“Hey doc, why aren’t we doing physicals any more?”

It’s a conversation we’ve all had with our patients. That difficult discussion where we explain why they don’t need annual physicals any more.

The patient’s initial reaction usually involves questioning why they aren’t getting the same level of care they are accustomed to. Will their health be compromised? How we deal with this complex discussion will resonate for years in the patients’ eyes, and will impact the trust they have in their physician.

We need to be quite familiar with the evidence that does not support annual physicals, and reassure patients that this has been studied at length.

Choosing Wisely has put together a very useful page for patients explaining a lot of the concepts that we want to communicate to patients around the topic of annual health exams. (Here’s the Choosing Wisely page for all of the patient pamphlets that Choosing Wisely provides, it’s quite a good collection.

Make it crystal clear to patients that even though they may not be having physicals any more, that all aspects of their care are still being monitored. When they come in for another issue, be vocal that you are simultaneously re-assessing their cancer screening, whether they need bloodwork done, reviewing their immunizations, addressing their risk factors, and evaluating whether you would make any general health recommendations or order any tests. Tell them that with our EMRs, this process is taking place in real-time, not just once a year like it was in the pre-EMR age.

If a patient doesn’t come regularly for other reasons, you may consider bringing them in every year or two, for what is sometimes being called a Periodic Health Examination. Patients should understand that this isn’t a physical, and for them not to be concerned when you aren’t listening to their heart or lungs, or looking in their ears. The purpose of this visit is to review their history including immunizations, family history, and social history, make sure screening is up to date, check a blood pressure, get a weight, and take care of other health-related measures that are appropriate for their demographic.

Bottom line: don’t quickly gloss over the fact that patients aren’t receiving physicals any more. This needs to be carefully explained to them, and physicians should also educate their staff to communicate the message equally clearly, not framing it as a potential decline in care, but rather an evidence-based change in how care is delivered.

(As an aside, I think it’s time that the “Annual Physical”, billed in Ontario as an A003, is completely de-listed as an OHIP service. Patients can still request their physical, and we can go through the motions of doing a physical exam on them, but it’s completely out of pocket and billed at OMA rates. And make it quite clear that the Periodic Health Examination is not a physical, but rather a comprehensive health review, ideally with this messaging coming centrally through provincial advertisements.)

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