Correspondence

Executive Physicals

N Engl J Med 2009; 360:421-423January 22, 2009

Article

To the Editor:

The Mayo Clinic's Executive Health Program was one of two programs specifically mentioned in the Perspective article by Rank (Oct. 2 issue1) that characterized executive physicals as expensive, ineffective, and inequitable. We disagree.

An executive health evaluation is essentially a periodic health evaluation in a defined population. A recent systematic review concluded that the periodic health evaluation improves delivery of some preventive services.2

Costs vary, but executive health programs can be cost-effective.3 There is little evidence they divert resources and deprive others of appropriate medical care. Everyone in the United States should have basic preventive services covered, yet more than 45 million people do not because they are uninsured. In some cases, executive health programs may help support care for those with no insurance coverage.

Considerable disparity exists among programs in terms of testing and other clinical services. Some executive health programs provide comprehensive, efficient, effective, and individualized patient-based care at a reasonable cost. When practiced in this way, these programs emulate a model of medical care that American health care should embrace and provide to a larger proportion of the population.

Donald D. Hensrud, M.D., M.P.H.
Deborah J. Rhodes, M.D.
Mayo Clinic, Rochester, MN 55905
hensrud.donald@mayo.edu

Dr. Hensrud reports serving as the chairman of the Division of Preventive, Occupational, and Aerospace Medicine, in which the Executive Health Program is located, and having served as director of this program. Dr. Rhodes reports serving as the current director of the Executive Health Program.

No other potential conflict of interest relevant to this letter was reported.

3 References

1
Rank B. Executive physicals -- bad medicine on three counts. N Engl J Med 2008;359:1424-1425
Full Text | Web of Science | Medline

2
Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med 2007;146:289-300
Web of Science | Medline

3
Burton WN, Chen CY, Conti DJ, Schultz AB, Edington DW. The value of the periodic executive health examination: experience at Bank One and summary of the literature. J Occup Environ Med 2002;44:737-744
Web of Science | Medline

To the Editor:

Rank opines that executive health physicals are “bad medicine.” His discussion fails to investigate the impetus for their growth: patients' desire for more time with a physician. Currently, patients spend about 15 minutes with their primary care provider at each visit.1 Evidence suggests that this is insufficient to adequately address even the screening recommendations of the U.S. Preventive Services Task Force.2 Is it surprising, then, that programs allotting upward of 90 minutes for patient–physician encounters have grown?

As physicians who participate in such programs, we are delighted to have the time to discuss patients' medical conditions, risk factors for disease, family history, life stressors, vaccination status, and medication and supplement use and to perform a detailed physical examination. We have time to discuss the implications of unnecessary tests that are marketed directly to patients. We review test results, use evidence-based risk calculators, and set health goals for prevention. Rather than making generalizations and summarily dismissing these programs, we should consider how they can serve as a model of comprehensive care for all.

Paula Kue, M.D.
Bimal Ashar, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21287
paula.kue@jhu.edu

Dr. Ashar reports serving as the medical director of the Johns Hopkins Executive Health Program.

No other potential conflict of interest relevant to this letter was reported.

2 References

1
Blumenthal D, Causino N, Chang YC, et al. The duration of ambulatory visits to physicians. J Fam Pract 1999;48:264-271
Web of Science | Medline

2
Yarnall KSH, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-641
CrossRef | Web of Science | Medline

To the Editor:

The article by Rank is very timely, especially in the context of health care delivery in developing countries such as India, where the gap between the neorich new world and the old world is ever increasing. It is ironic that executive physicals (fashionably called master health checkups in India) is a thriving business when most of the country's 1-billion-plus population barely has access to accurate blood-pressure checks and follow-up.

As a practicing physician in internal medicine, I find it painful to see people becoming patients, as they clutch their whole-body scans and frantically doctor-shop to seek clarity about the incidentalomas picked up during the checkup. In resource-limited settings, it is time for a nationwide audit to be done and for the government to develop strict regulations so that health care delivery can become more physician-centric rather than lab-report–directed.

Manjunath Dinaker, M.D.
Mediciti Hospital, Hyderabad 500063, India
jitika@sify.com

Author/Editor Response

Citing Boulware et al., Hensrud and Rhodes suggest that a “periodic health evaluation improves delivery of some preventive services.”1 They do not note that, in the same study, Boulware et al. found that periodic health evaluations may “induce unnecessary costs and patient harm by promoting the use of non-recommended services.”1 The latter finding is especially relevant to executive physicals, many of which include services outside of those based on the recommendations of the U.S. Preventive Services Task Force. Hensrud and Rhodes offer no backing for their contention that executive physicals may help support care for those without insurance, and there is no published or anecdotal evidence of which I am aware that supports this claim.

Kue and Ashar make a good point that 15 minutes with a primary care provider is “insufficient to adequately address even the screening recommendations of the U.S. Preventive Services Task Force.”2 I agree that all patients should have the opportunity to spend enough time with their physicians and care teams to create and sustain a healing and wellness relationship and receive appropriate services. I disagree, however, about how to accomplish this. The suggestion that we might look to an expensive, unproven niche service as a model is an alarming one, especially considering that the United States already spends nearly 18% of its gross domestic product (GDP) on health care. By comparison, Germany, France, and Canada each spend less then 11% of their GDP, with better outcomes. We should instead be supporting efforts to reform our system with team-based care and methods focused on cost-effectiveness, proven efficacy, and support for equal access to high-quality care. I am encouraged to see a growing number of medical groups doing groundbreaking work on these kinds of reforms.

This is one small part of a larger debate we need to have as we consider overall health care reform in the United States and, as Dinaker suggests, approaches to the same challenges around the world.

Brian Rank, M.D.
HealthPartners Medical Group and Clinics, Minneapolis, MN 55425

2 References

1
Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med 2007;146:289-300
Web of Science | Medline

2
Yarnall KSH, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-641
CrossRef | Web of Science | Medline

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