Learning Objectives

As a family doctor I am to provide care:

1. Across the lifecycle (including prevention, acute, and chronic illness management)
2. In a variety of care settings (urban, rural, home, ambulatory, as well as emergency, hospital, and long-term care facilities)
3. To a broad base of patients including those from underserved and marginalised populations

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Domains of Care

Family Medicine

By the end of postgraduate training, using a patent-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to... 

1. Use a patient-centred approach to care of patients and families through exploration of both the disease and illness experienced, understanding the whole person, and negotiating informed shared decision making regarding management
2. Provide continuity of care to a patient population through coordination, advocacy and interdisciplinary collaboration in a variety of settings
3. Demonstrate an understanding of the process of repatriating a patent in one’s practice after a referral process, including ongoing communications with the specialist(s) or institution(s) involved
4. Demonstrate knowledge of disease processes including undifferentiated presentations, differential diagnoses, diagnostic con rmations and management across the lifespan
5. Differentiate between normal range of experiences and pathological presentations
6. Use a multifaceted approach to treatment
7. Diagnose and treat serious complications and adverse effects of medications
8. Demonstrate strategies to aid in the management of ‘clinical uncertainty’ and ‘clinical dissonance’
9. Distinguish between serious illness and minor medical concerns and take appropriate action including telephone triage, referring, and consulting
10. Perform an appropriate assessment of patients using skilled interviewing and physical examination techniques in gathering clinical data
11. Demonstrate the ability to manage patients with complex and multiple problems
12. Demonstrate an ethical approach to the patient-doctor relationship, maintaining a respectful, nonjudgmental
    focus
13. Demonstrate awareness that illness and disability makes patients vulnerable
14. Discuss the potential effects of power in the relationship of the physician with the patient, the patient’s family, and community
15. Assist the patient to express their own beliefs and values in solving ethical issues
16. Exhibit ethical decision-making such as discussion of capacity of patients to make decisions
17. Demonstrate an understanding of informed consent
18. Discuss issues involved in relaying medical information to the extended family
19. Demonstrate strategies for lifelong learning given that the knowledge of family medicine is vast and rapidly changing 
20. Demonstrate application of evidence-based medicine to daily clinical practice
21. Analyze the communities or environments in which patients live and work with regards to their impact on patient health
22. Demonstrate the application of basic occupational disability prevention and management principles and practices in clinical settings
23. Demonstrate an understanding of the impact of occupation on the health of an individual and the impact of health on work
24. Differentiate multiple roles a physician may play in the community and the potential for role conflict
25. Discuss the role of primary health care in Canada and globally as an essential tool towards improving and main taining the health of people locally and globally
26. Describe community-based care resources and rehabilitation services available
27. Describe the spectrum of institutional care options available ​

care of children + adolescents

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... 

1. Describe how the presentation and management of disease in children differs from adults 
2. Outline normal parameters in the physical examination of children 
3. Demonstrate skill in neonatal resuscitation 
4. Manage common neonatal problems
5. Provide comprehensive well baby care
6. Manage urgent and emergency medical conditions in various settings, recognizing the trend towards short stay
   hospital observation and outpatient management
7. Manage common paediatric problems in an office setting
8. Monitor and coordinate care of children with chronic illnesses, disabilities, or serious disease, using available
   community supports as necessary
9. Use consultation services of pediatricians appropriately
10. Demonstrate skill in the procedures relative to pediatrics
11. Demonstrate skill in use of common preventative screening tests 
12. Utilize immunization schedules, growth and development charts, and questionnaires in patient management
13. Demonstrate knowledge in accessing provincial and tertiary care hospital guidelines and algorithms for management of illnesses in children
14. Demonstrate ability to quickly access and apply accurate information on drug dosing and toxicity in children, as well as normal laboratory values for the various ages
15. Demonstrate knowledge of child protection issues including identification and management of suspected and
    confirmed child abuse
16. Demonstrate knowledge of pediatric palliative care issues
17. Provide advice to parents regarding age-appropriate safety of children’s environment
18. Modify history taking and physical exam to engage and maximize cooperation by the pediatric patient
19. Assess family dynamics and their effects on illnesses and behaviours in children and vice versa
20. Assess and manage common adolescent problems
21. Demonstrate appropriate attention to adolescent functioning in various domains (for example: home, school, employment, friends, use of alcohol and drugs, safety concerns, suicidal thoughts) with focus on urgent issues
22. Demonstrate patient-centred counselling to the adolescent capable of making informed decisions on self-determination and reproductive choice
23. Demonstrate the ability to discuss importance of immunization with parents

Women's health

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... 

1. Using their knowledge of normal sexual development and function, fertility, menopause and aging processes, manage (including referral as appropriate) patients with disorders of sexual development and function
2. Describe the wide range of development, attitudes, and experiences in sexual health
3. Discuss breast health and use of self-examination, physician breast examination and imaging for breast disease
   diagnosis
4. Counsel women about appropriate contraceptive choices
5. Apply Canadian guidelines for gynecologic cancer screening with PAP testing and options for vaccinations
6. Demonstrate comfort with broaching discussions of gender, sex and sexuality, including lesbian, bisexual, heterosexual and transgender women and girls
7. Demonstrate an approach to women experiencing unwanted pregnancy
8. Demonstrate awareness of ethical and cultural considerations and legislation involved in women’s health (ex: contraceptive and pregnancy counseling for minors, childhood sexual abuse, female circumcision, the rights of a woman to refuse sexual intercourse within a marriage)
9. Screen, diagnose, and treat sexually transmitted infections, including managing or referring for contact tracing
10. Demonstrate how to counsel (and examine if required) a woman who has been sexually assaulted, including
    referral for forensic examination and counseling as appropriate (e.g. local sexual assault team, post-exposure
    prophylaxis and counselors)
11. Screen, counsel, treat and/or refer patients for past or present domestic violence and abuse (physical, sexual, emotional or financial)
12. Recognize differences between genders with respect to pharmacology, disease prevalence, presentation laboratory screening and epidemiology

Maternity care

By the end of postgraduate training, using a pa ent-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to... 

1. Describe accepted guidelines for perinatal and obstetrical care (ex: SOGC)
2. Provide preconception counselling and optimize preconception health
3. Educate and arrange initial investigations regarding infertility and difficulties conceiving
4. Provide counselling around the potential for emotional, psychological, and nancial stress associated with infertility and infertility treatment, and the potential subsequent effects on pregnancy
5. Counsel women about options for pregnancy termination
6. Explain fetal and maternal legal rights, and the medical and ethical issues surrounding termination of pregnancies
7. Counsel patients and appropriately manage pregnancy loss
8. Provide appropriate prenatal care (using standardized provincial prenatal forms and guidelines) including education regarding pregnancy progression and symptoms/signs requiring prompt medical attention
9. Counsel patients regarding prenatal screening options and pathways
10. Recognize and manage common antepartum care issues (including identification and management of patients who become at risk during any point in pregnancy) 
11. Discuss how illnesses may present and/or be managed differently in pregnant patients
12. Demonstrate knowledge of diseases unique to obstetrical patients
13. Demonstrate ability to interact appropriately with other members of the obstetrical team
14. Discuss delivery options for women who have had a previous Caesarean section
15. Demonstrate knowledge of the common indications and methods for induction of labor
16. Educate women about the signs and symptoms of labour and discuss available pain control modalities
17. Assess and manage normal labour and delivery 
18. Assess and manage abnormal labour and delivery (ex: preterm labour, fever in labour, abnormal fetal heart rate dystocia, malpresentation, etc.)
19. Identify and manage obstetrical emergencies
20. Consult obstetricians appropriately
21. Recognize indicators for complicated delivery and refer or manage with assistance
22. Provide comprehensive postpartum care in the hospital, community, and office
23. Manage common postpartum care issues including postpartum depression and breast feeding issues
24. Initiate management of common neonatal problems including those conditions requiring urgent intervention or referral​

Mental health

By the end of postgraduate training, using a pa ent-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to... 

1. Diagnose common mental health problems
2. Demonstrate knowledge, use, and limitations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) system
3. Generate appropriate differential diagnoses for common mental health presentations taking into consideration medical, psychiatric, environmental, and emotional issues 
4. Apply and interpret appropriate investigations for common mental health presentations 
5. Develop therapeutic liaisons with patients with mental health disorders 
6. Recognize, and appropriately respond to, the need for urgent and emergent intervention
7. Develop appropriate pharmacologic and non-pharmacologic management plans including follow-up for patients with common mental health disorders
8. Demonstrate knowledge of indications, contraindications, side effects, and monitoring requirements, of medications used in mental health conditions
9. Assess mental competency
10. Discuss the role of cultural resilience in promoting health and well-being
11. Initiate screening for mental health disorders in high-risk situations (ex: patients with cancer, chronic pain, war veterans, refugees, victims of domestic violence, etc.)
12. Assess a patient’s suicide risk, homicide risk and judgment
13. Screen for abuse, neglect and domestic violence (child, adult and elder) and assess the level of risk for all members of the household, generating an emergency plan if needed
14. Perform a history of an abused or neglected patient of any gender or age
15. Anticipate and develop a plan for possible violent or aggressive behaviour and recognize the warning sign
16. Discuss different forms of therapy (including brief psychotherapy, long-term psychotherapy, couples/ family therapy, and cognitive behavioural therapy), and the selection of patients for each modality
17. Identify mental health resources in the community and appropriately connect people to these resources
18. Screen for and have an approach to caring for patients with concurrent substance use and mental health disorders 

care of men

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... 

1. Using their knowledge of normal sexual development and function, fertility and aging processes, manage (including referral as appropriate) patients with disorders of sexual development and function, including erectile dysfunction and ejaculatory disorders 
2. Discuss the wide range of development, attitudes, and experiences in sexual health
3. Evaluate and counsel men around appropriate contraceptive choices
4. Demonstrate an approach to benign, infectious/inflammatory and malignant prostate disorders 
5. Demonstrate an approach to testicular and scrotal masses and pain, gynecomastia and chest wall masses
6. Discuss evidence-based recommendations for the periodic health exam and resources in the community for men
7. Recognize differences between genders with respect to pharmacology, disease prevalence, presentation, laboratory screening and epidemiology
8. Demonstrate comfort with broaching discussions of gender, sex and sexuality, including gay, bisexual, heterosexual and transgender men and boys
9. Demonstrate awareness of ethical and cultural considerations and legislation involved in men’s health (ex: contraceptive and pregnancy counselling for minors, childhood sexual abuse, effects of poverty, low self-esteem and marginalization on the health of men)
10. Screen, diagnose and treat sexually transmitted infections, including managing or referring for contact tracing and supportive counselling
11. Demonstrate how to counsel (and examine if required) a man who has been sexually assaulted including referral
    for forensic examination and counselling as appropriate (ex: local sexual assault team, post-exposure prophylax-
    is and counsellors)
12. Screen, counsel, treat and/or refer patients for past or present domestic violence and abuse (physical, sexual,
    emotional, or financial)
    

care of the elderly

By the end of postgraduate training, using a pa ent-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to... 

1. Perform a cognitive assessment using standard cognitive testing and collateral history relevant to cognitive and/or functional decline
2. Evaluate premorbid and current functional abilities using reliable sources of information and standardized assessment tools
3. Distinguish between the clinical presentations of delirium, dementia and depression
4. Assess and manage delirium
5. Assess and manage common forms of dementia (NB Canadian Consensus Guidelines on Dementia)
6. Recognize and initiate management of common issues in dementia care (ex: driving, capacity, wandering, pharmacologic therapy, behavioural and psychological symptoms of dementia BPSD, caregiver stress, falls (ex: gait and balance assessment tools))
7. Construct a differential diagnosis (including risk factors) and plans for the evaluation, management and prevention of falls
8. Identify consequences of immobility in the elderly patient
9. Work with interdisciplinary teams to prevent, manage and treat consequences of immobility in the elderly patient
10. Obtain a structured medication review including identification of potential drug-drug and drug-disease interactions (if appropriate, in consultation with a pharmacist)
11. Identify and alter medication therapy that is most likely to cause adverse drug events in an older individual
12. Outline the pharmacokinetic changes that commonly occur with aging and demonstrate the ability to modify
    drug regimens accordingly
13. Describe the usual anatomical and physiological changes seen with aging and understand the concept of frailty
14. Assess and manage atypical presentations of common medical conditions in the elderly
15. Justify the indications, risks, alternatives, and contraindications for physical and chemical restraints
16. Evaluate and initiate management (including pharmacologic and non-pharmacologic therapies) for transient
    (acute) and established (chronic) urinary incontinence
17. Describe the use and risks of indwelling catheters versus intermittent catheter
18. Identify and manage common end of life care issues (ex: nutrition, dysphagia, code status, hospital transfer, home and LTC visits)
19. Apply the key principles of the Mental Health Act, Personal Directive Act, and Adult Guardianship and
    Trusteeship Act
20. Describe advance planning directives (including the roles of physicians and substitute decision-makers) dealing
    with personal and financial decision-making emphasizing a “goals of care” approach
21. Develop and implement plans for the assessment and management of patients with functional deficits, including
    the use of adaptive interventions, in collaboration with interdisciplinary team members
22. Assess and manage skin breakdown and wounds in the frail elderly

palliative care

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... 

1. Identify patients who might benefit from a palliative approach and identify this early in the disease trajectory 
   1. ​Identify opportunities for advance care planning discussions, whether or not a patient has a life- threatening or life-limiting illness
   2. Initiate a palliative care approach early in the illness trajectory
   3. Identify the patients stage of illness using appropriate tools
2. Break bad news and discuss prognosis
   • Demonstrate compassion, empathy and respect for patients and their families through verbal and nonverbal means
   • Inform patients of the diagnosis of life-threatening or life-limiting illness or change in trajectory of chronic illness
   • Inform patients of progression of disease and complications
3. Establish and advocate for the patient’s goals of care, and needs (spiritual, emotional and psychosocial).
   • Identify situations that may bene t from a family meeting and facilitate these meetings.
   • Support patients and families coping with loss and bereavement, grief (including anticipatory grief), risk factors for atypical grief and develop an awareness of local resources to assist families through this process
4. Communicate with patient, families and care team about palliative and end of life options and care.
5. Assess function and symptoms using palliative care tools (ex: ESAS, PPS) and manage symptoms by multiple
   modalities
   • Assess and manage pain, nausea, nutrition, bowel management and other symptoms that arise during palliation and end of life
   • Assess pain effectively using history, physical exam and investigations appropriate to the illness trajectory and goals of care
   • Prescribe opioids effectively including proper initiation, repeated assessment, dosage, titration Priority Topics: ACLA, Palliative Care, Cancer, COPD 

emergency medicine

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... 

