What happened to my annual physical?

Most people are still used to getting an annual physical exam by their doctor.  In fact, some people think that their doctor is lazy, negligent or just not a very good doctor if they don't get examined.  

There are many instances where the physical exam is absolutely essential.  If you complain to your doctor you were exerting yourself and you fainted, you can bet they will listen to your heart and with good reason!

Right now we are talking about annual physical exams in people without symptoms.  You come in to your doctor's office and you are ready for your annual physical.  Your doctor or nurse takes your blood pressure, does your height and weight, gives you a vaccination, reviews your cholesterol, asks how you are feeling.  You feel ok, no symptoms other than this mole on your arm, your doctor looks and says no need to biopsy because it is benign but you do need to be using sunscreen.  He says you are doing well other than you can reduce your cardiac risk by losing a couple pounds and he makes some diet and activity recommendations.  "See you in two years."

"Wait a sec, this is my annual physical, aren't you going to listen to my heart and my lungs, test my reflexes"?

Well no actually.  Many smart people over the years looked at this question and continue to look at questions regarding ordering tests in people without symptoms.  A physical exam is a test.  If we are going to order a test, there should be a reasonable chance we will find something that we are going to do something about.  It should be more good than harm.  And in Canada, it should be a good use of taxpayer money because there are a finite number of dollars for healthcare.  If we do lots of things that give no benefit, there is less money for the things that really help people.  It is often a lot easier to see the things with benefit when the money isn't there to pay for them than count up all the wasted money on investigations with little to no value.  

The latest research on periodic health exams, because that is what we call them these days, is that they don't need to be annual and they don't need to be physical.   They should have a point; they should make you live longer or better.  They should be to find something early like cancer or diabetes or high blood pressure when you can't feel anything wrong, before your health starts failing and it is too late to turn it around.  

In general, screening physical exams where doctors listen to your lungs and test your reflexes and all that just don't make the cut when it comes to providing much benefit to you.  It may make you feel cared for by your doctor and I think part of the doctor patient relationship is strengthened by the physical exam. Good old days, Norman Rockwell, whatever.  That doesn't mean we should do things that don't have evidence to say they help you.   

Think about it this way.  If your doctor is paid to do things that are or quite possibly could be useless, is this a good thing?  Obviously no.  This means that the money isn't being spent on something useful and furthermore, doctors themselves are finite and so is the amount of hours in a day.  Doctors are expensive to train.  Med schools are subsidized by government.  In our community there are many people without family doctors and that really sucks because they pay taxes like everyone else. 

If doctors did less things that were of dubious value, they could ideally have more time and could take on and care for a few more patients.  If you are a patient without a family doctor then this might make the difference between having a doctor and not.  

There is also a more subtle aspect to physical exams in people without symptoms and that is a false sense of security.  If you are overweight, you smoke, you drink too much and you don't exercise, your doctor could do a physical exam and find nothing "wrong" with you.  That is a problem because now you think that your doctor just examined you and despite all the things he told you not to do and all those unhealthy habits, you are no worse for wear, you think.  Well you certainly are worse. Certain things are just hard to measure until they are really bad and to balance the risk of the test we often need a reason to do it (chest pain).   You would be better served if that extra time was spent educating and counselling you on strategies for quitting smoking for example.

In this clinic we try our best to focus on things that make you live longer or feel/live better while eliminating all the other stuff, but no one is perfect.  The evidence isn't perfect.  The evidence changes.  The best we can do is keep learning and stay up to date and do the best for our patients.  This is the long answer for why I don't listen to your lungs every year.

-Brad White

How your taxes pay for your healthcare in Ontario

This is a very very complex topic and certainly too complex to explain all the details.  However, if you live in Ontario, pay taxes, vote, and see a doctor, you may want to know how the system works.  It isn't perfect but many smart people between physicians and government officials are constantly trying to make it better at the provincial level.

The two most common ways for family doctors to get paid are fee for service (FFS) and capitation.

Fee for service is exactly what it sounds like.  Your doctor does a specific thing like see your for your chest pain, orders lab work, and writes a referral letter to a cardiologist. Your doctors gets a single fee for that visit.  Your doctor would probably bill an "intermediate assessment A007" to your "health insurance company", which in our case is the Ontario Health Insurance Plan (OHIP).  If your doctor sees you for 3 other things and you spend four times as much time in the office, he or she gets paid for the first thing and the rest are free.  

This is one of the reasons you doctor might want to limit the number of issues discussed.  If you worked 10 hours per day and only got paid for 5 of them, it would make you sad.  This is one of the big limitations of the FFS system.  Most patients have lots of things they want to talk about so the patient's interest and their doctor's interest don't always align exactly. 

