UBC Objectives: Women's Health, UBC Objectives: Care of Men, & Priority Topic: Rape/Sexual Assault12/4/2018 By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 2: Apply the same principles of managing sexual assault in the acute setting to other ambulatory settings (i.e. medical assessment, pregnancy prevention, STI screening/treatment/prophylaxis, counselling). Skill: Clinical Reasoning Phase: Treatment Key Feature 3: Limit documentation in sexual assault patients to observations and other necessary medical information (i.e., avoid recording hearsay information). Skill: Clinical Reasoning, Professionalism Phase: History Key Feature 4: In addition to other post-exposure prophylactic measures taken, assess the need for human immunodeficiency virus and hepatitis B prophylaxis in patients who have been sexually assaulted. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 5: Offer counselling to all patients affected by sexual assault, whether they are victims, family members, friends, or partners; do not discount the impact of sexual assault on all of these people. Skill: Clinical Reasoning Phase: Treatment Key Feature 6: Revisit the need for counselling in patients affected by sexual assault. Skill: Clinical Reasoning Phase: Treatment, Follow-up I have yet to encounter a patient disclose to me that they have been sexually assaulted. At least not acutely, as some women have shared with me a a past history of being sexually assaulted. Even then, this has been very few, and never with a man. I imagine this is partly because I do not probe, because as a resident I generally still have fleeting relationships of care. I expect this will change as I build rapport with a panel of patients and develop a zone of comfort where patients may feel more comfortable to disclose these experiences. At this time, it would at best be insensitive and at worst retraumatizing without having a relationship in which I could continue to support the patient physically, mentally, emotionally, and spiritually. When a patient discloses that they have been sexually assaulted, regardless of whether they disclose this in the outpatient setting or in a more urgent care setting, a number of things need to be arranged by the health care provider. First and foremost, patients need a comprehensive medical assessment and thorough documentation including a history and physical examination as indicated. They then may require a series of investigations including STI testing. Possible steps in management include emergency contraception, empiric treatment of STIs, and prophylaxis for possible transmitted infections such as as PEP for HIV or Hepatitis B vaccination and immunoglobulin (if not on PrEP and if not already immunized against Hepatitis B). Some treatment options may only be able to be provided in certain treatment facilities (ex: rapid access to PrEP), and in any case I think it is best to connect with a local sexual assault team for guidance on navigating important steps that must be taken fairly urgently and that may vary on a case-by-vase basis. These teams also provide assistance with forensic examination as may be necessary. Beyond immediate care of the physical state, generally with assessment and management that is fairly time sensitive, a patient must be supported more holistically with counseling and other forms of social support, ideally through longitudinal relationships of care. There are of course many different forms of sexual assault and harassment. It is important not to make assumptions. Even if a patient has not been raped, they may still be suffering undue harm from an encounter that occurred without their consent. Likewise, patients may suffer vicarious harm if they have witnessed or cared for someone who has experienced sexual harassment. Check out one of my absolute favourite videos on consent.
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Breast Lump Key Feature 1a: Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Identify high-risk patients by assessing modifiable and non-modifiable risk factors. Skill: Clinical Reasoning, Selectivity Phase: History, Diagnosis Key Feature 1b: Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Advise regarding screening (mammography, breast self-examination) and its limitations. Skill: Clinical Reasoning, Patient Centered Phase: Treatment Key Feature 1c: Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Advise concerning the woman’s role in preventing or detecting breast disease (breast self-examination, lifestyle changes). Key Feature 2a: Given a woman presenting with a breast lump (i.e., clinical features): Use the history, features of the lump, and the patient’s age to determine (interpret) if aggressive work-up or watchful waiting is indicated. Skill: Selectivity, Clinical Reasoning Phase: Diagnosis, Treatment Key Feature 2b: Given a woman presenting with a breast lump (i.e., clinical features): Ensure adequate support throughout investigation of the breast lump by availability of a contact resource. Skill: Patient Centered, Professionalism Phase: Treatment, Follow-up Key Feature 2c: Given a woman presenting with a breast lump (i.e., clinical features): Use diagnostic tools (ex: needle aspiration, imaging, core biopsy , referral) in an appropriate manner (i.e., avoid over- or under-investigation, misuse) for managing the breast lump. Skill: Clinical Reasoning Phase: Investigation, Treatment Key Feature 3a: In a woman who presents with a malignant breast lump and knows the diagnosis: Recognize and manage immediate and long-term complications of breast cancer. Skill: Clinical Reasoning Phase: Diagnosis, Treatment Key Feature 3b: In a woman who presents with a malignant breast lump and knows the diagnosis: Consider and diagnose metastatic disease in the follow-up care of a breast cancer patient by appropriate history and investigation. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, History Key Feature 3c: In a woman who presents with a malignant breast lump and knows the diagnosis: Appropriately direct (provide a link to) the patient to community resources able to provide adequate support (psychosocial support). Skill: Patient Centered, Clinical Reasoning Phase: Follow-up, Treatment Cancer Key Feature 3: In patients diagnosed with cancer, offer ongoing follow-up and support and remain involved in the treatment plan, in collaboration with the specialist cancer treatment system. (Don’t lose track of your patient during cancer care.) Skill: Patient Centered, Professionalism Phase: Follow-up, Treatment Key Feature 4: In a patient diagnosed with cancer, actively inquire, with compassion and empathy, about the personal and social consequences of the illness (ex: family issues, loss of job), and the patient’s ability to cope with these consequences. Skill: Patient Centered, Communication Phase: History Key Feature 5: In a patient treated for cancer, actively inquire about side effects or expected complications of treatment (ex: diarrhea, feet paresthesias), as the patient may not volunteer this information. Skill: Clinical Reasoning Phase: History, Follow-up Key Feature 6: In patients with a distant history of cancer who present with new symptoms (ex: shortness of breath, neurologic symptoms), include recurrence or metastatic disease in the differential diagnosis. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 7: In a patient diagnosed with cancer, be realistic and honest when discussing prognosis. (Say when you don’t know.) Skill: Communication, Professionalism Phase: Treatment, Follow-up Many women present to clinic with concern about a breast lump, depending on their age and other risk factors, the risk that their lump is breast cancer varies significantly. Risk factors for breast cancer are:
Besides determining whether the patient has risk factors for breast cancer, it is also important to gather information to decide whether the presentation fits a description of how breast cancer may present, or if it presents in keeping with a manifestation of one of a number of benign processes resulting in a breast lump. To do so, it's useful to know if the breast lump presents as part of a cyclic pattern, and if any activities (ex: trauma) or medications have aggravated or alleviated the lump. If the woman has nipple discharge, it is important to characterize this. It's also important to gather a history regarding whether the woman has constitutional symptoms (ex: fever/chills, general malaise, unintentional weight loss). In terms of physical examination, it is important to do a complete breast examination, examining both breasts by inspection and palpation and examining the adjacent lymph nodes. The entirety of the clinical assessment (history and physical examination) inform whether or not and how intense further workup need be, if needed. First line options include mammography and ultrasound +/- needle aspiration. MRI and core needle biopsies tend to be after at least one initial investigation. In a women under the age of 30 years old without increased risk for breast cancer, holding off a mammography and starting with an ultrasound is totally appropriate. Many breast lumps are not breast cancer. In fact, 90% of the time that women between the ages of 20 and 50 years old present with a lump, it is likely to be benign. I remember this statistic to tell women who present to clinic with a breast lump if they are in this age group, because many women are scared, although chances are, everything else being equal, odds are in their favour. I hope this provides some measured reassurance, while still conveying that there is a realistic chance that a lump could, unfortunately, be on the ominous side. The degree of concern I convey about this latter fact is in proportion to my pretest clinical assessment of probability. In any case, I make a point of letting all women know that we won't know for sure what the lump is until we have the results back from the investigations, and I remind them to always return to clinic if they are feeling they could benefit from support in the meantime. Sometimes breast lumps are malignant, although nowadays breast cancer is often treatable for cure depending on the stage at which someone presents. In fact, many women are now living long lives after a diagnosis of breast cancer. However, there are some for whom this is not the case. It is important when delivering a diagnosis of cancer to do so while keeping in mind how to break bad news with honesty and compassion, striking a balance between maintaining realistic hope that is not false. Telling a patient about a new diagnosis of breast (or any other) cancer can cause a lot of harm through loss of hope, and this could even be seen as the first possible negative consequence of being diagnosed with cancer. There are, of course, many other more traditionally thought of complications of cancer that may arise and that we must keep in mind as we care for our patients with breast cancer. Many of these occur as short-term consequences of treatment for cancer, but we now also have to think about the long term concerns, part of the phenomenon of breast cancer survivorship. The table below provides an overview of the short- and long-term complications of breast (and colorectal) cancer, as well as various recommendations for the primary care physician in collaboration with the patient's oncology team. It is important that the primary care provider maintain follow-up with the patient despite them also having other health care providers, including an oncologist who is highly knowledgeable about their disease; much benefit can be provided by constant relationships of care. Included below is a list of supportive resources for patients and their health care providers, considering the many medical and psychosocial considerations that come along with a diagnosis of breast cancer. Apart from the fact that women are living longer and are at greater risk of long-term complications from breast cancer treatment, there's also a higher risk of recurrence and secondary metastasis. Anytime a patient with a history of breast cancer presents with new onset bony pain or neurologic symptoms, consider the possibility of bone or brain metastasis, just like you would consider cancer recurrence or metastasis in any patient with a past history of cancer in general and symptoms that could present accordingly. The list below is not exhaustive for all of the possible complications of breast cancer; different patients may have a very different physical and emotional illness experience and associated repercussions. To be a compassionate and patient-centered holistic primary care provider, it necessitates asking patients how they as individuals are impacted by their diagnosis. Just like side effects of medical therapy, which we too must ask about, not all patients will have the same physical effects and complications that ensue. Breast cancer often presents without the finding of a breast lump. With screening programs, we are able to detect breast cancer at an earlier stage, with improved outcomes for the affected women. Currently, it is recommended that women between the ages of 50 and 74 years old be screened every 2-3 years for breast cancer with mammography. This applies to the general population of asymptomatic women without a breast lump, and without higher risk due to personal history of breast cancer, history of breast cancer in first degree relative, known BRCA1/BRCA2 mutation, or prior chest wall radiation. A handful of years ago, women were also advised to perform breast self-examination to screen for breast cancer, but it was realized that this does more harm than good, as many breast lumps are not breast cancer, and this creates much worry for patients and over-investigation for benign processes. Occasionally women present to clinic for breast cancer screening (without a breast lump) and inquire about breast examination. Screening recommendations always change, and counseling patients about current recommendations for screening based on the most up to date evidence is a continuous process. Although breast self-examination is no longer recommended for early detection of breast cancer, there are things women can do to prevent her risk of getting breast cancer. Namely, these are the lifestyle choices that can modify their risk per the list of risk factors above, some more realistic and logical to strive for than others. The only lifestyle choice I routinely advise patients at average risk (without significant increased baseline risk of breast cancer) to adhere to is moderate alcohol consumption (ideally no greater than 1 drink daily). I also want to make a small plug here about how men can also develop breast cancer. Although this is of course a rare phenomenon, it happens, so any man presenting with gynecomastia or a chest wall mass must also be considered for a work up for possible breast cancer. UpToDate provides an overview algorithm that is useful in working up a concern of gynecomastia/chest wall mass. For any suspicion for breast carcinoma, mammography is more sensitive, but ultrasound is more specific.  And then there are the other lumps that males only may present with, testicular and scrotal masses. Sometimes, males may also present with pain in these areas without a mass or concern for one. It's important to do a focused clinical assessment, and then ultrasound is pretty much always ordered first-line in these situations, along with other investigations depending on the suspected etiology. If infection is a concern, order a urinalysis along with urine culture and sensitivity and urine NAAT for sexually transmitted infections. Give analgesia for pain, antibiotics for infections, and refer to surgery for disease processes requiring procedural repair.