1. Manage a patient with an urgent/emergent problem Priority Topics: Abdominal Pain, Allergy, Anemia, Antibiotics, Anxiety, Asthma, Atrial Fibrillation, Chest Pain, COPD, Cough, DVT, Dehydration, Diabetes, Diarrhea, Difficult Pa ent, Domestic Violence, Dyspepsia, Dysuria, Earache, Eating Disorder, Elderly, Epistaxis, Fever, GI Bleed, Hepatitis, In Children, Infections, Ischemic Heart Disease, Joint Disorder, Laceration, Loss of Consciousness, Low Back Pain, Meningi s, Mul ple Medical Problems, Pneumonia, Pregnancy, Prostrate, Rape/Sexual Assault, Schizophrenia, Seizures, Sexually Transmitted Infections, Substance Abuse, Trauma, Travel Medicine, UTI, Vaginal Bleeding, Violent/Agressive Patient
2. Manage a patient presenting with a mental health concern
   Priority Topics: Suicide, Crisis, Anxiety, Depression, Eating Disorders, Schizophrenia, Somatization, Personality Disorder
3. Demonstrate knowledge of emergency resources for psychosocial issues
   Priority Topics: Family Issues, Domes c Violence, Behavioural Problems, Substance Use, Grief
4. Assess and manage a patient with acute pain including appraisal and use various methods of analgesia, topical/local anesthesia and sedation
   Priority Topics: Laceration 
5. Demonstrate basic airway assessment and management skills
6. Recognize and initiate management in a patient with acute respiratory distress or ventilatory failure Priority Topics: Asthma, Croup, COPD, Pneumonia, URTI
7. Identify, classify and treat shock
   Priority Topics: GI Bleed, Abdominal Pain, Allergy, ACLS, Anemia, Atrial Fibrillation, Chest Pain, Dehydration, Diarrhea, Dizziness, Laceration, Loss of Consciousness, Meningitis, Poisoning, Seizures, Stroke, Trauma, Vaginal Bleeding
8. Obtain appropriate vascular access for drugs and fluids Priority Topics: Dehydration
9. Exhibit basic skills in interpreting 12 lead electrocardiograms, including identification and management of acute dysrhythmias
   Priority Topics: Ischemic Heart Disease, Atrial Fibrillation, ACLS
10. Manage the patient in cardiorespiratory arrest
    Priority Topics: ACLS
11. Assess and manage a patient with altered level/loss of consciousness/coma
    Priority Topics: Loss of Consciousness, Seizures, Meningitis, Trauma, Poisoning
12. Assess need for and manage resuscitation in adults and children
13. Priority Topics: Trauma, Newborn
14. Identify patients who are in crisis and appropriately manage their disposition
15. Outline the components of the trauma care system in your region ​

internal medicine

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... 

1. Assess and manage acute and chronic medical illnesses in a variety of settings (hospital, outpatient or emergency room) Priority Topics: (including but not limited to...): Abdominal Pain, Allergy, Anemia, Antibiotics, Anxiety, Asthma, Atrial Fibrillation, Cancer, Chest Pain, Chronic Disease, COPD, Cough, DVT, Dehydration, Diabetes, Diarrhea, Disability, Dizziness, Earache, Eating Disorder, Fatigue, Fever, GI Bleed, Hepatitis, Hyperlipidemia, Hypertension, Immigrants, Immunization, Infections, Insomnia, Ischemic Heart Disease, Joint Disorder, Lifestyle, Loss of Weight, Low Back Pain, Meningitis, Multiple Medical Problems, Neck Pain, Obesity, Osteoporosis, Parkinsonism, Periodic Health Assessment, Pneumonia, Prostrate, Red Eye, Seizures, Sexually Transmi ed Infections, Skin Disorder, Smoking Cessation, Stroke, Thyroid, Travel Medicine, URTI
2. Recognize the effect of acute and chronic illness on patients
3. Explain the importance of lifestyle on disease management, appropriate to the patient’s context
4. Utilize age appropriate screening and periodic/preventive health examination
5. Describe evidence based guidelines for appropriate investigations and treatments
6. Outline indication for admission to and discharge from hospital
7. ​Utilize appropriate consultants in patient care including appropriate community resources and support systems 
8. ​Discuss advanced directives and end of life issues

musculoskeletal medicine

By the end of postgraduate training, using a pa ent-centred approach and appropriate selec vity, a resident, considering the pa ent’s cultural and gender contexts, will be able to... 

1. Perform a thorough examination of limbs, joints, back and neck Priority Topics: Joint Disorder, Low Back Pain, Neck Pain
2. Assess and manage common sports and exercise related injuries Priority Topics: Joint Disorder
3. Assess and manage acute and chronic repetitive stress injury (including occupational) Priority Topics: Joint Disorder, Low Back Pain
4. Determine risk of fracture or injury to tendon, ligament, muscle, nerve, vessel etc. based on pattern of injury and results of physical examination
   Priority Topics: Neck Pain
5. Order appropriate investigations where risk of fracture exists
   Priority Topics: Neck Pain
6. Demonstrate immobilizing techniques such as splints, basic casts and taping
7. Evaluate vessel and nerve injuries that can be associated with fractures and dislocations
8. Triage, and where necessary refer, more complex or unstable fractures for surgical consultation
9. Recognize and initiate management of orthopedic emergencies, arranging referral when appropriate
10. Assess and manage rheumatological disease including: rheumatoid arthritis, osteoarthritis, bromyalgia, and osteoporosis
    Priority Topics: Join Disorder, Osteoporosis
11. Outline common drug therapies, and the use of non pharmacological treatment modalities such as exercise pre-
    scriptions
    Priority Topics: Joint Disorder, Bow Back Pain, Neck Pain, Osteoporosis
12. Demonstrate appropriate medical consultation and shared responsibility of family doctor and consultant to the
    patient
13. Recognize and initiate management for infectious musculoskeletal conditions
    Priority Topics: Joint Disorder
14. Assess basic orthopedic illnesses in children including gait abnormalities and the limping child
    Priority Topics: Joint Disorder
15. Examine for congenital hip disease
16. Perform joint aspiration and joint injection of selected joints as outlined in Procedural Skills
17. Participate in the multidisciplinary approach to chronic musculoskeletal disease
18. Support the special needs of the athlete
19. Support the orthopedic needs of the handicapped patient, ex: those with contractures or severe muscle imbal- ance
20. Provide up-to-date information on rehabilitation and recovery expectations
    Priority Topics: Low Back Pain
21. Outline what community rehabilitation services are available, e.g. physiotherapy, massage therapy, exercise
    classes and groups, and independent rehabilitation programs as well as those available through MSP
22. Explain the use, risks, and bene ts of allied health professions such as chiropractic, massage therapy, acupunc- ture, physiotherapy and occupational therapy to enhance MSK care
23. Assess and manage patients at risk for falls from a musculoskeletal perspective Priority Topics: Elderly, Trauma
24. Recognize musculoskeletal-related medication side effects ex: extrapyrimidal symptoms of antipsychotics as well as side effects of medications used to treat musculoskeletal conditions
25. Assess and manage common neuromuscular disorders: including Parkinson’s disease, essential tremors and epilepsy
    Priority Topics: Parkinsonism, Seizures​

surgical + procedural skills

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... 

1. Diagnose the common acute and non-acute disease entities requiring surgical treatment
2. Assess and manage surgical disease including referral to surgical specialties as needed 
3. Manage routine preoperative and post-operative care
4. Assess and manage preoperative medical problems which affect surgical care (ex: cardiorespiratory disease,
   diabetes, medication)
5. Provide proficient surgical assistance
6. Perform minor surgical procedures and wound closures
7. Assess and manage common post-operative complications (ex: atelectasis, infections, DVT, uid and electrolyte imbalances)
8. Manage wound care
9. Provide immediate resuscitative care in patients with major trauma (including placement of chest tubes)
10. Medically manage long term chronic surgical conditions (ex: amputation, colostomy)
11. Describe how surgical risks vary depending on patient pro le (ex: elderly, concurrent disease, paediatric)
12. Explain the role of adequate nutrition to optimize healing in perioperative care
13. Demonstrate selectivity in deciding whether or not to perform a given procedure (including indications/contrain- dications, personal skills and readiness and context)
14. Explain indications and contraindications to a given procedure
15. Choose among several possible approaches to a given procedure
16. Counsel and educate patients on common surgical procedures including description of the procedure and possi-
    ble outcomes andcomplications as part of obtaining informed consent
17. Prepare for a procedure by preparation of physical environment (ex: equipment, personal protection, aseptic technique) and by cognitive preparation (ex: mentally rehearse anatomic landmarks, technical steps and potential complications and their management)
18. During performance of a procedure, keep the patient informed and ensure patient comfort and safety always
19. During performance of a procedure, continuously reevaluate the situation, and stop and/or seek assistance as
    required
20. Develop a plan with your patient for after care and follow-up after completion of a procedure
    Please refer to the list of core procedures ​

addiction medicine

By the end of postgraduate training, using a pa ent-centred approach and appropriate selec vity, a resident, considering the patient’s cultural and gender contexts, will be able to... 

1. Differentiate between substance intoxication, withdrawal, dependence and abuse
2. Describe the major categories of substances (stimulants, depressants, opioids, hallucinogens, etc.) with potential
   for abuse and their basic neuropathophysiology
3. Address substance use as a regular topic with patients of all socioeconomic and cultural backgrounds
4. Identify, in a safe and non-judgmental fashion, individuals with substance use disorders
5. Describe the developmental, psychological, social, biological, environmental and spiritual contexts that impact the experience of addiction
6. Identify addiction as a chronic disease
7. Undertake an appropriate addiction history and focused physical exam
8. Assess a patient’s motivation to change and suggest appropriate interventions for each stage of change (‘Stages of Change’ theory – DiClemente and Prochaska)
9. Manage – including referral when appropriate – the most common acute intoxication and/or withdrawal syndromes
10. Demonstrate appropriate use of pharmacologic agents utilized in the management of substance use disorders
11. Describe the needs of the pregnant patient dealing with addiction
12. Assess and manage common comorbidities including chronic pain, abscess, endocarditis, HIV, hepatitis and mental illness
13. Demonstrate awareness of the differing community perspectives towards addictions, the values they represent and the social, political and judicial challenges communities face in dealing with these differing perspectives
14. Describe the processes of co-dependence and enabling in the context of addiction, and can identify these pro- cesses when happening in a therapeutic relationship ​

indigenous health

1. Terminology
   
   • We use the term Indigenous to refer to “communities, peoples and nations...which, having a historical continu- ity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing on those territories, or part of them. They form, at present, non-dominant sectors of society and are determined to preserve, develop and transmit to future generations their ancestral territories, and their ethnic identity, as a basis of their continued existence as peoples, in accordance with their own cultural patterns, social institutions and legal system.”
     
   • We have deliberately used the term Indigenous in our revised objectives to re ect the principle that residents developing competencies in Indigenous health will be learning within a speci c local context depending on
     their training site (ie. Nanaimo site residents train on Snuneymux First Nation territory, Prince George site res- idents train on Lheidli T’enneh territory etc.). They will have reciprocal educational relationships with the local Indigenous peoples they are serving. In addition to being based on a speci c Indigenous territory, the residents will be expected to care for other Indigenous peoples who currently reside on that territory (ie� Cree or Mohawk people that now live on the West Coast)� The intention of the objectives is for the residents to develop a set of skills, attitudes and approaches to culturally safe care that will assist them to develop therapeutic relationships with Indigenous peoples in their future practice locales, regardless of the speci c geography.
     
   • Cultural safety: Cultural safety is the outcome of interactions where individuals experience their cultural identity and way of being as having been respected or, at least, not challenged or harmed. It is determined by the recipi- ent of a service, or the participant in a program or project. 
     

​
Medical Expert
The resident will demonstrate the knowledge, skills and behaviours necessary to providing compassion- ate, culturally safe, relationship-centred care for Indigenous patients, their families and communities. (see de nition of cultural safety above)

1. Demonstrate awareness of the connection between historical and current government practices towards Indigenous peoples (including, but not limited to: colonization, residential schools, treaties, bills, land claims, segregation and Indian hospitals), and the intergenerational health outcomes that have re- sulted�
2. 
   • 1.2 Demonstrate an understanding of the impact and correlation of the various medical, social and spiritu- al determinants of health and well-being on Indigenous peoples�
   
   • 1.3 Demonstrate an awareness of the context of patient referrals, especially as it relates to patients trav- elling unaccompanied from remote locations, and engage in effective patient-centered consultation with health care professionals in the patients’ home community to establish and ensure appropriate support systems and follow-up for sustained culturally appropriate care�
   
   • 1�4 Demonstrate an understanding of the cultural diversities of Indigenous peoples that result in a variety of perspectives, attitudes, beliefs and behaviours.
   
   • 1.5 Demonstrate an understanding of the strengths and resilience of Indigenous peoples, families and communities�
   

Communicator

The resident will demonstrate effective and culturally safe communication with Indigenous patients, their families and peers. (see de nition of cultural safety above)

• 2�1 Demonstrate cultural safety as it pertains to individual Indigenous patients�

• 2�2 Establish positive therapeutic relationship with Indigenous patients and their families� Effective and culturally safe communication encourages reciprocity, equality, trust, respect, honesty and empathy.


2.3 Deliver information to Indigenous patients and their families regarding tests, reports, protocols and diagnoses and treatment plans in a way that is understandable, respectful and encourages participation in decision-making� 

Collaborator

The resident will demonstrate the skills of effective collaboration with both Indigenous and non-Indige- nous health care professionals in the provision of effective health care for Indigenous patients/popula- tions�

• 3�1 Demonstrate how to appropriately enquire whether an Indigenous patient is taking traditional herbs or medicines to treat their ailment and how to integrate that knowledge into their care�

Manager

The resident will be able to demonstrate an approach to optimizing the health of Indigenous communities through an equitable allocation of health care resources, balancing effectiveness, ef ciency and access, employing evidence-based and Indigenous best practices.

