My guess is that this is an historic practice which stems from the time when only rich people could afford a personal doctor. When faced with an anxious rich patron wanting the attention but without showing apparent health issues, the doctor probably was forced to perform a "check up" to see if there are any signs of possible future trouble.
However, like many other "historic" practices, it always has been my opinion that this practice lacks any evidence for positive outcomes. For one thing, we are taught that through evidence-based medicine, that if the pre-test probability is low, there is a good chance that a test with poor sensitivity and specificity will yield a false positive result. We are well aware of this phenomenon with the treadmill test for chest pain. If a person with atypical chest pain and a low pre-test probability of having a coronary artery disease, goes through such a test, then a positive result is of very limited value. The test is not very sensitive or specific and therefore, you would be second guessing whether the positive result is true or not. In the end, it was waste of time for the doctor, for the patient and the system that paid for it.
Such is the case when a doctor examines a completely asymptomatic person for a "checkup." The pre-test probability of anything is very low, and you are applying almost next to worthless (in terms of sensitivity and specificity) tests of the doctors' physical examination. However, lay people are led to believe in such magic in the doctors' skill in physical examination.
At the same time, many physicians are ordering all kinds of tests as a part of the checkup, which again are of very limited value in asymptomatic patients. Very often I see that a young asymptomatic person will get: CBC, electrolytes, creatinine, TSH (+/- T3 and T4), Vitamin B12, liver enzymes, PSA, fasting glucose, CRP and many others. Some even go further to do "screening imaging" with ultrasounds and CT scans.
There are only a few screening tests that have any, if moderate, evidence of preventing actual tangible negative outcomes in people, or that are guaranteed to not cause more problems during and after testing. The most obvious one, in my opinion, is the "Pap" test for cervical cancer. I think this one unequivocally has reduced cancer mortality and morbidity in women. Potentially, the blood pressure check could be another one, since the harm in the testing process is quite benign.
Then follows a slew of tests that are at best debatable when it comes down to the hard benefit-harm ratio. These are mammograms, colon cancer screening tests and diabetes screening.
Of course, then there are tests that appear to be a waste of time and money. PSA, manual breast exam (self-performed or by physicians), TSH, Vitamin B12 and routine chest x-ray for lung cancer. The list goes on. The history of medicine is littered with failed attempts of screening diseases. Add the following list of debatable ones, that in my opinion, are worthless given the current state of evidence: bone marrow density, cholesterol/lipids and CRP.
The humbling fact is that this leaves us with very few things that are shown to be clearly beneficial for screening purposes. Despite all the progress in medicine, we still don't have many good tools to truly prevent diseases, without causing similar degree of harm.
I wholeheartedly agree with the OCFP that the "routine annual checkups" are wasteful (of public resources and time of those involved) and non-evidence based. At Rainbow Valley Community Health Centre where I work, one year ago we initiated what is called a "periodic health questionnaire". This is a nurse-led process, where a client will spend 30-60 minutes going through many questions. The patients are also given information about common health issues ranging from smoking, diet, to hearing protection at work. The nurse also checks the immunization status and the last dates for a few predetermined screening tests that have some evidence. (Currently these are: fasting glucose, fecal occult blood, mammogram and Pap test.) If the client wishes to receive other tests with debatable evidence, the client is invited to book an appointment with the physician to discuss pros and cons of these tests. Similarly, if there are any significant health issues identified by the nurse and a physician's attention is required, there will be an appointment made.
This approach is efficient in many fronts. Nurses typically have much more time than family physicians to discuss health issues in detail and give appropriate counselling, and that is at a much lower cost to the system. I believe this would lead to more satisfactory visits from the client's perspective than being rushed through with a physician who gives a misleading "clean bill of health."
Also, this permits physicians to focus more on clients who actually have problems. I find that it is very unfortunate that quite a large chunk of family physicians' time is currently used to prod and poke people who seemingly have no problem, while there are many thousands of orphaned patients that actually have identified health issues. They are forced to visit walk-in clinics and emergency rooms with ensuing fragmented care.
This approach will also save billions of tax dollars in unnecessary doctor visits and testing for which the government pays (exactly 2.2 billion a year only in direct cost). Hopefully, this will free up money to go towards where it is really needed, such as for more facilities, services and less waiting time for sick people.
Bravo OCFP for raising an important issue and breaking with tradition! And to quote them, it only took about 34 years after a task-force in 1979 recommended against the annual checkup in asymptomatic adults.
Here is a copy of the statement:
_______________________________________________________________________
Don’t Just Do Something,
Stand There!
Best Practices: The
Routine Annual Check Up is of Limited Value
It was
over 30 years ago that the Canadian Task Force on Periodic Health Examination
(1979), followed by the U.S. Preventative Services Task Force (1996), provided
evidence-based guidelines that did not recommend routine annual physical
examination or multi-phasic testing for asymptomatic adults.
Steeped in historical significance, yet
lacking in clinical evidence, still today many asymptomatic adult patients
regularly attend their family physician for this annual ritual. The “annual
physical” often involves a panel of tests and investigations that take place
before the actual examination to facilitate discussion during the visit. This
annual “check-up” accounts for approximately 11,000 visits per year in Canada
and an estimated $2.2 billion a year in direct costs.
One
year ago, following guidance and research from Health Quality Ontario (HQO), the
Ministry of Health and Long-term Care, in negotiations with the Ontario Medical
Association, removed the annual health examination from the Schedule of
Benefits. They replaced it with a new encounter-code – ‘The Wellness Visit”.
Moving away from the concept of mass
screening through annual check-ups to patient-specific health promotion
implemented when the physician sees a patient for another reason appears to be
the preferred approach. This means using other visits to talk to a patient about
possible health issues or concerns based on the patient’s personal and family
history and specific risks. This
practice of evidence-based stewardship of resources will reduce health care
expenses and improve access for needed care. Electronic Medical Record software
can alert clinicians to the appropriate timing for preventative interventions
during regular visits. This
functionality facilitates the process of addressing such things as screening for
hypertension, and breast, colon and cervical cancer and ensuring that
immunizations are updated.
Certainly there are select patients in
clinical practice that would benefit from more intensive or proactive
preventative care strategies and relationship building. As well, there are many
patients who, without having a scheduled annual examination, would not seek
care. These individuals should be
identified and encouraged to schedule a visit periodically for a patient-centred
focus on preventative aspects of health care (ie the “Wellness
Visit”).
The
following are links to further reading and tools that may help you improve the
preventative focus of the Wellness Visit, as well as capturing evidence based
interventions in preventative health encounters.
Literature:
Tools:
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