The Preventative Visit and Choosing Wisely

The preventive health visit is not synonymous with an 'annual physical'

I always felt lost when asked to do a general exam on a healthy person. Every physician performed it differently. Do we check for breast masses? Feel the thyroid? Look at the tongue and mouth for squamous cell carcinomas? Check the belly for a pulsatile mass? Listen for a murmur? Heck it would take hours to go over every mole and mucosa, to palpate every bump and move each joint. So what were we doing?

The American Choosing Wisely campaign, in the list of Society of General Internal Medicine suggestions, recommended in 2013 that physicians stop “performing routine general health checks for asymptomatic adults." (see some backing data)

Many were outraged by this, and a similar decision in Ontario by the provincial government to de-list the annual physical exam, such that physicians would no longer be paid to provide this service to patients who don't require it. The concern was mainly that very important preventative health and screening measures would no longer be undertaken.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

Prevention is essential. Not sure about the "quality" of the helmets here, but even the dog is at least trying to being careful.

But, a preventative health visit is not the same thing as an annual physical. For example, we've got decent evidence that pap tests are important screening tools for cervical cancer, and have changed our guidelines to use them less frequently. And we are not suggesting dispensing with this. However, recent studies have shown that the pelvic exam (feeling the uterus and ovaries, essentially) really is not essential and many organizations are beginning to recommend against this practice. We had been doing pelvic exams out of "tradition" for the longest time - how much else is driven by tradition?

I come back time and time again to the Milstein paper from Health Affairs, Why Behavioral And Environmental Interventions Are Needed To Improve Health At Lower Cost. We know that prevention is key, but we don't know how, when, or where to deliver it. Dispensing lifestyle advice in the office probably doesn't work (eg. GP advice is ineffective in improving metabolic outcomes in high risk patients). Clearly we need something different to achieve a persuasive, meaningful impact.

A colleague recently sent me an article, from the American Journal of Preventative Medicine (access required - ePub ahead of print, Jul 2014),  which addresses concerns with the way our push for efficiency and appropriateness may be drawing attention away from the real issue of prevention. Wong, Gaster, and Dugdale write:

. . . the Choosing Wisely Campaign sends the wrong message at a time when prevention remains more important than ever, and as the data supporting it grow more complex and more nuanced. The preventive health visit has and will continue to evolve . . . The preventive health visit currently remains an effective tool for increasing adherence to evidence-based service guidelines. This is no time for us to abandon it.

I would personally need to learn a lot more about what "effective" is meant to construe in the above sentences before agreeing wholeheartedly. I don't disagree that we need to spend a lot more effort looking at prevention, but I don't think Choosing Wisely contravenes that effort. 


What do you think?