• 4�1 Describe the complexity of providing health care in context to jurisdictional areas and local health service models�

• 4�2 Understand the discrimination which occurs in allocating medical resources or treatments which impact the inequalities in medical care at the population level�

• 4�3 Practice due diligence in applying a decolonizing approach to measurements of outcomes and in- terpretation of statistical data as it relates to overall improvements in population health for Indigenous populations�

• 4.4 Describe the concepts of community development, ownership, engagement, empowerment, capaci- ty-building, reciprocity and respect in relation to health care delivery in and by Indigenous communities.

• 4.5 Identify and describe key Indigenous community contacts, resources and support structures in the provision of effective health care for Indigenous patients

• 4�6 Research successful approaches that have been implemented to improve the health of Indigenous peoples, either locally or nationally.

Health Advocate

The resident will be able to identify the determinants of health of Indigenous populations relevant to the specialty and use this knowledge to promote the health of individual Indigenous patients and their commu- nities.

• 5.1 Demonstrate an understanding of the inequity of access to health care/health information for Indigenous peoples and factors such as discrimination, racism and assimilation that contribute to it.


5�2 Demonstrate an understanding of the impact of government policies on the healthcare of Indigenous communities

• 5�3 Identify and acknowledge racism towards Indigenous people as a risk factor for illness and health inequity�

• 5.4 Demonstrate ways of respectfully addressing direct, indirect and institutionalized racism towards Indigenous peoples�

Scholar


6�1 Demonstrate appropriate strategies of working with Indigenous populations to identify health issues and needs�

• 6�2 Demonstrate effective sharing and promotion of population health strategies and health information with Indigenous patients/populations.

• 6�3 Demonstrate ways of respectfully acquiring information (in a transparent manner) about Indigenous populations which involves communities as partners� This may include respectfully engaging in local community protocols required to seek knowledge/research.

• 6�4 Critically assess the strengths and limitations of available data used as key indicators of Canadian Aboriginal health and recognize the rights of Indigenous communities relating to self-determination of research agendas and processes�

Professional

The resident will demonstrate a commitment to engaging in dialogue and relationship- building with Indigenous peoples to improve health through increased personal and professional development, aware- ness and insights of Indigenous peoples, cultures, and health practices.

• 7.1 Identify, acknowledge and analyse one’s own cultural values or considered emotional response to the many histories and contemporary environment of Indigenous peoples and offer opinions respectfully�

• 7.2 Acknowledge and analyse the limitations of one’s own knowledge and perspectives, and incorporate new ways of seeing, valuing and understanding with regard to Indigenous health practice.

• 7�3 Understand the importance of reciprocity and exchange with Indigenous communities and engage in opportunities to give back to communities in return for contributing to resident’s learning opportunity�

• 7.4 Demonstrate authentic, supportive and inclusive behaviour in all exchanges with Indigenous individu- als and communities�

Global + international health

By the end of postgraduate training, using a pa ent-centred approach and appropriate selec vity, a resident, considering
the pa ent’s cultural and gender contexts, will be able to...

1. Demonstrate knowledge of where to access travel medicine and tropical medicine information and support
   
2. Conduct pre-travel consultations, including providing safety and hygiene information, appropriate immunizations,
   and prophylaxis and awareness of local resources
   
3. Discuss the resources available to meet the speci c needs of new immigrants and refugees (including current national guidelines)
   
4. Describe the pathophysiology, epidemiology, and treatment of diseases that have major global health implica- tions (current or historical) both in Canada and internationally (e.g. TB, HIV, malaria, in uenza, Ebola, West Nile, Zika, SARS), and explain how Canada is linked to other countries with respect to these diseases
   
5. Initially manage tropical diseases that can be encountered in BC including initiating appropriate responses to dis- eases with public health implications (eg personal protective equipment, rapid noti cation of public health etc)
   
6. Describe the public health system of British Columbia and its relation to international health problems
   
7. Describe how social determinants of health, distribution of health resources and burden of illness contribute to
   global health inequities
   
8. Describe how con ict/war negatively impacts the social determinants of health on an individual and community level
   
9. Identify clinical interventions which have the most impact in resource-constrained environments e�g� immuniza- tions, essential drugs, maternal/infant health programs, health education
   
10. Describe how limited access to specialist support and diagnostic technologies changes clinical practice
    
11. Discuss ethical implications, both positive and negative, of international health work 
    

hiv primary care

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...

1. Describe HIV transmission routes, risk factors and counsel prevention strategies
2. Explain HIV/AIDS pathogenesis
3. Distinguish the populations and the vulnerabilities of the populations most impacted by HIV/AIDS
4. Offer HIV testing to all patients as appropriate
5. Offer vaccinations appropriate for an HIV positive person
6. Discuss antiretroviral therapy and ongoing monitoring
7. Demonstrate awareness of the most common opportunistic infections 
8. Manage risk and occupational exposures according to provincial guidelines including post-exposure prophylaxis
9. Discuss strategies for prevention of mother to child transmission with reference to protocols for pregnant women at risk/HIV+ through pregnancy/labour and delivery, and the postpartum
10. Describe, investigate for and manage important co-infections (e.g. Hepatitis C, syphilis)
11. Identify when specialist advice/referral is indicated including how and when to access the BC Centre For Excellence in HIV 

rural medicine

1. By the end of postgraduate training, using a pa ent-centred approach and appropriate selec vity, a resident, considering
   the pa ent’s cultural and gender contexts, will be able to...
   
   • Display increasing independence and responsibility in the comprehensive care of patients across the lifespan
     
   • Identify the diversity and variety of procedural skills required by the rural physician
     
   • Demonstrate competence in advanced lifesaving skills
     
   • Demonstrate how to transport a patient in a timely and effective manner despite signi cant barriers
     
   • Identify ways in which successful rural physicians maintain their knowledge, skills, competence, con dence and resilience
     
   • Display understanding of the role of a rural physician within a community-based hospital and integrated medical community
     
   • Manage acute and chronic medical illnesses in various rural settings (community, outpatient clinic, emergency room, and hospital)
     
   • Demonstrate core procedural skills with increasing con dence
     
   • Justify the indications for admission of patients to hospital for investigation and/or treatment in a rural setting
     
   • Consider the effects of hospitalization on the patient and family taking into account the distance, cost and logis- tics associated with transfer to a higher level of care
     
   • Utilize specialists’ guidance appropriately from a remote setting either hospital orclinic, using telehealth, video- conferencing and teleconferencing
     
   • Develop and use fallback measures for emergent and clinic care of patients inthe event of telecommunication, technology, or transfer failure
     
   • Commit to on-going medical education, with an emphasis on rural healthcare
     
   • Describe the advisory role of rural physicians in the management and operations of health care facilities
     
   • Demonstrate an awareness for the need to have a heightened sensitivity to patient con dentiality and profes- sional boundaries while practicing in a rural or remote setting 
     

​

behavioural medicine + resident wellness

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...

• Demonstrate proficient assessment and management of patients using the patient-centred method
• Demonstrate proficient active listening, verbal and non-verbal skills, expression of empathy, unconditional positive regard and genuineness
• Demonstrate proficiency in establishing a strong doctor-patient relationship and therapeutic alliance
• Recognise how past personal and professional experiences (including Family of Origin) impact the Doctor-Patient relationship
• Evaluate the impact of his or her own personal feelings on the therapeutic alliance (self-FIFE)
• Recognize signs and symptoms of burnout in one’s self and colleagues
• List resources to promote and support physician health
• Use reflective practice as a means of promoting personal and patient care
• Recognize the importance of wellness and resiliency in personal and patient care
• Demonstrate awareness that the physician is perceived in community as a role model for healthy lifestyle/living
• Demonstrate appropriate personal and professional boundaries in the doctor-patient relationship
• Outline a patient’s problems with a realistic and longitudinal view, while balancing the priorities of the patient and physician
• Devise a management plan that the patient agrees to and can ful l and provide appropriate follow up for mental health and lifestyle change problems
• Demonstrate the con dence and skills to manage dif cult (emotionally intense) interactions
• Address all aspects of a person including: physical health, emotional health, life stage and individual development (normative developmental stages), sexuality, spirituality, health beliefs, culture/ethnicity, relationships, work, school, household, money/ nances, leisure time
• Demonstrate sensitivity to the power differential between doctor and patient and understand the potential for the abuse of that power
• Differentiate between normal range of experiences and common mental health disorders (normal vs� atypical grief, mood symptoms vs. mood disorders, age-related cognitive decline and dementia etc.) and manage appro- priately
• Discuss the effects of abuse, neglect, and psychological/emotional/physical trauma on future health
• Recognize the role of advocacy in patient and physician health 

​

transition to practice

By the end of postgraduate training, using a pa ent-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Perform the basics of fee-for-service billing for full service family practice (including office and out-office billing), and demonstrate familiarity with fee incentives and alternative payment models
• Identify local, regional and national Family Medicine professional organizations that support our work as family physicians (ex: CPSBC, Doctors of BC, CFPC/BCCFP, GPSC, PSP, Divisions of Family Practice) 
• Explain the concept of incorporating your practice, its pros and cons, and the resources required (Accountant, Lawyer)
• Demonstrate an understanding of corporate and personal taxation as it applies to professional income and your ling requirements upon graduation from Residency
• Discuss what you should consider before joining a practice and common pitfall
• Discuss ways to promote teamwork amongst your clinic staff to support your work flow, improve efficiency, and encourage collegiality
• ​Identify resources and contacts available to physicians for starting or joining a practice
• Demonstrate knowledge and skills in the use of Electronic Medical Records and understand how they can sup- port practice improvement
• Identify the basics of a medicolegal report and other legally binding forms (ex: Disability, WorkSafeBC)
• Describe an approach to negotiating a Locum Contract
• Outline the obligations, benefits and risks of locum work
• Outline the College complaints process and the implications of formal complaints
• Describe a basic approach to dealing with College complaints, including available resources and supports
• Demonstrate complete charting for patient-care and medicolegal protection (i.e., legibility, pertinent positive and
  negatives, and clear follow-up instruction)
• Describe strategies for practice management and human resource management in the office
• Describe a strategic approach to scheduling that improves efficiency and provides patients access to timely care
• Discuss ways to promote teamwork amongst your clinic staff to support your workflow, improve efficiency, and encourage collegiality
• Describe the benefits of disability insurance, professional liability insurance, and malpractice insurance
• Demonstrate awareness of medicolegal process (i.e., know to call CMPA) ​

collaborator

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...

1. Apply strategies to integrate and engage health care profession colleagues in respectful shared decision-making
2. Negotiate role overlap and responsibilities in longitudinal patient centred care (including explanation of own role and responsibilities, active inquiry about others roles and responsibilities, con rmation of understanding)
3. Demonstrate pro ciency in active team-based care including determining when care should be transferred to another physician or health care provider, safe handover of care and structured approaches to both transitions in care and ongoing shared care
4. Manage transitions and transfers of care through clear communication (verbal and written) with all health care providers
5. Demonstrate strategies of collaborative leadership
6. Demonstrate constructive con ict resolution with patients and other medical professionals
7. Exhibit the ability to work collaboratively and effectively within a collegial, multidisciplinary framework of health care delivery, including working with colleagues and institutions from/in other cultures
8. Use referrals, support networks and community resources as part of a patient-centred management plan
9. Communicate and implement the key components of an appropriate transfer or discharge plan using interdisci- plinary team resources (e.g. accurate documentation and con rmation of accountability)
10. Demonstrate respect for patient’s choice through support of a patient’s desire to include other health care pro- fessionals in the care team
11. Demonstrate accountability to team
12. Describe the role of other health professionals in the management of acute and chronic illness
13. Coordinate community-based, shared-care management of illnesses
14. Participate effectively in interdisciplinary team meetings
15. Integrate an evidence-based practice model into the collaborative / interdisciplinary care of patients with chronic illness
16. Collaborate with patients, families, and other health care workers when ethical dilemmas arise
17. Empower patients to participate collaboratively in their treatment goals by establishing common ground in an
    atmosphere of safety and trust
18. Provide appropriate advice and reassurance regarding common illnesses which do not routinely require medical attention
19. Incorporate families and other caregivers in the care of patients, while abiding by the ethical standards of patient autonomy and consent ​

communicator

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...

• Illustrate the importance of family meetings and demonstrate a systematic approach to working with families of patients managing their needs and expectation
• Use both general and active listening skills to facilitate communication and allow the patient tell their story
• Demonstrate awareness of different cultural views of ethics, the birthing process, illness, death and dying
• Demonstrate sensitivity to patients who are a different age, gender or cultural group from oneself
• Actively elicit and synthesize information from and perspectives of patients and families, colleagues and other professionals
• Effectively communicate medical evidence to patients in a manner that respects their autonomy and empowers them to make informed decisions
• Provide patients and families with information or sources such as the internet and written literature regarding preventative care and management of illnesses
• Use verbal and written language that is understandable by the patient
• Demonstrate a process of review with trusted and respected colleagues around ethics when adverse events or “near misses” occur
• Demonstrate the ability to disclose medical error to a patient in a timely manner
• When confronted with a dif cult patient interaction, seek out information about their life circumstances, current context and functional status to help better understand the patient’ s frame of reference
• Demonstrate an understanding of administrative issues associated with transfer of a critically ill patient, and include the patient and family in decision-making, follow-up after transfer
• Demonstrate effective empathic communication skills in delivery of life-altering news and difficult information
• Demonstrate an ability to assess a patient’ s motivation to change (ex: ‘ Stages of Change’ theory)
• Utilize effective documentation to record patient information using medical records that are clear, concise, timely and accessible
• Outline how Electronic Medical Records (EMRs) and other electronic tools can be used in practice and how their use can positively and negatively impact the doctor-patient relationship
• Discuss the use and limitations of communicating by telephone, instant messaging and email both from both a clinical and security perspective
• Gather information not only about the disease but also about the patient’ s beliefs, concerns and expectations about the illness, while considering the in uence of factors such as the patient’ s age, gender, ethnic, cultural and socio-economic background,and spiritual values on that illness
• Express the importance of continuity, trust and relationships especially when working with marginalized commu- nities
• Take the time to explore patients preconceived ideas regarding medical care and provide accurate explanations regarding care
• Show concern for the effects of patients’ past experiences, coping mechanisms or lay knowledge on a patient’ s expectations of outcomes
• Respect privacy and confidentiality of patients
• Demonstrate pro ciency in active listening, verbal and non-verbal skills, expression of empathy, and a respectful,
  non-judgmental focus
• Build positive, compassionate therapeutic relationships between patients, families, and health care team members
• Recognize the importance of continuity in patient care and building rapport and earning trust
• Use interpersonal skills to effectively manage dif cult situations such as con ict, uncertainty, frustration, fear,
  and grief be it in the physician, patient, and the healthcare team
• Include psychosocial support of patients, families and friends as part of the treatment plan
• Develop a common understanding on issues, problems, and plans with patients and families, colleagues, and other professionals to develop, provide and follow-up on shared plan of care ​

health advocate

By the end of postgraduate training, using a pa ent-centred approach and appropriate selec vity, a resident, considering the pa ent’s cultural and gender contexts, will be able to... 

