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Key Feature 3: In patients with prostate cancer, actively search out the psychological impact of the diagnosis and treatment modality. Skill: Patient Centered, Communication Phase: History Key Feature 4a: In patients with prostate cancer, considering a specific treatment option (ex: surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment): Advise about the risks and benefits of treatment. Skill: Clinical Reasoning, Patient Centered Phase: Treatment Key Feature 4b: In patients with prostate cancer, considering a specific treatment option (ex: surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment): Monitor patients for complications following treatment. Skill: Clinical Reasoning Phase: Hypothesis generation, Follow-up Key Feature 5: In patients with prostate cancer, actively ask about symptoms of local recurrence or distant spread. Skill: Clinical Reasoning Phase: History, Hypothesis generation In patients who undergo investigations for prostate cancer and who subsequently are considering or have received treatment, it is important to assess the impact of this on their physical and psychological well-being. The diagnosis of cancer is rarely an easy thing to accept without some stress, and when it comes to the treatment of prostate cancer, the available modalities are also not without at least potential negative ramifications. In fact, the lack of options without a decent enough risk of negative side effects for treatment of prostate cancer is one of the main reasons some groups of health care providers lobby against population-wide screening for it. (As well, there is always the chance that despite treatment the cancer could recur, so it's also important to inquire about symptoms suggestive of this and to be on alert for new complaints that could indicate metastatic spread.) This PDF of the harms vs benefits of prostate cancer screening takes into account available treatment options and helps to shed some light in framing this discussion. As well, check out the video below by Dr. Mike Evans for more context on the side of the debate that encourages caution when it comes to screening for prostate cancer. In any case, in my opinion all patients diagnosed with prostate cancer deserve to make an informed choice as to how they wish to proceed, with the option of speaking to a Urologist to discuss the available treatment options in detail.
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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...
Crisis Key Feature 1: Take the necessary time to assist patients in crisis, as they often present unexpectedly. Skill: Patient Centered, Professionalism Phase: Treatment Key Feature 6: Inquire about unhealthy coping methods (ex: drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 11a: When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia): Assess the environment for needed resources (people, material). Skill: Clinical Reasoning Phase: Treatment Stress Key Feature 4b: In patients not coping with the stress in their lives: Explore their resources and possible solutions for improving the situation. Skill: Patient Centered Phase: History, Treatment Key Feature 5: In patients experiencing stress, look for inappropriate coping mechanisms (ex: drugs, alcohol, eating, violence). Skill: Clinical Reasoning, Communication Phase: Hypothesis generation, History I am currently working at an HIV primary care clinic. What this means is that all of the patients attached to this clinic have HIV, but they present to this clinic to deal with all of the usual general medical concerns that any person may have along with their HIV care. With advancements in recent years in the diagnosis and management of HIV, this means that most patients here are actually quite stable when it comes to management of their HIV (most patients have undetectable viral loads and protective CD4 cell counts). Their lives are still certainly complicated by it, as they need to be diligent about taking their daily medications and receiving regular followup medical care, which really is not unlike care for most chronic diseases. Today in the HIV clinic I met a 56 year old man who was doing perfectly well from an HIV medical care perspective. However, he was coping with a lot of financial stress in his personal life. He had recently been hired again a few months ago after losing his job for many more, and he was having a very hard time making ends meet. He presented with concerns about depressed mood or feeling "subdued," which was how he described it. Upon assessment, he was clearly having a relapse of Major Depressive Disorder, which he had been in remission for and off antidepressants for over 3 years. Clearly, financial stress was a precipitant for this active episode of major depression, so along with treating the depression, my role today was to help him address the reasons underlying it. I screened him for other interrelated comorbidities and coping behaviours that can have negative repercussions, such as substance use, and asked him about the consequences that his depressed mood was having in his life, to assess for complicating features. Experienced with having gone through a Major Depressive Episode before, he had a lot of insight this time around and presented to clinic before things got too far out of hand. So many patients present for medical problems that are protracted consequences of the social determinants of health, and to address them, we really need to address those determinants. And it's not easy, particularly when you think about how deep their influence goes, such as impact of adverse childhood experiences (ACEs) and the pervasiveness of the impact. Fortunately, here at the well-supported HIV clinic, we have access to a Registered Social Worker on our team to assist patients with the many financial and other realities of life that have immense repercussions on patient wellbeing. While this doesn't eradicate all negative social determinants of health by any means, it helps to foster a culture of resilience whereby patients are empowered to live lives with better health and quality of life. One of the supports that I think is fantastic is the nurse who triages patients who present to the HIV clinic on an urgent basis, without having booked appointments. This means that patients with urgent needs can be seen by a