Hi, everyone. I’m Dr Kenny Lin. I am a family physician at Georgetown University Medical Center, and I blog at Common Sense Family Doctor.
2020 was a very tough year for primary care clinicians, even when we weren’t regularly treating patients with COVID-19. Last spring, the number of preventive services provided at community health centers — well-child visits, Pap smears, A1c tests for patients with diabetes, and screening mammograms — fell by one half to two thirds compared with the previous year and had not returned to their usual levels by the end of the summer. Although in some cases telehealth can replace in-person visits, a retrospective analysis posted online ahead of print by the American Academy of Family Physicians’ Robert Graham Center suggested that two thirds of typical primary care visits require at least one in-person service, such as an immunization or blood draw.
Pandemic-related declines in well-child visits and adult physical examinations not only had negative financial effects on primary care practices, but also raised fears that delayed cancer diagnoses would lead to thousands of preventable deaths in children (O’Neill A and colleagues; Ding Y and colleagues) and in adults (Sharpless NE; Maringe C and colleagues). As a result, even though daily death and hospitalization rates from COVID-19 are exceeding the peaks from last spring and summer, hospitals and medical practices have been strongly encouraging patients not to defer routine care.
Medical offices are generally safer for patients now than they were during the first few months of the pandemic, when infectious disease protocols were not well established, and in many places surgical masks and other PPE were in short supply. But we do patients a disservice by pretending that primary care can or should return to “business as usual.” Preventive services, by definition, are offered to persons without symptoms of the diseases we are trying to prevent, and false-positive test results can lead to harmful diagnostic cascades. For example, one study found that nearly 1 in 5 seniors who underwent a Medicare annual wellness visit in 2014 received at least one nonrecommended test (eg, electrocardiography, urinalysis, thyroid-stimulating hormone), and many of these “low value” tests led to further tests that required additional in-person encounters.
Even for recommended screenings, overall benefits may only exceed harms by a small margin (Ropeik D; Carr T). Compared with management of acute symptoms or chronic conditions, cancer screening does not help most patients; the best evidence indicates that one needs to screen approximately 1000 patients to avoid one death from breast, colorectal, or prostate cancer.
Last summer, current and former members of the Canadian Task Force on Preventive Health Care argued that the increased infection risk associated with an in-person healthcare visit during the pandemic should cause us to consider extending recommended screening intervals and permanently abandon the evidence-free tradition of performing annual or periodic physical examinations on adults without a specific indication. I wholeheartedly agree!
The development of effective coronavirus vaccines has raised hopes that disruptions to primary care will only persist until enough people have been immunized to make it safe to fill up our waiting rooms again. That prediction may turn out to be true, but it would be a shame to miss this once-in-a-lifetime opportunity to reassess the value of routine medical services.
Sorenson and colleagues have suggested that health professional organizations develop “do not restart” lists for their members on pandemic-deferred services that are wasteful or likely to do more harm than good; the American Board of Internal Medicine’s Choosing Wisely campaign is a good place to begin. I propose that family medicine’s “do not restart” list include not only outdated tests but office processes, too, including the aforementioned waiting room. As is routine in many restaurants and hair salons, patients could wait outside or in their vehicles and receive a text message when it’s time for them to be seen, limiting exposure to other potentially ill persons and allowing the practice to use the no-longer-needed waiting space for another purpose.
Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician.
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