4 New Views on Primary Care Practices

The pros and cons of eliminating the annual physical examination are debated in the New England Journal of Medicine. Primary care physicians (PCPs) are becoming a primary source for mental health care for children. The idea of medical screening conducted in dental offices has received a positive response from organizations.

Read on for a brief summary of the latest concepts in the evolving role of primary care.

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An Argument AGAINST the Annual Physical

• The annual physical is difficult to assess because its content is poorly defined and its focus has evolved over time. Many components are included because of billing regulations established by health plans and Medicare.

• Two systematic reviews that summarized randomized trials and observational studies showed that annual physicals do not reduce morbidity or mortality.

• The annual physical may be harmful. Some aspects (routine tests) have low specificity, leading to false-positives.

• Reducing the use of annual physicals could save money and free up PCPs’ time.

• Three steps are suggested: (1) create a new type of visit to establish relationships, (2) PCPs change their approach to ensuring that patients’ preventive care is up to date, and (3) health plans and federal payers no longer reimburse for annual physicals or use receipt of physicals as a measure of health care quality.

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An Argument FOR the Annual Physical

• Patients desire or need to establish and maintain a close, trusting relationship with the doctor they consider their personal physician. Benefits include enhancements in functional status, patient satisfaction, and adherence to medication regimens.

• The annual visit frequently becomes a rushed, impersonal, and largely bureaucratic exercise. There needs to be sufficient time for an unhurried inquiry into the aspects of a person’s life that can affect health and well-being.

• The performance of the physician's annual physical examination becomes as much an act of relationship building and continuity as it is a means of searching for clinically significant findings.

• The challenge PCPs face is how to deliver a more personalized, more comprehensive care experience without shrinking panel sizes to concierge-practice levels.

• A promising solution is the multidisciplinary-team–based approach, exemplified by the patient-centered medical home model.

• The annual physical should be improved, not eliminated, with a team effort that frees the physician from the more routinized aspects and provides time for physician-optimized value-added elements.

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Primary Care a Primary Source for Kids’ Mental Health Care

• PCPs appear to be the only physician managers for the care of 4 in 10 US children who have attention-deficit/hyperactivity disorder (ADHD).

• Of youth aged 2 to 21 years receiving outpatient care for mental health conditions, one-third saw PCPs only, 26.2% saw psychiatrists only, and 15.2% saw psychologists/social workers only. Close to one-fourth saw multiple providers.

• A greater proportion of children with ADHD vs children with anxiety/mood disorders saw a PCP only (41.8% vs 17.2%).

• PCPs prescribed medications to a higher percentage of children than did psychiatrists.

• Efforts that support mental health in primary care will reach a substantial portion of children who are receiving mental health services, the authors concluded.

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Medical Screening in the Dentist’s Chair?

• An analysis of the question of medical screening conducted in dental settings revealed a generally positive view among authorities and organizations in Sweden.

• The practice of identifying persons with undiagnosed type 2 diabetes mellitus or undiagnosed hypertension by medical screening in dental settings has been well-received by patients and dentistry professionals, it was noted.

• The analysis resulted in 4 categories: (1) medical screening ought to be established in the society, (2) dentistry must have relevant competence to perform medical screening, (3) medical screening requires cooperation between dentistry and health care, and (4) dentistry is not the only context where medical screening could be performed.

• Further scientific knowledge and guidelines are needed, as well as research on implementation strategies and long-term follow-up.

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Take-aways:

• Anti annual physicals: they do not reduce morbidity or mortality, and reducing their use could save money and free up PCPs’ time.

• Pro annual physicals: they become as much an important act of relationship building and continuity as a means of searching for clinically significant findings.

• PCPs appear to have become a primary source for children’s mental health care.

• The concept of medical screening conducted in dental settings has received a generally favorable response.