Why do we need annual exams?

The United States Preventive Services Task Force recently issued a draft recommendation saying that there is not enough evidence to tell if routine pelvic examinations are necessary or whether they help prolong a woman's life. A beautifully thought out summary of the issue in adult medicine last year in the New England Journal of Medicine showed the problems with the current practice. Why is a pediatric columnist discussing annual adult exams? Because I think that these recommendation, and similar ones in adult medicine and even pediatrics—while they may be technically correct, they are missing the point.

The recommendations do not take into account the relationship building of regular visits because almost no one has studied the issue scientifically. Periodic patient visits play a role in minimizing lifestyle issues and chronic diseases such as obesity, diagnosing and treating sexually-acquired disease, chronic illnesses such as asthma and diabetes, and screening for depression. Without wellness visits, primary care practitioners have fewer opportunities to treat and refer these problems.

Maybe I am just getting old or more likely just living in the past, but I think regular meetings with one's primary care patients builds a relationship. If something is wrong, it leaves the doctor in a much stronger position to discuss it with the patient. Even though I work in an extremely large (more than 15,000 primary care patients) hospital-based practice, I know the 1,400 or so children that think of me as their doctor and I know their families – having often taken care of their parents over the last 40 years.

I have used modern technology to keep in touch, answering dozens of emails and even occasional texts coming into me weekly, which I answer and dutifully copy into the patients' charts. I dislike phone calls because it is hard to accurately record exactly what was said. The patients' parents send me pictures of rashes and trauma, which our medical records system lets me record in their charts and follow the progress of recovery or increased injury.

Soon we will have a nearly science-fiction ability to communicate. For about a $100, one can buy an electronic otoscope, camera, stethoscope, and blood pressure cuff that hooks up to your cell phone and turns a tele-medicine visit into almost a full visit. However, it is hard to palpate an abdomen through a cell phone.

Having been trained during the time when primary care practitioners did not really separate patient time and personal time very well (often to detriment to their families), I have always been available all the time. I answer patient emails every few hours even on weekends and holidays. I was lucky to have a wife who grew up in a primary internist's home and as a gynecology specialist had a similar idea of patient care to mine.

But I am retiring in the fall of this year (which is to say I am going from working 60 hours plus weekly to working part-time after I take a long sabbatical to do some writing) and the younger pediatricians following in my footsteps are almost all women with families. Although they are amazingly dedicated to patient care, none of them are interested in working my crazy hours.

The periodic examination by the same practitioner who is then available for emergencies is vital to minimalizing over testing and over treatment when the primary care patient gets ill.  Electronic connections such as Care Everywhere (where doctors and hospitals using the EPIC electronic health record can share results and even doctors' notes instantaneously) are great for avoiding duplication and making the chart quickly present. It will have to fulfill some of the current loss of personal contact.

As medical payment systems change, and medical malpractice suits continue to diminish, maybe the tendency to do unnecessary testing such as routine ECGs and blood tests without symptoms or even a good screening rationale will also writher away.  Unnecessary testing leading to unnecessary care is usually the main criticism of routine examination. Maybe the pelvic cervical testing is not needed, but just the visit for regular doctor-patient human contact. The same is true for children and even adult males (who never go to the doctor unless forced to do so). Let us not dismiss the continuity of regular patient-doctor contact.  Personal contact gives the patient an anchor when the health storms strike.

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