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CMAJ - July 14, 1998JAMC - le 14 juillet

Applying behaviour theory to the periodic health exam

CMAJ 1998;159:17

In their article "Provision of preventive care to unannounced standardized patients" (CMAJ 1998;158[2]:185-93 [full text / résumé]), Dr. Brian Hutchison and colleagues report that the recommendations of the Canadian Task Force on the Periodic Health Examination have been incompletely integrated into clinical practice. As a primary care physician, I am aware of some of the barriers that might prevent implementation of such guidelines. Prochaska and associates1 have described the stages that people go through to effect a change in their behaviour: pre-contemplation, contemplation, preparation, action and maintenance. Dissemination of guidelines attempts to bring us from pre-contemplation to contemplation by offering evidence and appealing to our intellect. The next step is preparation — thinking about how to integrate this information into practice. This stage seems, at least in the literature, to be divorced from the previous one. Once the decision has been made to implement guidelines, an action plan must be created and followed. Finally, the newly acquired skills must be maintained.

As an example, I recently decided to add visual screening to periodic health examinations of patients over 65 years of age in my office, on the basis of recommendations in the US Guide to Clinical Preventive Services,2 which are based in part on materials prepared for the Canadian task force. After some deliberation, I decided to ask my staff to perform an abbreviated exam using the Snellen chart. They now ask elderly people to read the 20/40 line; if visual acuity is less than 20/40, the patient is informed and is asked to make an appointment with an optometrist.

Making this change in practice involved some planning and work for both me and my staff, since ways to implement the change were not obvious from the recommendations themselves. Perhaps the work of Prochaska and associates could be applied to improve compliance.

To return to the article by Hutchison and colleagues, I note that folic acid supplementation, a grade A recommendation,3 was not included in the manoeuvres for the 28-year-old woman. My patients receive a hand-out on folate along with verbal reinforcement during their periodic health examinations, and these steps are recorded on their cumulative practice profiles. Unfortunately, the cumulative practice profile, produced by the University of Toronto's Family and Community Medicine Information Systems and apparently not updated since 1977, does not have a space to record immunizations or recommended screening manoeuvres. The form should probably be updated to include these components of the periodic health exam.

Michelle Greiver, MD
Willowdale, Ont.


  1. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol 1992;47:1102-14.
  2. Screening for visual impairment. In: US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: Williams & Wilkins; 1996 p. 373-82.
  3. Beaulieu MD, Beagan BL. Primary and secondary prevention of neural tube defects. In: Canadian Task Force on the Periodic Health Examination. The Canadian guide to clinical preventive health care. Ottawa: Health Canada; 1994. p. 74-81.

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