Moving annual visits into the 21st century

Moving annual visits into the 21st centuryA guest column by the American College of Physicians, exclusive to KevinMD.com.

The recent uproar over the American College of Physicians’ recommendation against routine pelvic examinations made me think about the status of the annual visit (a.k.a. yearly physical, annual exam) on average risk, asymptomatic adults that most internal medicine specialists perform. Some would say that it is at the core of what we do, given its focus on prevention and relationship building between patient and physician. Nonetheless, I think that our day of reckoning is not far off.

Like many tests and treatments, an annual comprehensive history, examination, and testing seemed like a good idea when it was presented at an American Medical Association meeting by Dr. George Gould in 1900. However, the evidence supporting such a visit is weak. That is not a recent observation; in fact, in 1981, ACP’s Medical Practice Committee published a clinical guideline in the Annals of Internal Medicine stating that “Present data are not adequate evidence justifying annual complete examination of the asymptomatic patient at low medical risk. The American College of Physicians recommends that each internist develop individualized plans for patient examination.”

In order to interpret the evidence, it’s important to know what question is being asked. It is not whether counseling, screening, or case finding for certain diseases is worth doing. The question is whether having patients come in annually for a dedicated visit to do all of those things and more is better than doing it at visits that are scheduled for other purposes (opportunistic screening), or, as I’ll discuss later, without a face-to-face visit at all.

For purposes of this discussion I will assume that most of us do not perform a “one size fits all” annual visit but tailor the visit to the patient’s age, gender, and risk factors, as ACP and others recommended in the 1970s and 80s. In reality, many “annual” visits may not even occur yearly, for example in younger and healthier persons. In addition, I’m certain that many physicians no longer perform a comprehensive history and head-to-toe examination at these visits, but instead customize the content to the patient’s needs.

Still, the question remains whether this tradition benefits patients, and more importantly, does it harm patients? By now, you’re probably reminiscing about the times that you discovered something at an annual visit that led to an important diagnosis, or even saved a life. How many of these diagnoses would have been just as treatable if detected at a later, symptomatic stage, since not all conditions benefit from early detection? Also, how many times have you turned up abnormalities that ended up being false alarms, one or more tests later? A recent JAMA Piece of My Mind column described what may be an extreme example of harms from an annual visit. More common examples include hearing heart murmurs that generate echocardiograms showing clinically insignificant findings for which no action is recommended, or ordering “routine” metabolic profiles that turn up minor abnormalities requiring repeat testing or imaging to prove that nothing is wrong.

If you would like to look at the best evidence on the topic, read this review and a more recent Cochrane review.

The bottom line from these and other papers is that the evidence supports some components of the annual visit but does not support the value of the entire visit. Persons who undergo annual visits feel more reassured and are more likely to receive some recommended preventive services than those who do not have an annual visit.  There is no evidence of a morbidity or mortality benefit from annual visits. There is very little evidence on the harms and additional costs resulting from annual visits.

Recently, the Society of General Internal Medicine (SGIM) recommended “Don’t perform routine general health checks for asymptomatic adults” as one of its Choosing Wisely items. To its credit, SGIM was one of very few groups whose Choosing Wisely recommendations involved a service or procedure that its own members provide. However, the recommendation on the annual exam upset SGIM members, according to press reports.

The logic behind the annual visit is mired in the paradigm of face-to-face care provided exclusively by the physician. What if we took a twenty-first century approach instead? Care is delivered increasingly by teams using health information technology. Many of the evidence-proven services delivered or discussed at annual visits can be tracked and require little more than periodic reminders to patients. A high-functioning patient care team, prompted by a good EHR, could ensure that patients get routine screenings using phone calls from medical assistants or nurses, or computer-generated text messages, patient portal alerts, and other means that do not require an in-person visit with the physician. Some interventions, such as counseling, would still require a visit, but not necessarily with a physician, nor as part of a comprehensive evaluation.

Next to the culture change required to replace the annual visit, the two most significant barriers are the payment system and patient expectations. Our current system does not value non-face-to-face care adequately. Under the status quo, annual or periodic preventive visits are covered by most insurers, so how might a move away from annual exams be funded? If we intend to keep our patients up to date with their screening in real time instead of using the traditional annual visit, someone will have to pay for the necessary systems, staff, and other resources in a way that the current payment system does not.

