For the scholarly, free-thinking family physician

Roger Ladouceur

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RE: The annual history and physical has actually bee dead for decades
R. Warren Bell

Published on: 29 January 2018
Think and practice reflectively
Martin Hofmeister

Published on: 26 January 2018
RE: Annual physical
John W. Crosby

Published on: 23 January 2018

Published on: (29 January 2018)
Page navigation anchor for RE: The annual history and physical has actually bee dead for decades
RE: The annual history and physical has actually bee dead for decades
R. Warren Bell, Family Physician, Shuswap Lake General Hospital & UBC
When I was a medical student at McGill in the 1970s, I was overwhelmed by the conflicting recommendations from various services to include specific questions and investigations in the complete exam - so overwhelmed that I took a 3 month sabbatical in third year to explore this subject.

This resulted in a paper in the CMAJ (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1947878/) which challenged the conventional model of the "complete history and physical" and recommended two things: 1) selective examinations, based on the reason for the patient presenting, and 2) getting to know the patient as a person, in all her or his rich complexity.

A few years later, the Canadian Task Force on the Periodic Health Examination was formed, and in 1979 it published its report, which concluded that "the Task Force's main recommendation is, therefore, that the routine annual check-up be abandoned in favour of a selective approach that is determined by a person's age and sex." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1704686/?page=2

The reason the annual check-up has persisted for nearly 4 decades since these findings were first shared reflects the often convention-ridden and protocol-oriented core of much medical practice, embedded in a fee-for-service system that rewards many short visits and...
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When I was a medical student at McGill in the 1970s, I was overwhelmed by the conflicting recommendations from various services to include specific questions and investigations in the complete exam - so overwhelmed that I took a 3 month sabbatical in third year to explore this subject.

This resulted in a paper in the CMAJ (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1947878/) which challenged the conventional model of the "complete history and physical" and recommended two things: 1) selective examinations, based on the reason for the patient presenting, and 2) getting to know the patient as a person, in all her or his rich complexity.

A few years later, the Canadian Task Force on the Periodic Health Examination was formed, and in 1979 it published its report, which concluded that "the Task Force's main recommendation is, therefore, that the routine annual check-up be abandoned in favour of a selective approach that is determined by a person's age and sex." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1704686/?page=2

The reason the annual check-up has persisted for nearly 4 decades since these findings were first shared reflects the often convention-ridden and protocol-oriented core of much medical practice, embedded in a fee-for-service system that rewards many short visits and most procedural interventions more than it encourages careful and comprehensive critical thinking.

Add in a certain amount of irrational paranoia about negative medical-legal outcomes if some clinical stone is left unturned. There is a conspicuous absence of downward pressure against the constant expansion of investigative procedures -- especially our increasing reliance on the CT scanner. There seems to be little appetite for truncating our relentless scanning for non-existent diseases or "pre-diseases", most of which are simply proxy markers -- the lipid profile, the AIC or even blood pressure.

When I researched my paper 45 years ago, I found one research project that compared an exhaustive complete history and physical, replete with intricate questions and multiple investigations, with another approach that relied simply on 7 open-ended questions -- questions like "Is there anything you'd care to tell me about your health?" and "Is there anything you might have forgotten" -- with no examination at all. The two approaches attained very similar comprehensive and useful results; neither was perfect, but both were effective. The advantage of the second approach, however, was that is was much less expensive, while producing similar patient benefits.

