Twelve years after Marc Lalonde’s cornerstone report was released (Lalonde, 1974), the Ottawa Charter for Health Promotion reiterated the importance of the health care system as a determinant of the health of populations (World Health Organisation, 1986). Since physician services were the only “medically required” services insured under the Canada Health Act, family physicians became the natural target of Public Health efforts to integrate health promotion and disease prevention into the Canadian system of health care delivery. As a result, strategies to influence the preventive practices of family physicians became a research priority: family physicians were to be informed, convinced, trained, and organized to integrate prevention into their practices.

Canada was to become a leader in this area; as early as 1976 it commissioned a task force to the Conference of Deputy Ministers of Health “to consider evidence for the benefit of early detection or prevention of killing and disabling conditions … in non-complainant individuals. …[and] To make recommendations on the procedure, content, frequency and appropriate provider of periodic examinations and preventive interventions at defined ages and for defined population groups” (Health and Welfare Canada, 1980). This task force was to become the Canadian Task Force on the Periodic Health Examination (CTFPHE), and its first report was the first explicit attempt at producing an “evidence-based clinical practice guideline” (the expression had not yet become a stock phrase).

As a young, newly certified family physician, I had the privilege of taking part in this fascinating endeavour, first as an epidemiology student at McGill University under the direction of Task Force President Walter O. Spitzer, and later as a member of the CTFPHE for ten years. Thus, it was with enthusiasm that I accepted the JASP symposium invitation to participate in this reflection 20 years later on the effectiveness of the contribution of Public Health to the efforts to “reorient health services,” one of the six action measures identified in 1986 in the Ottawa Charter for Health Promotion. In what follows, I will first try to sketch a portrait of the evolution of the preventive practices of Canadian family physicians in the last twenty years, discussing health promotion and disease prevention practices as well as the evolution of the attitudes of physicians and patients towards preventive services. I will conclude by discussing some of the challenges and opportunities facing us, as I see them.

The evolution of family physicians’ preventive practices:   where we are now

Prevention and early detection

In 1981, almost two years after the publication of the first CTFPHE report, Battista conducted a survey of the adult cancer prevention practices of general practitioners in the provinces of Québec and New Brunswick, one of the first attempts to portray the situation following the release of the report (Battista, 1983). Although more that 90% reported they performed annual breast examinations (probably an overstatement), Pap smears and anti-smoking counseling, only 8% said they recommended annual mammography (which was recommended for inclusion in the periodic health examination of all women aged between 50 and 69 years), and 77% reported ordering an annual chest X-ray for smokers (a test that the CTFPHE recommended be excluded).

Unfortunately, there have not been longitudinal studies that permit to follow the evolution of family physicians’ preventive practices over time in Canada. I propose to sketch an impressionist picture of this evolution by looking at the practices observed in studies undertaken at different periods in time to ascertain and improve the preventive practices of family physicians. I purposefully chose studies that used observed rather than self-reported measures in their assessment of practices (Borgiel et al. 1985; Battista et al., 1991; Hutchison, Woodward, Norman, Abelson, & Brown, 1998; Beaulieu et al., 2002; Lemelin, Hogg, & Baskerville, 2001). They have in common to be based on samples of physicians in the community who had accepted to participate to an intervention, with the exception of Hutchison study that was only descriptive. Table 1 summarizes the practices observed at baseline in those studies

The progression toward the desired practices can be observed, both for recommended and non-recommended interventions. A ceiling effect is also suggested, particularly for screening mammography. In addition, it can be seen that the recommendation to administer a Diphtheria-Tetanus booster – a classic disease prevention intervention - never made it into the practices of family physicians. These observations are comparable to what has been observed in the US (Luckmann & Melville, 1995; Ewing, Selassie, Lopez, & McCutcheon, 1999; Prochazka, Lundahl, Pearson, Oboler, & Anderson, 2005).