doctor that same day, while those with less urgent needs can get booked for an appointment within the next few days. Although the patient may be seen by one of the doctors working in the clinic that day, and this person is often not their primary care physician, the information about the patient is in their chart, and so there is more continuity of care than at a walk-in clinic. (There may also be a need for more specialized urgent care at the HIV primary care clinic rather than a routine walk-in clinic as well, since treatment decisions may be influenced by the presence and active treatment of the patient's HIV, which many physicians may not have much experience with managing.) The reality is that while many medical issues are best managed in an outpatient setting, and others require emergency medical care, many fall in the grey zone in between, needing so-called urgent care. There is a need to see patients who are having urgent issues not in the Emergency Department when they don't need a high acuity level of care, and ideally by a primary care practitioner who knows them well. Unfortunately, when the health care system is structured with a gap in primary care providers delivering urgent care services, patients have little choice. I think the best option is to have walk-in clinics for those who do not have a family doctor, but ideally attaching these patients at the same time to regular family doctors who can provide routine care as well as urgent care. The primary care clinic just needs to be set up in such a way so as to make that work (ex: in my home family clinic, one doctor every day leaves a certain number of slots open to address urgent concerns). Back to the patient: The gentleman in clinic who I met with today received a referral to meet with the team social worker to discuss how he is currently managing and what his options are moving forward. As a family doctor in the community, I will likely not have the privilege of having a social worker at my fingertips, so it will be extremely helpful for me to become familiar with local resources, especially financial supports. At the same time, it's important to remember that there are social workers in the community who I may be able to refer patients to for extra support. And by setting up my practice so that I can help patients manage urgent concerns I am most likely to be able to do what needs to be done. Key Feature 1: Given a symptomatic or asymptomatic patient at high risk for diabetes (ex: patients with gestational diabetes, obese, certain ethnic groups, and those with a strong family history), screen at appropriate intervals with the right tests to confirm the diagnosis. Skill: Clinical Reasoning, Selectivity Phase: Investigation, Hypothesis generation Key Feature 2: Given a patient diagnosed with diabetes, either new-onset or established, treat and modify treatment according to disease status (ex: use oral hypoglycemic agents, insulin, diet, and/or lifestyle changes). Skill: Clinical Reasoning Phase: Treatment, Follow-up Key Feature 3: Given a patient with established diabetes, advise about signs and treatment of hypoglycemia/hyperglycemia during an acute illness or stress (i.e., gastroenteritis, physiologic stress, decreased intake. Skill: Clinical Reasoning, Patient Centered Phase: Treatment Key Feature 4: In a patient with poorly controlled diabetes, use effective educational techniques to advise about the importance of optimal glycemic control through compliance, lifestyle modification, and appropriate follow-up and treatment. Skill: Communication, Patient Centered Phase: Treatment Key Feature 5a: In patients with established diabetes: Look for complications (ex: proteinuria). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 5b: In patients with established diabetes: Refer them as necessary to deal with these complications. Skill: Clinical Reasoning Phase: Treatment, Follow-up Key Feature 6: In the acutely ill diabetic patient, diagnose the underlying cause of the illness and investigate for diabetic ketoacidosis and hyperglycemia. Skill: Clinical Reasoning, Selectivity Phase: Diagnosis, Treatment Diabetes is common, and it is continuing to be so as rates of overweight and obesity continue to climb. It can also be present for many years and start to cause damage to the small blood vessels and raise risk for multiple complications down the line, without becoming apparent to the individual walking around with high blood glucose, at least for type 2 diabetes, which is the type that is associated with the metabolic syndrome. Because of the prevalence, screening guidelines suggest screening all people who are 40 years and older for diabetes every 3 years, but screening should start sooner and more frequently for those at increased risk (ex: overweight or obese or with other comorbidities that increase risk, with a family history, with a personal history of gestational diabetes, who use medications associated with hyperglycaemia, and who are of any ethnicity other than white pretty much). The CANRISK tool is an online risk calculator to assess who might and who might not need blood work to assess for the presence of diabetes, and I prefer to start with that to avoid unnecessary blood work. However, if a patient is symptomatic (presenting with polyuria, polydipsia, nocturia, and blurred vision) they should have bloodwork done straight away to look for hyperglycemia. If a patient has type 1 diabetes or symptomatic type 2 diabetes, they will need to be started on insulin straight away. If a patient has type 2 diabetes, depending on how severe it is (as measured by a recent HbA1c, generally measured every 3-6 months), a combination of lifestyle measures +/- oral antihyperglycemic agents can be tried first (and generally metformin is always the first agent). All patients warrant a referral to a dietician to get a handle on how structure their diet with this new diagnosis, which is really not easy! Patients with type 1 diabetes should be referred to see an endocrinologist straight away. There is much more to the management of diabetes than this, and it is important to spend time with patients to provide education and counseling on this life-changing diagnosis. I won't get into the details of the medication and lifestyle recommendations for diabetes here, as there is just SO MUCH one needs to know in order to manage diabetes. But the