For the scholarly, free-thinking family physician

A commentary published in the November issue of Canadian Family Physician stated that annual physical examinations are no longer necessary: “The traditional annual physical examination of asymptomatic adults is not supported by evidence of effectiveness and might result in harm. It should not be a regular activity.”¹ This is important news considering the substantial role played by annual physical examinations within family practice. Visiting your family physician every year was, until recently, the norm advocated by all and sundry.

Yet this claim was not made by some quack with a sudden epiphany or in pursuit of sensationalism, but by the Canadian Task Force on Preventive Health Care, a prestigious organization that has directed our preventive practices for more than 40 years. They are the Canadian equivalent of the US Preventive Services Task Force. This is hardly insignificant! What is more, this recommendation is similar to a statement made in 2016 by Choosing Wisely Canada (another highly respected body) in their list of 11 things that family physicians and patients should question: “Don’t do annual physical exams on asymptomatic adults with no significant risk factors.”²

If today these recommendations seem reasonable and generally well accepted, understand that, not so long ago, this was not at all the case. Barely 5 to 10 years ago, doubting the value of annual physical examinations would have been viewed negatively. I know this because in 2013 I published a blog entitled, “What If Annual Physical Examinations Were Useless?”³ You should have seen the reactions! Even though the article merely asked some simple questions and was evidence-based, it provoked a massive stir in my sphere: public health was up in arms; threats of reprisal were fired from all directions. Simply put, had we been in the Wild West, they would have hung me high and dry; in the Middle Ages they would have burned me alive or until I admitted heresy! Clearly, I am exaggerating, but it goes to show that any family physician who dares deviate in the slightest from normal practices exposes themselves to the risk of prejudice. As though we need to subscribe absolutely to the idea of “do it because everyone else is doing it.”

In reality, this brings into question the right of family physicians to contest the validity of the many recommendations we receive. Must family physicians silently and unconditionally adhere to every recommendation made? Do we need to apply every recommendation given exactly to the letter and without questioning the strength of the evidence, as though they were dogma or divine word? Must we blindly prescribe every new allegedly miraculous and “clearly superior” drug classification or medication raved about by advertisements, “continuing medical education” (!), and key leaders of opinion, without confirming that their claims are true?

Surely not.

Family physicians have good reason to doubt them. Scholarship and critical thinking are intrinsic requirements for all physicians. Reading “A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices,”⁴ published in the Mayo Clinic Proceedings in 2013, is enough to confirm this. More than 40% of recommendations on standards of practice were ultimately revealed to be wrong. It is highly probable that within the next 5 to 10 years, several of the certainties that we hold dear today will also be revealed as erroneous.

Is this a bad thing? Absolutely not. It simply demonstrates the importance of scientific thought in advancing our knowledge. You need only read the history of Captain James Cook’s fight against scurvy in Yuval Noah Harari’s Sapiens.⁵ It demonstrates how doubting and questioning contributes to scientific advancement.

There is definitely a place for scholarship and critical thinking in family medicine.

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