Dr. Ezekiel Emanuel published a misguided and extremely myopic op-ed in the New York Times on January 9. He recommended that everyone forgo annual physicals by their primary care physician (PCP). Annual physicals are often conflated with health checks or wellness visits, in which it may be appropriate to have a focused physical exam. A more constructive call would have been for Dr. Emanuel to clarify the PCP’s role in collaborating towards a culture-of-health, and he should have advised all Americans to demand a wellness visit.
Dr. Emanuel overstates the scientific merit of the Cochrane review, which is a narrowly-focused meta-analysis of very old data on morbidity and mortality. Far from being the final word on health checks, the authors excluded 144 studies that examined other reasons and aspects of health checks. The meta-analysis included 14 studies, with the primary mortality analysis on 9 of them. Dr. Emanuel doesn’t mention that 5 of the 9 studies were published in the 1960s, 7 of 9 published before 1972, even the most recent one was published in 1992. Almost all of the studies that were excluded were published after the oldest paper in the meta-analysis. The review looked past newer science to examine old data obtained under an outdated health system paradigm.
It is scientifically invalid for Dr. Emanuel and the American Board of Internal Medicine Choose Wisely campaign to use such a narrow analysis to discard all health maintenance visits. The studies included in the review are predicated on paternalistic 50 year-old notions rooted in a culture-of-disease — doctors catching something early to protect you from disease and death. The resulting review has absolutely no bearing whatsoever on how visits rooted in a collaborative culture-of-health — doctors collaborating with you and your local resources to preserve your well-being, reduce your burden from chronic disease, and improve your quality-of-life.
Dr. Emanuel and the Choose Wisely campaign essentially espouse that you should go to your PCP only when you’re sick. Why don’t they also, then, stop calling our system “health care” and call it “disease care”? It is dumbfounding that a Provost for one of America’s best academic medical centers could, together with the august ABIM, have such poor insight on how to create a culture-of-health. Instead, they reveal their bias towards a culture-of-disease, heavily dominated by an exorbitantly expensive, technologically-driven business model. Precious little will be saved by cutting out wellness visits.
In contrast, many health insurers and employers are actively working towards a culture-of-health. The Centers for Disease Control encourages employers to provide workforce wellness programs. The Affordable Care Act mandates that all non-grandfathered health insurance plans cover an annual wellness visit with no-copay and no deductible. Indeed, Medicare specifically advises PCPs to do annual wellness visits, including a physical exam on the very first wellness visit. Managed-care Medicare plans and accountable care organizations (ACOs) use annual wellness visits to assign the PCP who will be held accountable for a patient’s health costs.
So whose opinion on staying healthy would you respect most?
- Your employer (which wants to keep you as productive as possible),
- Your disease-care insurance company (which wants to keep your premiums as profits), or
- Your PCP (personally chosen by you as your advisor on matters related to your well-being, quality-of-life and longevity).
Which among those three would be most likely to advise you solely on your own best interests? Do you not value being able to receive counsel from the professional you trust with looking out for your holistic health?
Annual wellness visits are important whether you’re healthy or have multiple chronic diseases, because a very different kind of discussion happens during a wellness visit. In a disease-care visit, it is more-or-less impossible to have in-depth health-oriented discussions as an add-on, because of time constraints in practice operations. Depending on age and individual circumstances, important issues to be discussed include tobacco, alcohol and drug use, safe sex, appropriate vaccinations, need for health education, fall risks, mobility and physical functioning (the ability to get around on one’s own), as well as the capability to maintain independent living and not be a burden on one’s children. Americans deserve to have a visit dedicated solely to these important aspects in the pursuit of health.
Another extremely important element of health, greatly overlooked by today’s culture-of-disease, is exercise. About ¼ of all Americans are completely sedentary; they get no physical activity aside from daily living. About ½ of all Americans don’t meet the guidelines for healthy physical activity. One of the most important things a PCP can do is to engage their patient on the critically important role of exercise in health, and to write a personal exercise prescription. The American College of Sports Medicine’s Exercise is Medicine program and the Bipartisan Policy Center, in Washington, D.C., are striving to improve this physician function.
Given America’s need for PCPs to provide moral imperative on physical activity, one must ask if exercise prescription was studied in the Cochrane review. It was not. And while moderate-intensity activity is generally extremely safe, exercise (like all prescriptions) is not without adverse effects. Remember, the first rule of medicine -– primum non nocere (first, do no harm). A physician prescribing exercise would be negligent if he or she did not also do a limited examination to avoid hurting a patient who has arthritis or back problems or asthma or other limiting condition(s). This important role of physical exams, akin to sports pre-participation physicals required for scholastic and college sports, was not examined in the Cochrane review.
It’s dismaying to see an architect of the Affordable Care Act abandon one of its key purposes — promoting good health. America’s medical system is so deeply inculcated in the culture-of-disease that physicians like Dr. Emanuel stumble on providing a culture-of-health. Well-intentioned, Dr. Emanuel and the ABIM reveal that they are locked into the culture-of-disease mentality. We will never transition to a culture-of-health as long as we continue to be driven by health science that is predicated on a culture-of-disease.
Having an annual wellness visit (with or without a physical exam) is not about cost-savings or living longer. Rather, it’s about creating a nationwide culture-of-health to make LIFE more fulfilling and worthwhile. Wellness visits are about how you can preserve health, reduce your burden of chronic disease, improve quality-of-life and, maybe, live longer (it has been proven that active and physically fit people live longer).
Americans, you should demand a wellness visit with your PCP. Meet with a fresh mind, open to creating a culture-of-health, and set aside your biases towards the culture-of-disease. Then work with your PCP to improve your well-being and quality-of-life. Do this, and you’ll find it’s one of the best values in health care.