majority of the recommendations are similar to what physicians recommend for all people, which is to eat a healthy diet, get lots of exercise, avoid harmful substances, and do whatever it is that decreases stress on the body (ex: sleep, mental health, self-care). If interested, check out Diabetes Canada and all of its exhaustive resources for both patients and clinicians. There was a new publication this year of new diabetes clinical guidelines. All primary care physicians ought to be well-versed with these recommendations. The reason for all of the recommendations (and there really are oh-so-many) is not in vain. It's to prevent short-term complications while mitigating the long-term ones. Short term complications include hypoglycemia, which may present with the following symptoms: The other major short-term complication is symptomatic hyperglycemia, which may present with the following:  (Note that the presentation of acidosis typically occurs in patients with type 1 diabetes exclusively, although severe dehydration is a very real and life-threatening concern in patients with type 2 diabetes.) Hope/plan for the best and prepare for worst! These emergency short-term complications can be life-threatening, so it is best to try to avoid them as much as possible, best to be prepared for what to do should they occur, and best to know what to do to correct the problem. For prevention, it's all about good routine management of blood sugar levels, which involves managing lifestyle (diet and exercise), medications, and monitoring as indicated (varies depending on the type of medications and individual factors). No one said diabetes was a cakewalk! As well, when a patient is unwell to the point that it may be affecting what they are putting in their body or what is coming out of it, or if they are under undue stress, or if they are simply feeling at all unwell, it is critical that there is a plan in place to check blood glucose more frequently to pick up when their blood glucose may be outside a safe range (<4 or >14) so as to be able to intervene prior to rampant hypo- or hyperglycemia. If a patient is hypoglycemic, they need glucose, such as in the form of glucose tablets, and part of the routine education of a patient with diabetes should include how to correct hypoglycemia. If unconscious, a loved one should give a glucagon injection and should know how to do this as well. If a patient is hyperglycemic >14 and not improving, they should be seeking medical care. Patients should also be given a "sick day" medication list to know which medications they should not be taking should they become unwell. If a patient presents to care with an episode of hypo- or hyperglycemia, it's important to search for the underlying reason to attempt avoiding recurrence and during an acute episode, to treat the problem that is still at hand (i.e., work the patient up for hypo- or hyperglycemia as indicated*). Please know that I am barely scratching the surface in terms of how to manage diabetes with this post - I almost feel guilty explaining so little. Given all of this, as well as the fact that people are just trying to live their lives, which is already no easy feat, it's no surprise that many patients have poorly controlled diabetes. I think starting with this empathic perspective and learning best practices in terms of evidence-based approaches to helping patients achieve better management is what we need to do to most effectively help our patients in both the short and the long-term. Often it can be hard for patients with type 2 diabetes that isn't severe enough to cause short-term complications to be motivated to adopt oftentimes challenging life modifications necessary for good glucose control. If hypertension is "the silent killer" and obesity an impossible disease to fight on an individual level, diabetes is like the intersection of those two evils. Even when the short-term complications do not manifest, the long-term complications - namely retinopathy, nephropathy, neuropathy, and increased rates of peripheral vascular disease, heart attack, stroke, and all-cause mortality - are ever-present. Dang. But like any issue where there is a lag in the consequence from when the behaviour occurred, it's just human nature to not be so motivated to change the behaviours. We need to work with patients in realistic ways and in as many supportive ways as possible (ex: including motivational interviewing, education, and regular engagement with their health care team) to help make health-conscious choices easier ones for them to make. This is also what I think we need to be striving for all people, but I digress. People are the masters of their domain and they will be the best judge of what is and isn't realistic in their life. You may have noticed way up there that I used the phrase "mitigate long-term complications." In an ideal world, with perfect blood glucose control, theoretically long-term complications could be altogether avoided. But alas the world is not perfect, although some patients get pretty darn good at managing their blood glucose despite this. But the bottom line is that all patients with diabetes are at increased risk for long-term complications and warrant screening and management accordingly. For the risk of retinopathy, patients need a referral for an annual ophthalmologic eye examination; for the risk of nephropathy, patients need annual testing for renal function and albuminuria, and if they develop chronic kidney disease, they warrant assessment by a nephrologist depending on the severity; for the risk of neuropathy, patients need annual diabetic foot exams. Generally these screening maneuvers should start 5 years after the diagnosis of type 1 diabetes and straight away for patients diagnosed with type 2 diabetes. There are other screening considerations as well, many of which are standard for the general population but perhaps recommended more frequently (ex: serum cholesterol), and others that depend on other patient factors (ex: baseline ECG). The Sample Diabetes Patient Care Flow Sheet for Adults is a great example of the multitude of complications the primary care physician needs to be mindful of screening for and tracking, all of which I really have only skirted around in this blog post. 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. 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).
