GE Moore MD's blog

The New England Journal of Medicine recently ran a Pro -vs- Con op-ed debate on the merits of well-patient visits in primary care. Like other such discussions, wellness visits were conflated with physical exams, the operative words are wellness and physical exam, not annual. Wellness visits and physicals are 2 completely different things, different processes, different goals, and thus it is unreasonable (if not a completely misguided use of the research literature) to address them as one entity.

Annual Wellness Visits

Somewhere between the age of 3 and 4 years old, while playing on the swingset next to the gravel driveway at my grandparent’s house, I heard my Grandfather say:

 “There’s more than one way to skin a cat”.

He explained the metaphor, it is playground wisdom still guiding me.

Today I went to the calling hours for a family friend, who was a physician to my family as well as to me when I was an adolescent, and who was also a fellow sailor with whom we all spent many happy days. Dr. Frederick Harrison Grabo was 87.

According to Adam Smith, people make choices that serve their enlightened self-interest. Truthfully, people also make a lot choices that are unenlightened, but that’s a problem for another blog! Today, let’s examine the question of why an enlightened primary care physician (PCP) would choose to do wellness visits.

Well, like other businesses, PCPs need to do things that make more money…and wellness visits are the easiest path to making more money. How could that be - don’t doctors get paid for managing disease-care?

 In 1993, an intrepid group of exercise physiologists, physical therapists and one physician (me) drafted the first edition of a textbook called Exercise Management of Persons with Chronic Diseases and Disabilities (CDD). Working on behalf of the American College of Sports Medicine, we sought to fill a void of exercise guidelines for patients with chronic conditions beyond the “Big Five” (heart disease, high blood pressure, high cholesterol, arthritis and diabetes). Through 3 editions with a 4th now in press, CDD addresses nearly 50 chronic conditions.

Reductionism vs Complexity

Definitions

In Part 1 of false dichotomies, we consider widely divergent studies on the nature of Life. Each provides a different view of reality, somewhat like the way MRI “slices” are oriented in different planes to give different 2-dimensional images of a 3-dimensional organ, like a brain.

In the 1968 science fiction thriller 2001: A Space Odyssey, written by writer Arthur C. Clark and the film directed by Stanley Kubrick, the computer named HAL 9000 was touted as being incapable of error. In an infamous unintended coincidence, which Clark said he would have changed had he realized it, the letters H, A and L sit 1 position in front of the letters I, B and M.

A major flaw of the human mind is that it tends towards dichotomization - perceiving everything as two-sided: black vs white, hot vs cold, good vs evil, right vs wrong. The undesirable consequence is that we misperceive reality, which is extremely complex with many more than two sides. One only has to read the daily news to see the trouble this causes, but dichotomization also affects health care.

"Go Outside and Play"!

Those 4 words were often the instructions I got when I was young. And, apparently, I was not the only one who was told to come inside when the street lights came on. Or so I learned from Bill Sells and Tom Cove on March 4th, when they opened the Sports and Fitness Industry Association (SFIA) National Health Through Fitness Day, in partnership with the American College of Sports Medicine (ACSM).

When there are lots of ways to do something, it’s a good bet that none of them work. Everyone uses a technique or tool if it really is superior. So with the internet, bookstore shelves and junk mail bins filled by peddlers selling motivation...hmmm. Since getting patients activated – actively engaged in maintaining their health – is a huge element of plans to improve population health, it’s worth examining how that might work.