Periodic preventive health visits: a more appropriate approach to delivering preventive services

Birtwhistle and team from the Canadian Task Force on Preventive Health Care provide an excellent review of the (lack of) evidence that the traditional routine annual checkup decreases mortality in asymptomatic patients (1). They propose attractive alternatives to organizing preventive services.
I'm not sure, however, how much we can improve the landscape by redesigning one of the silos.

It's surely true that medicine is weighed down by the baggage of unproven interventions and unnecessary practices. Many waste time and resources, some harm patients, all rob us of opportunities to make care – and patients – better. This is true even for preventive care.

In theory there is no difference between theory and practice, but in practice there is. In family practice, there is no such thing as the asymptomatic patient, certainly not for people in middle age or beyond. Even fewer have no targeted risk factors.

I have never seen a patient with hypertension or at risk for a cardiovascular event. I have seen Mrs. Jones with hypertension and diabetes and vaginitis and depression and unknown lipid values and a teenager on drugs. I have also seen Mr. Gomez, Miss Anderson and little Timmy. All were individuals, not diseases, interventions or outcomes.
The Canadian Task Force on Preventive Health Care and the United States Preventive Services Task Force have pioneered and refined scientific methods for evaluating the evidence to support recommendations for screening tests, preventive drugs and behavioural counselling services. Family physicians have been major leaders and big beneficiaries of these advances.
The approach has been to parse diseases and clinical interventions into stand-alone entities for evidence review and analysis. Crisp as this method may be, it does not reflect the complexity of practice or the richness of care. Just as when we try to apply data from randomized clinical trials to primary care, we soon see that the map of controlled research does not match the territory of community practice. Primary care is the management of undifferentiated problems in unselected patients. It is not a series of decisions about how frequently to do a Pap smear, or if obesity counseling is indicated at this visit. Playing each note perfectly does not make for a virtuoso performance and certainly cannot create a symphony.

Doctor-patient encounters are routine only if we let them be (2). The risk of the routine is even greater when the content and pace of care are driven by clinical protocols, algorithms and productivity demands. Even routinely scheduled visits can quickly become key encounters. Some patients fail to recognize important symptoms, underestimate health risks or need help changing behavior. Just because the patient doesn't need an annual check-up doesn’t mean she cannot benefit from a conversation with her personal physician. Just because she doesn’t need a complete physical exam doesn't mean she doesn’t deserve compleat care.

The authors wisely call for “a more appropriate approach to delivering preventive services.” But we need more: a more thoughtful and powerful approach to delivering care to whole patients (and populations). Evidence-based preventive services are but one key component of value-based comprehensive care. Primary care is not a schedule of discrete encounters and services, but the orchestration of care delivered over time, across problems and through conversations.

Birtwhistle and colleagues do emphasize that “preventive health service delivery should support the development and maintenance of the core ideas of the patient-physician relationship as part of providing continuity of care….” They understand that there is more to care and health than is dreamt of in meta-analysis.
The complete physical examination we were taught in medical school and hospital wards was never designed to be a prevention tool. It is little surprise that annual recital of the ritual is of little value (3). What is exciting is our opportunity to ask meaningful questions, design high-quality research in primary care settings and reengineer the ways we connect with patients and deliver the care they want and need.

Do we have good data describing how many doctors and patients do annual check-ups, complete physical examinations or periodic preventive health checks? What do patients and doctors actually discuss and do at these “annual exams.” I suspect only a small part of the interaction was ever about preventive services, physical exams or reviews of systems. Do we know how patients, doctors and teams would like to organize regular interactions? Do we know what they want to get out of them? Can we measure the needs, expectations, services and outcomes? What should, or could, occur at regular encounters between patients and their personal primary care physicians? As healthcare needs, expectations and resources all change, we should ask the question of how best to use the time clinicians and patients have together (4). Enlarge the primary care team and the questions becomes more complex and probably more important.
Prevention facilitators, waiting room kiosks and web-based patient portals might contribute to getting services of proven value performed at recommended intervals. They might even help activate patients, improve shared decision-making and help patients change health-related behaviors. We agree that more research is needed to test such interventions and better funding will be required to implement what is demonstrated to work.

The challenge, of course, is that the processes and outcomes of greatest value may well be the hardest to measure. Interactions occur at regular or random encounters and outcomes may be seen only in the future at a variety of times and places. Family medicine is the specialty devoted to care of the whole patient the whole time and each visit is an opportunity to
activate, orchestrate, and integrate. A conversation at the periodic health care visit may be the foundation for helping patients choose wisely (5,6) and for key decisions at later encounters in the office, emergency department, hospital or hospice. The patient’s (and family’s) trust in the physician, built over routine encounters, may help avoid the unnecessary CT scan for headache months or years later. Such discussions ¬– and the relationships they help build – may help avoid low value routine tests, inappropriate emergency room visits or unneeded hazardous procedures. They may get the family on the same page for birth plans or end-of-life care. Just because these processes and outcomes are not easy to measure doesn't mean they're not important. If we leave them out of the discussion and off the research agenda, we threaten the appreciation and understanding of family medicine and primary care.
The value of family medicine and the importance of a continuous relationship with a personal physician are under attack from many quarters (7,8). If we are to defend their potential, study their benefits (and harms) and pursue this shared vision, we must raise our sites to horizons beyond the silos.

The real question is not whether annual check-ups are worthwhile, but how can we make scheduled visits and every clinician-patient encounter as valuable as they can be.

References

1. Birtwhistle R, Bell NR, Thombs BD, Grad R, Dickinson JA. Periodic preventive health visits: a more appropriate approach to delivering preventive services. From the Canadian Task Force on Preventive Health Care. Can Fam Physician 2017;63: (11) 824-6.
2. Phillips WR. Should we abandon routine visits? Ann Intern Med. 2016;165(7):528.
3. Ladouceur R. For the scholarly, free-thinking family physician. Can Fam Physician 2018; 64(1):6.
4. Reid M. You asked: Do I really need an annual physical? TIME 2018; Jan 10. http://time.com/5095920/annual-physical-exam. Accessed 2018 April 10.
5. Choosing Wisely Canada. Family medicine. Thirteen things physicians and
patients should question. Toronto, ON: Choosing Wisely Canada; 2018 Jan.
Available from: https://choosingwiselycanada.org/family-medicine. Accessed 2018 April 10.
6. Choosing Wisely. Philadelphia, PA: American Board of Internal Medicine Foundation; 2018. Available from: http://www.choosingwisely.org. Accessed 2018 April 10.
7. Green LA. Will people have personal physicians anymore? Dr Ian McWhinney lecture, 2017. Can Fam Physician 2017; 63(12):909-912.
8. Phillips RL. Preserving primary care robustness despite increasing health system integration. Fam Med 2017;49(8):591-3.