• Advocate with (or on behalf of when appropriate) individual patients with respect to physical, psychological and social health issues
• Facilitate access to services for all patients, being mindful of the patient with social, economic and/or health barriers
• Assess barriers to rehabilitation and recovery
• Identify and encourage patients’ strengths
• Incorporate relevant health promotion and disease prevention strategies into the clinical encounter including lifestyle assessment, screening and education
• Support public education which promotes health and prevention of illness and injury
• Evaluate the health needs of a community and identify at-risk communities
• Demonstrate awareness of local culture as it pertains to certain medical conditions (ex: HIV and international work)
• Develop meaningful and trusting relationships to become an advocate for community issues
• Outline population-based approaches to health care services and their implication for medical practice including
  impact on individual patients and prioritization to access (ex: mammography, HIV treatment as prevention).
• Address determinants of health as it pertains to the health status of and individual or community
• Outline services and resources available to meet the needs of patients in the hospital and community and utilize them appropriately
• Identify barriers to improved health, and accessing resources in the community, and work to ameliorate these barriers
• Apply knowledge of the health system and community resources to advocate for change (ex: practice, hospital, community, or policy level) to best care for the people they serve ​

Manager

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...

1. Integrate community resources to support continuity of patient care including other health professionals, com-munity agencies and groups either within the community or on referral out of the community
2. Work collaboratively with public health officials, community leaders, alternative health providers, and educators in the promotion of public and preventative health
3. Identify and manage potential hazards of hospital/institutional care (ex: delirium, falls, immobility, pressure ulcers, incontinence, indwelling catheters, adverse drug events, malnutrition)
4. Provide cost effective medical care in decisions regarding hospitalization, test utilization and billing, balancing effectiveness, efficiency and access with optimal patient care
5. Accurately assess local resource limitations and appropriately communicate with specialists at a tertiary care centre and with patient’s families regarding the transfer process if necessary
6. Justify priority setting in the context of communities with limited resources
7. Advise on the management and use of scarce resources, based on international evidence 
8. Describe the role the physician in the prioritization, management and utilizations of health care facility resources.
9. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
   to ensure personal health and a sustainable practice
10. Integrate electronic tools into daily practice
11. Describe family practice role in community disasters and mass-casualty incidents
12. Evaluate and improve one’s clinical knowledge and practices, by developing expertise in practice-based clinical practice audit
13. Describe the opportunity for family physician involvement in the business and scal management in health care setting
14. Work collaboratively with MOA, clinic manager and others in a clinic setting in a way that optimizes clinic effectiveness
15. Describe the process of patient transfer network communication and patient transfer logistics ​

professional

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...

1. Exhibit day to day behaviour that is responsible, reliable and trustworthy
2. Recognize limits of clinical competence and seek help appropriately
3. Operate with a exible, open-minded approach that is resourceful and deals with uncertainty
4. Demonstrate confidence without arrogance, and does so even when needing to obtain further information or assistance
5. Act in a caring and compassionate manner
6. Show respect for patients in all ways, maintain appropriate boundaries and demonstrate committed to patient
   wellbeing
7. Demonstrate effective time management, appropriate availability and willingness to assess performance
8. Demonstrate respect for colleagues and team members
9. Display commitment to societal and community well being
10. Show a commitment to personal health and seek balance between personal life and professional responsibilities
11. Demonstrate a mindful approach to practice by maintaining composure/equanimity, even in dif cult situations and by engaging in thoughtful dialogue about values and motives
12. Act in an ethical and honest manner
13. Collaborate and facilitate ethical decision making with patients, families and other health care workers/spiritual
    caregivers when ethical dilemmas arise
14. Recognize cultural and gender differences in values and demonstrate awareness of how past personal and professional experiences may affect decision making
15. Consider the role of power in interactions with the patient, the patient’s family, and community
16. Describe the UBC Policy on Personal Beliefs, Education, and Patient Care
17. Outline the Canadian Medical Association’s Code of Ethics
18. Explain the role of professional ethicists and ethics committees and suggest when and how to call on them for
    assistance
19. Interpret the core principles of medical ethics (autonomy, beneficence, nonmaleficence, justice) as they apply to clinical encounters
20. Apply appropriate medical, ethical, and medico-legal frameworks to decision making
21. Explain the regulations around terminating physician-patient relationship
22. Demonstrate knowledge of child protection issues
23. Demonstrate knowledge about patient con dentiality, informed consent, competence and substitute decision makers, about proper interaction with law enforcement agencies and about the role of the medical examiner’s of ce
24. Demonstrate knowledge of relevant jurisprudence (ex: Mental Health Act, Duty to Disclose, Apology Act, Health Professions Act)
25. Discuss the effect of legal considerations in the application of ethics 

Scholar

1. By the end of postgraduate training, using a pa ent-centred approach and appropriate selec vity, a resident, considering the pa ent’s cultural and gender contexts, will be able to...
   Lifelong learning and continuing professional development: Maintain and enhance professional ac vi es through ongoing self-directed learning based on re ec ve prac ce
   
   • Describe the principles in maintaining professional competence and implementing a personal knowledge man- agement system
     
   • Recognize and re ect learning issues in practice
     
   • Conduct a personal practice audit
     
   • Formulate a learning question
     
   • Identify sources of knowledge appropriate to the question
     
   • Access and interpret the relevant evidence
     
   • Integrate new learning into practice
     
   • Evaluate the impact of any change in practice
     
   • Document the learning process
     Evidence-based medicine: Cri cally evaluate medical informa on, its sources, and its relevance to their prac ce, and apply this informa on to prac ce decisions
     
   • Describe the principles of critical appraisal
     
   • Critically appraise retrieved evidence in order to address a clinical question 
     

Integrate critical appraisal conclusions into clinical care
Resident as Educator: Facilitate the educa on of pa ents, families, trainees, other health professional colleagues, and
the public, as appropriate

• Describe principles of learning relevant to medical education and practical strategies to apply these in medical education settings
  
• Co-develop an educational plan with a learner, including strategies to assess identi ed learning goals
  
• Apply learner-centered clinical teaching techniques, such as using questioning, the One Minute Preceptor, or
  SNAPPS Identify strategies for enhancing the quantity and quality of direct observation of learner performance
  
• Provide effective feedback to a learner
  
• Design and deliver an interactive group learning session
  
• Identify patient-centered strategies to facilitate patient learning
  
• Assess and re ect on a teaching encounter
  Scholarship: Contribute to the crea on, dissemina on, applica on, and transla on of new knowledge and prac ces
  

• Describe the principles of research and scholarly inquiry
  
• Judge the relevance, validity, and applicability of research ndings to their own practice and individual patients
  
• Describe the principles of research ethics
  
• Pose a scholarly question
  
• Conduct a search for evidence
  
• Select and apply appropriate methods to address the question
  
• Appropriately disseminate the ndings of a study 
  

​

Priority Topics

Abdominal Pain

1. Given a patient with abdominal pain, paying particular attention to its location and chronicity:
   a) Distinguish between acute and chronic pain. 
   b) Generate a complete differential diagnosis (ddx).
   c) Investigate in an appropriate and timely fashion.
2. In a patient with diagnosed abdominal pain (ex: gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (ex: with. medication, lifestyle modifications).
3. In a woman with abdominal pain:
   1. Always rule out pregnancy if she is of reproductive age.
   2. Suspect gynecologic etiology for abdominal pain.
   3. Do a pelvic examination, if appropriate.
4. In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen.
5. In specific patient groups (ex: children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx.
6. Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy):
   1. ​Recognize the life-threatening situation.
   2. Make the diagnosis.
   3. Stabilise the patient.
   4. Promptly refer the patient for definitive treatment.
7. In a patient with chronic or recurrent abdominal pain:
   1. Ensure adequate follow-up to monitor new or changing symptoms or signs.
   2. Manage symptomatically with medication and lifestyle modification (ex: for irritable bowel syndrome).
   3. Always consider cancer in a patient at risk.
8. Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation. 

Advanced cardiac life support

1. Keep up to date with advanced cardiac life support (ACLS) recommendations (i.e., maintain your knowledge base).
2. Promptly defibrillate a patient with ventricular fibrillation (V fib), or pulseless or symptomatic ventricular tachycardia (V tach).
3. Diagnose serious arrhythmias (V tach, V fib, supraventricular tachycardia, atrial fibrillation, or second- or third-degree heart block), and treat according to ACLS protocols.
4. Suspect and promptly treat reversible causes of arrhythmias (ex: hyperkalemia, digoxin toxicity, cocaine intoxication) before confirmation of the diagnosis.
5. Ensure adequate ventilation (i.e., with a bag valve mask), and secure the airway in a timely manner.
6. In patients requiring resuscitation, assess their circumstances (ex: asystole, long code times, poor pre-code prognosis, living wills) to help you decide when to stop. (Avoid inappropriate resuscitation.)
7. In patients with serious medical problems or end-stage disease, discuss code status and end-of-life decisions (ex: resuscitation, feeding tubes, levels of treatment), and readdress these issues periodically.
8. Attend to family members (ex: with counselling, presence in the code room) during and after resuscitating a patient.
9. In a pediatric resuscitation, use appropriate resources (ex: Braeslow tape, the patient’s weight) to determine the correct drug doses and tube sizes.

Allergy

1. In all patients, always inquire about any allergy and clearly document it in the chart. Re-evaluate this periodically.
2. Clarify the manifestations of a reaction in order to try to diagnose a true allergic reaction (ex: do not misdiagnose viral rashes as antibiotic allergy, or medication intolerance as true allergy).
3. In a patient reporting allergy (ex: to food, to medications, environmental), ensure that the patient has the appropriate medication to control symptoms (ex: antihistamines, bronchodilators, steroids, an EpiPen).
4. Prescribe an EpiPen to every patient who has a history of, or is at risk for, anaphylaxis.
5. Educate appropriate patients with allergy (ex: to food, medications, insect stings) and their families about the symptoms of anaphylaxis and the self-administration of the EpiPen, and advise them to return for immediate reassessment and treatment if those symptoms develop or if the EpiPen has been used.
6. Advise patients with any known drug allergy or previous major allergic reaction to get a MedicAlert bracelet.
7. In a patient presenting with an anaphylactic reaction:
   1. Recognize the symptoms and signs.
   2. ​Treat immediately and aggressively.
   3. Prevent a delayed hypersensitivity reaction through observation and adequate treatment (ex: with steroids).
8. In patients with anaphylaxis of unclear etiology refer to an allergist for clarification of the cause.
9. In the particular case of a child with an anaphylactic reaction to food:
   1. ​Prescribe an EpiPen for the house, car, school, and daycare.
   2. Advise the family to educate the child, teachers, and caretakers about signs and symptoms of anaphylaxis, and about when and how to use the EpiPen.
10. In a patient with unexplained recurrent respiratory symptoms, include allergy (ex: sick building syndrome, seasonal allergy) in the differential diagnosis. 

Anemia

1. Assess the risk of decompensation of anemic patients (ex: volume status, the presence of congestive heart failure [CHF], angina, or other disease states) to decide if prompt transfusion or volume replacement is necessary.
2. In a patient with anemia, classify the anemia as microcytic, normocytic, or macrocytic by using the MCV (mean corpuscular value) or smear test result, to direct further assessment and treatment.
3. In all patients with anemia, determine the iron status before initiating treatment.
4. In a patient with iron deficiency, investigate further to find the cause.
5. Consider and look for anemia in appropriate patients (ex: those at risk for blood loss [those receiving anticoagulation, elderly patients taking a nonsteroidal anti-inflammatory drug]) or in patients with hemolysis (mechanical valves), whether they are symptomatic or not, and in those with new or worsening symptoms of angina or CHF.
6. In patients with macrocytic anemia:
   a) Consider the possibility of vitamin B12 deficiency.
   b) Look for other manifestations of the deficiency (ex: neurologic symptoms) in order to make the diagnosis of pernicious anemia when it is present.
7. As part of well-baby care, consider anemia in high-risk populations (ex: those living in poverty) or in high-risk patients (ex: those who are pale or have a low-iron diet or poor weight gain).
8. When a patient is discovered to have a slightly low hemoglobin level, look carefully for a cause (ex: hemoglobinopathies, menorrhagia, occult bleeding, previously undiagnosed chronic disease), as one cannot assume that this is normal for them.
9. In anemic patients with menorrhagia, determine the need to look for other causes of the anemia. ​​

antibiotics

1. ​In patients requiring antibiotic therapy, make rational choices (i.e., first-line therapies, knowledge of local resistance patterns, patient’s medical and drug history, patient’s context).
2. In patients with a clinical presentation suggestive of a viral infection, avoid prescribing antibiotics.
3. In a patient with a purported antibiotic allergy, rule out other causes (ex: intolerance to side effects, non-allergic rash) before accepting the diagnosis.
4. Use a selective approach in ordering cultures before initiating antibiotic therapy (usually not in uncomplicated cellulitis, pneumonia, urinary tract infections, and abscesses; usually for assessing community resistance patterns, in patients with systemic symptoms, and in immunocompromised patients).
5. In urgent situations (ex: cases of meningitis, septic shock, febrile neutropenia), do not delay administration of antibiotic therapy (i.e., do not wait for confirmation of the diagnosis).

anxiety

1. Do not attribute acute symptoms of panic (ex: shortness of breath, palpitations, hyperventilation) to anxiety without first excluding serious medical pathology (ex: pulmonary embolism, myocardial infarction ) from the differential diagnosis (especially in patients with established anxiety disorder).
2. When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder:
   1. Exclude serious medical pathology
   2. Identify:
      1. Other co-morbid psychiatric conditions
      2. Abuse
      3. Substance abuse
   3. Assess the risk of suicide
3. In patients with known anxiety disorders, do not assume all new symptoms are attributable to the anxiety disorder.
4. Offer appropriate treatment for anxiety:
   1. Benzodiazepines (ex: deal with fear of them, avoid doses that are too low or too high, consider dependence, other anxiolytics)
   2. Nonpharmacologic treatment
5. In a patient with symptoms of anxiety, take and interpret an appropriate history to differentiate clearly between agoraphobia, social phobia, generalized anxiety disorder, and panic disorder.

