Dr. Ezekiel Emanuel, an oncologist, just wrote in an op-ed piece in The New York Times (January 9, 2015) that you should skip your “annual physical” because such exams have never been shown to prevent disease or disability. Moreover, he said, over 45 million people have such healthy exams annually (only about 15% of the population, incidentally), and they are a waste of money. From my decades of patient care experience, I think Dr. Emanuel is profoundly off-base and does not understand the process of good primary medical care and the important role of periodic comprehensive exams that focus on maintaining health and preventing illness and not just on treating illness.
Dr. Emanuel Is Not Typical
I expect Dr. Emanuel was a good clinical oncologist before becoming a medical administrator, so he is certainly medically knowledgeable and may be able to look after all of his general health needs without the direct counsel of an experienced primary care physician except for illness care. As a professional, he can read the medical literature and interpret confusing medical issues as reported in the press. I would guess that he is trim, eats well-distributed nutritious meals, does some form of regular exercise, and uses modest alcohol and no tobacco or illicit drugs. He may require no medications for any continuing illness, and only calls his physician for an acute illness. He scheduled his own colonoscopy without reminders or prodding. Good for him. Or, “Bully!” as Teddy Roosevelt might have said.
Normal Healthy People Benefit From Physician’s Counsel
Are you a Dr. Emanuel? Or are you one of the more normal middle-aged persons who populate Orchard Health Care and every internist’s practice. You could be a very healthy 50-55-year-old, but adhering to good diet and exercise patterns is difficult because of your intense work schedule. You don’t sleep particularly well and have been gaining a bit of weight, but are confused about whether the paleo diet is what you want, or the polar opposite very low fat. But then there is Grain Brain that you read, and nothing makes sense now. And you heard from friends about these special supplements you can take that will stave off Alzheimer’s, which afflicts one of your parents and you wonder if you should get the genetic testing for that. You Googled all these issues and even got more confused, and you don’t have time to pursue them further since you have to earn a living and rear your children. And by the way, the marriage is a bit rocky the last year or two.
What Is a Comprehensive Exam?
The purpose of a comprehensive periodic exam for a healthy adult is only partially to evaluate that person’s health status, through discussion with the person, some comprehensive yet inexpensive lab tests, and a relevant physical exam, the latter taking perhaps 5-6 minutes. Much more important is establishing and nurturing a clinical relationship between the person as patient and the physician, so both know and trust each other, and so that the physician is in position to offer a wide range of health advice and counsel, and so that the person, with a substantive knowledge and trust relationship with that physician, might actually heed the advice he or she receives.
This is not the trivial issue Emanuel suggests it is. Would you take financial advice about your career and investments from someone you just met and spent 15 minutes with and whom you last saw 3 years ago? Would there be knowledge and mutual trust. I doubt it. And I think the importance of getting and heeding excellent customized health advice is at least as important as managing your assets.
Medical Issues Require Periodic Comprehensive Evaluations
If you are a 50+ person with some established health issues, such as diabetes, hypertension, cholesterol issues, arthritis and so forth, then you have a lot of company, because starting by the sixth decade of life most people have something specifically medical that annoys them or that is of true import and requires regular treatment with medication or more complex therapy. For all of you, who are the majority of the population over 50 or so, it is critical to have periodic long appointments with your physician.
The comprehensive appointment allows the physician to review all your medical issues carefully and thoughtfully, to discuss the current care program, to review your self-care program, to offer additional counsel on disease particulars and encouragement or exhortation as appropriate about how to follow through. It is an opportunity to educate the patient about those illness conditions and about how the body works and how to keep as healthy as possible. It is also the time to talk about the marriage that isn’t working so well and how that relates to too much alcohol, perhaps to encourage using a psychologist and helping pick one out. There are myriad things that go into such an appointment, both illness and health related, and it is unique to each person. Or it should be. And it takes time, more like an hour and frequently more, to process fully. Relevant lab tests and a physical are part of the process. While the results of labs and physical can be mostly predicted by a physician who knows the patient, there are occasional biological surprises that can be highly relevant and of great import.
Most important, at the end of the comprehensive periodic exam, the physician has a clear plan, a medical strategy for the patient’s diseases and preventive care, backed by current data, as to how he can and will help the patient going forward for an extended period. This knowledge makes ensuing appointments dramatically easier to manage, since they are now mostly implementation. Care going forward is more efficient and effective. And the patient gets a clear understanding of where he or she is medically, and exactly what to expect over the coming months to year or so.
Comprehensive Exams for Younger Patients
A comprehensive exam is not necessarily annual. Healthy younger people may well not need a comprehensive exam except every few years. And many fewer lab tests are relevant. I think of the 20-year-old somewhat like the new car. It probably is fine, no matter what, but you do want to check carefully as to how it is driven and maintained, since that will be a good predictor of future of how it will fare. Young adults, in particular, mainly need counsel and guidance at their checkups (you are much too tan, wear more sunscreen) from a knowledgeable non-parent they respect. Frequency of such exams hardly needs to be annual.
Why Do I Care About Dr. Emanuel’s Opinion?
Perhaps what bothered me the most about his opinion piece was that he took a straw man, the alleged “annual physical” for healthy younger people, and failed to distinguish the vastly different real needs for monitoring and counseling at different ages, where older normally means more. And, by failing to acknowledge or perhaps comprehend the content or centrality of the discussion and analysis and review of a comprehensive exam, he implicitly devalues such comprehensive exams and effectively endorses the economic pressures that have devastated primary care in the past two decades. These pressures have pushed most physician-patient interactions into standardized and inadequate 15-minute blocks, where we have ended up with broadly unhappy people as patients, who do not think their PCP knows them or understands them and whom they do not fully trust, while the overworked PCP stumbles along doing formulaic brief problem-oriented visits that are not professionally sufficient for them to fully understand or to do a proper job for the patient. Suboptimal care. Unhappy patients. Unhappy primary physicians. U.S. medicine, 2015.
Orchard Health Care Outlook
As our patients know, we are diligent in arranging periodic, relaxed comprehensive exams at all ages. Such visits are central to the Orchard Health Care approach to your care and are the basis of good preventive or interventional care that follows. The frequency of such long visits varies with age and complexity, and the precise content (general health or disease-specific counseling), depends on the individual’s needs. We are all better informed for it and, I believe, our patients are more knowledgeable about their own health and follow through more carefully because of the education and counseling. And your internist is profoundly more informed about you and relaxed and confident about what I do with each of you because of adequate time to evaluate, think, plan, and communicate with you.
