Periodic Health Examinations and Missed Opportunities among Patients Likely Needing Mental Health Care

Abstract

OBJECTIVES

Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs.

STUDY DESIGN

Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care.

METHODS

Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient's agenda. A generalized ordered logit model was used.

RESULTS

Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients' agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD.

CONCLUSIONS

If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients' agendas and to listen more attentively.

INTRODUCTION

The majority of patients with mental health concerns turn to their primary care physicians for help.^1,2 Many rely on periodic health examinations (PHEs), the most common reason for adults to visit physicians.³ Proponents of PHEs argue that, besides increasing the use of preventive services, PHEs bring patients into contact with their primary care physicians, and therefore provide a route by which patients seek services they feel uncomfortable disclosing to the scheduling staff. In fact, as many as one in three patients have undisclosed reasons for requesting a PHE ⁴. Mental health care needs may be an example of undisclosed reasons which prompt some patients to use the time-honored PHE tradition as a “safe portal” to seek mental health care.

Evidence-based mental health care improves patient outcomes not only in reducing mental illness symptoms but also in improving physical and social function.⁵ Primary care physicians’ communication practices and skills have been documented to influence the quality of mental health service delivery in primary care visits.⁶ It has been shown that even when patients have an agenda, they commonly do not make it explicit in ambulatory encounters^7,8 because they may be concerned about what is “appropriate” to communicate to their physician and not wanting to “waste” the physician’s time⁹. Essential communication approaches that ensure effective communication, e.g., being open to patients’ agendas,¹⁰ fully eliciting patients’ concerns and preferences,¹¹ and co-creating the visit agenda with them^12–17 contribute to improving the overall quality of patient-provider communication.

In addition to fully eliciting patients’ agendas, physicians must give patients enough time to speak. It is necessary to balance the need to manage the conversation with the need to let the patient speak. It is not uncommon that some physicians dominate the conversation, which enables them to control the conversation and time use. Verbally dominant physicians disempower patients and impair patient engagement, however.¹⁸ It has been well documented that patients were less satisfied with their physicians when physicians talked more and when patients perceived their physicians as domineering.^14,19 Patients were less likely to sue physicians with low verbal dominance.^14,19 The literature is relatively silent on how primary care physicians’ verbal dominance could affect the quality of discussions about mental health during PHEs.

Giving patients time to speak rather than dominating the conversation can affect the length of visits, however. Visit length has long been the subject of research and has been shown to be associated with the delivery of evidence-based preventive health services (both screening and counseling).^20,21 It is not known if patients with mental health needs seeing PCPs who tend to have longer visits with patients may be more likely to receive evidence-based mental health services. Mental health issues are perceived to be difficult topics of discussion and have been well documented to receive suboptimal attention in ambulatory care settings.⁶ Furthermore, the provision of mental health screening and counseling during PHEs has received less attention than the delivery of evidence-based biomedical screening and lifestyle counseling during PHEs.²⁰

For PHEs to be valuable to patients with mental health needs, evidence-based discussion about mental health is required. Figure 1 illustrates our hypothesis that three sets of predisposing physician and patient factors influence the quality of mental health discussion (MHD): evidence-based, perfunctory, or absent. The first group of factors consists of physician practice styles: how much time a physician usually provides in visits; a physician’s openness to the patient’s agenda; and a physician’s verbal dominance. The second set of factors relates to patients’ mental health status such as depressed mood or experience with anxiety and if the patient is in an ongoing episode of care²² for a mental health issue. The third factor relates to a patient’s preparedness for the visit: if a list has been prepared and brought to the visit for discussion with the physician. These tasks have also been shown to increase patient satisfaction and subsequent patient self-management.^10,12–15

Figure 1. Predisposing physician and patient factors influence what happens in a visit.

Note: ^§: An evidence-based mental health discussion (MHD) is considered to be present if physician performed any guideline-concordant actions, including assessment and diagnosis, education and treatment, monitoring response to treatment, and treatment modification or intensification. Perfunctory MHDs are those that are limited to brief and close-ended questions by physicians unaccompanied by follow-up investigation even if there may be cues from patients that could warrant further exploration.

Using qualitative and quantitative research methods, we investigated whether PHEs offer patients needing mental health care an opportunity to have a mental health discussion (MHD) with physicians. We also measured the quality of MHD based on its concordance with evidence-based practices by coding audio recordings and transcripts of PHEs (described below). We further sought to operationalize measures of physician communication styles that could be associated with the delivery of evidence-based MHD and are also potentially malleable.