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 3: When men and women present with stress-related health concerns, assess the possible contribution of role-balancing issues (ex: work-life balance or between partners). Skill: Patient Centered, Clinical Reasoning Phase: Hypothesis generation, History Sex Key Feature 1a: In patients, specifically pregnant women, adolescents, and perimenopausal women: Inquire about sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction). Skill: Patient Centered, Clinical Reasoning Phase: History Key Feature 1b: In patients, specifically pregnant women, adolescents, and perimenopausal women: Counsel the patient on sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction). Skill: Patient Centered, Communication Phase: Treatment Key Feature 2: Screen high-risk patients (ex: post-myocardial infarction patients, diabetic patients, patients with chronic disease) for sexual dysfunction, and screen other patients when appropriate (ex: during the periodic health examination). Skill: Selectivity, Clinical Reasoning Phase: Hypothesis generation, History Key Feature 3: In patients presenting with sexual dysfunction, identify features that suggest organic and non-organic causes. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 4: In patients who have sexual dysfunction with an identified probable cause, manage the dysfunction appropriately. Skill: Clinical Reasoning Phase: Treatment Key Feature 5: In patients with identified sexual dysfunction, inquire about partner relationship issues. Skill: Patient Centered Phase: History Sexual problems are common. Despite this fact, for multiple reasons, they are often not talked about. At some level, I get it. It's not necessarily a fantastic conversation starter. But as a family doctor with patients who I will see regularly, I'm hoping I can break through the stigma and address sexual health much as any other component of wellbeing. As in a previous post where I discuss obesity, there is still much stigma regarding certain medical problems. Medical doctors (or at least family doctors in Canada) are moulded to view these issues within a biopsychosocial framework. Knowing the current stigma that exists, and the lengthy process required to break down stigma in society in reality, it really is up to doctors (and especially family doctors) to inquire about these issues that patients may feel too embarrassed to bring up without prompting. This is particularly true during periods of transition in life, when sexual concerns may more frequently arise, as is true with adolescence, pregnancy, and the menopausal transition. It can also be more common in males secondary to aging and underlying disease affecting the physiology of obtaining and maintaining an erection. These patients with chronic medical conditions can be at increased risk of sexual dysfunction as biological complications of their disease state but also as a consequence of psychiatric issues that can arise secondary to having chronic disease. As a family physician, it is my role to help the patient take care of their illness and promote wellness in all facets of life, and this includes sexual health. Patients need to be asked about sexual concerns in a safe environment. They need to be asked about safe sex practices and use of contraception and given tools to manage these that fit with their lifestyle. And, where we go less often, they need to be asked about sexual function/wellness. I screen for such concerns by stating that many patients have concerns regarding sexual functioning and sexual orientation, and that because of this I routinely ask about it with patients in my practice. I do this to shape a safe space for discussing issues the patient may feel are sensitive, to help them understand just how normal it is for the physician to talk about. Indeed, because of a lack of common discussion about these issues, some patients find that their "concerns" are really totally a part of the spectrum of normal sexuality. And for those whose concerns are true problems for them, there are effective treatment options that I can offer as a physician, whether they are psychologically based or organic or both. Once a patient has endorsed having a concern with sex that is indeed dysfunctional, it is my job to elucidate just what really is going on. Often there is more than one contributing factor. Reasons for sexual dysfunction include having a history of genital trauma, medication side effects, vascular insufficiency, neurologic dysfunction, hormonal problems, and psychological or emotional factors (including relationship difficulties). Each etiology creates problems in its own way, and can further lead to problems involving the psyche or other systems, and frequently affecting relationships; obtaining a good clinical assessment helps to create a tailored approach to treatment. Basically my history involves assessing whether any of the known causes may be contributing. In males complaining of erectile dysfunction, the classic question to ask to suss out whether this dysfunction is largely organic in nature is to ask if he still has nocturnal erections or other spontaneous erections. The absence of these does suggest the dysfunction is largely organic. As well, whenever erectile dysfunction is more sudden onset rather than gradually worsening with time, that suggests a non-organic etiology. And it is important to not assume that a male presenting with concerns regarding sex or infertility is having erectile dysfunction; although it is very common, there are other sexual concerns that are managed differently (ex: first-line treatments for ejaculatory disorders, which are considered psychiatric disorders, include SSRIs, topical anaesthetics, +/- psychotherapy).