Linking payment to meeting screening goals using a “pay for performance” methodology could be part of the solution, but it does not guarantee payment for the up-front costs of acquiring the information technology and adopting new workflows. A “per member per month” payment would work, as would “add on” codes for the extra time spent at other encounters when face-to-face counseling is needed. Moving away from yearly “well-adult visits” could have implications on access, as physician time currently spent on these encounters could be used for other patient visits, such as same day access.

As to how to change patient expectations, that may not be as difficult for us to achieve as it seems. After all, who created patient expectations around the annual visit in the first place?

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Patient Kit

    My purely anecdotal experience is that my ovarian cancer was found at an early stage (1A) during my annual well-woman visit with my GYN. Maybe it was a fluke, fate, coincidence, luck or an angel on my shoulder. I was totally asymptomatic and healthy. I had just “passed” my annual pap smear and mammogram and my first ever colonoscopy when the “suspicious” cyst/tumor was found. I realize that most — 80%? — of OVCA is found at stages 3 and 4, often too late, but, frankly, I don’t care what the stats are or what the odds were of finding early stage OVCA during a well-woman visit. I’m just glad it was found early and, going forward, it’s hard for me to see annual well-woman visits as meaningless or useless. What if I didn’t go for that annual exam? What if I skipped a year or two? Thankfully, I’ll never know the answer to that question. But I can’t help feeling that data isn’t everything.

    • Yul Ejnes, MD, MACP

      Your experience illustrates why these discussions can be challenging, and I respect that you acknowledge all of the possibilities regarding your diagnosis (it could have been the fact that you had the well-woman visit, a fluke, fate, etc.). Whether you’re the patient who benefitted or the physician who made the diagnosis, those “saves” stick in your mind, which makes it difficult to change how we do things. What the studies do is aggregate data to tell us how often experiences such as yours occur relative to women having completely normal examinations or, worse yet, having abnormalities that lead to additional, sometimes risky, testing that turns out to be normal. But I understand that even if the stats say it’s a low value proposition but you had a life-changing experience, it’s still valuable to you. I hope all goes well for you.

      • Patient Kit

        Here’s my personal dilemma with making medical decisions purely by The Data: There was a very small chance of finding OVCA in stage 1A, but we did. There was a very small chance of finding early stage OVCA during an annual well-woman visit, but we did. That annual GYN exam may statistically seem wasteful to the system, but it doesn’t feel wasteful to me individually (even if there is a good chance that visit merely provided a portal for something unscientific like fate or an angel). Now, going forward, there is a good chance that my OVCA won’t recur. But there are no guarantees and it might recur. So, is it now wasteful for me to have follow up visits with my GYN oncologist 4x/yr for 2yrs, then 2x/yr for 3 yrs, then annually to monitor for recurrence? I’m 1.5 years post-dx and post-surgery now and, so far, I’ve been going for those checkups. Here’s my question for The Data worshippers: if I fell into the lucky 10% whose OVCA was found at stage 1, what are my odds of now falling into the unlucky 10% whose early-stage OVCA recurs?

        And then there are all those things that are unmeasureable by scientific data that greatly effect how we approach medicine: Like trust. From a patient’s POV, on the issue of all the widely done screenings and procedures that have suddenly been deemed unnecessary (see the long Choosing Wisely list), who are we supposed to trust on this? Is this a play, driven by the payers, to save a boatload of money? Is it cheaper to just treat those women who develop breast cancer and find it later stage than it is to provide regular mammograms for every woman? Sure, surgery and chemo are more expensive than mammograms, but it will less expensive for the whole system, if we stop regular mammograms for all women. On the plus side financially, many of those advanced stage breast cancer patients will die. It would definitely be less expensive if so many patients with serious disease didn’t live so long. I know that’s extremely cynical but not many of us trust the bean-counting powers that be in healthcare. And then there are our doctors. Most of us still trust doctors more than we trust insurance companies and government, but that trust in doctors is seriously eroding. If doctors have been routinely doing hundreds of things that Choosing Wisely now says are unnecessary, why were doctors doing those things? To make money? To cover their asses legally? Who are patients supposed to trust about whether mammos, pap smears, well-woman visits, etc are necessary or unnecessary?

