As primary care physicians, we see firsthand the waste in our health care system: unnecessary testing, duplication of services with poorly coordinated care, and overuse of procedures that may cause more harm than good in some situations. Such waste crowds out important high-value care, and we are strong advocates of efforts to reduce it.
The fight against health care waste has taken aim at a surprising target: the routine wellness visit. This is the regularly scheduled checkup with a primary care clinician that experts have long encouraged. New recommendations calling for the elimination of routine wellness visits in adults were backed by purportedly high-quality evidence.
That caught us off guard. In our experience, these visits seemed to help us identify patients with treatable conditions like diabetes and hypertension, or to pick up on mental health problems, substance abuse disorders, and even intimate partner violence.
Had we been deceiving ourselves? Were we unknowingly ordering wasteful tests? Were the supposedly evidence-based preventive services we offered at these visits not as beneficial as we thought? Maybe the stress of finding parking at our offices was counterbalancing any beneficial effects.
Despite our intuition that wellness visits were good for patient care, we tried to eliminate them from our practice. After all, who could argue with the data?
An opinion piece published last month in the Annals of Internal Medicine caused us to again rethink our views. In the article, a pair of internal medicine doctors with extensive research experience in primary care and health policy critiqued the data damning wellness visits. They highlighted how the studies almost invariably excluded the elderly and other vulnerable groups, and instead focused predominately on Europeans, who for generations have had access to more comprehensive health care systems than we do in the United States. Thus, the findings may not be germane to low-income populations in the US, high-risk older adults, or those with unreliable health coverage.
Just as important, many of the studies didn’t evaluate wellness visits at all. Instead, they were batteries of screening panels that weren’t always evidence-based. Somewhat shockingly, these checkups were often administered by a study clinician rather than by the patient’s regular primary care doctor, making it impossible to assess the value of the relationship building that occurs during these visits.
The opinion piece highlights one prominent “wellness visit” study that subjected its participants to “5 radiography examinations, mammography and Papanicolaou smears for women, spirometry, electrocardiography, tonometry, audiometry, visual acuity testing, screening for sexually transmitted diseases, 12 blood tests, and 6 urine tests” — all without any consultation between the patient and his or her primary care clinician. Few primary care clinicians we know conduct wellness visits like this.
The authors of the Annals of Internal Medicine article concluded that the “evidence against ‘health checks’ is insufficient and arguably irrelevant to questions about the value of routine visits with a personal physician.” We wholeheartedly agree.
We remain committed to eliminating wasteful care. The way routine wellness visits are conducted could be reformed. Some clinicians may overdo preventive visits, for example, by requesting that patients come in for an annual head-to-toe checkup regardless of their circumstances. Others order extensive screening tests and X-rays that aren’t necessary and may even be harmful.
For many healthy adults, a wellness visit every few years, involving only a small number of evidence-based tests, would more than suffice. But completely doing away with routine wellness isn’t supported by evidence, particularly for vulnerable populations who might suffer increased disparities by eliminating this aspect of health care.
Emboldened by this new analysis, we choose not to follow the new guidelines and will continue to schedule routine wellness visits, particularly when our patients ask for them. In so doing, we recognize that we must not waste our patients’ time nor our system’s resources by performing excessive testing. In fact, these visits don’t need to be about testing at all. We can use the time instead to talk with our patients about lifestyle changes, explore their health care goals, and establish relationships that will help us provide them with better care in the years to come.
Ben Smith, MD, is a resident in the Fort Collins Family Medicine Residency at Poudre Valley Hospital in Colorado. Michael Hochman, MD, is a general internist and director of the Gehr Family Center for Implementation Science at the Keck School of Medicine of USC in Los Angeles.