The Case FOR the Annual Check-Up

Blink and it will be gone. Make no mistake about it: the “Annual Check-up,“ once the pillar of our preventative health care system, is on the verge of becoming obsolete – or `medically “insignificant“.

Already, the Annual Health Exam has been de-listed in several provinces:
British Columbia, Nova Scotia, New Brunswick, and Newfoundland and Labrador no longer cover annual physicals in patients without symptoms of illness. Ontario offers “personalized health reviews” in which the doctor focuses on the health risks specific to the patient and the patient’s age.
If you live in Alberta, Manitoba, Saskatchewan, Quebec, Prince Edward Island, and the Northwest Territories – appreciate the Check-up while it lasts.
Calls to eliminate the annual physical examination are not new. In 1979, the Canadian Task Force on the Periodic Health Examination recommended “that the annual checkup, as practiced almost ritualistically for several decades in North America, be abandoned.”
In 2013, the Choosing Wisely campaign (see poster below) recommended against annual preventive examinations in asymptomatic patients.
Despite these calls, many people still want an annual physical. Not surprisingly, surveys show that the majority of both patients and physicians remain strong proponents of the annual check-up.
Ironically, while experts are divided on whether there is a benefit to getting an annual exam, the federal Affordable Care Act (ie. Obamacare in the United States) requires insurers to cover annual physicals free of charge.
So, what exactly is the controversy? Simply, some research has demonstrated that regular physicals do not reduce rates of illness or mortality. At best, the researchers suggest that these exams are an egregious waste of health-care resources, and at worse, they are dangerous by promoting “superfluous,“ expensive testing.
The research most frequently cited against the annual physical is a 2012 analysis of 16 trials by the Cochrane Collaboration. This study concluded that “physicals“ do not reduce mortality or illness. Critics point out that the trials excluded elderly patients and were predominantly performed in Europe, where most patients were already regularly seeing doctors. In other words, do these results really reflect our reality in Canada?
In more detail, the Cochrane review included 16 trials and 182,880 participants. While the authors concluded that they did not find an effect on clinical events or other measures of morbidity, one trial found an increased occurrence of hypertension and hypercholesterolemia with screening and another trial found an increased occurrence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. Two trials found an increased number of people using antihypertensive drugs, and another two trials found small beneficial effects on self-reported health. The authors also comment, “we did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied.“ Of note, two additional studies were excluded from the analysis.
In the end, the author`s concluded, “General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.“
Why did the author`s conclude that the General Health Check, or Annual Check-up, were “unlikely to be beneficial?“
The authors suggest:
1. “One reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.
2. Also, those at high risk of developing disease may not attend general health checks when invited.
3. Most of the trials were old, which makes the results less applicable to today’s settings because the treatments used for conditions and risk factors have changed.“

I have included a few clippings from news organizations on this heated topic (see below). But I was amused by the “observations“ of the following physician to the Wall Street Journal article:
Observations as a physician:
1. Nothing ultimately improves mortality since everybody dies. Unfortunate fact overlooked in medical trials.
2. Ironic that presumed liberals (Ivy League affiliated) want universal healthcare but don’t want patients to be seen.
3. If they don’t come in yearly, how else will I be able to nag them every year to quit smoking and tell them that they’re too fat?
4. Hypertension: the “silent” killer because often there are no symptoms until a stroke or heart attack. But don’t see me unless you have symptoms.

In the end, I am reminded of Malcolm Gladwell`s brilliant bestseller “Blink.“ Sometimes we simply overthink the obvious. We become all-consumed with the analysis that we ignore the simplicity in front of us. Annual check-ups, like everything, need to evolve. Preventative medicine should be personalized – but it needs to be planned. Air Canada (hopefully) does not wait for the airplane to make funny noises before checking it out. Routine maintenance is neither a luxury nor superfluous – it is common sense.
We cannot and should not base care or conclusions on old studies that are “less applicable to today`s settings.“ We should make recommendations on well-designed, up-to-date studies that reflect our current health care needs.
Why do the majority of patients and physicians remain strong proponents of the annual check-up? Because it feels right. All the analysis to devalue the annual check-up simply cannot compete with the primal benefit of nurturing a meaningful, trusting, patient-physician relationship. For my part, I certainly hope the annual check-up lives on.

Bill 20

OPEN LETTER TO MR. DAVID BIRNBAUM, MNA DARCY MCGEE

Bill 20 – will adversely affect Cote Saint Luc’s only GMF Clinic

Dear Mr. Birnbaum,

As the Medical Director of Cote Saint Luc’s only GMF clinic, I must express my concerns regarding the proposed Bill 20.

GMF Sante Kildare serves almost 20 000 registered patients in our community.  We are a group of 25 family physicians – offering medical services 365 days per year, including evenings, weekends and holidays.