Asthma

1. In patients of all ages with respiratory symptoms (acute, chronic, recurrent):
   1. Include asthma in the differential diagnosis
   2. Confirm the diagnosis of asthma by appropriate use of:
      1. History
      2. Physical examination
      3. Spirometry
2. In a child with acute respiratory distress, distinguish asthma or bronchiolitis from croup and foreign body aspiration by taking an appropriate history and doing a physical examination.
3. In a known asthmatic, presenting either because of an acute exacerbation or for ongoing care, objectively determine the severity of the condition (ex: with history, including the pattern of medication use), physical examination, spirometry. Do not underestimate severity.
4. In a known asthmatic with an acute exacerbation:
   1. Treat the acute episode (ex: use beta-agonists repeatedly and early steroids, and avoid under-treatment).
   2. Rule out co-morbid disease (ex: complications, congestive heart failure, chronic obstructive pulmonary disease).
   3. Determine the need for hospitalization or discharge (basing the decision on the risk of recurrence or complications, and on the patient’s expectations and resources).
5. For the ongoing (chronic) treatment of an asthmatic, propose a stepwise management plan including:
   1. Self-monitoring
   2. Self-adjustment of medication
   3. When to consult back
6. For a known asthmatic patient, who has ongoing or recurrent symptoms:
   1. Assess severity and compliance with medication regimens.
   2. Recommend lifestyle adjustments (ex: avoiding irritants, triggers) that may result in less recurrence and better control.

Atrial fibrillation

1. In a patient who presents with new onset atrial fibrillation, look for an underlying cause (ex:, ischemic heart disease, acute myocardial infarction, congestive heart failure, cardiomyopathy, pulmonary embolus, hyperthyroidism, alcohol, etc.)
2. In a patient presenting with atrial fibrillation:
   1. Look for hemodynamic instability
   2. Intervene rapidly and appropriately to stabilize the patient
3. In an individual presenting with chronic or paroxysmal atrial fibrillation:
   1. Explore the need for anticoagulation based on the risk of stroke with the patient
   2. Periodically reassess the need for anticoagulation
4. In patients with atrial fibrillation, when the decision has been made to use anticoagulation, institute the appropriate therapy and patient education, with a comprehensive follow-up plan
5. In a stable patient with atrial fibrillation, identify the need for rate control
6. In a stable patient with atrial fibrillation, arrange for rhythm correction when appropriate.

Bad news

1. When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality.
2. Give bad news:
   1. In an empathic, compassionate manner
   2. Allowing enough time
   3. Providing translation, as necessary
3. Obtain patient consent before involving the family.
4. After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding.

Behavioural problems

1. Because behavioural problems in children are often multifactorial, maintain a broad differential diagnosis and assess all factors when concern has been raised about a child’s behaviour:
   1. Look for medical conditions (ex: hearing impairment, depression, other psychiatric diagnoses, other medical problems).
   2. Look for psychosocial factors (ex: abuse, substance use, family chaos, peer issues, parental expectations).
   3. Recognize when the cause is not attention deficit disorder (ADD) (ex: learning disorders, autism spectrum disorder, conduct disorder).
2. When obtaining a history about behavioural problems in a child:
   1. Ask the child about her or his perception of the situation.
   2. Use multiple sources of information (ex: school, daycare).
3. When treating behavioural problems in children for whom medication is indicated, do not limit treatment to medication; address other dimensions (ex: do not just use amphetamines to treat ADD, but add social skills teaching, time management, etc.).
4. In assessing behavioural problems in adolescents, use a systematic, structured approach to make an appropriate diagnosis:
   1. Specifically look for substance abuse, peer issues, and other stressors.
   2. Look for medical problems (bipolar disorder, schizophrenia).
   3. Do not say the problem is “just adolescence”.
5. In elderly patients known to have dementia, do not attribute behavioural problems to dementia without assessing for other possible factors (ex: medication side effects or interactions, treatable medical conditions such as sepsis or depression).

breast lump

1. Given a well woman with concerns about breast disease, during a clinical encounter (annual or not):
   1. ​Identify high-risk patients by assessing modifiable and non-modifiable risk factors
   2. Advise regarding screening (mammography, breast self- examination) and its limitations.
   3. Advise concerning the woman’s role in preventing or detecting breast disease (breast self-examination, lifestyle changes).
2. Given a woman presenting with a breast lump (i.e., clinical features):
   1. ​Use the history, features of the lump, and the patient’s age to determine (interpret) if aggressive work-up or watchful waiting is indicated.
   2. Ensure adequate support throughout investigation of the breast lump by availability of a contact resource.
   3. 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.
3. In a woman who presents with a malignant breast lump and knows the diagnosis:
   1. ​Recognize and manage immediate and long-term complications of breast cancer.
   2. Consider and diagnose metastatic disease in the follow- up care of a breast cancer patient by appropriate history and investigation.
   3. Appropriately direct (provide a link to) the patient to community resources able to provide adequate support (psychosocial support).

Cancer

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.
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).
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.)
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.
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.
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.
7. In a patient diagnosed with cancer, be realistic and honest when discussing prognosis. (Say when you don’t know.) 

chest pain

1. Given a patient with undefined chest pain, take an adequate history to make a specific diagnosis (ex: determine risk factors, whether the pain is pleuritic or sharp, pressure, etc.)
2. Given a clinical scenario suggestive of life-threatening conditions (ex: pulmonary embolism, tamponade, dissection, pneumothorax), begin timely treatment (before the diagnosis is confirmed, while doing an appropriate work-up).
3. In a patient with unexplained chest pain, rule out ischemic heart disease.*
4. Given an appropriate history of chest pain suggestive of herpes zoster infection, hiatal hernia, reflux, esophageal spasm, infections, or peptic ulcer disease:
   1. Propose the diagnosis.
   2. Do an appropriate work-up/follow-up to confirm the suspected diagnosis.
5. Given a suspected diagnosis of pulmonary embolism:
   1. Do not rule out the diagnosis solely on the basis of a test with low sensitivity and specificity.
   2. Begin appropriate treatment immediately.

*See also the key features on ischemic heart disease.

chronic disease

1. In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:
   1. Acute complications of the chronic disease (ex: diabetic ketoacidosis).
   2. Acute exacerbations of the disease (ex: asthma exacerbation, acute arthritis).
   3. A new, unrelated condition.
2. Regularly reassess adherence (compliance) to the treatment plan (including medications).
3. In patients with chronic disease:
   1. Actively inquire about pain.
   2. Treat appropriately by:
      1. Titrating medication to the patient's pain.
      2. Taking into account other treatments and conditions (ex: watching for interactions).
      3. Considering non-pharmacologic treatment an adjuvant therapies.
4. In patients with chronic disease, actively inquire about:
   1. The psychological impact of diagnosis and treatment.
   2. Functional impairment.
   3. Underlying depression or risk of suicide.
   4. Underlying substance abuse.
5. Given a non-compliant patient, explore the reasons why, with a view to improving future adherence to the treatment plan.

chronic obstructive pulmonary disease

1. ​In all patients presenting with symptoms of prolonged or recurrent cough, dyspnea, or decreased exercise tolerance, especially those who also have a significant smoking history, suspect the diagnosis of chronic obstructive pulmonary disease (COPD)
2. When the diagnosis of COPD is suspected, seek confirmation with pulmonary function studies (ex: FEV1)
3. In patients with COPD, use pulmonary function tests periodically to document disease progression
4. Encourage smoking cessation in all patients diagnosed with COPD.*
5. Offer appropriate vaccinations to patients diagnosed with COPD (ex: influenza/pneumococcal vaccination)
6. In an apparently stable patient with COPD, offer appropriate inhaled medication for treatment (ex: anticholinergics/bronchodilators if condition is reversible, steroid trial)
7. Refer appropriate patients with COPD to other health professionals (ex: a respiratory technician or pulmonary rehabilitation personnel) to enhance quality of life.
8. When treating patients with acute exacerbations of COPD, rule out comorbidities (ex: myocardial infarction, congestive heart failure, systemic infections, anemia)
9. In patients with end-stage COPD, especially those who are currently stable, discuss, document, and periodically re- evaluate wishes about aggressive treatment interventions.

Note: *See the key features on Smoking Cessation.

contraception

1. ​With all patients, especially adolescents, young men, postpartum women, and perimenopausal women, advise about adequate contraception when opportunities arise.
2. In patients using specific contraceptives, advise of specific factors that may reduce efficacy (ex: delayed initiation of method, illness, medications, specific lubricants).
3. In aiding decision-making to ensure adequate contraception:
   1. Look for and identify risks (relative and absolute contraindications).
   2. Assess (look for) sexually transmitted disease exposure.
   3. Identify barriers to specific methods (ex: cost, cultural concerns).
   4. Advise of efficacy and side effects, especially short-term side effects that may result in discontinuation.
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]).
5. In all patients, especially those using barrier methods or when efficacy of hormonal methods is decreased, advise about post- coital contraception.
6. In a patient who has had unprotected sex or a failure of the chosen contraceptive method, inform about time limits in post- coital contraception (emergency contraceptive pill, intrauterine device).

Cough

1. In patients presenting with an acute cough:
   1. Include serious causes (ex: pneumothorax, pulmonary embolism [PE]) in the differential diagnosis.
   2. Diagnose a viral infection clinically, principally by taking an appropriate history.
   3. Do not treat viral infections with antibiotics. (Consider antiviral therapy if appropriate.)
2. In pediatric patients with a persistent (or recurrent) cough, generate a broad differential diagnosis (ex: gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis).
3. In patients with a persistent (ex: for weeks) cough:
   1. Consider non-pulmonary causes (ex: GERD, congestive heart failure, rhinitis), as well as other serious causes (ex: cancer, PE) in the differential diagnosis. (Do not assume that the child has viral bronchitis).
   2. Investigate appropriately.
4. Do not ascribe a persistent cough to an adverse drug effect (ex: from an angiotensin-converting enzyme inhibitor) without first considering other causes.
5. In smokers with persistent cough, assess for chronic bronchitis (chronic obstructive pulmonary disease) and make a positive diagnosis when it is present. (Do not just diagnose a smoker’s cough.)

counselling

1. In patients with mental health concerns, explore the role of counselling in treating their problems. (Intervention is not just about medication use.)
2. When making the decision about whether to offer or refer a patient for counselling:
   1. ​Allow adequate time to assess the patient.
   2. Identify the patient’s context and understanding of her or his problem/situation.
   3. Evaluate your own skills. (Does the problem exceed the limits of your abilities?)
   4. Recognize when your beliefs may interfere with counselling.
3. When counselling a patient, allow adequate time.
4. When counselling a patient, recognize when you are approaching or exceeding boundaries (ex: transference, counter-transference) or limits (the problem is more complex than you originally thought), as this should prompt you to re- evaluate your role. 

crisis

1. Take the necessary time to assist patients in crisis, as they often present unexpectedly.
2. Identify your patient’s personal resources for support (ex: family, friends) as part of your management of patients facing crisis.
3. Offer appropriate community resources (ex: counselor) as part of your ongoing management of patients with a crisis.
4. Assess suicidality in patients facing crisis.
5. Use psychoactive medication rationally to assist patients in crisis.
6. Inquire about unhealthy coping methods (ex: drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis.
7. Ask your patient if there are others needing help as a consequence of the crisis.
8. Negotiate a follow-up plan with patients facing crisis.
9. Be careful not to cross boundaries when treating patients in crisis (ex: lending money, appointments outside regular hours).
10. Prepare your practice environment for possible crisis or disaster and include colleagues and staff in the planning for both medical and non-medical crises.
11. When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia),
    1. Assess the environment for needed resources (people, material).
    2. Be calm and methodical.
    3. Ask for the help you need.

Croup

1. In patients with croup,
   1. Identify the need for respiratory assistance (ex: assess ABCs, fatigue, somnolence, paradoxical breathing, in drawing)
   2. Provide that assistance when indicated.
2. Before attributing stridor to croup, consider other possible causes (ex: anaphylaxis, foreign body (airway or esophagus), retropharyngeal abcess, epiglottitis).
3. In any patient presenting with respiratory symptoms, look specifically for the signs and symptoms that differentiate upper from lower respiratory disease (ex: stridor vs. wheeze vs. whoop).
4. In a child presenting with a clear history and physical examination compatible with mild to moderate croup, make the clinical diagnosis without further testing (ex: do not routinely X-ray).
5. In patients with a diagnosis of croup, use steroids (do not under treat mild-to-moderate cases of croup).
6. In a patient presenting with croup, address parental concerns (ex: not minimizing the symptoms and their impact on the parents), acknowledging fluctuating course of the disease, providing a plan anticipating recurrence of the symptoms. 

Dehydration

1. ​When assessing the acutely ill patient, look for signs and symptoms of dehydration (ex: look for dehydration in the patient with a debilitating pneumonia).
2. In the dehydrated patient, assess the degree of dehydration using reliable indicators (ex: vital signs) as some patients' hydration status may be more difficult to assess (ex: elderly, very young, pregnant).
3. In a dehydrated patient,
   1. Determine the appropriate volume of fluid for replacement of deficiency and ongoing needs
   2. Use the appropriate route (oral if the patient is able; IV when necessary)
4. When treating severe dehydration, use objective measures (e.g., lab values) to direct ongoing management.
5. In a dehydrated patient,
   1. Identify the precipitating illness or cause, especially looking for non-gastro-intestinal, including drug-related, causes
   2. Treat the precipitating illness concurrently
6. Treat the dehydrated pregnant patient aggressively, as there are additional risks of dehydration in pregnancy.

dementia

1. ​In patients with early, non-specific signs of cognitive impairment:
   1. Suspect dementia as a diagnosis.
   2. Use the Mini-Mental State Examination and other measures of impaired cognitive function, as well as a careful history and physical examination, to make an early positive diagnosis.
2. In patients with obvious cognitive impairment, select proper laboratory investigations and neuroimaging techniques to complement the history and physical findings and to distinguish between dementia, delirium, and depression.
3. In patients with dementia, distinguish Alzheimer’s disease from other dementias, as treatment and prognosis differ.
4. In patients with dementia who exhibit worsening function, look for other diagnoses (i.e., don’t assume the dementia is worsening). These diagnoses may include depression or infection.
5. Disclose the diagnosis of dementia compassionately, and respect the patient’s right to autonomy, confidentiality, and safety.
6. In patients with dementia, assess competency. (Do not judge clearly competent patients as incompetent and vice versa.)
7. In following patients diagnosed with dementia:
   1. Assess function and cognitive impairment on an ongoing basis.
   2. Assist with and plan for appropriate interventions (e.g., deal with medication issues, behavioural disturbance management, safety issues, caregiver issues, comprehensive care plans, driving safety, and placement).
8. Assess the needs of and supports for caregivers of patients with dementia.
9. Report to the appropriate authorities patients with dementia who you suspect should not be driving.
10. In patients with dementia, look for possible genetic factors to provide preventive opportunities to other family members, and to aid in appropriate decision-making (ex: family planning).

