PhysicalFirst Vicar: I take as my text for today…

(Cut to bishop and vicars at doorway.)

Bishop: The text, Vic! Don’t say the text!

(Cut back to vicar.)

First Vicar: Leviticus 3-14. . .

(The pulpit explodes. Vicar disappears in smoke, flying up into the air. Cut to close-up of the bishop. Behind him there is smoke and people rushing about. Sound of people scrambling over pews in panic etc.)

Bishop: We was too late. The Reverend Grundy bit the ceiling.

Monty Pythons Flying Circus Episode 17

A recent article in Slate (found here) and a less recent article in the New York Times (found here) outlined the problems associated with the annual physical. The problems are many, with the Canadians recommending dropping a physicians visit  for those not suffering from an illness since the 1970s. That’s the Canadians, you say, we Americans deserve to stay healthier and deserve more and better care. Unfortunately, we often don’t even get the care we need.

The problems begin with the concept. There is no template for these visits so often the patient is given what the physician learned in residency as a “check-up.” Only half of check-ups incorporate the evidence based recommendations as outlined by the US Preventive Services task force. In addition, 80% of things that are recommended are arranged outside of the asymptomatic visit. Another reason the physical may be outdated is that the recommendations over the years for those who are without symptoms have become less and less. Annual PAP Smear? Try every 5 years. Annual stress test looking for silent, atypical heart disease? Been shown to actually cause harm.

If we are going to discourage people from coming in when they are healthy, how are they going to stay well? Doctors are being measured on how many of their patients get this care. How are we going to get these folks screened for colon cancer?

First, we physicians need to get over the fact that we must control the means of production for all things medical. The Affordable Care Act assures access to evidence based preventive services without out-of-pocket expense. We need to improve access for healthy people to these services and reduce barriers. We shouldn’t make people come in for a physical exam when they need a FIT test.

Second, we need to provide better outreach to patients who are not highly motivated to seek out preventive care on their own. The “check-up” at best captures those who want to be “check-upped.” We now have the ability to provide outreach to those who need gentle (and not so gentle) reminders.

Lastly, insurance companies need to pay for the right thing to happen. If I do one bad physical, I get paid real money. If I call 10 people and remind them to get a needed mammogram, I get nothing. The right thing needs to get paid for as well.

Why do physicals not work? Perhaps the consequences are too small. If I do a poor physical the patient gets false reassurance, I get paid, and the insurance company (under the current rules) is none the wiser. If  explosives were involved, the outcomes might end up being different,