We need less paint-by-numbers medicine and more genuine and meaningful human interactions between doctors and patients.
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Competing Interests: None declared.
Published on: (26 January 2018)
Page navigation anchor for Think and practice reflectively
Think and practice reflectively
Martin Hofmeister, Dr., Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Germany
Dear Editor,

I congratulate Dr. Roger Ladouceur for his reflective editorial in the January 2018 issue of the Canadian Family Physician, which I absolutely support [1]. Thinking and practicing scientifically means primarily asking questions or questioning them, whereby the new cannot be understood, judged and used without the old. Today, the founder of the systematic anamnesis Rufus of Ephesus (c. 80 - 150 AD) would probably ask in connection with the handling of clinical recommendations in medical practice: How and to what extent are patients' preferences taken into account in the conceptual process of preparing a clinical recommendation? [2, 3] Do we have a one-size-fits-all mentality in the recommendations or enough flexible room for physicians to tailor care to the patient's personal circumstances and medical history? What concrete procedures should be used to create practice-oriented and usable guidelines? Today, the Greek physician Rufus would agree with Dr. Ladouceur: many guidelines are not properly developed [1].

Almost 20 years ago, an attempt was made to find out what potential barriers to physician guideline adherence could exist: lack of awareness and lack of familiarity (volume of information, time needed to stay informed guideline accessibility), lack of agreement with specific guidelines or guidelines in general, lack of self-efficacy, lack of outcome expectancy, lack of motivation/inertia of previous practice (habit, routines), and...
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Dear Editor,

I congratulate Dr. Roger Ladouceur for his reflective editorial in the January 2018 issue of the Canadian Family Physician, which I absolutely support [1]. Thinking and practicing scientifically means primarily asking questions or questioning them, whereby the new cannot be understood, judged and used without the old. Today, the founder of the systematic anamnesis Rufus of Ephesus (c. 80 - 150 AD) would probably ask in connection with the handling of clinical recommendations in medical practice: How and to what extent are patients' preferences taken into account in the conceptual process of preparing a clinical recommendation? [2, 3] Do we have a one-size-fits-all mentality in the recommendations or enough flexible room for physicians to tailor care to the patient's personal circumstances and medical history? What concrete procedures should be used to create practice-oriented and usable guidelines? Today, the Greek physician Rufus would agree with Dr. Ladouceur: many guidelines are not properly developed [1].

Almost 20 years ago, an attempt was made to find out what potential barriers to physician guideline adherence could exist: lack of awareness and lack of familiarity (volume of information, time needed to stay informed guideline accessibility), lack of agreement with specific guidelines or guidelines in general, lack of self-efficacy, lack of outcome expectancy, lack of motivation/inertia of previous practice (habit, routines), and external barriers (guideline-related, patient-related, and environmental-related) [4]. On the other hand, critical thinking skills in family medicine residents also seem to be associated with better performance and academic success [5].

YES, think and practice reflectively is very important. Therefore, it is also not uncommon for family physicians and guideline developers to get occasionally supported by Rufus' "Quaestiones Medicinales". As reflective primary care physicians/practitioners and other front-line health care professionals we try every day from the literature and practice to develop the current state of "error".

Sincerely,

Dr. Martin Hofmeister, Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Germany

References

1. Ladouceur R. For the scholarly, free-thinking family physician. Can Fam Physician 2018;64(1):6.

2. Alfandre D. Clinical recommendations in medical practice: a proposed framework to reduce bias and improve the quality of medical decisions. J Clin Ethics 2016;27(1):21-7.

3. Mühlbacher AC, Juhnke C. Patient preferences versus physicians' judgement: does it make a difference in healthcare decision making? Appl Health Econ Health Policy 2013;11(3):163-80.

4. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282(15):1458-65.

5. Ross D, Schipper S, Westbury C, Linh Banh H, Loeffler K, Allan GM, Ross S. Examining critical thinking skills in family medicine residents. Fam Med 2016;48(2):121-6.
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Competing Interests: None declared.
Published on: (23 January 2018)
Page navigation anchor for RE: Annual physical
RE: Annual physical
John W. Crosby, Family Doctor, U of T
I so agree. I have been a doctor for 45 years and have never picked up anything of value on an annual physical. It was good for giving us time for talking to the patient and getting paid appropriately.
Doing a BP on everyone is a much better thing to do as it is symptomless.

Competing Interests: None declared.