Depression

1. In a patient with a diagnosis of depression:
   1. Assess the patient for the risk of suicide.
   2. Decide on appropriate management (i.e., hospitalization or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk).
2. Screen for depression and diagnose it in high-risk groups (ex: certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain).
3. In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient.
4. After a diagnosis of depression is made, look for and diagnose other co-morbid psychiatric conditions (ex: anxiety, bipolar disorder, personality disorder).
5. In a patient diagnosed with depression, treat appropriately:
   1. Drugs, psychotherapy
   2. Referral as necessary
   3. Active modification (ex: augmentation, dose changes, drug changes)
   4. Monitor response to therapy
6. In a patient presenting with symptoms consistent with depression, consider and rule out serious organic pathology, using a targeted history, physical examination, and investigations (especially in elderly or difficult patients)
7. In patients presenting with depression, inquire about abuse: sexual, physical, and emotional abuse (past and current,
   witnessed or inflicted) and substance abuse
8. In a patient with depression, differentiate major depression from adjustment disorder, dysthymia, and a grief reaction.
9. Following failure of an appropriate treatment in a patient with depression, consider other diagnoses (ex: bipolar disorder, schizoaffective disorder, organic disease).
10. In the very young and elderly presenting with changes in behaviour, consider the diagnosis of depression (as they may not present with classic features). 

diabetes

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.
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).
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.
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.
5. In patients with established diabetes:
   1. Look for complications (ex: proteinuria).
   2. Refer them as necessary to deal with these complications
6. In the acutely ill diabetic patient, diagnose the underlying cause of the illness and investigate for diabetic ketoacidosis and hyperglycemia.
7. Given a patient with diabetic ketoacidosis, manage the problem appropriately and advise about preventing future episodes.

Diarrhea

1. In all patients with diarrhea,
   1. Determine hydration status,
   2. Treat dehydration appropriately.
2. In patients with acute diarrhea, use history to establish the possible etiology (ex: infectious contacts, travel, recent antibiotic or other medication use, common eating place for multiple ill patients).
3. In patients with acute diarrhea who have had recent hospitalization or recent antibiotic use, look for clostridium difficile.
4. In patients with acute diarrhea, counsel about the timing of return to work/school (re: the likelihood of infectivity).
5. Pursue investigation, in a timely manner, of elderly with unexplained diarrhea, as they are more likely to have pathology.
6. In a young person with chronic or recurrent diarrhea, with no red flag symptoms or signs, use established clinical criteria to make a positive diagnosis of irritable bowel syndrome (do not overinvestigate).
7. In patients with chronic or recurrent diarrhea, look for both gastrointestinal and nongastrointestinal symptoms and signs suggestive of specific diseases (ex: inflammatory bowel disease, malabsorption syndromes, and compromised immune system). 

difficult patient

1. When physician-patient interaction is deemed difficult, diagnose personality disorder when it is present in patients.
2. When confronted with difficult patient interactions, seek out and update, when necessary, information about the patient’s life circumstances, current context, and functional status.
3. In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times.
4. With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain).
5. When confronted with difficult patient interactions, identify your own attitudes and your contribution to the situation.
6. When dealing with difficult patients, set clear boundaries.
7. Take steps to end the physician-patient relationship when it is in the patient’s best interests.
8. With a difficult patient, safely establish common ground to determine the patient’s needs (ex: threatening or demanding patients).

disability

1. Determine whether a specific decline in functioning (ex: social, physical, emotional) is a disability for that specific patient.
2. Screen elderly patients for disability risks (ex: falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.
3. In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present.
4. In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).
5. For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.
6. In patients at risk for disability (ex: those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (ex: exercises, braces, counselling, work modification).
7. Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is only part of the plan).

dizziness

1. In patients complaining of dizziness, rule out serious cardiovascular, cerebrovascular, and other neurologic disease (ex: arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis).
2. In patients complaining of dizziness, take a careful history to distinguish vertigo, presyncope, and syncope.
   
3. In patients complaining of dizziness, measure postural vital signs.
4. Examine patients with dizziness closely for neurologic signs.
5. In hypotensive dizzy patients, exclude serious conditions (ex: MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) as the cause.
6. In patients with chronic dizziness, who present with a change in baseline symptoms, reassess to rule out serious causes.
7. In a dizzy patient, review medications (including prescription and over-the-counter medications) for possible reversible causes of the dizziness.
8. Investigate further those patients complaining of dizziness who have:
   
   1. Signs or symptoms of central vertigo
      
   2. A history of trauma
      
   3. Signs, symptoms, or other reasons (ex: anticoagulation) to suspect a possible serious underlying cause.

domestic violence

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).
2. In a patient in a suspected or confirmed situation of domestic violence:
   1. Assess the level of risk and the safety of children (i.e., the need for youth protection).
   2. Advise about the escalating nature of domestic violence.
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.
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.

dysuria

1. In a patient presenting with dysuria, use history and dipstick urinalysis to determine if the patient has an uncomplicated urinary tract infection.
2. When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result.
3. Consider non-urinary tract infection related etiologies of dysuria (ex: prostatitis, vaginitis, sexually transmitted disease, chemical irritation) and look for them when appropriate.
4. When assessing patients with dysuria, identify those at higher risk of complicated urinary tract infection (ex: pregnancy, children, diabetes, urolithiasis).
5. In patients with recurrent dysuria, look for a specific underlying cause (ex: post-coital urinary tract infection, atrophic vaginitis, retention).

earache

1. Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM).
2. Include pain referred from other sources in the differential diagnosis of an earache (ex: Tooth abscess, trigeminal Neuralgia, TMJ dysfunction, pharyngitis, etc.).
3. Consider serious causes in the differential diagnosis of an earache (ex: tumours, temporal arteritis, mastoiditis).
4. In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (ex: through proper patient selection and patient education because most otitis Media is of viral origin), and by ensuring good follow-up (ex: reassessment in 48 hours).
5. Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.)
6. In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics).
7. In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever).
8. Test children with recurrent ear infections for hearing loss.

eating disorders

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.
2. When diagnosing an eating disorder, take an appropriate history to differentiate anorexia nervosa from bulimia, as treatment and prognosis differ.
3. In a patient with an eating disorder, rule out co-existing psychiatric conditions (ex: depression, personality disorder, obsessive-compulsive disorder, anxiety disorder).
4. When managing a patient with an eating disorder, use a multidisciplinary approach (ex: work with a psychiatrist, a psychologist, a dietitian).
5. When assessing a patient presenting with a problem that has defied diagnosis (ex: arrhythmias without cardiac disease, an electrolyte imbalance without drug use or renal impairment, amenorrhea without pregnancy), include “complication of an eating disorder” in the differential diagnosis.
6. In the follow-up care of a patient with a known eating disorder:
   1. Periodically look for complications (ex: tooth decay, amenorrhea, an electrolyte imbalance)
   2. Evaluate the level of disease activity (ex: by noting eating patterns, exercise, laxative use)

Elderly

1. In the elderly patient taking multiple medications, avoid polypharmacy by:
   1. Monitoring side effects
   2. Periodically reviewing medication (ex: is the medication still indicated, is the dosage appropriate)
   3. Monitoring for interactions
2. In the elderly patient, actively inquire about non-prescription medication use (ex: herbal medicines, cough drops, over-the- counter drugs, vitamins).
3. In the elderly patient, screen for modifiable risk factors (ex: visual disturbance, impaired hearing) to promote safety and prolong independence.
4. In the elderly patient, assess functional status to:
   1. Anticipate and discuss the eventual need for changes in the living environment
   2. Ensure that social support is adequate
5. In older patients with diseases prone to atypical presentation, do not exclude these diseases without a thorough assessment (ex: pneumonia, appendicitis, depression). 

Fatigue

1. In all patients complaining of fatigue, include depression in the differential diagnosis.
2. Ask about other constitutional symptoms as part of a systematic approach to rule out underlying medical causes in all patients complaining of fatigue.
3. Exclude adverse effects of medication as the cause in all patients complaining of fatigue.
4. Avoid early, routine investigations in patients with fatigue unless specific indications for such investigations are present.
5. Given patients with fatigue in whom other underlying disorders have been ruled out, assist them to place, in a therapeutic sense, the role of their life circumstances in their fatigue.
6. In patients whose fatigue has become chronic, manage supportively, while remaining vigilant for new diseases and illnesses.​

Fever

1. In febrile infants 0-3 months old:
   1. Recognize the risk of occult bacteremia.
   2. Investigate thoroughly (ex: blood cultures, urine, lumbar puncture +/- chest X-ray)
2. In a febrile patient with a viral infection, do NOT prescribe antibiotics.
3. In a febrile patient requiring antibiotic therapy, prescribe the appropriate antibiotic(s) according to likely causative organism(s) and local resistance patterns.
4. Investigate patients with fever of unknown origin appropriately (ex: with blood cultures, echocardiography, bone scans).
5. In febrile patients, consider life-threatening infectious causes (ex: endocarditis, meningitis).
6. Aggressively and immediately treat patients who have fever resulting from serious causes before confirming the diagnosis, whether these are infectious (ex: febrile neutropenia, septic shock, meningitis) or non-infectious (ex: heat stroke, drug reaction, malignant neuroleptic syndrome).
7. In the febrile patient, consider causes of hyperthermia other than infection (ex: heat stroke, drug reaction, malignant neuroleptic syndrome).
8. In an elderly patient, be aware that no good correlation exists between the presence or absence of fever and the presence or absence of serious pathology.

fractures

1. In a patient with multiple injuries, stabilize the patient (ex: airway, breathing, and circulation, and life-threatening injuries) before dealing with any fractures.
2. When examining patients with a fracture, assess neurovascular status and examine the joint above and below the injury.
3. In patients with suspected fractures that are prone to have normal X-ray findings (ex: scaphoid fractures in wrist injuries, elbow fracture, growth plate fracture in children, stress fractures), manage according to your clinical suspicion, even if X-ray
4. In assessing elderly patients with an acute change in mobility (i.e., those who can no longer walk) and equivocal X-ray findings (ex: no obvious fracture), investigate appropriately (ex: with bone scans, computed tomography) before excluding a fracture.
5. Identify and manage limb injuries that require urgent immobilization and/or reduction in a timely manner.
6. In assessing patients with suspected fractures, provide analgesia that is timely (i.e., before X-rays) and adequate (ex: narcotic) analgesia.
7. In patients presenting with a fracture, look for and diagnose high-risk complications (ex: an open fracture, unstable cervical spine, compartment syndrome).
8. Use clinical decision rules (ex: Ottawa ankle rules, C-spine rules, and knee rules) to guide the use of X-ray examinations.

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gender specific issues

1. In the assessment of clinical problems that might present differently in men and women, maintain an inclusive differential diagnosis that allows for these differences (ex: women with coronary artery disease, depression in males).
2. As part of caring for women with health concerns, assess the possible contribution of domestic violence.
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).
4. Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (e.g., positioning for Pap, chaperones for genital/rectal exams).
5. Interpret and apply research evidence for your patients in light of gender bias present in clinical studies (ex: ASA use in women).

Grief

1. In patients who have undergone a loss, prepare them for the types of reactions (ex: emotional, physical) that they may experience.
2. In all grieving patients, especially those with a prolonged or abnormal grief reaction, inquire about depression or suicidal ideation.
3. Recognize atypical grief reactions in the very young or the elderly (ex: behavioral changes).
4. In patients with a presentation suggestive of a grief reaction without an obvious trigger, look for triggers that may be unique to the patient (ex: death of a pet, loss of a job). 

hypertension

1. Screen for hypertension.
2. Use correct technique and equipment to measure blood pressure.
3. Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits).
4. In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications:
   1. Take an appropriate history.
   2. Do the appropriate physical examination.
5. Arrange appropriate laboratory investigations.
   
6. In appropriate patients with hypertension (ex: young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics):
   1. Suspect secondary hypertension.
      
   2. Investigate appropriately.
7. Suggest individualized lifestyle modifications to patients with hypertension. (ex: weight loss, exercise, limit alcohol consumption, dietary changes).
8. In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (ex: consider the patient’s age, concomitant disorders, other cardiovascular risk factors).
9. Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly.
10. In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow- up visits.

immigrants

1. As part of the periodic health assessment of newly arrived immigrants:
   1. Assess vaccination status (as it may not be up to date).
   2. Provide the necessary vaccinations to update their status.
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).
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).
4. As part of the ongoing care of all immigrants (particularly those who appear not to be coping):
   1. Screen for depression (i.e., because they are at higher risk and frequently isolated).
   2. Inquire about a past history of abuse or torture.
   3. Assess patients for availability of resources for support (ex: family, community organizations).
5. In immigrants presenting with a new or ongoing medical condition, consider in the differential diagnosis infectious diseases acquired before immigration (e.g., malaria, parasitic disease, tuberculosis).
6. As part of the ongoing care of all immigrants, inquire about the use of alternative healers, practices, and/or medications (ex: ‘‘natural’’ or herbal medicines, spiritual healers, medications from different countries, moxibustion).

immunization

1. ​Do not delay immunizations unnecessarily (ex: vaccinate a child even if he or she has a runny nose).
2. With parents who are hesitant to vaccinate their children, explore the reasons, and counsel them about the risks of deciding against routine immunization of their children.
3. Identify patients who will specifically benefit from immunization (ex: not just the elderly and children, but also the immunosuppressed, travellers, those with sickle cell anemia, and those at special risk for pneumonia and hepatitis A and B), and ensure it is offered.
4. Clearly document immunizations given to your patients.
5. In patients presenting with a suspected infectious disease, assess immunization status, as the differential diagnosis and consequent treatment in unvaccinated patients is different.
6. In patients presenting with a suspected infectious disease, do not assume that a history of vaccination has provided protection against disease (ex: pertussis, rubella, diseases acquired while travelling).