METHODS

Study Sample and Data Sources

Patients with mental health needs were drawn from a sample of 484 participants, 50 years of age or older, in a study of preventive health discussions (particularly colorectal cancer screening) between 64 physicians and patients (the parent study),²³ which took place at an integrated health delivery system in Detroit, Michigan, between February 2007 and June 2009. Patients completed a brief telephone survey at recruitment. The survey contained questions about their preferences and beliefs about screening, mental health treatment, PHQ2,²⁴ tobacco/alcohol use, and socio-demographic characteristics. Furthermore, each patient’s visit was observed and audio recorded by a research assistant. Additional details of the study have been reported elsewhere.^21,23,25 The institutional review boards of relevant organizations approved the study. Informed consent of study participants conveyed that the study would examine patient-physician communication about preventive health issues. No specific mention of mental health focus was made.

The sample for the current study consisted of 56 PCPs and 255 patients identified as likely in need of mental health care if they met any of the following inclusion criteria: 1) scored ≥2 on the PHQ2,²⁴ 2) filled or were prescribed a psychotropic medication in the 12 months before the observed visit, 3) had a mental health diagnosis code (ICD9 codes 290, 293–302, 306–316) in the electronic health record (EHR) in the prior 12-month period, or 4) visited a behavioral health provider in the 12 months before the visit.

Coding Of Audio-Recordings Of PHEs

Five researchers coded audio recordings and transcripts of the visits to capture topics within seven major areas: biomedical (e.g., high blood pressure, diabetes), health behaviors (e.g., smoking, alcohol), mental health (e.g., depression, anxiety), psychosocial (e.g., work, family and friends), physician-patient relationship (e.g., physician availability), visit flow management (e.g., agenda setting, mid-visit check-in of understanding, and concluding visit), and other (e.g., small talk about weather or clothing). Topics were defined as issues that had at least two complete exchanges between patient and physician. The time spent on discussing each topic, defined as the amount of time between the start and end of all instances of the topic, was also recorded for both the patient and the physician. This analytical approach has been described in detail and applied in previous research.²⁶ Studying a visit as a conversational event, with topics unfolding over time, enabled us to understand the relative time spent on each topic by the patient and the physician and if and how one person dominated the conversation.²⁶

Furthermore, the parent study team coded delivery of evidence-based preventive services by counting the number of topics including screening, health behaviors counseling (e.g., tobacco, obesity, diet, aspirin), and immunizations.²¹ The study also used patient data from the electronic health record in the 12 months before and after the observed visit, and characteristics of participating physicians from organizational files.

Scores from different raters were compared using intraclass correlations for numerical variables and percentage agreement for categorical variables. Intraclass correlations between raters and within the same rater ranged from 0.78 to 0.99.

Variables

The dependent variable was a three-level variable for the quality of MHD. We defined MHD as any exchange about depression, general anxieties and worries, emotional distress, death, bereavement, grief, mourning, death of others, pain, suffering, concerns, and worries regarding one's own physical condition, tests, treatments, procedures, or other mood disorders.⁶ Whether or not the MHD was evidence-based was determined by the degree of concordance with treatment guidelines,²⁷ including if the physician assessed the patient’s mood using any item from the PHQ9,²⁸ made a mental health diagnosis, prescribed psychotropic medication, made a referral to a mental health specialist, or made a plan for active surveillance of mental health symptoms. (Figure 1) Perfunctory discussions, e.g., “Any anxiety or depression?” followed immediately by a non-related statement or questions (e.g., “Any vaginal spotting or bleeding?”) were coded as non-evidence-based. The value of the outcome measure is 0 for no MHD, 1 for a perfunctory MHD, and 2 for an evidence-based MHD.

Key explanatory variables included both measures of physician practice style and patient characteristics. Physician practice style measures included visit length, eliciting patient agendas, and verbal dominance gathered from their visits with other study patients to form exogenous measures of these constructs to the index visit. Visit length was measured by the face-to-face interaction time in minutes between patients and physicians from other visits. Eliciting patient agenda was defined as the proportion of visits in which the physician attempted to fully elicit the patient’s agenda (5 on a scale of 1 to 5).²⁹ (There was unanimous agreement among the five coders for this variable.) Verbal dominance was defined by the ratio of actual talk time by the physician divided by talk time by the patient. We again used the data from other visits of individual physicians to obtain an exogenous measure of verbal dominance. These exogenous variables reduced measurement bias. To account for physicians’ proclivity to provide evidence-based services, we also included a count of evidence-based preventive services.²¹

Patient characteristics were obtained from the EHR, a pre-visit patient survey, and direct office visit observation. Patient health status included whether in an ongoing episode of care (EOC) for mental illness,²² PHQ-2 score, and if the patient had brought a list of issues to discuss.

