Thursday, April 9, 2015

The Quantified Self and Patient- Centered Medicine

Ali Khan, MD, MPP is a clinician-innovator at Iora Health and a clinical instructor of medicine at Yale. He currently serves as the chair of the American College of Physicians’ National Council of Resident/Fellow Members. Leah Marcotte, MD is a senior medicine resident at the University of Washington. As a medical student at Penn, she served as a fellow at the Office of the National Coordinator for Health Information Technology. Among her varied policy pursuits, she serves as an associate editor for the journal Health Care. In a recent article ALI KHAN, MD and LEAH MARCOTTE, MD discuss Ezekial Emanuel' pronouncement that the annual physical examination is worthless. (worthless for what and to whom ?) The Wellness Revolt What Zeke Missed on the Annual Physical Are we being reduced to a series bits and bytes ? Can patients be distilled into a series of numbers, or symbols wnich requires a huge overlay of technology? Can human beings be defined and judged by electronic devices, computers and sensors ? The wave of HIT, mobile health,and health data exchanges bring this question to the forefront. It's not a new question, however one that is bold-faced by current events, cost, and still questionable value. We have been using bits/bytes for several decades with MRI, Ultrasound,ekg,pacemakers, implantable devices and sensors. Without these things we could not be delivering high quality care as we do now. Note that physicians definition of quality has nothing to do with length of stay, nor readmission to hospitals. Zeke,(Ezekial EmanuelM.D.) as he is called, one of the country’s foremost health experts threw a presumptive grenade into the national discourse: "the annual physical is worthless". As we watched the initial burst of reactionary fervor following his New York Times opinion piece, we weren’t quite sure what to think. Dr. Emanuel who is respected speaks from a far away place, somewhere between the NIH (National Institutes of Health and other well known Institutions. My comments are not related to the high) esteem in which I hold "Zeke" He is a welcome additon and possible heir to the ideas of another bio-ethicist, Dr Arthur Kaplan N.D. Then we realized why: in our training and burgeoning careers in primary care, neither of us has ever scheduled an “annual physical” for a patient. To us, the notion of such a visit – for scheduled, non-urgent care, and one not specifically for chronic disease management – is already dated. Given current trends in American health care delivery and professional training, we argue it is one that may well soon be obsolete. Many physicians would argue that opinion. But does that obsolescence change the value of that time – whether 15 minutes or 60 – with a patient, on a regular interval? Our perspective from medicine’s emerging front line offers a resounding no. Furthermore the indications for annual exams should be based upon diagnoses of the individual patient. One cannot extrapolate the necessity for annual physical examinations without a frame of reference. The most obvious argument for regular primary care visits is preventive care. Dr. Emanuel bases much of his argument on the validity (or lack thereof) of annual physicals. Drawing off that same evidence base, the U.S. Preventive Services Task Force sets recommendations for evidence-based screening in various populations. Even the young and healthy benefit from cervical cancer screening, initiated at 21 years of age and continued every three years provided negative results until the age of 30 (when the recommendations change slightly). Patients with higher risk earn further screenings, based on whether they smoke, their weight, their age and their family history.
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