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Domestic Violence Key Feature 1: In a patient with new, obvious risks for domestic violence, take advantage of opportunities in pertinent encounters to screen for domestic violence (ex: periodic annual exam, visits for anxiety/depression, ER visits). Skill: Patient Centered, Clinical Reasoning Phase: History Key Feature 2a: In a patient in a suspected or confirmed situation of domestic violence: Assess the level of risk and the safety of children (i.e., the need for youth protection). Skill: Selectivity, Clinical Reasoning Phase: History Key Feature 2b: In a patient in a suspected or confirmed situation of domestic violence: Advise about the escalating nature of domestic violence. Skill: Clinical Reasoning, Patient Centered Phase: Treatment Key Feature 3: In a situation of suspected or confirmed domestic violence, develop, in collaboration with the patient, an appropriate emergency plan to ensure the safety of the patient and other household members. Skill: Clinical Reasoning, Patient Centered Phase: Treatment Key Feature 4: In a patient living with domestic violence, counsel about the cycle of domestic violence and feelings associated with it (ex: helplessness, guilt), and its impact on children. Skill: Patient Centered, Communication Phase: Treatment Immigrants Key Feature 2: As part of the ongoing care of immigrants, modify your approach (when possible) as required by their cultural context (ex: history given only by husband, may refuse examination by a male physician, language barriers). Skill: Patient Centered, Communication Phase: Treatment, History Key Feature 3: When dealing with a language barrier, make an effort to obtain the history with the help of a medical interpreter and recognize the limitations of all interpreters (ex: different agendas, lack of medical knowledge, something to hide). Skill: Communication Phase: History Rape/Sexual Assault Key Feature 1: Provide comprehensive care to all patients who have been sexually assaulted, regardless of their decision to proceed with evidence collection or not. Skill: Clinical Reasoning, Professionalism Phase: Treatment It is always important to have a high index of suspicion for abuse, but this may be easier said than done. There are many things in medicine that physicians should "always" be on alert for, which really isn't realistic. So, knowing the factors that raise a patient's risk for a given circumstance is useful to know when you should perk up and become suspicious for that circumstance. Factors that increase one's risk of being afflicted by domestic violence in particular are as follows:
It is also useful to know that domestic violence often begins or increases during pregnancy and the postpartum period. In fact, even in situations not involving a pregnant female, domestic violence tends to gradually escalate over time, at least without intervention. It is important to communicate this fact to any patients who are suspected or confirmed victims of domestic violence, to help them make more realistic choices as they decide how they want to navigate their often complex situations. Not all people are prepared to disclose that they have been impacted by domestic violence, just like many victims of sexual assault do not disclose this, and not all people who do disclose are prepared to take action to alter their circumstances or to charge a perpetrator. Regardless, the first step when interacting with a patient who is a possible victim of abuse is promoting an environment of safety and building rapport so that the person can feel safe to disclose and feel supported no matter what they choose. Depending on the region you live in, there may be a duty to report domestic violence or sexual assault to the police, but many regions do not mandate this. As is always important when practicing ethical medicine, it is best to support the patient as much as possible in keeping with their informed choices. You may have noticed that many of the risk factors for domestic violence are also features more prevalent among patients who have migrated from abroad. This adds an extra layer of complexity, as cultural norms vary, and it can be particularly challenging to tease out when an issue is a violation of a person's human rights versus a true value/belief/desire from within the patient (ex: when a women prefers her husband to speak for her, does she really want this or is this being imposed on her). Language barriers and communicating through translators is only yet another factor that muddies the water. (ex: Often translators who speak the same language as the patient come from the same and often not-that-small community. Could there be things that the patient is not saying? Could the interpreter have their own interpretation of the message and is some of it lost in translation?) It is important to approach this situation with thoughtfulness around cultural safety and cultural awareness while taking extra steps to ensure such patients are not both presumed to be victims of domestic violence nor less at risk because the risk factors present are seen as simply part of their culture. If I have identified a patient with suspected or confirmed ongoing risk of domestic violence, I use the Danger Assessment screening tool to help quantify just how worried I should be, regardless of whether or not a patient wants to report the perpetrator or stay silent. This screening tool includes a question to prompt assessment of the safety of any children who may be at risk as well. Beyond quantifying risk, the screening tool also helps the patient and care provider devise a safety plan that is tailored to the patient's unique circumstances. Some strategies that might be helpful include:
Beyond immediate safety, with rapport and good communication skills, motivational interviewing skills can be used to explore the impact of the patterns of domestic violence on everyone in the household. As well, it is important to continue to provide care for the patient who has experienced abuse in a comprehensive sense, not forgetting about the other aspects of the health care you provide as their primary care provider. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Dysuria Key Feature 1: In a patient presenting with dysuria, use history and dipstick urinalysis to determine if the patient has an uncomplicated urinary tract infection. Skill: Clinical Reasoning, Selectivity Phase: Diagnosis Key Feature 2: When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result. Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 3: Consider non-urinary tract infection related etiologies of dysuria (ex: prostatitis, vaginitis, sexually transmitted disease, chemical irritation) and look for them when appropriate. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 4: When assessing patients with dysuria, identify those at higher risk of complicated urinary tract infection (ex: pregnancy, children, diabetes, urolithiasis). Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation Key Feature 5: In patients with recurrent dysuria, look for a specific underlying cause (ex: post-coital urinary tract infection, atrophic vaginitis, retention). Skill: Clinical Reasoning Phase: Hypothesis generation Prostate Key Feature 7a: In patients presenting with specific or non-specific urinary symptoms: Identify the possibility of prostatitis. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 7b: In patients presenting with specific or non-specific urinary symptoms: Interpret investigations (ex: urinalysis, urine culture-and-sensitivity testing, Digital Rectal Exam, swab testing, reverse transcription-polymerase chain reaction assay) appropriately. Skill: Clinical Reasoning Phase: Diagnosis, Investigation Sexually Transmitted Infections Key Feature 2a: In a patient with symptoms that are atypical or non-specific for STIs (ex: dysuria, recurrent vaginal infections): Consider STIs in the differential diagnosis. Skill: Selectivity, Clinical Reasoning Phase: Hypothesis generation Key Feature 2b: In a patient with symptoms that are atypical or non-specific for STIs (ex: dysuria, recurrent vaginal infections): Investigate appropriately. Skill: Clinical Reasoning, Selectivity Phase: Investigation UTIs are extremely common, and quite frankly the discomfort is sucky. Usually they're uncomplicated, presenting with the classic symptoms of dysuria with increased urinary frequency and urgency along with suprapubic pain. Sometimes there is also hematuria. What would make such a presentation "complicated" would be any of the following 3 things:
In such a classic presentation, all it takes is a urine dipstick test, easily done in real-time in the office, to confirm this diagnosis (or raise the question about other etiologies instead; if you are unsure based on history whether a patient is pregnant, you can also dip the urine for B-hCG at this time). Positive indicators in keeping with a presumed diagnosis of UTI would be a urine dipstick result that is (+) for nitrites +/or leukocyte esterase. If the urine dip is not positive for either of these, this does not absolutely rule out a UTI, but it does make it less likely, and the urine should be sent for culture and sensitivity to confirm or refute a diagnosis of uncomplicated UTI. I have pretty well always seen the doctors I work with in clinic do a urine dip to look for the above supporting evidence for a UTI when clinically suspected. According to UpToDate, it is not always necessary, if patients presents with very classic symptomatology and are a healthy female with no other risk factors, to do any testing at all, including a urine dipstick test in the clinic. Testing is typically low yield in this situation. In such a setting, empiric treatment and follow-up if there is not quick improvement can be totally appropriate, but again, this is when it is uncomplicated and the suspected likelihood of something else on the differential is very low. Patient with risk factors for complications for whom you should always get a urinalysis and urine culture and sensitivity include children and patients with diabetes mellitus. In any case, even if a urine dip is done and suggests UTI +/- the urine being sent for culture (which should be done if the dip is not supportive of a clinically suspected UTI, in patients with risk factors for unusual infectious causes, when the possibility of different diagnoses responsible for the symptoms are on the table, or when symptoms have not completely responded to empiric antibiotics), treatment is empirically initiated when suspected clinically. The reason we test the urine is to confirm our suspected diagnosis, or find out that perhaps there is something else going on. Dysuria doesn't necessarily mean a patient has a UTI, even though this is certainly the most common reason. Other reasons for dysuria include sexually transmitted infection*, non-infectious urinary tract inflammation (ex: chemical irritation), and causes of dysuria that are outside the urinary tract (ex: vaginitis). Also, the patient could have a UTI, but a more complicated type, such as prostatitis in a male (urinalysis would also suggest UTI, urine C&S/NAAT/swab of any discharge would also be expected to grow a microbial isolate, but DRE would be expected to reveal a boggy and tender prostate, unlike with a simple UTI in which you would expect prostate examination to be fairly unremarkable), or as a complication of urolithiasis. Reasons on history for which you would consider these other diagnoses may be a complaint of genital discharge or pruritus, risk factors for an STI, a failure of empiric antibiotic therapy or relapsing symptoms, or any other features that are outside of the classic uncomplicated UTI symptomatology, such as colicky flank pain or pain at the tip of the penis (symptoms that raise suspicion for urolithiasis). Also consider other diagnoses if the patient appears unwell, is febrile, or has costovertebral tenderness on examination, all features that go beyond what we would expect in a patient with an uncomplicated UTI. If a patient has risk factors and has a presentation in keeping with a possible STI, empiric treatment should strongly be considered while awaiting results of confirmation. If confirmed, public health needs to be notified, and follow-up is warranted for further counselling. It is also prudent to screen patients for STIs regardless of whether or not they are symptomatic if they continue to have sexual risk factors for acquiring an STI. If a patient does have an uncomplicated UTI, and if it is part of a pattern of recurrent UTI (defined as 2 or more UTIs within 6 months, or 3 or more episodes within a year), it is important to asses why this might be happening, and to offer up some strategies to try to prevent recurrence going forward. This is largely informed by the demographic the patient falls within, with common reasons being common, as well as by individual patient factors such as known disease that may suggests a reason for the recurrence, such as urinary retention from benign prostatic hypertrophy in an older male. In females who are sexually active, sexual activity is a common precipitating factor for UTI, so they should be given advice to void urine after sex. Postmenopausal changes also lead to an increased frequency of UTI, so a trial of vaginal estrogen may be offered for these women. All people should be counselled to drink enough fluid such that they are voiding urine regularly (a rule of thumb I've heard a doctor tell people was to drink enough so that your urine is clear), which helps to flush out bacteria that sit around for too long and start to multiply and lead to infection. Sometimes people want to know if there are any natural supplements they can take. There is some evidence that cranberry can help (some women will swear by the fact that drinking cranberry juice significantly helps with the symptoms of a UTI), so taking prophylactic cranberry pills is an option. Another option, albeit with even less evidence but little risk of harm (expect to the wallet) is to try prophylactic probiotic supplements. However, if a patient continues to have recurrent UTIs, it's probably safe to say it's a waste of their money. For those patients who continue to have recurrent UTIs despite the recommendations above, and who have no known reversible reason to address, they may be considered for prophylactic antibiotics, such as a one-time dose taken immediately after sex, or on daily basis. Given concern for antibiotic resistance, however, this would be a last resort. *Diagnostic investigations for chlamydia and gonorrhea:
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Cancer Key Feature 2: In all patients, provide the indicated evidence-based screening (according to age group, risk factors, etc.) to detect cancer at an early stage (ex: with Pap tests, mammography, colonoscopy, digital rectal examinations, prostate-specific antigen testing). Skill: Clinical Reasoning, Selectivity Phase: Diagnosis Periodic Health Assessment/Screening Key Feature 2: In any given patient, selectively adapt the periodic health examination to that patient’s specific circumstances (i.e., adhere to inclusion and exclusion criteria of each manoeuvre/intervention, such as the criteria for mammography and prostate-specific antigen [PSA] testing). Skill: Selectivity, Patient Centered Phase: Investigation, Hypothesis generation Key Feature 3a: In a patient requesting a test (ex: PSA testing, mammography) that may or may not be recommended: Inform the patient about limitations of the screening test (i.e., sensitivity and specificity). Skill: Clinical Reasoning Phase: Treatment, Investigation Key Feature 3b: In a patient requesting a test (ex: PSA testing, mammography) that may or may not be recommended: Counsel the patient about the implications of proceeding with the test. Skill: Clinical Reasoning, Patient Centered Phase: Treatment, Investigation Key Feature 4: Keep up to date with new recommendations for the periodic health examination, and critically evaluate their usefulness and application to your practice. Skill: Professionalism Phase: Treatment, Diagnosis Prostate Key Feature 1: Appropriately identify patients requiring prostate cancer screening. Skill: Selectivity Phase: Diagnosis, History Key Feature 6: Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations. Skill: Clinical Reasoning Phase: Diagnosis Today I will be doing a Pap clinic with the Portland Hotel Society. Although I've done many Pap smears during my training, this afternoon will be great to refine my skill at performing this procedure. The population I will be screening will be women from the Downtown East Side (DTES) of Vancouver, often with significant histories of trauma, higher rates of infection include sexually transmitted ones, and who may present infrequently for care. I am not exactly sure what to expect, but I am looking forward to learning from these women. The Pap test is a screening test to look for evidence of cervical cancer. It is not a test for sexually transmitted infections (STIs), although many people think it is (and I know that's what I used to think before entering Medicine). So it is important to consider that women who