As a family doctor, I sometimes wonder if I provide too much care for some patients in my practice. Do my elderly patients with diabetes need very low A1Cs? What about the risk of falls and fractured hips due to hypoglycemia associated with enthusiastic use of diabetic medications? Should patients over the age of 90 really be on a statin? Should they be on anything that does not improve their quality of life? Perhaps I should be asking them what they would like?
I have been a member of a Practice Based Small Group since 1995; we are a group of community based family physicians who get together once a month for cookies and medical education. We review evidence based modules, discuss the cases provided, and complain about our local health care system. A recurring item in our Small Group is the fact that I have been gradually giving up many parts of the Annual Check up: I don’t do routine urine samples, I don’t do screening rectal exams, I no longer do screening pelvic exams. This provides an ongoing source of amusement for my colleagues, and even led to a CMAJ article entitled “Let’s leave the shorts on, shall we?”
I must admit, however, that I was really struck by how difficult studying and discussing overprovision of care can be while attending this year’s NAPCRG conference. I saw Dr LeFevre’s keynote presentation, “postcards from the edge”. Dr LeFevre was the Chair of the US Preventive Services Task Force (USPSTF). In 2009, the Task Force recommended against routine screening mammograms for women age 40 to 49. The American College of Radiology then issued a position statement entitled “USPSTF Mammography recommendations will result in countless unnecessary breast cancer deaths each year”. Rep Schultz (D-Florida) stated: “We know there are women that will die if this recommendation goes through”. The US congress passed legislation to override the USPSTF recommendation.
At which point in time should we stop and think, “will my patient really benefit from this test, this procedure, this drug”? To what degree should politics, profit or advocacy trump science? Have we sometimes forgotten what we pledged to do when we embarked on health care as a profession: First, do no harm?
Would you do this if it was you, Doctor?
The 43rd North American Primary Care Research Group (NAPCRG) Annual Meeting ran from October 24-28, 2015, in Mexico. Dr Greiver was a speaker at the conference. CMAJ was one of the sponsors of the meeting.