Analytic Approach

For the quantitative analysis, we specified a generalized ordered logit model with partial proportional odds for the 3-level ordinal dependent variable of evidence-based MHD, defined above. This model was selected over an ordered logit model because the Brant test showed that the ordered logit’s parallel lines assumption was not met. Our model constrained the odds ratios to be proportional across these three levels for all variables except PHQ2 score. Tests of the proportional odds assumption indicated it was reasonable for the remaining variables. Three groups of explanatory variables were included in the model, as illustrated in Figure 1. The first group included physician practice style factors as measured in the other visits to the same physician among the study sample: (a) average visit length, (b) percent of visits in which they fully elicited the patient’s agenda, and (c) verbal dominance.

The second group were patient factors: patient’s mental health needs, i.e., self-reported depressive symptoms in the PHQ2;²⁴ anxiety (self-reported anxiety attack in the previous 4 weeks); and whether the patient was in an ongoing episode of care for mental health.²² The third related to patient activation level, i.e., whether the patient brought a list of issues to discuss with the physician. Finally, we controlled for patient demographics (age, sex, race/ethnicity), comorbidity (Charlson index³⁰), and the number of evidence-based services delivered in the visit.²³ Standard errors were clustered by physician. The statistical analyses were conducted using Stata 14.

To provide some contextual information on how visits between physicians at different levels of verbal dominance might evolve differently, we selected a few visits with high versus low verbal dominance physicians seeing patients with similar PHQ2 scores to examine the timing and quality of mental health discussion. We mapped the topics, sequentially, as they took place during the visit.

RESULTS

Visit, Patient, and Physician Characteristics

Table 1 summarizes the characteristics of the study sample: 255 patients likely in need of mental health care saw 53 physicians practicing in about two dozen primary care clinics. The majority of patients were white (66%) and female (63%) with an average age of 60 years. About 9% of patients reported having an anxiety attack in the 4 weeks prior to study recruitment, the average PHQ2 score was 1.1 (SD=1.5), and 37% were in an ongoing episode of care for a mental health condition. Their Charlson index scores averaged 0.8 (SD=1.4); 11% of the patients in the sample brought a written list of concerns to the visit. These did not vary by MHD levels.

Table 1.

Information on Patients, Physicians, and Visits, Occurrence of Mental Health Discussion (MHD) and Its Concordance with Evidence-Based Practice Guidelines

	All patients	No MHD	With MHD
			Perfunctory	Evidence-based	p-value
Number of patients	255	85	87	83
Median Time of MHD initiation	4.9	N.A.	6.3	3.3	0.03
Patients
Mean age (SD)	59.6 (8.3)	61.7 9.0)	58.5 (8.0)	58.6 (7.5)	0.05
Male %	36.9	52.9	34.5	22.9	<0.001
Non-white %	33.7	43.5	28.7	28.9	0.05
High school/GED or higher %	95.7	91.8	97.7	97.6	0.07
Mean PHQ2 score (SD)	1.1 (1.5)	1 (1.3)	0.6 (1.0)	1.8 (1.8)	<0.001
In ongoing EOC⌘ %	37.3	29.4	39.1	43.4	0.06
Anxiety attack in past 4 weeks %	9.0	4.7	3.4	19.3	0.01
Mean Charlson score (SD)	0.8 (1.4)	0.8 1.1)	0.9 (1.8)	0.8 (1.2)	0.91
Brought written list to visit %	10.6	8.2	8.0	15.7	0.11
Physicians
Number of physicians	53	36	43	36
Mean MD age (SD)	49.4 (8.7)	51.3 7.5)	50.2 (8.2)	51.8 (8.0)	0.73
MD male %	41.5	54.1	46.0	36.1	0.05
MD Family Medicine %	32.1	30.6	34.5	31.5	0.94
Mean verbal dominance at other visits§ (SD)	3.2 (2.2)	3.8 2.8)	3.2 (2.1)	2.6 (1.2)	<0.01
Mean length of physician’s other visits (SD)	27.4 (7.8)	25.1 6.4)	28.0 (8.6)	29.1 (7.6)	<0.01
Outstanding agenda setting at other visits %	25.1	19.4	27.1	28.9	0.03
Mean number of evidence-based services delivered (SD)	2.9 (1.5)	2.7 1.4)	2.8 (1.4)	3.2 (1.6)	0.01

^§The ratio of average total physician talk time over average total patient talk time in other visits.

