Rebuttal: Should we abandon the periodic health examination?

Dr Mavriplis states that it is often difficult to dedicate time for preventive care in a busy family practice. According to McWhinney,1 if every patient in a practice of 2000 had a 20-minute annual health examination, it would occupy the physician full-time for 22 weeks of every year. Another study estimated that more than 40% of all direct patient time for primary care physicians is taken up by dedicated preventive care visits.2 Discontinuing dedicated periodic health examinations (PHEs) would immediately provide substantially more time for regular patient care, including a few minutes for prevention at each visit, and would allow more people access to family physicians. It should be noted that the number of appointments dedicated to PHEs in 2009 (21.4 million, if you account for the fact that PHEs take twice as long) is more than all of the visits for hypertension (20.9 million) during the same period.3

Dr Mavriplis suggests that dedicated time for a PHE fosters the building of relationships and rapport, and allows the physician to place the patient’s medical concerns into context. One of the core tenets of family practice is cumulative consultation—the continual building of therapeutic relationships over a period of months or years. Every patient contact requires effective communication and understanding of the patient’s context, which is central to the patient-centred clinical method.1

Dr Mavriplis found that the PHE was consistently associated with the improved delivery of Papanicolaou tests, cholesterol testing, and fecal occult blood testing. However, Mehrotra et al2 have demonstrated that only 19.9% of 8 different preventive services occurred at PHEs or preventive gynecologic examinations, and that preventive care, in particular counseling services, frequently occurred at visits for immediate care or chronic illness. Despite the small benefits attributed to having dedicated PHEs, the delivery of evidence-based preventive care during the PHE is poor and there is still no convincing evidence that it leads to better health outcomes. I believe that there is still insufficient justification for the continued and substantial cost of the PHE to the Canadian health system, particularly as it should be easy to schedule patient-specific preventive care, using computerized systems, during visits for immediate care.

I agree with Dr Mavriplis that patient handouts and self-administered questionnaires can be useful. Providing a patient handout that explains why an “annual physical” is no longer provided and details which evidence-based preventive care maneuvers are generally recommended would prepare the patient for discussing these tests during regular care visits.

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