I am honored to be a contributor to WBUR Congnoscenti, WBUR’s online magazine of commentary. My first article, The End of the Annual Physical as We Know It was published 12/27/2013. Here’s the text:
Every day, newspapers, television, and social media dissect the potential and shortcomings of the Affordable Care Act (ACA). Will we lose our existing insurance? Will we gain greater access to care? Will the websites ever unsnarl? Gnashing over the mechanics of reform masks a deeper fear: that our idealized view of individual healthcare, rooted in trusted relationships, will be forever lost to a maze of impersonal transactions. We pine for Marcus Welby, M.D., that caring soul who knows us well and champions our interests, every time we’re forced to reveal personal intimacies to nameless providers prompted by their computer screen.
Last week I had my annual physical. My doctor of over 20 years thumped my chest, probed my prostate and listened to my heartbeat. More importantly he listened to my questions, asked about my work, my mental health, and my children. I described pinpoint headaches I’d noticed at my right temple. He ordered a blood test to check for a pressure block.
Despite the ACA’s stated aim to provide greater access to primary care, my annual physician check-up will probably not survive healthcare reform.
First, there are not enough primary care doctors to go around. Although the ACA promises to provide regular medical care to 15 million more Americans, we lack primary care physicians to treat them. The American Academy of Family Physicians predicts we will need over 50,000 more primary care physicians by 2025 to address the trifecta of population growth, aging population, and the newly insured. Yet, medical schools continue to emphasize specialty care. There are nearly 30,000 first year residency positions in the United States, but less than 3,000 in family practice and of those, the Student Doctor Network reports that only 40 percent will ultimately practice primary care.
This shortage of doctors leads to relying on nurse practitioners and physician assistants to fill out healthcare teams. Unfortunately, calling them ‘mid-level providers’ conveys to patients their second tier status and dilutes primary relationships. If I can’t see my doctor until I’ve climbed through the caregiver ranks, I won’t see him until I’m already sick.
Second, The Agency for Healthcare Research and Quality (AHRQ) has decided my annual physical is a waste of medical resources. The $7 billion America spends on 64 million annual physicals is not cost-effective. The study is probably correct: my annual physicals never turn up much of anything. But the study also ignores the most important aspect of the annual ritual: reinforcing my relationship with my doctor.
The true value of our 20 minutes together is greater than what my doctor diagnoses and treats. Our visits inform whatever issues lay ahead. Because our face-to-face connection is strong, I’m more comfortable relying on our web portal when I’m ill. Twenty years of mutual trust means that I accept his specialty recommendations at face value and don’t seek second opinions. Since my doctor knows me in health, he can serve me better in disease.
To be sure, electronic communications are more efficient than office visits. But as anyone who’s ever spiraled down a series of email miscommunications can attest, the potential for mistakes through remote media is great.
We do not expect the nameless clerk at Wal-Mart or Home Depot to know us; we’ve forfeited the familiarity of neighborhood storekeepers in favor of the huge selection and low-costs that superstores offer. Yet we still yearn for personal attention in healthcare. When even the simplest procedure requires us to interact with five, maybe 10 different faces, we’re frustrated when each repeats the same annoying questions. We fantasize that if the system were simpler, if these people actually knew us, we could avoid these dehumanizing protocols.
The ACA is neither the villain nor savior of our healthcare system. I hope that its kinks will smooth and more people will receive better access to healthcare. But ACA will do nothing to align our fantasy that healthcare is a vocational calling to serve mankind with the reality that it’s just another big business.
So far my doctor’s office has not adopted the AHRQ recommendations against annual physicals; my doctor and I will meet again next year. But I foresee a time when our annual chats, relics of relationship-based medicine, become memory. I won’t be able to defer a pinpoint headache by putting it on my list of annual discussion topics. I’ll have to evaluate the pain and decide myself whether it needs immediate action. This could lead me to seek more frequent care and turn me into just another transaction for that harried provider who knows nothing about me except what the screens displays. My anxiety will certainly rise, even if my blood test comes back negative.