Choosing Wisely Canada

Family medicine recommendation 8

Do not do annual physical examinations on asymptomatic adults with no significant risk factors.

How have you implemented this recommendation in your practice?

A few years ago, we started looking at whether or not we should be doing annual physical examinations. We reviewed the Choosing Wisely Canada recommendations, statements from the Canadian Task Force on Preventive Health Care, and other supportive research. We condensed the information into one chart and created what we call practice solutions stamps summarizing preventive care guidelines based on patient sex and age. This guideline summary was published previously in Canadian Family Physician¹; the accompanying comprehensive table uses different fonts to identify which recommendations are evidence-based and which ones are 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 physical examinations: you do not need to examine a healthy, young, non-symptomatic patient from head to toe.

How have you brought the Choosing Wisely principles to your relationship with patients?

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 posters^* help legitimize what we are 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 overscreening. 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.

We created videos for Family Medicine Forum 2016 showing how to talk to patients about evidence-based screening. These videos focus on 2 common discussions: routine mammography for women aged 40 to 50, and appropriateness of prostate-specific antigen testing in men. Many primary care providers know these tests are not appropriate but do not know how to have these conversations with patients. We hope these videos help. We are in the process of revising them to share with Choosing Wisely Canada.

What does Choosing Wisely mean to you as a clinician?

Choosing Wisely Canada is one of the few campaigns that models doing less rather than doing more. Very few authoritative sources tell patients, “You don’t need this.” It was interesting to learn that Choosing Wisely Canada has research data on 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 prostate-specific antigen testing to patients about 15 years ago, there was not much information to support us. Now there are more tools like, for example, the Choosing Wisely Canada website. Hopefully it will be more publicized to patients because they need to hear the message as often as possible and from different sources so that the messages become more credible. 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.