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. 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. Key Feature 1: In patients who appear to be obese, make the diagnosis of obesity using a clear definition (i.e., currently body mass index) and inform them of the diagnosis.
Skill: Clinical Reasoning Phase: Diagnosis Key Feature 2: In all obese patients, assess for treatable co-morbidities such as hypertension, diabetes, coronary artery disease, sleep apnea, and osteoarthritis, as these are more likely to be present. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 3: In patients diagnosed with obesity who have confirmed normal thyroid function, avoid repeated thyroid-stimulating hormone testing. Skill: Clinical Reasoning, Selectivity Phase: Investigation, Treatment Key Feature 4: In obese patients, inquire about the effect of obesity on the patient’s personal and social life to better understand its impact on the patient. Skill: Patient Centered Phase: History Key Feature 5: In a patient diagnosed with obesity, establish the patient’s readiness to make changes necessary to lose weight, as advice will differ, and reassess this readiness periodically. Skill: Patient Centered Phase: History, Follow-up Key Feature 6: Advise the obese patient seeking treatment that effective management will require appropriate diet, adequate exercise, and support (independent of any medical or surgical treatment), and facilitate the patient’s access to these as needed and as possible. Skill: Clinical Reasoning Phase: Treatment Key Feature 8: In managing childhood obesity, challenge parents to make appropriate family-wide changes in diet and exercise, and to avoid counterproductive interventions (ex: berating or singling out the obese child). Skill: Clinical Reasoning, Communication Phase: Treatment In my first year or residency I did a quality improvement project in my clinic, with the hopes of performing an intervention that would lead to increased screening and diagnosis of overweight and obesity. The intervention was having signage in the office encouraging patients to start a conversation about their weight if they were interested. Of the approximately 300 patients who came through the clinic during the intervention period, 1 patient initiated a conversation about their weight, and this patient had a normal BMI. Although my quality improvement project did not increase the ability to screen for overweight and obesity, it did increase my understanding that screening for overweight and obesity is likely not sensitive unless it is physician-directed, or that at least passive that signage as I had put out was not effective in my current patient population. I screen patients with an objective measure of overweight and obesity by assessing their BMI along with other interventions during a periodic health assessment. In adults, I also obtain a measure of central adiposity by assessing what their waist circumference is at any given BMI as some patients with a normal BMI may have a large enough waist circumference that they may be at increased risk for cardiovascular disease. As well, some patients with an elevated BMI may have greater risk for cardiovascular disease than this number alone suggests, as people who are "apples" and carry most of their weight around their abdomen and this increases their risk, as opposed to the "pears" that have a more distributed weight. These measurements are objective, and I believe that doing them with all patients helps alleviate the stigma that persists in Western culture regarding having overweight/obesity. That being said, the stigma and the social and psychological consequences are pervasive, so when patients have overweight or obesity, I also perform an assessment of their mental health. Beyond the negative consequences on mental health, overweight and obesity can occur alongside a slough of comorbidities and an enlist a number of complications. These include hypertension, sleep apnea, polycystic ovarian syndrome, osteoarthritis, gastroesophageal reflux disease, fatty liver disease, a decrease in exercise capacity or ability to perform activities of daily living attributed to excess weight, dyslipidemia, and diabetes mellitus. It is important to assess for and address these other concerns alongside the provision of treatment and management of overweight and obesity. Laboratory investigations are necessary to assess whether of not the weight gain is complicated by new diabetes (fasting blood glucose or hemoglobin A1C), dyslipidemia (lipid panel), or fatty liver disease (ALT), or is a result of hypothyroidism (TSH), which is common enough with a presentation that can be fairly non-specific and so warrants a blood test to be ruled out, in a patient presenting with new-onset overweight/obesity without a previous test of their thyroid function since the onset of overweight/obesity. In terms of the treatment and management of obesity, society has drilled it into us that it is typically a consequence of poor lifestyle choices. That if we only ate less and exercised more, overweight and obesity would not be an issue. The emphasis on personal behaviours neglects the reality of just how complicated the innate pathways wiring our brain and endocrine systems are, encouraging weight gain and fighting efforts to lose weight, and this perspective does not take into account the societal