^⌘Episode of care for mental illness.

The median visit length was 26 minutes (SD=10.3). A third of visits (33%) contained no MHD, an evidence-based MHD occurred in 33% of visits, and a perfunctory MHD occurred in 34% of visits.

Among the physician factors, the average length of other, non-index visits was 27 minutes (SD 8) and rose with the level of MHD from no MHD to perfunctory MHD to evidence-based MHD: 25 (SD 6), 28 (SD 9), and 29 (SD 8), respectively. The average percent of visits in which the physician fully elicited the patient’s agenda in other, non-index visits was 25% and increased with the level of MHD from no MHD to perfunctory to evidence-based: 19, 27, and 29, respectively. The average physician verbal dominance in other visits was 3.2 (SD 2.2) and declined in visits with no MHD, with perfunctory MHD, and evidence-based MHD: 3.8 (SD 2.8), 3.2 (SD 2.1), and 2.6 (SD 1.2), respectively. Finally, the average number of evidence-based services delivered was 2.9 (SD 1.5); and increased with the level of MHD: 2.7 (SD 1.4), 2.8 (SD 1.4), and 3.2 (SD 1.6), respectively.

Mental Health As A Reason For Some Patients To Schedule A PHE

Over 50% of MHDs occurred within the first five minutes of visit initiation (median=4.9, SD=9.1). Ninety percent of them occurred within the first 19 minutes of the visit, which is 7 minutes fewer than the median visit length. The median time of MHD initiation was 6.3 minutes for perfunctory discussions versus 3.3 minutes for evidence-based discussions (p<0.05). Thus, evidence-based MHDs occurred 3 minutes earlier in the visit than perfunctory MHDs.

In addition to MHDs occurring in the first few minutes of the visit, the nature of the conversation also suggested that MH concerns might have been a reason some patients scheduled a visit. For example, one patient said that she “might need kind of an anti-depressant” 54 seconds into her visit. She then broke down in tears and told the doctor that her sister was recently diagnosed with lung cancer and she was going to go see her and was worried about how she would manage her emotions.

Another patient started to cry before the physician closed the exam room door: “And I knew as soon as I saw you I would start to cry.” When asked how she had been, 49 seconds into the visit, the patient replied that she never had any energy, was stressed out at work, “wake[s] up in the middle of the night, worry, worry, worry” and then says, at one minute 24 seconds, “And I want a happy pill. Is there such a thing?”

Factors Associated With the Quality of Mental Health Discussion

Figure 2 shows results from the proportional logistic model for the three levels of MHD. The model cumulates over adjacent levels of the 3-level MHD quality outcome variable to form odds ratios. Our model assumes the odds ratios are the same for evidence-based MHD versus the combination of perfunctory MHD and no MHD as they are for the combination of evidence-based MHD and perfunctory MHD versus no MHD. For ease of exposition, we say that each odds ratio is the proportional change in the odds of a “higher-quality visit” for each unit increase in the explanatory variable (scaled to standard deviations for the continuous variables age, Charlson score, physician verbal dominance, visit length, and PHQ2 score). For every standard deviation increase in length of the physician’s other visits (SD 7.8), the odds of having a higher-quality visit was 1.4 times greater. Similarly, the odds of having a higher-quality visit were 2.7 times higher for every one percentage point increase in the physician’s score on eliciting the patient’s agenda. The odds of a higher-quality visit were 0.6 times greater for every 1 SD increase in physician verbal dominance (SD 2.2). Female patients were twice as likely as males to receive a higher-quality visit. White patients’ odds were 1.8 times higher than non-whites’ of receiving higher-quality visit. Note that we relaxed the constraint on the odds ratios for PHQ2, because it was not reasonable. Thus, higher PHQ2 scores (SD 1.5) were associated with 1.8 times higher odds of evidence-based MHD compared to the combined perfunctory and no MHD, but not with increased odds of having any MHD versus no MHD.

Figure 2. Factors Associated with Levels of Evidence-Based Practice of Mental Health Discussion from a Proportional Logistic Model.

Coefficients and 95% confidence intervals for the proportional logit model for no mental health discussion (MHD), perfunctory MHD, or evidence-based MHD. Odds are constrained to be proportional across these levels except for PHQ2 score. Intervals that exclude 1 (the null value) are plotted in black, otherwise in grey. Values greater than one indicate variables associated with increased odds of mental health discussion (either perfunctory or evidence-based)

Mental Health Discussion and Physician Verbal Dominance

Below we describe two mental health discussions (one perfunctory, the other evidence-based) that exemplified physicians with different levels of verbal dominance.