​in children

1. When evaluating children, generate a differential diagnosis that accounts for common medical problems, which may present differently in children (ex: urinary tract infections, pneumonia, appendicitis, depression).
2. As children, especially adolescents, generally present infrequently for medical care, take advantage of visits to ask about:
   • Unverbalised problems (ex: school performance).
   • Social well-being (ex: relationships, home, friends).
   • Modifiable risk factors (ex: exercise, diet).
   • Risk behaviours (ex: use of bike helmets and seatbelts).
3. At every opportunity, directly ask questions about risk behaviours (ex: drug use, sex, smoking, driving) to promote harm reduction.
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).
5. In assessing and treating children, use age-appropriate language.
6. In assessing and treating children, obtain and share information with them directly (i.e., don’t just talk to the parents).
7. When investigation is appropriate, do not limit it because it may be unpleasant for those involved (the child, parents, or health care providers). 

infections

1. In patients with a suspected infection,
   1. Determine the correct tools (ex: swabs, culture/transport medium), techniques, and protocols for cultures,
   2. Culture when appropriate (ex: throat swabs/sore throat guidelines).
2. When considering treatment of an infection with an antibiotic, do so
   1. Judiciously (ex: delayed treatment in otitis media with comorbid illness in acute bronchitis)
   2. Rationally (ex: cost, guidelines, comorbidity, local resistance patterns).
3. Treat infections empirically when appropriate (ex: in life threatening sepsis without culture report or confirmed diagnosis, candida vaginitis post-antibiotic use).
4. Look for infection as a possible cause in a patient with an ill- defined problem (ex: confusion in the elderly, failure to thrive, unexplained pain [necrotizing fasciitis, abdominal pain in children with pneumonia]).
5. When a patient returns after an original diagnosis of a simple infection and is deteriorating or not responding to treatment, think about and look for more complex infection. (i.e., When a patient returns complaining they are not getting better, don’t assume the infection is just slow to resolve).
6. When treating infections with antibiotics use other therapies when appropriate (ex: aggressive fluid resuscitation in septic shock, incision and drainage abscess, pain relief).

infertility

1. ​When a patient consults you with concerns about difficulties becoming pregnant:
   1. Take an appropriate history (ex: ask how long they have been trying, assess menstrual history, determine coital frequency and timing) before providing reassurance or investigating further.
   2. Ensure follow-up at an appropriate time (ex: after one to two years of trying; in general, do not investigate infertility too early).
2. In patients with fertility concerns, provide advice that accurately describes the likelihood of fertility.
3. With older couples who have fertility concerns, refer earlier for investigation and treatment, as their likelihood of infertility is higher.
4. When choosing to investigate primary or secondary infertility, ensure that both partners are assessed.
5. In couples who are likely infertile, discuss adoption when the time is right. (Remember that adoption often takes a long time.)
6. In evaluating female patients with fertility concerns and menstrual abnormalities, look for specific signs and symptoms of certain conditions (ex: polycystic ovarian syndrome, hyperprolactinemia, thyroid disease) to direct further investigations (ex: prolactin, thyroid-stimulating hormone, and luteal phase progesterone testing).

Insomnia

1. In patients presenting with sleep complaints, take a careful history to:
   1. Distinguish insomnia from other sleep-related complaints that require more specific treatment (ex: sleep apnea or other sleep disorders, including periodic limb movements, restless legs syndrome, sleepwalking, or sleep talking).
   2. Assess the contribution of drugs (prescription, over-the- counter, recreational), caffeine, and alcohol.
   3. Make a sspecific psychiatric diagnosis if one is present.
2. When assessing patients with sleep complaints, obtain a collateral history from the bed partner, if possible.
3. In all patients with insomnia, provide advice about sleep hygiene (ex: limiting caffeine, limiting naps, restricting bedroom activities to sleep and sex, using an alarm clock to get up at the same time each day).
4. In appropriate patients with insomnia, use hypnotic medication judiciously (ex: prescribe it when there is a severe impact on function, but do not prescribe it without a clear indication). ​

ischemic heart disease

1. Given a specific clinical scenario in the office or emergency setting, diagnose presentations of ischemic heart disease (IHD) that are:
   1. ​Classic
   2. Atypical (ex: in women, those with diabetes, the young, those at no risk)
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.
3. In a patient presenting with symptoms suggestive of ischemic heart disease but in whom the diagnosis may not be obvious, do not eliminate the diagnosis solely because of tests with limited specificity and sensitivity (ex: electrocardiography, exercise stress testing, normal enzyme results).
4. In a patient with stable ischemic heart disease manage changes in symptoms with self-initiated adjustment of medication (ex: nitroglycerin) and appropriate physician contact (ex: office visits, phone calls, emergency department visits), depending on the nature an severity of symptoms.
5. In the regular follow-up care of patients with established ischemic heart disease, specifically verify the following to detect complications and suboptimal control:
   1. ​Symptom control
   2. Medication adherence
   3. Impact on daily activities
   4. Lifestyle modification
   5. Clinical screening (i.e., symptoms and signs of complications)
6. In a person with diagnosed acute coronary syndrome (ex: cardiogenic shock, arrhythmia, pulmonary edema, acute myocardial infarction, unstable angina), manage the condition in an appropriate and timely manner.

lacerations

1. When managing a laceration, identify those that are more complicated and may require special skills for repair (ex: a second- versus third-degree perineal tear, lip or eyelid lacerations involving margins, arterial lacerations).
2. When managing a laceration, look for complications (ex: flexor tendon lacerations, open fractures, bites to hands or face, neurovascular injury, foreign bodies) requiring more than simple suturing.
3. Given a deep or contaminated laceration, thoroughly clean with copious irrigation and debride when appropriate, before closing.
4. Identify wounds at high risk of infection (ex: puncture wounds, some bites, some contaminated wounds), and do not close them.
5. When repairing lacerations in children, ensure appropriate analgesia (ex: topical anesthesia) and/or sedation (ex: procedural sedation) to avoid physical restraints.
6. When repairing a laceration, allow for and take adequate time to use techniques that will achieve good cosmetic results (ex: layer closure, revision if necessary, use of regional rather than local anesthesia).
7. In treating a patient with a laceration:
   1. Ask about immunization status for tetanus.
   2. Immunize the patient appropriately. 

learning (Patients/self)

1. As part of the ongoing care of children, ask parents about their children’s functioning in school to identify learning difficulties.
2. In children with school problems, take a thorough history to assist in making a specific diagnosis of the problem (ex: mental health problem, learning disability, hearing).
3. When caring for a child with a learning disability, regularly assess the impact of the learning disability on the child and the family.
4. When caring for a child with a learning disability, ensure the patient and family have access to available community resources to assist them.
5. To maximize the patient’s understanding and management of their condition,
   1. Determine their willingness to receive information,
   2. Match the complexity and amount of information provided with the patient’s ability to understand.
6. Continuously assess your learning needs.
7. Effectively address your learning needs.
8. Incorporate your new knowledge into your practice.

meningitis

1.  In the patient with a non-specific febrile illness, look for meningitis, especially in patients at higher risk (ex: immuno- compromised individuals, alcoholism, recent neurosurgery, head injury, recent abdominal surgery, neonates, aboriginal groups, students living in residence).
2. When meningitis is suspected ensure a timely lumbar puncture.
3. In the differentiation between viral and bacterial meningitis, adjust the interpretation of the data in light of recent antibiotic use.
4. For suspected bacterial meningitis, initiate urgent empiric IV antibiotic therapy (i.e., even before investigations are complete).
5. Contact public health to ensure appropriate prophylaxis for family, friends and other contacts of each person with meningitis.

menopause

1. In any woman of menopausal age, screen for symptoms of menopause and (ex: hot flashes, changes in libido, vaginal dryness, incontinence, and psychological changes).
2. In a patient with typical symptoms suggestive of menopause, make the diagnosis without ordering any tests. (This diagnosis is clinical and tests are not required.)
3. In a patient with atypical symptoms of menopause (ex: weight loss, blood in stools), rule out serious pathology through the history and selective use of tests, before diagnosing menopause.
4. In a patient who presents with symptoms of menopause but whose test results may not support the diagnosis, do not eliminate the possibility of menopause solely because of these results.
5. When a patient has contraindications to hormone-replacement therapy (HRT), or chooses not to take HRT: Explore other therapeutic options and recommend some appropriate choices
6. In menopausal or perimenopausal women:
   1. Specifically inquire about the use of natural or herbal products.
   2. Advise about potential effects and dangers (i.e., benefits and problems) of natural or herbal products and interactions.
7. In a menopausal or perimenopausal women, provide counselling about preventive health measures (ex: osteoporosis testing, mammography).
8. Establish by history a patient’s hormone-replacement therapy risk/benefit status.

mental competency

1. In a patient with subtle symptoms or signs of cognitive decline (ex: family concerns, medication errors, repetitive questions, decline in personal hygiene):
   1. Initiate assessment of mental competency, including use of a standardized tool
   2. Refer for further assessment when necessary
2. In a patient with a diagnosis that may predict cognitive impairment, (ex: dementia, recent stroke, severe mental illness) identify those who require more careful assessment of decision-making capability.
3. When a patient is making decisions (ex: surgery/no surgery, resuscitation status) think about the need to assess their mental competency.
4. In a patient with cognitive impairment, identify intact decision- making abilities, as many may be retained.

multiple medical problems

1. In all patients presenting with multiple medical concerns (ex: complaints, problems, diagnoses), take an appropriate history to determine the primary reason for the consultation.
2. In all patients presenting with multiple medical concerns, prioritize problems appropriately to develop an agenda that both you and the patient can agree upon (i.e., determine common ground).
3. In a patient with multiple medical complaints (and/or visits), consider underlying depression, anxiety, or abuse (ex: physical, medication, or drug abuse) as the cause of the symptoms, while continuing to search for other organic pathology.
4. Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it.
5. Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:
   1. ​Simplify their management (pharmacologic and other)
   2. Limit polypharmacy
   3. Minimise possible drug interactions
   4. Update therapeutic choices (ex: because of changing guidelines or the patient’s situation).
6. In patients with multiple medical problems and recurrent visits for unchanging symptoms, set limits for consultations when appropriate (ex: limit the duration and frequency of visits). 

newborn

1. When examining a newborn, systematically look for subtle congenital anomalies (ex: ear abnormalities, sacral dimple) as they may be associated with other anomalies and genetic syndromes.
2. In a newborn, where a concern has been raised by a caregiver (parent, nurse),
   1. Think about sepsis, and
   2. Look for signs of sepsis, as the presentation can be subtle (i.e., not the same as in adults, non-specific, feeding difficulties, respiratory changes)
   3. Make a provisional diagnosis of sepsis.
3. Resuscitate newborns according to current guidelines.
4. Maintain neonatal resuscitation skills if appropriate for your practice.
5. When a parent elects to bottle feed, support their decision in a non-judgemental manner.
6. In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (ex: hips, heart, hearing).
7. When discharging a newborn from hospital,
   1. Advise parent(s) of warning signs of serious or impending illness, and
   2. Develop a plan with them to access appropriate care should a concern arise.

obesity

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.
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.
3. In patients diagnosed with obesity who have confirmed normal thyroid function, avoid repeated thyroid-stimulating hormone testing.
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.
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.
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.
7. As part of preventing childhood obesity, advise parents of healthy activity levels for their children.
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).

osteoporosis

1. Assess osteoporosis risk of all adult patients as part of their periodic health examination.
2. Use bone mineral density testing judiciously (ex: don’t test everybody, follow a guideline).
3. Counsel all patients about primary prevention of osteoporosis (i.e., dietary calcium, physical activity, smoking cessation), especially those at higher risk (ex: young female athletes, patients with eating disorders).
4. In menopausal or peri-menopausal women, provide advice about fracture prevention that includes improving their physical fitness, reducing alcohol, smoking cessation, risks of physical abuse, and environmental factors that may contribute to falls (ex: don’t stop at suggesting calcium and vitamin D).
5. In patients with osteoporosis, avoid prescribing medications that may increase the risk of falls.
6. Provide advice and counseling about fracture prevention to older men, as they too are at risk for osteoporosis.
7. Treat patients with established osteoporosis regardless of their gender (ex: use bisphosphonates in men).

palliative care

1. In all patients with terminal illnesses (ex: end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e., do not limit the use of palliative care to cancer patients).
2. In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e., use a team approach when necessary).
3. In patients approaching the end of life:
   1. Identify the individual issues important to the patient, including physical issues (ex: dyspnea, pain, constipation, nausea), emotional issues, social issues (ex: guardianship, wills, finances), and spiritual issues.
   2. Attempt to address the issues identified as important to the patient.
4. In patients with pain, manage it (ex: adjust dosages, change analgesics) proactively through:
   1. Frequent reassessments
   2. Monitoring of drug side effects (ex: nausea, constipation, cognitive impairment).
5. In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (ex: wishes for treatment of infections, intubation, dying at home)

periodic health assessment/screening

1. Do a periodic health assessment in a proactive or opportunistic manner (i.e., address health maintenance even when patients present with unrelated concerns).
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).
3. In a patient requesting a test (e.g., PSA testing, mammography) that may or may not be recommended:
   1. Inform the patient about limitations of the screening test (i.e., sensitivity and specificity).
   2. Counsel the patient about the implications of proceeding with the test.
4. Keep up to date with new recommendations for the periodic health examination, and critically evaluate their usefulness and application to your practice.

personality disorder

1. Clearly establish and maintain limits in dealing with patients with identified personality disorders. For example, set limits for:
   1. Appointment length.
   2. Drug prescribing.
   3. Accessibility.
2. In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.)
3. Look for and attempt to limit the impact of your personal feelings (ex: anger, frustration) when dealing with patients with personality disorders (ex: stay focused, do not ignore the patient’s complaint).
4. In a patient with a personality disorder, limit the use of benzodiazepines but use them judiciously when necessary.
5. When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions.