The other big model used in Ontario is capitation.  This is where doctors are paid a set fee based on your age to be your doctor.  If they see you one time in a year or 20 times, they get paid the same amount of money.  The idea was that it created an incentive for your doctor to keep you healthy and to not generate extra visits for things that are not needed.  The fee is of course set by the Ministry of Health like all fees doctors charge.  The limitation of this model is that doctors can sometimes take on more patients than they can comfortably see to increase their income, or they have a full practice that simply gets older, sicker and more time consuming, or the doctor has a baby and doesn't get any maternity leave but cuts back her hours to care for her child etc. The end result it that it can take a really long time to see your family doctor and that isn't cool.  

One of the consequences of having to wait weeks to see your family doctor is that patients start going to walk-in clinics for their care.   Walk in clinics are good for quick issues but not very good at managing or investigating things over time.  You may see a different doctor each time you go who may not have access to your previous records.  

One of the ways that the Ministry tries to keep doctors in check regarding the size of their practice and their availability is by tying some of that capitation funding to your doctor's availability.  What this means is that if you have to wait three weeks to see your family doctor, you might instead decide go to a walk in clinic.  The walk-in doctor gets paid from the ministry to see you and that amount is clawed back from your family doctor as part of that yearly amount of "capitation" funding he got.  The math and calculations are considerably more complicated since doctors who work in capitation models often work in groups and are penalized as a group but the general idea is what is stated above.  

Often family doctors will have a blend of fee-for-service and capitation depending what types of services they offer.  

So where does this money go?

Well it goes to your doctor who then pays expenses.  For example, our clinic employees three staff in addition to your doctor.  The billings that come in are use to pay the salaries of the other staff in the clinic, pay the rent, pay for the electronic medical record software, purchase and maintain the computers, buy the autoclave to sterilize the equipment used to biopsy that worrying lesion on your back etc.  The ministry of health doesn't pay for any of these things directly.  This is why as doctors we sometimes get upset when the government publishes how much we make.  There is no context.  In addition, if one doctor works twice as many hours and does twice as many services, they bill twice as much in a fee for service system.  Is that a bad thing?  That doctor doesn't really "cost the healthcare system" double.  The healthcare system gets the equivalent of two full time doctors.

We get paid well for the responsibility and training that it takes to be a doctor but that number you read in the paper has to pay for multiple employees, insurance, rent and equipment so it is a tricky number to interpret on its own.  Honda charges me 100 dollars per hour for labor on my Civic.  The mechanic doesn't get paid 100 dollars per hour.  That money runs the whole maintenance department.  Most people know that but if they don't know how their doctor gets paid it is hard to be an informed taxpayer.  

Ultimately it is up to you as a voting taxpayer to determine if you are getting good value for your money when it comes to healthcare.  You will hear one thing from doctors and another from the government.  The truth is often hard to determine.  There has been a fairly bitter battle between doctors and government over the past year.  It is getting worse and starting to spill over into the media.  You will hear things and read things that might make you outraged.  

There are only so many tax dollars to pay your doctor, get the mail delivered on time or teach your child math and there will always be a public battle for public funds.  

Be critical of any statement that seems outrageous,  no matter which side it comes from. Read, become informed, ask questions and demand long answers because the truth is complicated. Your opinion and favor will be courted by doctors and by your government in soundbites meant to scare you; meant to make you angry.  Don't let that happen.  Let it be a starting point to becoming an informed taxpayer.  

-Brad White

How to get the most out of your visit

Here are some tips for making the most of the visit to make sure to get your issues addressed.

1 - Stay focused

Unfortunately there is only so much time for the visit, so make the most of that time.  It is nice to be friendly and develop a rapport with your doctor especially if you are both new to each other.  However, staying focused allows you to get more things addressed at a visit and also keeps wait times for other patients at a minimum.  

2- Have an agenda and disclose it at the beginning of the visit.

You may have multiple things that you want addressed at the visit.   If 15 minutes are spent talking about one or two things and your doctor is ready to leave and see the next patient, springing additional issues at that time isn't fair to the patients who are waiting to be seen.  A better plan would be to start the visit by going through all the issues that are important to you and then you and your doctor can plan which are the most important issues that need attention today and deal with those.  

3 - Always bring your medications with you.

In an ideal world, your medical record would have all of the medications that you are currently taking, no medications that you stopped on your own because it wasn't working or the side effects were terrible, all the medications from the specialists that you have seen as well as exactly when you are going to run out of all of your meds.  We try very hard to make this happen. 

Unfortunately the reality is that medication lists, despite our best efforts, are not up to date and this can be hazardous to your health.  The more doctors that you see and the more medications you have, the more important it is to bring in your actual medication bottles.   Also if your doctor tells you that you should stop a certain medication, he definitely does not know whether it is the little white round one or the little beige round one.  By bringing in your meds you are your doctor can more easily talk about each of your medications.  

-Brad White