We have an open, daily walk-in clinic for any patient (even “orphaned persons”).  We provide services to local Foster Homes, collaborate with McGill, coordinate with CSSS Cavendish, conduct research studies – all in an effort to provide the best, comprehensive and timely care to all persons.

We started with two physicians in October 2011 – and now pride ourselves on exceptional growth with a stellar and superb team of 25 committed doctors, nurses, and other health care professionals.

Of the 17 family doctors based at my location, 14 are female.  In fact, most are young doctors who recently completed their Family Medicine Residencies.  They were attracted to Sante Kildare for many reasons: our inclusive philosophy, teamwork, supportive network, flexibility and GMF status.

And this is my point – GMF works.  The incentives offered by previous Ministers of Health were working.  We actively remove orphaned patients from the CLSC Guichet list.  We keep doctors in our territory.  We offer extended hours.  We keep patients out of the ERs.  We cover young female doctors during maternity leaves.  We cover patient practices when doctors are away fulfilling their AMPs.

Group GMF coverage is the only solution.  80% of Family Medicine graduates are female!  While I personally work 70 hours each week, most doctors don’t.  It is ridiculous, unrealistic and unreasonable to demand young, female doctors to work 36+ hours/week.  They have made sacrifices to continue schooling to serve and heal others.  They should not be penalized for striving to balance home and work.

But this Bill punishes everyone.  Why should I be fined (or docked pay) if my patient sees another physician – even if I am open and available?  If you live in Quebec City and your family doctor works in Cote Saint Luc, should he/she be penalized if you seek urgent or semi-urgent attention locally?  What if someone lives in Dollard and works downtown?  What about chest pain at 3 am?  In all scenerios, it’s the family doctor who pays.

I care about quality.  I book 30 minutes per physical.  The RAMQ agrees that a check-up requires more time.  Am I to work 15 hours each day to meet the Minister’s quota of 30 patients?
Should I tell patients to book multiple appointments to “get through their list of problems?”

We need a system that rewards productivity – not a plan that punishes.  We need a Bill that recognizes the reality of our workforce – not an outdated, punitive vision that frowns upon families.  We need an open dialogue – not a demagogue.  Quality and commitment should be recognized and embraced – not attacked.  The family physician is the backbone of the health care system – the quarterback – the human face.  We only succeed by developing and nurturing the doctor-patient relationship – not timing it.

Family Medicine is not radiology.  We see patients – not their films.  We talk to patients – teach, advise, advocate, heal.

Please, please, please.  I urge you to visit our clinic and see how this Bill will devastate us.

Leadership should not be achieved through bullying.  We desperately need collaboration, discussion, vision.

Thank you.

Dr. Michael Kalin

VACCIN CONTRE LA GRIPPE
& FluMist

Sans rendez-vous.

Disponible à partir du: dimanche 2 novembre

Dimanche 8 h – 12 h

lundi au vendredi: 8 h – 12 h et de 15 h – 19 h

Le Vaccin est gratuit pour tout ceux qui répondent aux critères

Sante Kildare Green Thumb

Seems simple enough.  We have lots of talented, educated, successful professionals at Sante Kildare.  Surely, one of the doctors or nurses can nurture and sustain an office plant – after all, we treat acute and chronic illnesses all day.
Our challenge – to maintain an office plant for a month (or beyond)
The subject – The African Violet
According to Canadian Gardening, “the African violet may just be the perfect houseplant.  It blooms readily and has no specific flowering season, so it can be in bloom year-round. And it’s easy to multiply and share with others. As a result, it’s found worldwide, from the Far North to the Antarctic, anywhere there’s a cozy windowsill for it to grow on.”

To help us succeed, we have selected a plant that “can also cope with less light than most other flowering plants.”  Apparently, we should look for a spot that gets bright light most of the day with little full sun in the afternoon.
Here comes to tricky part: According to the Canadian Gardening website, we need to “ let the plant tell [us] what it needs: long, stretching petioles and leaves that bend toward the sun, or lack of bloom

indicate insufficient light, while dense, compact, hard growth with bleached-out leaves tells you the plant is getting too much light.”  Yikes – medicine already seems simpler.
We should “keep the growing mix (peat-based houseplant mix is fine) slightly moist; wait until it feels dry, then water abundantly, drenching it. Wet leaves can result in leaf spot, so it’s best to water from below by pouring tepid water into the plant’s saucer and letting it soak up what it needs. After 20 to 30 minutes, drain any surplus.”
Finally, we should “fertilize” the young plant with a foliage-plant fertilizer rich in nitrogen.”
I wonder if pharmaceuticals will help!  Maybe a little Cialis or testosterone?