Michelle Greiver is a family physician with the North York Family Health Team in Toronto
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.
I cannot understand why anyone would do Annual Health Exams, even with the American influence so strong here. In the UK, we never started them. Thank God! As we know, there is pretty near zero evidence to support the AHE. The debate on screening pelvic exams was had in the early 90s in the UK when—horror!–it was proposed that RNs start doing PAPs. I recall one study which showed you had to do something like 16,000 exams to pick up one significant asymptomatic gyn lesion. No mention of the false positives and un-necessary investigations generated by routine pelvic exams but I’m sure there were lots.
As for quality vs quantity of life in our seniors, yes indeed, let’s ask them. And let’s show them their Framingham CVD risk assessment so they can make an informed decision.
We are be-devilled here in Canada–where I now live—- with the American ways of doing things. We know that big business influences the American health care system—check some of the rearguard action against stopping prostate cancer screening. And so many good things have come out of American health care. Barbara Starfield, for example, working in Hopkins.
In closing, can I recommend choosing wisely? Wonderful website with loads of information on what works and what doesnt.