Priority Topic: Cancer

Key Feature 1: In all patients, be opportunistic in giving cancer prevention advice (ex: stop smoking, reduce unprotected sexual intercourse, prevent human papillomavirus infection), even when it is not the primary reason for the encounter.
Skill: Patient Centered, Communication
Phase: Treatment

Whenever I work in a family doctor's office, it seems as though almost once a day I encounter patients who come in for their "yearly check-up." The complete check-up, in which a patient is physically examined from head to toe and sent off for a batch of screening bloodwork, has fallen out of favour in the context of modern evidence-based medicine. It is simply not helpful overall, tends to do more harm than good, and is at the end of the day a waste of money, no matter who the payer is. Instead, new family doctors are taught only to screen for diseases, such as select cancers, for which there is evidence to show that screening actually saves lives and/or enhances quality of life for those in whom disease is detected. For more convincing on this issue, check out this website, part of the Choosing Wisely campaign.

Instead of performing an "annual physical," I am trained to approach preventative health at every appropriate opportunity. This means that if someone is coming in to see me who is acutely unwell, I'm going to focus my efforts on treating their active illness rather than try to counsel them on smoking cessation. On the other hand, in the patient who presents for a medication refill for a chronic disease that is well-controlled, broaching smoking cessation may be at the top of my (albeit maybe not their) agenda. This does not mean the patient who is acutely unwell does not deserve to have a discussion regarding preventing future illness. Rather, it means we ought to prioritize dealing with the most urgent issues first, and then approach preventative health and health promotion when the circumstances are appropriate. This makes for a bit of a harder job for the primary care physician, however, as there is not necessarily one dedicated appointment to reviewing the patient's health comprehensively. At least now, in the modern day of electronic medical records (EMRs), alerts can be set up and reminders activated for ensuring a patient is up to date on their screening. Notifications can also remind the clinician that the patient they are meeting with is an active smoker who may benefit from brief counselling on smoking cessation, and a host of other preventative health interventions. I can't wait to work in a clinic with an EMR system I can fine tune to maximise my ability to provide preventative health, with every patient, according to their circumstances, at every appropriate opportunity.

Until then, as I am training and working in many inefficient spaces, I must be diligent at combing through patients' medical charts to figure out if their cancer screening is up to date, asking repeatedly about any risky behaviours they might have around which counselling may be indicated, and hoping they remember what their vaccination history is. Truthfully, there is no degree of automization that can ensure all of my patients' constantly evolving risk factors are addressed and that can rid the need for real-time clinical perception and judgment. I cope with this fluidity by having a template of sorts in my approach to taking a social history, which helps me gather information I need to evaluate individual patient risk, but it could never be comprehensive enough to catch all possible risk factors. Much as a database of reminder notifications in an EMR could never be so sensitive as to detect all clinically relevant risk factors predisposing one to future illness. The bottom line is that the clinician must maintain flexibility in their approach to providing patient-centered health prevention and promotion advice, seizing opportunities to address risk factors that are both anticipated and unexpected.