Family Medicine Recommendation #8: Don’t do annual physical exams on asymptomatic adults with no significant risk factors.
Choosing Wisely Canada: How have you implemented this recommendation in your practice?
Dr. Cleo Mavriplis and Tawnya Shimizu: A few years ago, we started looking at whether or not we should be doing annual physicals. We reviewed Choosing Wisely Canada recommendations; statements from The Canadian Task Force on Preventative Health Care; and other supportive research. We condensed the information into one chart and created Practice Solutions stamps summarizing preventative care based on patient sex and age. These were published in Canadian Family Physician in February 2016, titled ‘Update on age-appropriate preventative measures and screening for Canadian primary care providers’. The table is comprehensive. It uses different fonts to identify what is evidence-based and what is consensus-based. We use these stamps for a streamlined evidence-based preventive visit or as a running checklist when we are seeing patients for medical problems.
As a clinic, we also ensure that primary care providers are given time to do data management. This ensures each patient’s chart is reviewed individually and screening tests are recommended based on need. As a result, we no longer perform annual physicals – you don’t need to examine a healthy, young, non-symptomatic patient from head to toe
CWC: How have you brought the Choosing Wisely principles to your relationship with patients?
CM & TS: We try to prompt patients to think about their visit in the waiting room by hanging posters about Choosing Wisely Canada and about evidence-based screening. These ‘official’ posters help legitimize what we’re saying to patients by showing them there are initiatives that support our messaging. They also help to initiate conversations about the newest scientific evidence. We often quote the Task Force resources around false positives that can arise from over screening. We have found that our patients understand that evidence changes, and when we take the time to clarify it, they trust the care we are providing.
Based on our experiences we created videos for Family Medicine Forum 2016 showing how to talk to patients about evidence-based screening. These focus on two common discussions: routine mammography for women aged 40-50, and appropriateness of PSA testing in men. Many primary care providers know these tests aren’t appropriate but don’t know how to have these conversations. We hope these videos help. We are in the process of revising them to share with Choosing Wisely Canada.
CWC: What does Choosing Wisely mean to you as a clinician?
CM & TS: I would refer to Choosing Wisely Canada as one of the few organizations that looks at doing less rather than doing more.
There are very few authoritative sources for patients saying, “You don’t need this”. We were interested to know that Choosing Wisely Canada has research data around the number of bone density tests in Ontario, how often they are ordered, and their probable “appropriateness”. This type of research will guide system changes. We need to take a closer look at what tests we order and whether they are evidence-based. A lot of funding is given for research on drugs, but there is not a lot of research done on ordering fewer tests. When we first tried to explain PSA testing to patients about fifteen years ago, there wasn’t much information to support us. Now there are more tools – for example, the Choosing Wisely Canada website. Hopefully it will be more publicized to patients because they need to hear the message as much as possible. For patients, the more they see common messaging from different sources, the more credible it is. Posters, handouts, websites, videos – with so many different mediums telling them ‘maybe you don’t need this’, we think they will start to understand the message.
Editor’s Note: Here is a link to the CFPC posters about appropriate screening and changes in the way we are doing “annual physicals”. These can be hung in your office and ordered by emailing firstname.lastname@example.org . – Dr. K. Wintemute
This article first appeared in Canadian Family Physician. The interview was prepared by Dr Kimberly Wintemute, Primary Care Co-Lead, and Diana Wegner, Project Manager, Programs & Practice Support, the College of Family Physicians of Canada.