High Verbal Dominance Physician

Patient 1’s PHQ2 score was 4, indicating a high likelihood of depression. The patient had no other mental health diagnoses besides hyperkinetic syndrome in her childhood recorded in the EHR. Physician A’s verbal dominance score for other sample visits was 9.7 (almost 3 standard deviations above the mean) indicating a tendency for Physician A to have a more dominant communication style relative to other physicians in the study. (There were only five physicians whose verbal dominance score was 10 or higher.)

Figure 3 illustrates the conversation flow between Physician A and Patient 1. Each color represents the total talk time spent by the participant for each instance, red for patient and yellow for physician. The longest biomedical exchange contained topics encompassing shortness of breath, high blood pressure, and bone density. Patient 1 talked for 56 seconds during the 10 minute 13 second exchange. For the mental health topic, the exchange between Physician A and Patient 1 was as follows:

Physician A:	… and you were followed back in behavioral services, and you still see [name of psychiatrist]?
Patient 1:	Yes.
Physician A:	Okay. Things are going well there?
Patient 1:	Yes. It’s going okay.

Figure 3.

Conversation Flow in One Visit with a Physician with High Verbal Dominance

When Physician A asked the leading questions, “Things are going well there?” Patient 1 answered “It’s going okay.” “Okay” is not the same as “great,” ”excellent” or “fine”. Conversation analysts have noted that “Okay” in response to an opening exchange typically operates as an invitation for further discussion.³¹

But Physician A did not explore why Patient 1’s response was only “Okay” and as a result the discussion was considered perfunctory.

Low Verbal Dominance Physician

The verbal dominance score of Physician B from other visits was 1.24, i.e., she spoke only somewhat more than her patients in the other visits in this sample. Patient 2’s PHQ2 was 6, the highest score for PHQ2. Physician B explored empathic opportunities,³² asked eight of the nine PHQ9 questions, diagnosed depression, prescribed Effexor, and made a referral for psychotherapy. Part of the discussion is as follows:

Physician B:	And you know what? Sometimes as crappy as it feels that you’re going through all these crappy feelings-
Patient 2:	Oh, this is awful.
Physician B:	-you could kind of look at it as a gift. Like okay, now’s your time. You have to do it. You have to deal with these things, you know?
Patient 2:	Right. Right.

DISCUSSION

Among patients likely needing mental health care, only a third had evidence-based mental health discussions, even using a rather liberal definition. Another third of the visits had perfunctory MHDs, leaving the remaining third of patients without any MHD. The significant effects of physician practice styles on presence and quality of an MHD deserve our attention.

Patients seeing physicians who spent more time with their other patients were more likely to have higher quality MHD. This finding echoes the observation that “slow medicine” can be more appropriate for serving patients with chronic conditions.³³ It is also consistent with previous research that suggests visits in which physicians provided appropriate counseling or screening took 2.6 to 4.2 minutes longer than visits in which patients did not receive these services.²⁰ An analysis of 190 video-recorded visits in Europe also suggests that when both doctor and patient considered psychosocial problems to be important, consultations lasted longer than those about biomedical problems only.³⁴ Though some physicians are reluctant to deal with patients’ complex agendas because they are “overly time consuming.”⁹ As our population ages, the number of patients with chronic conditions is rising rapidly. Visit lengths should not be arbitrarily set without much tailoring to patients’ individual needs.³⁵ Offering longer visits for patients with mental health needs would require either smaller caseloads or more staff to do pre-visit and post-visit services, or less frequent visits. Above all, evidence-based practices such as using standardized mental health assessment tools and engaging patients in shared decision making ought to be routine and not left to chance.

Efforts to improve quality of care should incorporate evidence beyond the simple association between visit length and quality of care, however. We need to examine potentially malleable physician communication behaviors and focus on their impact on quality of care. One of those behaviors is verbal dominance. Although it may be more expeditious to actively direct the conversation and maintain control, verbal dominance disempowers patients. Physicians who fear that addressing mental health issues is too time-consuming spend insufficient time addressing their patients’ mental health.^36–38 Other physicians find that asking patients about their suffering and listening to their answers is gratifying and takes little additional time.³⁹ A study of patient clues and physician responses in primary care and surgery found that 76% of patient-initiated clues were emotional in nature and visits in which physicians missed the opportunity to adequately address patients’ emotional clues were actually longer than visits with a positive response.⁴⁰ Furthermore, treating mental illnesses can improve the course of comorbid medical illnesses.⁴¹ The deficiencies in medical education regarding how to provide evidence-based mental health care should be addressed.