        • Yul Ejnes, MD, MACP

          The reason that they were doing those things in the first place was that they thought it was a good idea based on the information that was available at the time or because of the hypothetical benefits, but as is the case with many things, as more data and experience accumulated, other issues became apparent. That phenomenon isn’t specific to medicine, but true for life in general (“if I knew now what I knew then…”). Again, it also illustrates the tension between statistics and individual experience. Try telling a big jackpot lottery winner that buying scratch tickets is a waste of money, for example, even though the odds of winning are low.

          Also, while it might seem that way, it’s not always a matter of stopping things that we were doing – sometimes new knowledge tells us to start doing things – lung cancer screening might be an example of that.

          While much of the discussion on “to do or not to do” centers on benefits and harms to patients (one of the other posters, “disqus_question_everything” presented a counter-point on how screening might have harmed her), the cost issue is germane because it doesn’t just involve insurance companies, hospitals, government, or doctors. It affects the premiums that regular people pay, wages, the cost of goods, and other aspects of the economy. It isn’t politically correct to discuss this, because it brings out another area of tension, which is that each of these items adds to cost, and people generally don’t like paying more for things, but if we accept without challenge the “if it saves one life..” arguments, we add to the cost, since someone has to pay for those things.

          Not an easy discussion, but one that we need to have. Thanks for your thoughts.

        • SarahJ89

          Great questions, Kit. And yes, these are all the things patients grapple with, the cognitive conflicts we’re trying to resolve on our side of the equation.

          I think training is a large part of the decision making in which doctors engage so they were more likely to be doing all those tests because they thought they were appropriate. Sadly, medical education seems to be done by the insurance and pharmaceutical industries these days which makes your questions all the more valid.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Here is my twofold dilemma with this subject:
    1) Medicare and every payer out there are pushing people to get annual health assessments, and this is fairly new. Should we presume that the goals are not health related? If so, why are physicians complying, and why should the public bear the costs?
    2) Many of the experts arguing that yearly physicals are unnecessary, are employed by academic centers of excellence that are actively promoting executive physicals at astronomic prices for rich people who “value their health”. Most of the costs are covered by the employer, or out of pocket, but these same centers are also suggesting that at least some of the very extensive lab work can be billed to insurance. And these posh physicals are not administered remotely, or by computers or by lowly technicians. They are performed by full-service physicians.
    Is it just me, or is there a “slight” ethical problem here? Are physicals only recommended for the more valuable members of our society? Or are these medical centers engaging in fraud?
    Just a thought, but perhaps the ACP should publish a statement to that effect…..
    (I am having this sense of déjà vu and I think I may have asked this question before)

    • azmd

      Or, maybe all those experts are just really comfortable with the idea that there should be two levels of care; one for the elite and one for the rest of us…

    • Yul Ejnes, MD, MACP

      Interesting questions. To your first one, the goals might be health related but the concept of these assessments is built around the notion that a dedicated visit is needed to get the components of the assessment done rather than use non face-to-face contacts or face-to-face visits that occur for other reasons. If you break down the Medicare “Annual Wellness Visit,” which at the time it was introduced was criticized because it did not include an examination, it actually includes many evidence-based services and pays for spending time making sure that recommended (evidence-based) screening is up to date. The questions, still, are whether is it better to do it all in one sitting (the studies that I reviewed look at the traditional annual physical and not the more contemporary health assessments such as the Medicare AWV), does it need to be annual, and why the payment system can’t be reconfigured to pay for getting the job done some other way.

      To your second point, I agree that there is a disconnect. I touched upon a related issue in an earlier column (http://www.kevinmd.com/blog/2013/02/acp-medicine-air-inflates-patient-expectations.html) but what I wrote there could be said about the “executive physicals,” which are truly wasteful.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Thank you.

    • SarahJ89

      Oh yeah, “slight.”

  • disqus_question_everything

    I had a large ovarian cyst discovered 2 months AFTER my annual gyn pelvic exam (symptom of pelvic pain). Unfortunately, my gynecologist over-treated me by removing all my female organs even though the frozen section was benign. It is a travesty that far too many women are hysterectomized and/or castrated for benign conditions. Even though 76% of hysterectomies do not meet ACOG criteria, hysterectomy is not on ACOG’s Choosing Wisely list – http://www.choosingwisely.org/doctor-patient-lists/american-college-of-obstetricians-and-gynecologists/.

    I was never one who was totally sold on any annual doctors’ visits but now I am even more averse to being “poked and prodded.” I am ok with having lab work done but avoid other screenings. Can you blame me?!

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