An example of a concern about the shift in healthcare thinking
“To the best of my ability and judgment I will practice the Art only for the benefit of my patients.” From the Oath of Hippocrates. Late Fifth Century BC.
Hippocrates, often referred to as the father of medicine provided principles for the practice of medicine that remain in place today. He referred to the practice of medicine as an art as did many of the great medical pioneers and educators throughout the centuries that followed. It was not that medicine was not informed by science. Rather, the practice of medicine incorporated the principles of humanity and ethics as well as science.
Centuries after the Hippocratic Oath, Sir William Osler (1849 – 1919), considered the “Father of Modern Medicine” made the distinction between science and practice stating, “The good physician treats the disease; the great physician treats the patient who has the disease.” In his writings he emphasized the importance of the physical exam not only for the information that it revealed but also for the importance of physical touch to the patient. In short, the practice of medicine was based on science, but also considered the patient as person with additional social, psychologic, and emotional needs.
Why then are some individuals recommending the elimination of the annual physical exam?1 One reason is the ongoing disproportionate increase in the cost of healthcare coupled with greater government control and an increased use of economic analyses to determine healthcare delivery practices. Fundamental to these analyses, whether cost benefit analysis, cost effectiveness analysis, quality-adjusted years of life or any other method of taking into account the cost of healthcare delivery, is that they basically measure quantity versus quality on the basis of cost.
Quality is the most difficult measurement and the factor most often omitted as not directly related to a particular disease. Issues such as a patient’s emotional well-being, psychological stress, social interactions, and family relationships are too difficult to quantitate and therefore not considered. Without direct responsibility for the complete welfare of the patient, it is too easy for economists to dismiss essential, but difficult to quantitate healthcare issues, reducing economic analysis to include only objective costs that are easily measured in dollars.
In an effort to reduce the cost of healthcare delivery, the routine physical examination has been targeted as unnecessary. This is in part due to the rapid development of diagnostic techniques which in many instances are capable of making a diagnosis of a disease that simply cannot be detected utilizing a physical examination. The objective measures here are the cost of the diagnostic procedure versus the ability to make a specific disease diagnosis. The conclusion that follows, which can only be made if cost is the sole consideration, is that the annual routine physical examination is not economically justifiable. Of course the decision is made exclusively on the basis of cost without taking into account other critically important benefits to the patient that cannot be measured by dollars alone.
A recent commentary in the widely read New England Journal of Medicine titled, “Improving value in health care – against the annual physical” calls for abandoning the annual physical examination in spite of acknowledging that annual surveys consistently reveal that the majority of patients and physicians strongly support continuing annual physical examinations.(1) It illustrates the increasing dissociation between the ethical practice of medicine as an art and new injunctions to practice medicine based primarily on scientific and economic considerations. While this may seem a reasonable shift in healthcare policy given the continued increase in healthcare costs, what may get eliminated may be less in the interest of the patient and more in the interest of the healthcare provider as a business. In the process the physician may also lose control of the responsibility to protect the patient and, as expressed in the Hippocratic oath and in the writings of Osler, compromise the ability to practice medicine for the greatest benefit of their patients.
The assumptions and the vocabulary utilized by the authors of the commentary were largely dismissive illustrating the gap that exists between the practice of medicine and that of economics. They refer to the “disconnect between expert recommendations [most often from non-physicians] and real-world practice [from physicians]” thereby establishing the experts, not as those who actually care for patients and have responsibility for their health outcomes, but those who are “experts” in economic analyses. The authors also refer to observational studies that demonstrate that morbidity and mortality are not reduced by annual physical examinations. Unilaterally, they declare that the purpose of the annual physical examination is an immediate reduction in morbidity and mortality, ignoring it as an important means of establishing a relationship of trust and advocacy between the patient and the physician for the benefit of the patient.
Surprisingly, the authors use an argument comparable to the faulty logic of the “peace dividend”—if we save money but not doing X then we will have money to do Y. The fallacy in this argument is that you may have the power to do X but not the power to do Y or the money to do Y. Further if a cost savings occurs who is the beneficiary? The recipient of the cost savings is likely to be those in the business of medicine rather than the patient in need of care. The authors further argue that eliminating routine physicals would free up 10% of physicians time as well save an estimated $10 billion a year. However, a better way to free up physician’s time would be to free them from the increasingly overwhelming data entry requirements and documentation of items, not directly related to healthcare delivery, which are increasingly required by the businesses of medicine as well as government agencies. Their estimate of saving $10 billion a year is grossly exaggerated. Based on the number of practicing physicians in the US the cost of the annual physical examination would have to be more than $10,000 for each annual physical to save that amount of money.
Other arguments invoke the time that could be saved by patients by not requiring annual travel or waiting in the physician’s office for the annual physical examination. But why select the annual physical examination for elimination to save time when there are other targets including the time to obtain the rapid proliferation of duplicative diagnostic tests, geographic spread of healthcare facilities, increased physician visits related to medical sub-specialization, multiple laboratory visits, pharmacy visits, visits to clinic and hospital accounting departments, and time consumed filling out increasing numbers and lengths of duplicate medical and insurance forms?
An additional argument invoked is that the annual physical examination might increase patient apprehension concerning the performance of routine laboratory tests by the physician, an argument that fails to acknowledged that the patient is visiting the physician in the first place to allay apprehension that something might be going wrong with their health. (The argument is frequently used in medical economics analyses to justify the elimination of diagnostic tests such as screening mammograms.)
In a final disingenuous argument the authors declare that conducting an annual physical examination is not evidence-based. Increasingly the term “evidence-based” is utilized by economists and health care bureaucracies to deny healthcare to individual patients or even to large patient populations as a whole. The obvious conflict is that the conclusion of what evidence is required is determined by those proposing the argument to reduce costs and any evidence to the contrary is dismissed.
The article ends with what is hardly an evidence-based conclusion, “It’s time to… Stop wasting precious primary care time by having a third of the adult population coming for such visits [annual routine physical exam.” The statement is best countered with the opinion of patients on the value of physician engagement, whether the annual physical examination or seeing a physician during a clinic visit or during a hospitalization (all of which may sometime in the future be argued as being unnecessary and uneconomical). One such patient was Elizabeth Glaser, founder of the Pediatric AIDS foundation who contracted HIV infection following a blood transfusion. She and her daughter Ariel eventually died from AIDS. This is what she said about the value of patient-physician engagement— the art of practicing medicine.
“I know a doctor who did one of the most meaningful things I can ever remember. He will always be my hero because five years ago when my daughter was failing, it happened to be time for him to take his sabbatical… I was so scared thinking of not having him here to lean on, to hold my hand. He understood that and without my ever asking, he came to see us in the hospital every day of his vacation. To you it may not seem like much – to me it was the only lifeline I had to hold on to.”
Elizabeth Glaser in her address to the UCLA medical school graduation. Friday, May 21, 1993
In spite of her illness, what kept Elizabeth going to establish the Pediatric AIDS Foundation and advocate for hundreds of thousands of women and children was the lifeline of direct patient/physician engagement. An economist would be hard-pressed to measure that in a dollar amount.(2,3)
1- Improving Value in Health Care–Against the Annual Physical. Mehrotra A, Prochazka A. N Engl J Med. 2015 Oct 15;373(16):1485-7. PMID: 26465981
2- Lifelines. Matuchansky C, Lancet 386:2539-8
3- The complete physical. Rathe R. Am Fam Physician. 2003 Oct 1;68(7):1439, 1443-4. Review. PMID: 14567495