structures that promote and reinforce weight gain. Yes, personal lifestyle choices can make a difference, mostly by improving health and wellbeing rather than necessarily dropping numbers on the scale overly significantly (wide range of results here). It is important for us to encourage one another to adopt healthier behaviours whenever possible without compromising quality of life, with the intent of actually enhancing it. We all have a role in adopting healthy behaviours in families and other community and societal units, while at the same time avoiding behaviours that stigmatise people who have excess weight. The more we see it as a personal consequence, the further from the truth I believe it is, and the less effective will be the call to action. The impact of any given intervention on quality of life is individualistic as well, and the individual has to find proposed behaviour changes tolerable and worth it to be motivated to continue the behaviours long-term. As a family doctor, my role in this matter is to assist the patient in moving from ambivalence to action when it is something they truly want (aka motivational interviewing for healthy lifestyle changes), as well as promoting the best interests of the community. I am a firm believer that we need to strengthen our communities with healthy public policy. Unfortunately, no matter how motivated one is, once an individual has acquired enough weight such that they meet the criteria for overweight or obesity, healthy lifestyle behaviours alone are typically not sufficient to treat overweight and obesity so as to achieve a normal weight. On the flip side, there are medications and surgical treatments that are highly effective. While these treatment modalities do not replace the need for healthy lifestyle behaviours, they do make significant differences in the morbidity and mortality of patients with overweight and obesity. I am of the opinion that many physicians are not offering these treatments to patients frequently enough, probably as a consequence of a lack of discussion about weight with patients altogether. Fortunately, there are people who have started organisations such as Obesity Canada that seek to change this discourse. As the issue continues to be a growing concern as rates of overweight and obesity continue to increase, I suspect that eventually overweight and obesity will be managed much more effectively as the chronic disease process that it is. Key Feature 1: Take an appropriate history and do the required testing to exclude serious complications of urinary tract infection (UTI) (ex: sepsis, pyelonephritis, impacted infected stones).
Skill: Clinical Reasoning Phase: Hypothesis generation, Investigation Key Feature 2: Appropriately investigate all boys with urinary tract infections, and young girls with recurrences (ex: ultrasound). Skill: Clinical Reasoning Phase: Investigation Key Feature 3: In diagnosing urinary tract infections, search for and/or recognize high-risk factors on history (ex: pregnancy, immune compromise, neonate, a young male, or an elderly male with prostatic hypertrophy). Skill: Clinical Reasoning Phase: Hypothesis generation, History Urinary tract infections are extremely common, and most of the time they aren't complicated. When someone presents to my clinic with symptoms in keeping with a UTI (dysuria, urinary frequency and urgency +/- hematuria +/- suprapubic pain), it's my job to ensure that they don't have symptoms and signs suggesting a more complicated picture. The following features on clinical assessment take a UTI from simple to complicated:
All patients with features suggesting a complicated UTI warrant referral to the nearest ED for further workup. Beyond routine and microscopic urinalysis as well as urine culture and sensitivity, blood cultures are warranted if you are thinking about possible sepsis. In terms of imaging, if you are thinking about pyelonephritis, obtain a CT abdo/pelvis with contrast, and if you are thinking about infected kidney stones, obtain a non-contrast CT abdo/pelvis. If you wish to avoid contrast and have the option, consider starting with a renal ultrasound instead. Speaking of renal ultrasound, besides its utility in looking for pyelonephritis or nephrolithiasis, it is also useful to look for urinary tract malformations in pediatric patients when indicated. As in the adult population, UTIs are much more common in females as their urethral tract is much shorter and they are therefore at greater risk of bacteria finding their way up and into the bladder. However, recurrent UTIs in prepubertal females are not common, and any UTIs in prepubertal males are unusual. UpToDate recommends obtaining renal and bladder ultrasonography if the following indications are met:
Children should also be sent for a voiding cystourethrogram to look for vesicoureteral reflux if the following indications are met:
So now I've singled out two groups to be weary of with suspected UTI: those who have features suggestive of a complicated UTI and children with suspected UTI. Other groups that require special considerations, and the considerations they warrant, are as follows. Note that any patients with a suspected complicated UTI, recurrent UTI, or any features below warrant at the very least a urinalysis and urine culture & sensitivity.
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