present for Pap tests may really be more concerned about a possible STI. I expect this may be the case with the sample of patients I screen today, given their risk factors. Nevertheless, this provides an opportunity to perform both cervical cancer screening and STI testing (or screening), if indicated. STI screening or testing can also be done without collecting a Pap smear, and indeed it is a waste of resources if Pap tests or any other forms of cancer screening tests are overdone. If women are concerned about STIs, it's also an opportunity to ask about immunization against HPV. Nowadays Canadian students are offered this vaccination during the middle school years, but it is a relatively new initiative and so many people are not covered. When STI screening comes up, or when patients present for a Pap, I use this as an opportunity to discuss HPV vaccination for those who may not be covered and who are at increased risk (the HPV vaccine is recommended in all women up until the age of 45, in all males age 9-26, and in men who have sex with men [MSM]). This vaccine helps to prevent transmission of strains of HPV that can precipitate cellular transformations that can then lead to cervical, oral, anal, and penile cancer. The recommendations by the Canadian Task Force on Preventive Health Care give the following recommendations for cancer screening, given the sensitivity and specificity of available screening tests within a landscape influenced by logistics, economics, and politics. Note that for those patients who meet exclusion criteria for recommendations, consider referring to local (provincial) screening guideline for guidance. Some patients may present inquiring about or actually requesting screening investigations when it is not recommended according to guidelines. It is important to remember that guidelines are not the law of how to practice medicine, but rather offer guidance in a context of having to make so many medical decisions in a day, which is also in the language of the guideline "recommendations" themselves. For any patients for which screening investigations are recommended according to guidelines, it is always important to remember to obtain informed consent, which includes patient understanding as to why a test is being done and what the likely outcomes are. Just because a screening intervention may be recommended for a given population by guideline authorities, it does not mean that every individual within that population will want and choose to do the test. #patientcenteredcare Cervical Cancer Screening Recommendations Exclusion criteria Recommendations are presented for screening asymptomatic women who are or have been sexually active. They do not apply to women with symptoms of cervical cancer, previous abnormal screening results (until they have been cleared to resume normal screening), those who do not have a cervix (due to hysterectomy), or who are immunosuppressed. Recommendations
Breast Cancer Screening Recommendations Exclusion criteria Recommendations are presented for the use of mammography, magnetic resonance imaging, breast self exam and clinical breast exam to screen for breast cancer. These recommendations apply only to women at average risk of breast cancer aged 40 to 74 years. They do not apply to women at higher risk due to personal history of breast cancer, history of breast cancer in first degree relative, known BRCA1/BRCA2 mutation, or prior chest wall radiation. No recommendations are made for women aged 75 and older, given the lack of data. Recommendations
Colorectal Cancer Screening Recommendations Exclusion criteria These recommendations apply to adults aged ≥50 years who are not at high risk for colorectal cancer (CRC). They do not apply to those with previous CRC or polyps, inflammatory bowel disease, signs or symptoms of CRC, history of CRC in one or more first degree relatives, or adults with hereditary syndromes predisposing to CRC (ex: familial adenomatous polyposis, Lynch Syndrome). Recommendations
Lung Cancer Screening Recommendations Exclusion criteria These recommendations apply to adults aged 18 years and older who are not suspected of having lung cancer. These recommendations do not apply to individuals who have a history of lung cancer, or suspected lung cancer. Recommendations
Prostate Cancer Screening Recommendations Exclusion criteria This clinical practice guideline applies to all men not previously diagnosed with prostate cancer. This includes men with lower urinary tract symptoms (nocturia, urgency, frequency and poor stream) or with benign prostatic hyperplasia (BPH).* Recommendations
*Note that BPH and prostate cancer may present with the same lower urinary tract symptoms, so when making a diagnosis of BPH it's important to ensure there are no symptoms or signs suggestive of malignancy (or other diagnoses such as prostatitis), and that the PSA is not abnormally elevated. In this setting, the measurement of a normal PSA is done to assist in the diagnostic workup of BPH rather than as a screening test for prostate cancer, which would be done only if a male did not have any symptoms suggesting a current diagnosis of prostate cancer. If a man is diagnosed with BPH that responds well to treatment, recurrent testing of PSA in the interest of screening for prostate cancer is not indicated. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 5: Interpret and apply research evidence for your patients in light of gender bias present in clinical studies (ex: ASA use in women). Skill: Clinical Reasoning, Professionalism Phase: Hypothesis generation Ischemic Heart Disease Key Feature 2: In a patient with modifiable risk factors for ischemic heart disease (ex: smoking, diabetes control, obesity), develop a plan in collaboration with the patient to reduce her or his risk of developing the disease. Skills: Clinical Reasoning Phase: Treatment As a future family physician, a significant part of my role in the healthcare system will be to help patients understand the risks associated with cardiovascular disease (morbidity and mortality) and to assist patients to adopt behaviours that promote better health and quality of life. Ischemic heart disease is one of the cardiovascular diseases that has a large negative impact on the health of many, and very significantly so. In terms of mortality alone in developed countries, ischemic heart disease is responsible for at least one-third of the deaths in adults over the age of 35 (UpToDate). So what can be done to reduce one's risk of developing ischemic heart disease? The first part is helping patients understand what they can do to decrease their risk, and the second part is to promote those behaviours. The former is often done by use of a cardiovascular risk calculator if the patient is at least 40 years of age. According to UpToDate, "A number of multivariate risk models have been developed for estimating the risk of initial CVD events in apparently healthy, asymptomatic individuals based upon assessment of multiple variables. The choice of a specific risk model for CVD risk assessment should be individualized based on patient-specific characteristics (eg, age, gender, ethnicity).... While all of the risk models have advantages and disadvantages, no single risk model will be appropriate for all patients. We encourage clinicians to use a CVD risk calculator that has been locally endorsed and that has been validated for their locale and for patient-specific race and ethnic groups." Much of our strong evidence in medicine, having been studied for many years, was first originally collected on Caucasian males. This is a historical reality. This fact that many of our most "robust" tools and knowledge are not generalisable to every patient in front of us means we have to exercise clinical judgment, recognize the variability among various subsets of the population for different disease processes, different disease presentations, and the need to investigate accordingly. Screening tools still can be very useful to provide guidance, but they are not the be all end all. Ultimately, it is what it is, but it is important to try not to be complacent and really consider whether or not medical algorithms truly fit the individual patient. In Canada the most commonly accepted CVD risk calculator for the general population is the Framingham Risk Score (and yes, it is based on a cohort of middle-aged white men). After calculating a patient's risk and presenting them with the information, encouraging the behaviours that decrease their risk of acquiring cardiovascular disease is then as straightforward and as challenging as you'd think.
