Thursday, 9 April 2015

The Annual Physical Examination

              "I would argue that we should move forward with the elimination of the annual physical," says Dr. Ateev Mehrotra, a primary care physician and a professor of health policy at Harvard Medical School.

                I absolutely disagree with him!   The 'complete history and physical examination' was the foundation of the relationship between patient and physician, when I was a medical student and for hundreds of years before.  One could debate the optimal frequency and whether it needs to be annual and that depends on the patients age and other factors.   The Health Care Industry wants to change all that and is succeeding.   The general objective seems to be to weaken and ultimately undermine the physician patient relationship that results when a patient has built up a lifelong relationship with a doctor.  That relationship plays an important role in the healing process and is unlike any business or industrial relationship.   It is an essential ingredient of medical professionalism.  The last thing the health care administrators want is a relationship between doctors and patients that undermine their ability to engineer the health care system to fit their ideal model.  Bearing in mind that many of these administrators come from a financial background, it is not peculiar that cost is a major preoccupation.  And so  it should be, it is the manner in which they try to manipulate the changes that is destructive.     Ignorant of medicine and anxious to please their political masters, they try to effect savings without costing votes.  That is hard to do unless one can make it appear that a lot of the expenses incurred are wasteful and unnecessary.    They certainly don't want to cut back on any dramatic newsworthy procedures but if they can cut back on demand for perceptually minor, less newsworthy  services perhaps they can eat their cake and have it too.   So, the Choose Wisely Program (and who wouldn't want to choose wisely?) was born.   The doctor and patient would collaborate and decide what tests should be done, by mutual consent and (implicitly) do much less testing.     Nowadays, with universal internet access, patients often come in with reams of printouts that they'd like to discuss.   Doctors, with ten or fifteen minute appointments, struggling to meet the additional time requirements of their relatively recently introduced time consuming electronic medical records, are going to see fewer patients.  

            But let's get back to the annual history and physical examination.   I believe it to be one of the most relevant exchanges in health care, ancient or modern.  The conversation between patient and doctor is the essential exchange that is the initiating point for most medical care.   Conversation, the informal exchange of thoughts and information by spoken words; oral communication between people.   It is at the annual health examination that the doctor and  the patient get to know  each other.  The patient doesn't have to be sick for a valuable and meaningful exchange to take place.   For years we have idealized preventative medicine, the wellness model, total health care etc. etc. and while we sometimes have gone overboard, let's not throw out the baby with the bathwater, largely under the mistaken impression that it will make health care less expensive.   The  history, physical and screening procedures developed over the years have sometimes been excessive, but have played no small part in the improved health status that most Canadians enjoy.  The  educational opportunities that have been a part of that process have paid off big time.  Don't let any administridiot convince you otherwise.   I can assure you they won't be giving up their periodic health assessments.  

              In the course of the annual health examination one comes across a significant number of unsuspected morbidities, physical and psychological, diabetes, cardiac conditions from murmurs to atrial fibrillation, malignant skin lesions, cervical carcinomas. osteoporosis and conditions too numerous to list here.  Mothers ask about their children, middle-agers ask about their parents, and many other issues.  Other important health care topics are often briefly addressed , without any cost to the health care system,  which the administrators cannot even begin to perceive, because it does not fit in to the 'Health Care Industry' model, that they are understand.

               I am  afraid that medicine is going to do as well under the direction of the health care administridiots as finance would do under the direction of physicians!     In any event, let's not eliminate  the foundation block  of communication in  modern medicine, the periodic complete history and physical examination.


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