizations, and updating family history that might have an impact on patient risk factors are all part of an annual examination.
I regularly uncover mundane problems that have nothing to do with mortality, but can improve the quality of life such as tinea pedis or impacted cerumen.
The media is full of medically connected information. Patients have questions and physicians have perspectives and updates. This an opportunity to address those questions.
Finally, it is particularly difficult to quantify the potential benefit that results from a patient and physician reacquainting with each other annually. They become more comfortable with each other. This would be difficult to do if patients were seen for only acute visit problems
Reassurance and education of a patient have value for that patient even if these things do not prolong a life. Decreasing mortality or averting acute problems as the only acceptable medical goals of an annual physical examination devalues other benefits of an annual session with a primary care physician.
The bulk of the time spent at the annual examination is in discussion, review and education. This may not save lives but it can make lives better.
Stephen J. Gluckman, M.D, F.A.C.P.
Professor of Medicine
Perelman School of Medicine at the University of Pennsylvania
No conflicts of interest
David U. Himmelstein, M.D., Russell S. Phillips, M.D.
City University of New York at Hunter College and Harvard Medical School
June 6, 2016
Response to letters
Like us, three of the correspondents perceive potential value in so-called routine visits. We endorse Dr. Phillips’ call for research to optimize the value of each clinical encounter, and share his concern about threats to the doctor-patient relationship – including the possibility that payers may eventually proscribe payments for routine office visits. Drs. Pomerantz and Glucksman aptly emphasize the importance of trusting relationships, and physicians' role in making patients' lives better, not just longer. Dr. Poulton asserts that routine visits to primary care physicians lead to unnecessary, and even harmful interventions. As noted in our Commentary, such assertions rely on trials that examined add-on testing carried out in isolation from ongoing primary care, and in those trials routine primary care visits were the norm for the vast majority of both control group and intervention patients. Moreover, as we pointed out, a systematic review of more relevant studies (i.e. that examined visits consisting of history, risk assessment, and tailored physical examinations, rather than add-on testing) found evidence of benefit that “justifies implementation of the PHE [periodic health examination]." We are unaware of any data to support his contention that routine visits create infantilized, dependent patients. Dr. Poulton’s analogy between routine visits and car care seems misplaced. Auto mechanics carry out prescribed maintenance of inanimate objects, an approach more akin to primary care that’s limited to following algorithms. Optimal medical care requires more intimate and personal knowledge, and patients’ active participation.We fear that abandoning routine visits would lead to the emotional impoverishment of primary care, leaving patients isolated from their doctors and accelerating physician burnout. Moreover, physicians who never examine healthy patients are unlikely to become adept at differentiating normal from abnormal findings.While we agree that there is a paucity of evidence on the effects of routine visits, we believe the existing data are insufficient to change a practice that has been an important component of the primary care relationship. Starfield's work suggests that primary care is associated with better health and quality of care, and reduced healthcare costs . Absent a clear understanding of the contribution of the routine exam to the value proposition of primary care, dropping the routine exam from the armamentarium of primary care seems premature.Too many patients bear the costs and harms of unneeded tests and procedures. However, too few enjoy the open communication and interpersonal continuity that routine visits, done right, should foster. David U. Himmelstein, M.D.City University of New York at Hunter CollegeRussell S. Phillips, MDDirector, Center for Primary Care and William Applebaum Professor of MedicineHarvard Medical School1- Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med. Feb 20 2007;146(4):289-300.2- Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.
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