Preventive health care and the craft of family medicine

The family physician sees every contact with his patients as an opportunity for prevention or health education.

                                                  Dr Ian McWhinney, A Textbook of Family Medicine

Thinking about preventive health care and the most effective way to provide it has been a major preoccupation of my career. My interest began soon after I joined the Department of Family Medicine at Women’s College Hospital in Toronto, Ont, in 1994. I inherited many older patients from 2 family physicians who had recently retired. At the time, the Canadian Task Force on Preventive Health Care recommended opportunistic screening. For example, if a patient came to see you for a common cold, one should check the patient’s blood pressure and assess cardiovascular risk, as well. In other words, as Dr Ian McWhinney urged us, make every clinical encounter an opportunity for prevention.

Even then, with a limited number of preventive care maneuvers in older patients supported by good evidence, I found myself applying the principle inconsistently (and by that, I mean rarely). Instead, in a busy practice, I was more focused on the acute problem at hand. At the time, most of my colleagues in the clinic were booking patients of all ages for an annual checkup or periodic health examination. So, I wondered which older patients received the most preventive care: those who came in for other, more urgent reasons, or those who came in for an annual checkup? Working with Drs Amy Freedman and Gary Naglie, we discovered those who came for a checkup were twice as likely to receive appropriate preventive care as those who came to see the doctor for other reasons.¹

I also began my family medicine career at a time when clinical practice guidelines for screening and preventive care were expanding exponentially. Like many, I became preoccupied with how we were going to implement them when we were already busy providing acute and chronic illness care.² Most of my concern was practical—how were my colleagues and I going to find the time to do this³—rather than deeper and more philosophical.

British general practitioner Dr Iona Heath has always been an iconoclast, often challenging some of our most cherished beliefs in medicine, from the value of preventive care in the elderly⁴ to the health-improving benefits of disease-oriented health quality outcome measures.⁵

In this issue of Canadian Family Physician, Heath revisits McWhinney’s third principle of family medicine (quoted above) for our ongoing series, “Foundations for tomorrow” (page 230),⁶ which celebrates the centenary of McWhinney’s birth. In her own inimitable style, Heath goes beyond consideration of which preventive care maneuvers to offer or how to find time to implement all those that family doctors are expected to deliver in increasingly industrialized health care systems. Instead, she explores more deeply how we family doctors can reclaim the craft of prevention that leverages our knowledge of and long-term relationships with our patients.

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