The long-standing practice of visiting your doctor every year for a "complete" physical is not an effective strategy for improving health outcomes through preventive screening, said Neil Bell, a University of Alberta family physician and a former member of the Canadian Task Force on Preventive Health Care.
The task force-a group of Canadian physicians and medical and prevention experts tasked by the federal government to develop clinical practice guidelines for primary care practitioners-published an article yesterday in Canadian Family Physician calling for an end to the practice.
In its place, they are recommending the adoption of age-specific periodic health checks that emphasize the identification and early management of potentially preventable conditions.
Physicians across Canada have been debating the traditional annual physical exam for decades, explained Bell.
"Evidence from several trials suggests the annual physical examination is not a very effective strategy for providing preventive health care, and that periodic health visits occurring at intervals that depend on the patient's age, sex and individual health conditions would be more appropriate," he said.
For example, recommendations from the Canadian Task Force on Preventive Health Care on screening for breast cancer with mammography or cervical cancer with pap smears occur at intervals longer than one year.
"Screening for these conditions is more appropriately undertaken through periodic health visits with intervals that would change based on the needs of the patient."
Bell added that people need to be aware that more frequent screening does not necessarily result in better outcomes.
He said screening also has the potential to create harms for patients through false positive tests or overdiagnosis.
"False positive tests can result in the need for further investigation, cause patients anxiety and stress and may restrict participation in certain activities."
He noted that overdiagnosis (detection of a condition or abnormality that would not have caused symptoms or death and would have remained undetected if screening were not performed) can result in patients undergoing further investigation or treatment from which they receive no benefit.
"Many physicians and patients are unaware of the potential for overdiagnosis. In most screening circumstances patients and physicians should undertake shared decision-making that considers patients' preferences and values, and the potential for benefits and harms."
Better communication needed
After reviewing existing literature, including a 2012 Cochrane systematic review of 14 trials, the task force couldn't find a study that clearly showed annual non-specific checks on patients reduced mortality rates, said Bell.
He added that while there's a long-standing belief that early detection results in better outcomes, the potential for overdiagnosis means this is not always the case.
One of the other challenges in communicating the potential harms and benefits of screening to patients is how they're communicated, he added.
"Often the benefit is presented as a per cent improvement without any baseline risk. For example, the relative benefit of screening for lung cancer in high-risk patients with a low dose CT scan was reported as a 20 per cent reduction in lung cancer mortality. That seems like a big number," said Bell.
"If we present the information in a more appropriate format, we find the mortality in unscreened patients was 21 per 1,000, and in screened patients 18 per 1,000. That's an absolute risk reduction of three per 1,000 patients (0.3%). This presents patients with a more accurate picture of what could happen with screening."
The task force did find evidence, however, that personalized health interventions-assessing a patient by age and risk factors when needed rather than annually-reduced mortality in people over age 65 by 17 per cent. "That's after a meta-analysis of 19 trials," pointed out Bell.
The way forward
It's up to individual physicians to change their practice approach, said Bell. But the goal is to transform the varying application of universal annual visits across provinces to periodic visits for prevention activities across Canada-for example, women over 50 discussing the need for a mammogram to screen for breast cancer, or men over 65 discussing screening for abdominal aortic aneurysm.
"Empowered patients can make these appointments themselves. Or primary care offices can create a system that reminds patients based on their age and risk concerns," said Bell.
The task force also suggested having prevention facilitators, such as nurses and nurse practitioners in primary care offices, conducting prevention interventions, as well as web-based wellness portals to engage patients in preventive services.
The bottom line is that patients should visit primary care physicians when they are ill, managing chronic conditions or engaging in age-appropriate prevention activities, and should be involved in shared decision-making about whether screening is desired, said Bell.
"But visiting (doctors) annually for no good reason actually ties up an already limited supply of family doctors."