I confess that at times I feel like a broken record, lamenting the same story repeatedly; but I’m watching as the bulldozer of progress plows under a profession near and dear to my heart, a loss that will impact all of us, for better or for worse. The power behind these changes is nebulous and pervasive—and impossible to obstruct or thwart. While there is no blueprint for what they intend to construct out of the rubble, occasionally one can catch a glimpse of their vision; and a number of recent articles have served as triggers.
For years I have watched as the specialty of obstetrics and gynecology has struggled to define and justify their role in medical care. First we were specialists; then we sought to increase our market share by designating ourselves “primary care for women.” That became especially important as the specialized obstetrical procedures that marked us as obstetricians were eliminated from our armamentarium—and routine deliveries, whether vaginal births or cesarean sections, could and are being handled by others—family physicians, midwives, and/or general surgeons. But then the reasons for routine visits also began to be eliminated: long-acting reversible contraceptives were promoted over oral contraceptives (which had been tied to routine visits), and pap smear frequency was diminished (from yearly to every 3-5 years).
In 2012, the American College of Obstetrics and Gynecology (ACOG) defined the “well-woman visit” as consisting of “vital signs, BMI (a calculation of doubtful meaning and significance), abdominal palpation (of questionable value given the obesity of the general population), and palpation of inguinal lymph nodes (which are only palpably enlarged when there exists and serious and symptomatic problem—for which it would no longer be a “well-woman” exam!)—all else in the physical exam they declared to be discretionary.
Now the American College of Physicians has pounded in the last nail in the coffin: they state in their new practice guidelines that there is no evidence to support routine pelvic exams–that they cause more harm than benefit. ACOG, seeing the writing on the wall, is circling its wagons, stating “lack of evidence does not mean lack of value.” Value: there is that nebulous, unquantifiable, qualitative concept raising its head again.
But is there evidence of benefit for ANY preventive exam beyond the unquantifiable—beyond the relational? Other than vital signs, is there any evidence that physical examination is superior to laboratory testing or imaging studies?
The Institute on Medicine has just reported on its 2-year study of Graduate Medical Education, concluding that the current physician training system, subsidized by Medicare funds, is not producing physicians prepared for the changing health care system. They recommend transition to a “performance-based system” of funding—whatever that entails. In light of the “evidence” above, eliminating training in the physical exam as well as history-taking would be one step toward diminishing the cost and length of graduate medical education.
Therein lies the vision for the future of health services (a more appropriate term than “medical care”): health encounters will consist of scheduled appointments for vital signs, laboratory testing and imaging studies with interpretation and intervention based solely on objective data; emergent health issues will then be routed to emergency or urgent care centers (something we have tried to eliminate over the last decade), but they will now be anachronistically referred to as one’s “medical home.” It will be a clean, streamlined, and highly efficient system, having eliminated all of the messy interpersonal confounders.
But since it is those “messy interpersonal encounters” that have provided personal and professional fulfillment, I can see that I’m getting out none too soon….