Given that one of the undisclosed agendas for patients scheduling a PHE was to discuss mental health topics, physicians could be more purposeful about eliciting and uncovering and prioritizing the patient’s agenda. As it is often the case that the most important issues affecting patients’ wellbeing isn’t always the first topic discussed in a visit, negotiating around time and topics to be discussed becomes critical.⁴² Agenda setting is difficult. Even in a sample of psychiatric encounters, the evidence showed that two out of every three patients were not asked if they had any concerns to discuss.⁴³ Physicians fear that eliciting a complete agenda will be too time-consuming.⁹ Many physicians also feel unprepared to handle mental health problems.⁴⁰ Fully eliciting patient concerns adds less than a minute to the visit, however, and teaching these agenda setting skills requires as little as 3.5 hours to learn and implement.^43–45 Encouraging patients to fully voice their concerns, and preparing physicians to address difficult and potentially uncomfortable topics, can yield more effective consultations⁹ and mental health discussions, as shown in this study.

Limitations

This study included older and privately insured patients in one integrated delivery organization. The generalizability is not known. An additional limitation is the proxy measure of patient activation, i.e., patient bringing a list of issues to the visit. We didn’t have information regarding what topics were on the list. A more specific measure of patient activation related to mental health would have been helpful to understand if mental health was on patients’ agendas. It would have been informative had we been able to document what was on patients’ lists, which would enable us to understand if there were competing demands for the time with physician. Lastly, the study did not address health literacy training of the physicians (scientific or multiple syllable words could intimidate patients) and the patients’ ability to be highly verbal. Future research efforts should take account of these important factors.

CONCLUSION

The cup is 1/3 full, or 2/3 empty. PHEs could fill an important role for some patients to raise mental health concerns without directly stating that they are having mental health problems to the scheduling staff. Physicians should be on the look out to uncover these potential issues and use the time to assess and evaluate mental health (a high-value service) rather than on performing extensive physical exams (low value activities) during PHEs. Graduate medical education should spend at least as much time on training the next generation of physicians on how to ask open-ended questions, fully elicit patients’ agendas, and listen attentively as on how to listen for heart murmurs.

The annual costs of PHEs exceeded $10 billion per year, similar to the annual costs of all lung cancer care in the United States.⁴⁶ Many people have called for eliminating annual physicals,^46–48 based on systematic reviews and meta-analyses showing no reduction in morbidity or mortality, neither overall nor for cardiovascular or cancer causes.⁴⁹ This study revealed that some patients came to their PHEs with mental health concerns, yet only one third of patients likely needing mental health services had an evidence-based mental health discussion. Combined with findings of limited application of the 5As (assess, advise, agree, assist, and arrange) in colorectal cancer screening in PHEs,²³ this study contributes to the body of evidence that reveals suboptimal quality of care delivered in PHEs. Policy makers should revisit the ongoing challenges of asking primary care physicians, who often aren’t trained in evidence-based counseling approaches, to deliver this care under increasing time pressures. Doing this poorly is likely a waste of a scarce resource, physician time. We should consider means to offer support outside of the ambulatory encounters so that it is possible to extend the office visit conversation—that often falls short—beyond the visit so that it approaches recommended counseling content.

Since the Affordable Care Act mandates one “free” PHE per person per year, it is important that PHEs be effective, including identifying patients with mental health needs. Improving the quality of PHEs may require reimbursement for longer visits, training and rewards that enable physicians to more fully elicit patients’ agendas and to listen more attentively. Without significant improvement in the quality of PHEs, eliminating them may do more to improving value in health care for the nation.⁴⁶

Take-away points.

Periodic health exams (PHEs) could be a “safe portal” for patients with mental health needs to receive care. The quality of mental health discussions varied greatly in 255 audio-recorded PHEs in an integrated delivery organization: 1/3 was evidence-based, 1/3 was perfunctory, and 1/3 non-existent. Physicians who spent more time with patients, fully elicited patients’ agendas, and let patients talk were more likely to deliver evidence-based mental health care. Improving care quality may require reimbursement for longer visits, coaching for physicians to fully elicit patients’ agendas, and to listen more attentively. Routine assessment of mental health status should be reinforced.