Saturday, January 10, 2015

A Prominent Academic Specialist Denigrates the Periodic Physical

Is the advice of a skilled medical professional who knows you, cares about you, and sees you regularly, worth anything? According to one of the NYT's anointed medical columnists, Ezekiel Emanuel, the answer is no.

It will be hard for me to obscure my disdain for Zeke Emanuel. His arrogance is apparently familial. He doesn't seem to question his blinkered viewpoint of an academic administrator, an academic specialist as an oncologist, and his reflections on his role in shaping Obamacare seem always to be defensive – what we did was unalloyed good, and the best that could be had. He must be a politician of the “admit no mistakes” school. Although everyone does admit that he is smart, I have to say.

Zeke argues in this article that the yearly physical is an invalid procedure, something to be avoided. He says that “research shows” that little significant disease is discovered – “the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease.” He casts doubt on the value of early detection of disease. He implies that too many tests and studies are ordered by the doctors at a yearly physical. He says that these visits drive up health care costs. He compares the visit to an automobile service, but with fewer positive results. He denigrates the value of the doctor-patient relationship.

What a turkey he is.

First, let's look at research. If you want to prove something is worthless, the best tactic is to posit an end result that is either impossible, impossible to measure, or just not the reason that the thing is done in the first place. And if you are to practice sophism, make sure you simply assume that the goal of the procedure is what you want, not what the practitioners want it to be.

So, Zeke – remember, he is an oncologist who treats severe disease – assumes that the primary goal of the annual physical is to detect cancer (or, possibly, heart disease or something else) early. Then he says there is no evidence that the annual PE does this, and that screening asymptomatic populations is not a good procedure. Yes, Zeke, it's not good for cancer detection – except for mammograms and Pap smears, and I would say PSA in the hands of good doctors. Not that early detection doesn't happen – it does, it does, and it can save lives. Maybe not “cost effective,” but that's another argument. But Zeke – that's not the purpose of the periodic PE.

The purposes of the periodic PE are several. Health promotion and prevention are important objectives – maddeningly derided by Zeke as something he can do himself. Surveys show that the leading motivation for smoking cessation is recommendation by a doctor. Yes, we know “we should.” But when a doctor talks, we listen. Likewise for weight loss, exercise, and healthy eating. Zeke might say “I don't need no stinkin' primary care doctor,” but most of us really do.

Moreover, where exactly are we supposed to find out if our cholesterol and/or our blood pressure are too high? Careful questioning and screening can reveal depression, a condition with high prevalence, and eminently treatable. Alcohol addiction can be detected and discussed and treatment begun. Even as a general pediatrician I routinely inquire about the state of the parents' marriage, knowing that this is the most consequential condition for child health, and that once again, intervention can make a difference.

Measuring the results of health promotion and prevention is terribly difficult. In cancer it's pretty easy to distinguish useful from worthless therapies. But healthier lives are hard to identify in themselves, and the effects of prevention can be felt so far in the future that research can fail to find it. No one has done in depth studies of the results of close relationships with a primary care doctor, and I don't know how it could actually be done. For Zeke to place the onus of proof of effectiveness of primary care on those who practice it, according to his own rules of science, is outrageous. Prove that a caring parent is necessary for a child, why don't you, and banish them all to orphanages if you don't find that it is cost-effective. His “science” is suited to him, and he wants to use it on everything, which just coincidentally puts him in the driver's seat.

Actually, probably the worst sin of Zeke's jeremiad against PE's is his denigration of the doctor-patient relationship. Particularly in our world today, what is the value of being cared for? What is the value of having a serious professional who knows you well and who cares, who is on your side, paying attention to you, and helping you with your health in sickness and in health? The cyber-billionaires contend that 80% of what a doctor does will be supplanted by computers – you think? You think that what a doctor does is to reason all day? This is personal, gentlemen. We have a need to be cared for, and this is not irrational. There are choices to be made, there are feelings to be accounted for, and one size does not fit all, at all.

Finally, how specious is the cost of care argument! One of the first things I learned in the Public Health Service was, if someone says they can't do something “because of the budget,” it means they don't want to it. The budget is generally an excuse. In health care, we know that high costs reside in specialist care and hospitals – and remember, “costs” are related to “price,” which is highest by far in the US compared to Europe, probably especially in cancer care for all I know – not in primary care. Cut costs in primary care and you have accomplished very little except degrading quality, Zeke. Look to your own institutions if you want to cut costs. Gore your own calf, why don't you.

Let's once again revisit where Zeke sits – he is an influential voice in establishment medicine. All too many establishment policy makers truly believe his self-interested point of view. Prevention and health promotion are not sexy and not remunerative, and not what the academic centers interest themselves in. Training for prevention and health promotion in internal medicine and even family medicine are usually deficient. Even in these potentially primary care producing training programs, more and more subspecialists continue to be churned out, with fewer and fewer primary care docs. As a result, fewer and fewer practicing primary care docs have less and less time, training, and attention to spend on periodic PE's.

The biggest structural problem in the health care system of the United States is too much specialty and not enough primary care. Zeke Emanuel would do well to support primary care docs in their tasks rather than to attack their rationale.

Budd Shenkin

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