Health promotion and counseling

The progress in health promotion and counseling practices has been more modest (Table 2). Some recommendations have had a better fate than others– namely anti-smoking counseling and exercise counseling- probably because they fit better with the clinical skills of family physicians. Moreover, a classic health promotion tool- the CAGE questionnaire for the identification of “problematic drinking” (Haggerty, 1994)- is not being used routinely by Canadian Family Physicians in Canada. Again, comparable observations have been made in the US (Luckmann & Melville, 1995; Ewing et al., 1999; Prochazka et al., 2005; Wenrich, Paauw, Carline, Curtis, & Ramsey, 1995).

To see this snapshot of the degree to which health counseling has been integrated into practice as a disappointment is to see the glass as half empty. From another perspective, though, the glass is half full. In a study of the audio transcripts of some 145 visits to 35 family physicians in the province of Québec, Beaudoin et al. observed that an average of 3.7 “health related” topics were addressed by the studied physicians (Beaudoin, Lussier, Gagnon, Brouillet, & Lalande, 2001). The most frequently addressed were: weight (72% of visits), nutrition (60%), exercise (56%), and tobacco use (50%). However, the time devoted to these discussions was limited: a mean of 3.7 minutes- about one minute per topic. Beaudoin at al. (2001) reported that female physicians were more likely to get involved in such discussions, as were male patients, patients with cardiovascular risk factors and patients from low socio-economic status. Some studies suggest that family physicians doubt their capacity to act as “health educators” and question the impact of their counseling interventions (Nutting, 1986; Hudon, Beaulieu, & Roberge, 2004). The issue of the time it takes to incorporate health counseling into a consultation is an important one (Stange, Fedirko, Zyzanski, & Jaén, 1994; Stange, Flocke, & Goodwin, 1998).

Getting organized for prevention

It is not within the scope of this discussion to provide a systematic review of the effectiveness of different organizational interventions to improve the integration of preventive practices into medical primary care services. Interventions have evolved from health charts included in patients’ charts, to reminder systems, to practice audits with feedback, and, more recently, to the introduction of a new “professional”: the “prevention facilitator.” This is a variation on the “academic detailer,” someone who can help physicians get organized to incorporate preventive practices into their routines (Hulscher, Wensing, Van Der Weijden, & Grol, 2005). In Canada, Lemelin et al. (2001) recently conducted a study that can be considered a state-of-the-art example of this last approach. In a randomized controlled trial in one hundred primary care settings in Ontario, they showed that this approach was cost-effective (Hogg, Baskerville, & Lemelin, 2005), even if the net impact of the intervention was quite modest: the performance of recommended measures increased from 31.9% to 43.2%, while the performance of non recommended measures decreased from 25.5% to 19.1%, and the proportion of patients reached increased from 57.4% to 62.3%. The intervention itself was intensive: a mean of 33 visits that lasted an average of 1 hour 45 minutes over an 18 month period. Outcomes were measured 9, 15 and 18 months after the intervention.