Piece of cake (that you can't eat).  By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Contraception Key Feature 1: With all patients, especially adolescents, young men, postpartum women, and perimenopausal women, advise about adequate contraception when opportunities arise. Skill: Patient Centered, Communication Phase: Treatment Eating Disorders Key Feature 1: Whenever teenagers present for care, include an assessment of their risk of eating disorders (ex: altered body image, binging, and type of activities, as dancers, gymnasts, models, etc., are at higher risk) as this may be the only opportunity to do an assessment. Skill: Clinical Reasoning Phase: History Immigrants Key Feature 4c: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Assess patients for availability of resources for support (ex: family, community organizations). Skill: Clinical Reasoning, Patient Centered Phase: History In Children Key Feature 2: As children, especially adolescents, generally present infrequently for medical care, take advantage of visits to ask about:
Phase: History, Treatment Key Feature 3: At every opportunity, directly ask questions about risk behaviours (ex: drug use, sex, smoking, driving) to promote harm reduction. Skill: Clinical Reasoning, Communication Phase: History, Treatment Key Feature 4: In adolescents, ensure the confidentiality of the visit, and, when appropriate, encourage open discussion with their caregivers about specific problems (ex: pregnancy, depression and suicide, bullying, drug abuse). Skill: Communication, Patient Centered Phase: Treatment Substance Abuse Key Feature 4: Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (ex: school failure, behaviour change). Skill: Clinical Reasoning, Patient Centered Phase: Treatment, Diagnosis Key Feature 6: Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.) Skill: Patient Centered Phase: Treatment Trauma Key Feature 11: Find opportunities to offer advice to prevent or minimize trauma (ex: do not drive drunk, use seatbelts and helmets). Skill: Clinical Reasoning Phase: Treatment Being in the Pediatric Emergency Department for just over one week now, I've been getting much-needed exposure to sick kids. I need to know what they look like, how to recognise when they're at risk of decompensating, and how to intervene in this natural history. Being in the Pediatric ED has also reminded me that so many acute problems are really exacerbations of chronic issues with potential to be attenuated by strong primary care connections. This is because these problems are often significantly aggravated or alleviated by social issues that cannot be sufficiently addressed with fleeting relationships of care, as is the case with emergency department medicine. This is not to knock emergency medicine. It is a miraculous thing in a time of crisis. But it is not a solution (as it is not intended to be) to many problems grounded in and complicated by psychosocial factors, the rule rather than the exception when it comes to illness and wellness. The welfare of all people hinges on social determination. To have a significant positive impact on health and wellbeing it is necessary to modify the social factors that determine them. As a family doctor this means I must ask about patients' social factors to gain insight needed to modulate them, if possible. This is particularly important when it comes to managing the health of patients who are more vulnerable, having a reduced capacity to control the social factors that can seriously harm or help them. Children and adolescents make up a particularly vulnerable population for this reason, so although it is always important to gather any patient's social history, it is all the more critical when it comes to pediatric medicine. Furthermore, while the vulnerability of a child may decrease as they grow into adolescence with increased self-determination, this autonomy comes at a time when their capacity to manage emotions may be underdeveloped, increasing risk of harm by impulsive behaviour. People present for medical care for medical concerns. They typically do not present to address social determinants that may create or contribute to medical problems before they have arisen. So when it comes to primary care and its priority for preventative health, it is necessary that the primary care practitioner suss out those social barriers and strengths. The classic acronym used to remember the important elements to always ask about when it comes to the adolescent social history is HEADS (with a variable number of trailing S's as people tack on more things to alliterate with the letter S to remember to include). This is my version, with the general categories laid out that need to be explored more in depth as indicated. I also use it to think about the important elements to ask when interviewing people of all ages, so certain questions listed here may not be all that relevant for pediatric patients specifically. It may in fact seem quite odd to think about applying parts of this acronym to a 5 year old (unlikely to be using illicit drugs, for example), but sometimes these can still be helpful to keep on the template because it prompts me to think about factors influencing their circumstances (ex: parental illicit drug use). In fact, this concept serves as a reminder to me to ask about problems with important relationships in general, when taking any complete medical history as any patient's family doctor: it is not uncommon for parents to have distress over the problems their children may have as well, such as may be the case in the setting of substance use as well. HEADS
Gathering a history that includes the above elements, as tailored to the patient, +/- obtaining collateral history, can provide insight into salient social issues that may be impacting on - and that may be impacted by - the patient's health. I can then attempt to work with the teenager or parents of a child to address factors that may be the underlying reason they presented for medical care in the first place. One last comment I will make here is the importance of opening the process of gathering a social history from adolescents with a confidentiality statement. Adolescents are in a unique transitional period during which many aspects of their life are still being managed by parents or other guardians, but gradually they are assuming more responsibility. If the adolescent patient presents for care with a parent - after the parent has had opportunity to provide collateral information on the presenting concern - I have the parent leave the examining room so I can gather a social history from the adolescent in privacy. It goes without saying that many teenagers may not want to disclose sexual activity or substance use with a parent present, so this presumably increases my ability to gather accurate information. In the