It is often difficult to dedicate time for preventive care in a busy family practice. Patients seem to consult their family doctors more for specific health complaints than for advice on prevention. The periodic health examination (PHE) is a tradition in North America; however, it is not used in most other countries, such as the United Kingdom, where preventive care is still delivered. Do we really need the PHE in Canada?
The PHE can advance 2 critical elements of care for our patients: relationship building and preventive care. A large systematic review of studies on the value of periodic health evaluation found that the PHE was consistently associated with an improved delivery of Papanicolaou tests, cholesterol screening, and fecal occult blood testing.1 The PHE was also found to decrease patient worry. A third of the studies reviewed were done before 1989, before large-scale dissemination of Canadian and American task force recommendations on preventive care. As the number of evidence-based preventive care recommendations grows, a PHE that offers a planned focus on preventive care might become even more valuable.
Time for prevention
Many provincial health care billing systems in Canada currently include a fee for an annual examination, a visit usually double the length of time of the average visit. Having more allotted time allows physicians to deal with their patients’ immediate concerns as well as to pursue other issues that might be neglected over the course of a year. Many physicians appreciate a longer visit to obtain a more holistic view of their patients, via discussions about family, work, and social life. These conversations build relationships, give context to medical issues, and provide opportunities to screen for less obvious conditions, such as depression (an evidence-based recommendation). A longer visit also provides time to inquire about exercise and lifestyle issues, as symptom-driven discussions at other visits might preclude this. A regularly scheduled health examination helps build important rapport and understanding, while enabling the delivery of preventive care; for healthy individuals, this is often the only contact they have with their family physicians.
A certain proportion of our patient population is already used to receiving PHEs, and many physicians have been informing patients of the new focus on preventive care. Taking advantage of an established cultural habit, we can piggyback much-needed preventive care onto these visits. Unfortunately, patients in lower socioeconomic groups2 and some other subsets of patients (eg, new immigrants,3 men,4,5 and African-American men6) are less likely to attend preventive care visits. Research is needed to ascertain how to reach these populations more effectively and include them in preventive care maneuvers. For those patients who do not welcome regularly scheduled PHEs, physicians should develop flexible approaches and pursue other opportunities for preventive screening and delivery of preventive care when appropriate
Some physicians feel overwhelmed or distracted by the long list of symptoms that patients often bring to the appointment. Learning to reframe the agenda with the patient has helped many learners manage these situations. Additionally, educating the patients in your practice with handouts explaining the PHE’s focus on prevention might help raise the profile of that aspect of the visit. Providing questionnaires for patients to fill out in the waiting room can streamline the process. I worked in a clinic where the patients completed a lifestyle questionnaire as well as a short functional inquiry before being seen by the doctor. I found this to be a time-saving measure, as a quick look helped me to identify areas to focus on and general patterns pointing to problems, such as anxiety or mental health concerns.
Although it is true that preventive care can be delivered well without the PHE, or can be carried out by nonphysician members of primary care teams, it is nonetheless a valuable tool. If considering eliminating the PHE, physicians should review what else they have in place to meet the need for preventive care and health promotion. Similarly, physicians should consider what opportunities will be provided to ensure that building relationships and working to put patients’ care issues into context are not continually overshadowed by the pressing concerns of that day.
Use what works
One size does not fit all. If a longer appointment for preventive services and holistic care does not work well for certain patients or family physicians, they should be free to use a different system. But don’t throw out the baby with the bath water—if the PHE works for many patients and physicians, why abandon it? To improve delivery of the PHE, we need to educate patients on the importance of a dedicated visit for preventive maneuvers. We need to educate family physicians on how to deliver focused, cost-effective, periodic health assessments. Additional research is needed to assess the costs, benefits, and harms, as well as long-term outcomes, of the PHE and to compare it with alternative methods of delivering preventive medicine within the primary care environment.
Acknowledgments
I thank Dr Sharon Johnston and Ms Linda Mavriplis for their comments on earlier drafts of this article. I also thank Health Services at the University of Ottawa for the idea of the patient questionnaire with functional inquiry.
Notes
CLOSING ARGUMENTS
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The periodic health examination increases the delivery of preventive health care.
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The longer visit provides a more holistic view of the patient.
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Using an established cultural habit, we can piggyback much-needed preventive care maneuvers onto these visits.
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Research is needed to improve the delivery of preventive care to certain groups of patients.
Footnotes
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Cet article se trouve aussi en français à la page 165.
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Competing interests
None declared
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The parties in this debate refute each other’s arguments in rebuttals available at www.cfp.ca. Join the discussion by clicking on Rapid Responses.
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