We are responding to a recent public statement in which, as part of Heart Valve Awareness Week—September 16-22—a cardiologist colleague and a cardiac surgeon colleague recommended annual cardiac auscultation for all patients, regardless of age, and encouraged family physicians to develop this reflex during each visit. This recommendation seems to us not only ill-advised, but also contrary to evidence-based practices.
Since 1979, the Canadian Task Force on Preventive Health Care has recommended against routine annual examinations. This position is widely supported by the medical literature, which demonstrates that well-child visits do not provide benefits for most patients. Before recommending a practice in asymptomatic patients, it is essential to clearly demonstrate the benefits associated with this practice, and this, before encouraging it, which was not done here.
We have several concerns related to the recommendation of annual auscultation for all.
First, the recommendation issued is not rigorously supported by scientific data. In fact, there is no data demonstrating that annual auscultation in asymptomatic patients reduces mortality or improves quality of life. In addition, multiple articles exist that testify to the uselessness of an annual appointment with the doctor. Issuing the recommendation to be screened by auscultation annually without studies indicating benefits is contrary to the scientific approach.
Furthermore, this recommendation does not take into account the use of resources. The system is already struggling to provide care to patients who have symptoms and are sick, who have difficulty accessing care. We are very concerned about the impacts that could result from these recommendations, when there is no evidence of benefit. Before offering a test to someone who is healthy (without symptoms or asymptomatic), we must be certain that we are doing more good than harm.
We are also concerned about the presence of conflicts of interest: the awareness day to which our colleagues refer is supported and promoted by the organization Une voix aux maladies valvulaires, an organization funded by companies that produce valve replacement equipment. One can only wonder about the financial interest of the companies that support this campaign and this call for screening that is not recommended by other bodies.
Finally, the risks of such a recommendation are completely hidden. However, there are many negative effects documented in screening contexts: false alarms, overdiagnosis (finding anomalies that would not have had any consequences on the health of patients). A call for screening must be made by transparently establishing the balance between the benefits and potential harms.
To illustrate how implementing this measure could harm access to care (without any positive impact), let’s estimate the time it would take for Quebec family doctors to apply the recommendation to screen everyone once a year. Let’s conservatively estimate that this would concern 75% of the population and that the auscultation would only take one minute per patient. Remembering that there are 8.5 million Quebecers, we can predict that this would take 106,250 medical hours annually. Assuming a 45-hour week and 48 weeks worked per year, this represents nearly 50 family doctors performing this task full-time, to auscultate asymptomatic patients. These are hours that could most certainly be better used to benefit the health of the population.
Not only is the recommendation to perform annual auscultation in asymptomatic patients disconnected from clinical realities, it also goes against evidence-based best practices. Family physicians, in whom we have every confidence, are perfectly capable of determining when auscultation is necessary and appropriate, particularly when patients present with symptoms. No one questions the usefulness of conducting a careful assessment in this context and of being on the lookout for atypical presentations of valvular disease.
As colleagues expressed in a text published in Canadian Family Physician (free translation): “In an era where medical resources are limited and healthcare professionals struggle to integrate all the “good ideas” into their practice, it is essential to stay focused on the priorities that have a real impact on patient health.”
If you don’t have any symptoms, there’s no need to rush to the doctor. Conversely, if you have new symptoms, we recommend that you consult a healthcare professional. They can help you determine what is helpful based on your personal situation.
* Co-signed this letter: Geneviève Bois, family physician, president of the Collège québécois des médecins de famille; Emma Glaser, family physician; Isabelle Hébert, family physician; Frédéric Picotte, family physician; Caroline Laberge, family physician; Samuel Boudreault, family physician; Julie Laurence, specialized nurse practitioner; Guylène Thériault, family physician; Isabelle Leblanc, family physician; Sylvain Blanchet, family physician.