Heresy

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].