Physicians’ attitudes towards preventive clinical guidelines

As surprising as it may appear, considering the attachment family physicians have always demonstrated to prevention, the initial report of the CTFPHE in 1980 was not well received by the Canadian medical community. The report was perceived as a disavowal of the then-accepted medical practice of the annual physical examination, completed by a battery of diagnostic tests (Battista, Beaulieu, Feightner, Mann, & Owen, 1984). Indeed, the annual physical is still cherished by general practitioners and by the public in North America as an important preventive strategy (Beaulieu et al., 1999; Prochazka, Lundahl, Pearson, Oboler, & Anderson, 2005; O'Malley & Greenland, 2005). The paradoxical practices of primary care physicians – the prescription of useless batteries of tests to some “worried well patients” and the low uptake of interventions that have been proven to be effective in their population of patients (Santé Québec, 1988; Battista, 1983; Battista, Palmer, Marchand, & Spitzer, 1985; Abelson & Lomas, 1990) – have generated many studies attempting to understand what is going on. Surveys have shown that some recommendations –particularly those stating that screening tests should be excluded from the periodic health examination of non-complainant individuals- are met with disapproval by primary care physicians (Zyzanski et al., 1994; Beaulieu et al., 1999; Prochazka et al., 2005). Physicians perceive a conflict between their role as family physician to “rule out” the presence of disease in any individual who consults them, and the more general screening principle that one must have evidence of benefit on a population level in order to recommend an intervention (Beaulieu et al., 1999). Physicians also identify many obstacles to the integration of prevention and health promotion activities in their practices: patients’ expectations and degree of motivation to change are not always in tune with the recommendations; lack of access to resources, particularly to support lifestyle changes; competing demands within the medical encounter; lack of time and of adequate remuneration (Hudon et al., 2004; Jaén, Stange, & Nutting, 1994; Crabtree et al., 2005). Some even question whether it is their responsibility to get organized and to develop reminder systems to make sure that all eligible patients from their practice receive the recommended preventive manoeuvres (Hudon et al., 2004). It appears that the “annual check-up” –that is a visit planned for preventive purposes and not for follow-up of a specific problem- remains the preferred organisational strategy that family physicians use to integrate preventive care in their practice (Beaulieu et al., 1999; Prochazka et al., 2005). It is probably their way of coping with competing demands.

To conclude this overview of the road traveled since the publication of the first practice guideline on clinical prevention, which preceded the Ottawa Charter by five years and which served as a reference to support the objective of the charter “to reorient health services”, one can say that, by and large, we have made progress. However, studies suggest that a ceiling effect may have been reached and that physicians see a limit to their role in prevention.

Opportunities and challenges

What is my vision of the challenges ahead of us? First, I think that Public Health should accept the “person-oriented” focus of primary care and let go of its desire to turn family physicians into public health practitioners. The first responsibility of family physicians- and of health care providers in general- is to a “population of patients” and not “the” population. The difference may appear to be subtle, but there is one. Second, Public Health should be realistic in its expectations, and provide the necessary resources, particularly where health promotion activities are concerned. It is true that a simple recommendation from the family physician to cease smoking has an effect (Anonymous, 1990). However, the effectiveness of counseling provided during regular consultations on various other issues – exercise, nutrition, stress management- remains to be proven. Recent research confirms that behavioral changes have an impact on health status but that to be effective this counseling must be intensive and delivered by adequately trained practitioners (Elmer & et al, 2006). In its latest updates the US Preventive Services Task Force concluded that there is insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity and healthy nutrition leads to sustained increases in physical activity in unselected adult patients (U.S. Preventive Services Task Force, 2002; U.S. Preventive Services Task Force, 2003). However, it recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease (U.S. Preventive Services Task Force, 2003). As the Canadian health care system is changing to permit access to a variety of health care providers through health care teams, I think that Public Health authorities should stop making family physicians their main target where health promotion is concerned.

Physicians should also agree to change. I see two challenges. First, we should accept that one plus one equals two: we have to see our practice as a population at risk and accept responsibility for the care we provide to this population. Second, we should see our practices as organizations: we must get organized to put prevention into practice (reminder systems; etc) and to interact with the rest of the primary care delivery system.

Finally, I think that neither Public Health nor the Primary Care sector have all the tools necessary to successfully integrate prevention and health promotion clinical practices. We need 1) information systems – Canada is at the Stone Age in this regard; 2) access to expertise in  “micro-management” to support the development of “organized” primary medical care; 3) access to resources, particularly expertise from a variety of health professionals; 4) and access to safer and healthier environments. We should work together to improve the system and meet the objectives of primary care reform. Indeed, the current ongoing reform in Canada is probably the most significant transformation in the last twenty years to attain the objective of the Ottawa Charter, to “reorient health services”. We should take the opportunities it provides us with and hopefully, this will be debated in IUHPE’s 19^th world conference in Vancouver and other appropriate venues.

References

Abelson, J., & Lomas, J. (1990). Do health services organizations and community health centres have higher disease prevention and health promotion levels than fee-for-service practices? Canadian Medical Association Journal, 142, 575-581. URL: http://www.cmaj.ca/content/vol142/issue6/