SAN DIEGO -- A recommendation from the Society of General Internal Medicine to do away with annual checkups for asymptomatic adults evoked strong emotions in its membership.
"I felt very betrayed when this came out. I felt surprised and very disappointed in the process," one audience member said during a town hall session at the SGIM annual meeting.
SGIM was asked by the American Board of Internal Medicine (ABIM) Foundation to make recommendations for its campaign. The initiative involves 47 medical groups and societies that were asked to identify five tests or procedures commonly used in their fields in an effort to "spur conversation about what is " between patients and clinicians, according to the foundation.
One of the SGIM recommendations -- "Don't perform routine general health checks for asymptomatic adults" -- upset a large number of SGIM members.
"Think of all the good we do at those routine checks," said a member at the town hall meeting.
"What about for elderly people?" another asked.
"This is going to be a very difficult measure to operationalize. You won't be able to tell which routine checkup was indicated and which one wasn't," commented another.
"The lack of evidence [for annual checkups] is obviously not evidence of the lack of benefit," another member said. "I don't agree with the recommendation."
Many members pointed out a distinct difference between annual screenings and tests, and the human interaction involved with an annual checkup.
"Routine use of several testing methodologies that had been part of the routine physical exam has very little value. But to conclude that the visit doesn't have value is a stretch," one member said.
Background
SGIM tasked an ad hoc committee to develop their list of "Five Things Physicians and Patients Should Question." As SGIM is comprised of physicians affiliated with academic medical centers, they pride themselves on practicing evidence-based medicine. And that's exactly how the committee approached their list of five, which was voted on and passed unanimously by SGIM leadership.
Four out of the five recommendations didn't ruffle any feathers:
- Don't recommend daily home finger glucose testing in patients with type 2 diabetes not using insulin
- Don't perform routine preoperative testing before low-risk surgical procedures
- Don't recommend cancer screening in adults with life expectancy of less than 10 years
- Don't place, or leave in place, peripherally inserted central catheters for patient or provider convenience
SGIM's ad hoc committee looked at randomized clinical trials, Cochrane reviews, and a high-quality systematic review -- involving over 150,000 patients -- and found no clear benefit to annual health checkups for healthy, asymptomatic adults. They considered time and money and the potential stress from unnecessary screening tests and determined that the evidence came out against yearly maintenance visits for asymptomatic adults.
It's important to note that the ABIM imposed very strict parameters on the wording for the Choosing Wisely lists, requiring a limit of less than 16 words for each bullet point, less than 75 words for the explanatory paragraph, consumer-friendly language, and strong wording such as "Don't perform," and "Don't recommend." None of these parameters seem conducive to spurring conversation as the ABIM claims it wants to do.
"This is a commandment. It says 'Don't perform.' It doesn't say 'Please discuss with your doctor.' That would have been a great recommendation," one SGIM attendee said.
Another member did recommend that physicians be honest with patients about why they need annual checkups. "If we're honest with our patients -- that we're seeing them to build a relationship with them -- that is very different than coming in for the annual exam. It would be interesting to have the patient's voice in this," a notion that is supposedly part of the Choosing Wisely campaign.
In a Consumer Reports Health synopsis called "," annual checkups were made to seem superfluous and potentially dangerous: The synopsis had an entire section with the title "Tests and screenings can cause problems."
Confirmation and Criticism
At the SGIM town hall meeting, , a member of the ad hoc committee, defended the controversial recommendation.
According to Feldstein, SGIM, and one of the radiology groups, were the only two participating societies that made recommendations that affected their own members' finances.
In contrast, "participating societies generally named other specialties' services as low-value," according to a .
But David U. Himmelstein, MD, criticized the recommendation and the data that the ad hoc committee used to make their decision.
Himmelstein is an outspoken member of , an organization that advocates for a single-payer national health system. He also cited the same NEJM perspective article, which noted that "payers may use lists to inform coverage, payment, and utilization-management decisions."
Himmelstein pointed out that three of the 14 trials that the ad hoc committee reviewed were conducted in the U.S., while the other 11 were in countries with single-payer universal coverage systems.
Another critic was , of Massachusetts General Hospital in Boston. He spoke of individual patients with alcohol abuse issues, depression, and acute risk factors for high-risk behavior who would have fallen through the cracks if they did not have an annual visit with a primary care doctor.
"I was saddened when I [read] the item recommending against routine health checkups," he said.
Finally, several of the members brought up how unemployment can have negative health consequences, which may only be caught during an annual visit.
Yes, this is true. But you know what happens when you lose your job? You lose your health benefits to cover the cost of annual checkups. Also, the cost of transportation to get to routine checkup appointments can become burdensome. And what if tests or medication are deemed necessary? All stressful things that will create barriers for unemployed and underemployed patients to seek annual checkups anyway.
Prime Time is a blog by staff writer, Sarah Wickline, for readers with an interest in primary care.