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Contraception Key Feature 2: In patients using specific contraceptives, advise of specific factors that may reduce efficacy (ex: delayed initiation of method, illness, medications, specific lubricants). Skill: Clinical Reasoning, Patient Centered Phase: Treatment Key Feature 3a: In aiding decision-making to ensure adequate contraception: Look for and identify risks (relative and absolute contraindications). Skill: Clinical Reasoning Phase: History Key Feature 3b: In aiding decision-making to ensure adequate contraception: Assess (look for) sexually transmitted disease exposure. Skill: Clinical Reasoning, Patient Centered Phase: History Key Feature 3c: In aiding decision-making to ensure adequate contraception: Identify barriers to specific methods (ex: cost, cultural concerns). Skill: Clinical Reasoning, Patient Centered Phase: History Key Feature 3d: In aiding decision-making to ensure adequate contraception: Advise of efficacy and side effects, especially short-term side effects that may result in discontinuation. Skill: Clinical Reasoning Phase: Treatment Key Feature 4: In patients using hormonal contraceptives, manage side effects appropriately (i.e., recommend an appropriate length of trial, discuss estrogens in medroxyprogesterone acetate [Depo– Provera]). Skill: Clinical Reasoning Phase: Treatment Key Feature 5: In all patients, especially those using barrier methods or when efficacy of hormonal methods is decreased, advise about post- coital contraception. Skill: Clinical Reasoning Phase: Treatment Key Feature 6: In a patient who has had unprotected sex or a failure of the chosen contraceptive method, inform about time limits in postcoital contraception (emergency contraceptive pill, intrauterine device). Skill: Clinical Reasoning Phase: Treatment Sexually Transmitted Infections Key Feature 1: In a patient who is sexually active or considering sexual activity, take advantage of opportunities to advise her or him about prevention, screening, and complications of sexually transmitted diseases (STIs). Skill: Patient Centered, Clinical Reasoning Phase: Treatment Key Feature 3: In high-risk patients who are asymptomatic for STIs, screen and advise them about preventive measures. Skill: Clinical Reasoning, Patient Centered Phase: Treatment, Investigation There is more than one way to not have a baby, but some of these methods are less effective than others. As well, there are certain methods that become less effective under particular circumstances. Below is a diagram put out by the wonderful website Sex & U that provides an overview of the common forms of contraception and just how effective they truly are.  On the Sex & U website, there is an interactive webpage called "It's a Plan." Here, a menu of contraception methods can be found, along with pros and cons for each option. When having a conversation about contraception choices with patients, I pretty well always mention It's a Plan. That being said, if there is time to have an informed discussion and a patient feels prepared to make a decision during the current visit, I prefer to initiate a method of contraception in an otherwise unprotected person who does not desire pregnancy even if they haven't visited Sex & U already. In obtaining informed consent, for each method, I discuss:
As part of contraception counseling I always inquire obtain a sexual health history, inquiring about the need for STI screening or investigation for symptoms that suggest an infection is currently present (ex: genital discharge pruritus, dysuria, constitutional symptoms). I counsel the patient to consider STI testing as frequently as they would like, such as after new sexual partners if sex is unprotected, and that this could be as simple as peeing in a cup. I always remind patients that contraception (unless using a barrier method such as a condom) does not prevent against STIs. An important part of this counseling is also explaining that STIs may present without symptoms, but can lead to problems such as loss of fertility. If a patient is suspected of having an active STI, it is best to delay insertion of an IUD until the infection is treated or ruled out with testing. I also always advise patients about accessing emergency contraception if they have unprotected intercourse or failure of a contraceptive method (ex: broken condom), and the sooner the better as it loses its effectiveness with time. Options include the emergency contraception pill and the copper IUD, which can both be employed up to 5 days post-coitus.
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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...
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. |
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