same vein, I always start this sans parents portion of the visit with a confidentiality statement, to ensure the adolescent understands that whatever they tell me at this point is confidential, and that unless they tell me something would warrant an exception to the rule of confidentiality (that they are hurting themselves or others, or that someone is hurting them), then whatever they disclose to me is just between the two of us. When the adolescent patient does disclose information that indicates they are having a hard time coping, and considering my HEADS assessment as it pertains to social supports, if the adolescent has trust in their parents then I do encourage patients to share their concerns with their parents or other supportive allies. I do leave it up to them to decide what exactly and how much they wish to disclose, and say that if they chose not to that is completely okay. I also let them know regardless that they can always return to the clinic for further support with their ongoing issues. And last but not least, I often end my adolescent visits with a recommendation to check out the Sex & U website, a wonderful resource for all adolescents to learn about sexual health and a plethora of related topics, all organized on an aesthetically-appealing interface that is easy to navigate and understand. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
I spent a day in my first primary care transgender clinic and now I absolutely cannot wait to graduate from residency and begin practicing as a trans-affirming physician. I learned today that there is still a shocking degree of stigma that transgender patients face by medical professionals when opening up about their dysphoria with their birth-assigned gender. My third last patient of the day today, a 54 yo male to female transgender patient, was presenting to clinic for assessment of whether or not she is a candidate for hormone therapy. We spent quite a bit of time diving into her medical and social history, and I learned about how she first had wanted to come out at about 19 years of age, but in a twist of events, she fell in love with a woman (she had never felt romantic toward a woman before), and they formed a partnership that lasted almost 30 years. She had assumed the more masculine role in this relationship, but she was okay with that, because it worked for them, and that's just the way it was. Long story short, her partner moved away a couple of years ago in search of a different life, and she didn't want to leave her life in Vancouver. After all, she had a very secure pension lined up through her employer, and to move now would be to give up a lot of security, not to mention the rest of the life she built for herself. Vancouver is her home. About a year after her partner left, and after a steamroller incident which left her unable to work for 6 months, thoughts about her gender identity began to resurface. It gnawed in her mind with more and more ache, and eventually she couldn't bear to ignore it. She felt like a woman, this is who she is, and to deny herself this fundamental truth was to live a half-life. She gathered up all her courage and went to her family doctor of 15 years in search of self-actualisation. She sat down, made herself as vulnerable as one can by baring her deepest darkest secret, and in return, the family doctor laughed and told her he didn't believe being transgender was a "real" thing. She immediately welled up in tears and said she could never bear to see him again. She went home, and in a state of frank crisis she took the gun she had at home and put her lips around it. She couldn't bear the agony and wanted it to end. In this state of utter craziness, there was a part of her that didn't want to release the trigger, and instead her index finger dialled an SOS call to a help line she knew about. Someone answered the call, and talked her into putting the gun down. She came to her senses, and it wasn't many days before she was back to work as her ankle injury was healed enough to resume her usual duties. One night at work shortly after her return, when no one else was still around, her boss mentioned to her how her and her partner were going through divorce. The feelings resonated in my patient's heart as she knew that piercing pain that still lingered from when her partner moved away. One thing led to another, and this full-blown heart-to-heart led to my patient opening up about her state of being transgender. Much to her surprise, her employer actually had many friends within the queer community! And within the next week, all of the women at work were regularly organising lady nights with her and would take her for nights out on the town, dressing her up and giving her makeovers. She felt like a woman and she felt accepted. The community connections she developed eventually led her to Three Bridges, where she sat in front of me, now with courage restored to climb to the peak of her Maslow's hierarchy. OMG was my mouth gaping open this whole time? We bonded, her and I, sometimes laughing, sometimes coming to tears as we shared in her experiences over the years. I think mostly she had the opportunity to affirm herself while I learned invaluable lessons about the power a physician can have in their relationship with patients, for better or worse. No doubt, the cumulative impact of many peoples' words can have significant impact on how people feel in this world, on the nature of people's interpersonal relationships, and on the values that shape cultural identity, promoting or demoting one's sense of belonging in their community. Prior to this patient encounter, I did understand that physicians are oftentimes in a position of relative power in society, with voices that are often heard, listened to, and honoured as reasonable and truthful ones. But I didn't appreciate the extent to which this power was borne out in the physician-patient relationship. Patients seek help from physicians in some of their weakest, most vulnerable states, be they physical, mental, emotional, or spiritual, and because of this, there is a saliency in the response physicians have that can further harm or instead heal. As a resident physician I am constantly striving to learn the right way to do things (the most reliable way to diagnose, the most effective way to relieve symptoms, etc.), and much less frequently do I stop to critically consider how my actions can perpetuate harm. There is an inherent power dynamic in the physician-patient relationship, and thanks to my patient today, I am all the more mindful of the degree of harm that parallels the benefit in that relationship. May I never forget this as I progress toward greater physician independence and correspondingly increased patient dependence and vulnerability to my actions.  |
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