pneumonia

1. In a patient who presents without the classic respiratory signs and symptoms (ex: deterioration, delirium, abdominal pain), include pneumonia in the differential diagnosis.
2. In a patient with signs and symptoms of pneumonia, do not rule out the diagnosis on the basis of a normal chest X-ray film (ex: consider dehydration, neutropenia, human immunodeficiency virus [HIV] infection).
3. In a patient with a diagnosis of pneumonia, assess the risks for unusual pathogens (ex: a history of tuberculosis, exposure to birds, travel, HIV infection, aspiration).
4. In patients with pre-existing medical problems (ex: asthma, diabetes, congestive heart failure) and a new diagnosis of pneumonia:
   1. Treat both problems concurrently (ex: with prednisone plus antibiotics).
   2. Adjust the treatment plan for pneumonia, taking into account the concomitant medical problems (ex: be aware of any drug interactions, such as that between warfarin [Coumadin] and antibiotics).
5. Identify patients, through history-taking, physical examination, and testing, who are at high risk for a complicated course of pneumonia and would benefit from hospitalization, even though clinically they may appear stable.
6. In the patient with pneumonia and early signs of respiratory distress, assess, and reassess periodically, the need for respiratory support (bilevel positive airway pressure, continuous positive airway pressure, intubation) (i.e., look for the need before decompensation occurs).
7. For a patient with a confirmed diagnosis of pneumonia, make rational antibiotic choices (ex: outpatient + healthy = first-line antibiotics; avoid the routine use of “big guns”).
8. In a patient who is receiving treatment for pneumonia and is not responding:
   1. Revise the diagnosis (ex: identify other or contributing causes, such as cancer, chronic obstructive pulmonary disease, or bronchospasm), consider atypical pathogens (ex: Pneumocystis carinii, TB, and diagnose complications (ex: empyema, pneumothorax).
   2. Modify the therapy appropriately (ex: change antibiotics).
9. Identify patients (ex: the elderly, nursing home residents, debilitated patients) who would benefit from immunization or other treatments (ex: flu vaccine, Pneumovax, ribavarine) to reduce the incidence of pneumonia.
10. In patients with a diagnosis of pneumonia, ensure appropriate follow-up care (ex: patient education, repeat chest X-ray examination, instructions to return if the condition worsens).
11. In patients with a confirmed diagnosis of pneumonia, arrange contact tracing when appropriate (ex: in those with TB, nursing home residents, those with legionnaires’ disease).

poisoning

1. As part of well-child care, discuss preventing and treating poisoning with parents (ex: “child-proofing”, poison control number).
2. In intentional poisonings (overdose) think about multi-toxin ingestion.
3. When assessing a patient with a potentially toxic ingestion, take a careful history about the timing and nature of the ingestion.
4. When assessing a patient with a potential poisoning, do a focused physical examination to look for the signs of toxidromes.
5. When assessing a patient exposed (contact or ingestion) to a substance, clarify the consequences of the exposure (ex: don’t assume it is non-toxic, call poison control).
6. When managing a toxic ingestion, utilize poison control protocols that are current.
7. When managing a patient with a poisoning:
   1. Assess ABCs
   2. Manage ABCs
   3. Regularly reassess the patient’s ABCs (i.e., do not focus on antidotes and decontamination while ignoring the effect of the poisoning on the patient).

Pregnancy

1. In a patient who is considering pregnancy:
   1. Identify risk factors for complications.
   2. Recommend appropriate changes (ex: folic acid intake, smoking cessation, medication changes).
2. In a female or male patient who is sexually active, who is considering sexual activity, or who has the potential to conceive or engender a pregnancy, use available encounters to educate about fertility.
3. In a patient with suspected or confirmed pregnancy, establish the desirability of the pregnancy.
4. In a patient presenting with a confirmed pregnancy for the first encounter:
   1. ​Assess maternal risk factors (medical and social).
   2. Establish accurate dates.
   3. Advise the patient about ongoing care.
5. In pregnant patients:
   1. Identify those at high risk (ex: teens, domestic violence victims, single parents, drug abusers, impoverished women).
   2. Refer these high-risk patients to appropriate resources throughout the antepartum and postpartum periods.
6. In at-risk pregnant patients (ex: women with human immunodeficiency virus infection, intravenous drug users, and diabetic or epileptic women), modify antenatal care appropriately.
7. In a pregnant patient presenting with features of an antenatal complication (ex: premature rupture of membranes, hypertension, bleeding):
   1. ​Establish the diagnosis.
   2. Manage the complication appropriately.
8. In a patient presenting with dystocia (prolonged dilatation, failure of descent):
   1. ​Diagnose the problem.
   2. Intervene appropriately.
9. In a patient with clinical evidence of complications in labour (ex: abruption, uterine rupture, shoulder dystocia, non- reassuring fetal monitoring):
   1. ​Diagnose the complication.
   2. Manage the complication appropriately.
10. In the patient presenting with clinical evidence of a postpartum complication (ex: delayed or immediate bleeding, infection):
    1. ​Diagnose the problem (ex: unrecognized retained placenta, endometritis, cervical laceration).
    2. Manage the problem appropriately.
11. In pregnant or postpartum patients, identify postpartum depression by screening for risk factors, monitoring patients at risk, and distinguishing postpartum depression from the “blues.’’
12. In a breastfeeding woman, screen for and characterize dysfunctional breastfeeding (ex: poor latch, poor production, poor letdown). ​

prostate

1. Appropriately identify patients requiring prostate cancer screening.
2. In a patient suitable for prostate cancer screening, use and interpret tests (ex: prostate-specific antigen testing, digital rectal examination [DRE], ultrasonography) in an individualized/sequential manner to identify potential cases.
3. In patients with prostate cancer, actively search out the psychological impact of the diagnosis and treatment modality.
4. In patients with prostate cancer, considering a specific treatment option (ex: surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment):
   1. Advise about the risks and benefits of treatment.
   2. Monitor patients for complications following treatment.
5. In patients with prostate cancer, actively ask about symptoms of local recurrence or distant spread.
6. Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations.
7. In patients presenting with specific or non-specific urinary symptoms:
   1. Identify the possibility of prostatitis.
   2. Interpret investigations (ex: urinalysis, urine culture-and-sensitivity testing, Digital Rectal Exam, swab testing, reverse transcription-polymerase chain reaction assay) appropriately.

rape/sexual assault

1. Provide comprehensive care to all patients who have been sexually assaulted, regardless of their decision to proceed with evidence collection or not.
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).
3. Limit documentation in sexual assault patients to observations and other necessary medical information (i.e., avoid recording hearsay information).
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.
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.
6. Revisit the need for counselling in patients affected by sexual assault.
7. Enquire about undisclosed sexual assault when seeing patients who have symptoms such as depression, anxiety, and somatization.

 red eye

1. In addressing eye complaints, always assess visual acuity using history, physical examination, or the Snellen chart, as appropriate.
2. In a patient with a red eye, distinguish between serious causes (ex: keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis):
   1. Take an appropriate history (ex: photophobia, changes in vision, history of trauma).
   2. Do a focused physical examination (ex: pupil size, and visual acuity, slit lamp, fluorescein).
   3. Do appropriate investigations (ex: erythrocyte sedimentation rate measurement, tonometry).
   4. Refer the patient appropriately (if unsure of the diagnosis or if further work-up is needed).
3. In patients presenting with an ocular foreign body sensation, correctly diagnose an intraocular foreign body by clarifying the mechanism of injury (ex: high speed, metal on metal, no glasses) and investigating (ex: with computed tomography, X- ray examination) when necessary.
4. In patients presenting with an ocular foreign body sensation, evert the eyelids to rule out the presence of a conjunctival foreign body.
5. In neonates with conjunctivitis (not just blocked lacrimal glands or ‘‘gunky’’ eyes), look for a systemic cause and treat it appropriately (i.e., with antibiotics).
6. In patients with conjunctivitis, distinguish by history and physical examination between allergic and infectious causes (viral or bacterial).
7. In patients who have bacterial conjunctivitis and use contact lenses, provide treatment with antibiotics that cover for Pseudomonas.
8. Use steroid treatment only when indicated (ex: to treat iritis; avoid with keratitis and conjunctivitis).
9. In patients with iritis, consider and look for underlying systemic causes (rx: Crohn’s disease, lupus, ankylosing spondylitis).

schizophrenia

1. ​In adolescents presenting with problem behaviours, consider schizophrenia in the differential diagnosis.
2. In “apparently” stable patients with schizophrenia (ex: those who are not floridly psychotic), provide regular or periodic assessment in a structured fashion e.g., positive and negative symptoms, ther performance of activities of daily living, and the level of social functioning at each visit:
   1. Seeking collateral information from family members and other caregivers to develope a more complete assessment of symptoms and functional status
   2. Competency to accept or refuse treatment
   3. Document specifically suicidal and homicidal ideation, as well as the risk for violence
   4. Medication compliance and side effects.
3. In all patients presenting with psychotic symptoms, inquire about substance use and abuse.
4. Consider the possibility of substance abuse and look for it in patients with schizophrenia, as this is a population at risk.
5. In patients with schizophrenia, assess and treat substance abuse appropriately.
6. In decompensating patients with schizophrenia, determine:
   1. If substance abuse is contributory
   2. The role of medication compliance and side-effect problems
   3. If psychosocial supports have changed
7. Diagnose and treat serious complications/side effects of antipsychotic medications (ex: neuroleptic malignant syndrome, tardive dyskinesia).
8. Include psychosocial supports (ex: housing, family support, disability issues, vocational rehabilitation) as part of the treatment plan for patients with schizophrenia.

sex

1.  In patients, specifically pregnant women, adolescents, and perimenopausal women:
   1. ​Inquire about sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).
   2. Counsel the patient on sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).
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).
3. In patients presenting with sexual dysfunction, identify features that suggest organic and non-organic causes.
4. In patients who have sexual dysfunction with an identified probable cause, manage the dysfunction appropriately.
5. In patients with identified sexual dysfunction, inquire about partner relationship issues.

sexually transmitted infections

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).
2. In a patient with symptoms that are atypical or non-specific for STIs (ex: dysuria, recurrent vaginal infections):
   1. ​Consider STIs in the differential diagnosis.
   2. Investigate appropriately.
3. In high-risk patients who are asymptomatic for STIs, screen and advise them about preventive measures.
4. In high-risk patients who are symptomatic for STIs, provide treatment before confirmation by laboratory results.
5. In a patient requesting STI testing:
   1. ​Identify the reason(s) for requesting testing.
   2. Assess the patient’s risk.
   3. Provide counselling appropriate to the risk (i.e., human immunodeficiency virus [HIV] infection risk, non-HIV risk).
6. In a patient with a confirmed STI, initiate:
   - treatment of partner(s).
   - contact tracing through a public health or community agency.
7. Use appropriate techniques for collecting specimens.
8. Given a clinical scenario that is strongly suspicious for an STI and a negative test result, do not exclude the diagnosis of an STI (i.e., because of sensitivity and specificity problems or other test limitations).

smoking cessation

1. In all patients, regularly evaluate and document smoking status, recognizing that people may stop or start at any time.
   
2. In smokers:
   
   1. Discuss the benefits of quitting or reducing smoking.
      
   2. Regularly assess interest in quitting or reducing smoking.
      
3. In smokers motivated to quit, advise the use of a multi-strategy approach to smoking cessation.

somatization

1. In patients with recurrent physical symptoms, diagnose somatization only after an adequate work-up to rule out any medical or psychiatric condition (ex: depression).
2. Do not assume that somatization is the cause of new or ongoing symptoms in patients previously diagnosed as somatizers. Periodically reassess the need to extend/repeat the work-up in these patients.
3. Acknowledge the illness experience of patients who somatize, and strive to find common ground with them concerning their diagnosis and management, including investigations. This is usually a long-term project, and should be planned as such.
4. In patients who somatize, inquire about the use of and suggest therapies that may provide symptomatic relief, and/or help them cope with their symptoms (ex: with biofeedback, acupuncture, or naturopathy).

Stress

1. In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.
2. In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).
3. In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder).
4. In patients not coping with the stress in their lives,
   1. Clarify and acknowledge the factors contributing to the stress,
   2. Explore their resources and possible solutions for improving the situation.
5. In patients experiencing stress, look for inappropriate coping mechanisms (ex: drugs, alcohol, eating, violence).

Substance abuse

1. In all patients, and especially in high-risk groups (ex: mental illness, chronic disability), opportunistically screen for substance use and abuse (tobacco, alcohol, illicit drugs).
2. In intravenous drug users:
   1. Screen for blood-borne illnesses (ex: human immunodeficiency virus infection, hepatitis).
   2. Offer relevant vaccinations.
3. In patients with signs and symptoms of withdrawal or acute intoxication, diagnose and manage it appropriately.
4. Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (ex: school failure, behaviour change).
5. Consider and look for substance use or abuse as a possible factor in problems not responding to appropriate intervention (ex: alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients).
6. Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.)
7. In patients abusing substances, determine whether or not they are willing to agree with the diagnosis.
8. In substance users or abusers, routinely determine willingness to stop or decrease use.
9. In patients who abuse substances, take advantage of opportunities to screen for co-morbidities (ex: poverty, crime, sexually transmitted infections, mental illness) and long-term complications (ex: cirrhosis).

suicide

1. In any patient with mental illness (i.e., not only in depressed patients), actively inquire about suicidal ideation (ex: ideas, thoughts, a specific plan).
2. Given a suicidal patient, assess the degree of risk (ex: thoughts, specific plans, access to means) in order to determine an appropriate intervention and follow-up plan (ex:, immediate hospitalization, including involuntary admission; outpatient follow-up; referral for counselling).
3. Manage low-risk patients as outpatients, but provide specific instructions for follow-up if suicidal ideation progresses/worsens (ex: return to the emergency department [ED], call a crisis hotline, re-book an appointment).
4. In suicidal patients presenting at the emergency department with a suspected drug overdose, always screen for acetylsalicylic acid and acetaminophen overdoses, as these are common, dangerous, and frequently overlooked.
5. In trauma patients, consider attempted suicide as the precipitating cause.

Trauma

1. Assess and stabilize trauma patients with an organized approach, anticipating complications in a timely fashion, using the primary and secondary surveys.
2. Suspect, identify, and immediately begin treating life- threatening complications (e.g., tension pneumothorax, tamponade).
3. When faced with several trauma patients, triage according to resources and treatment priorities.
4. In trauma patients, secure the airway appropriately (ex: assume cervical spine injury, use conscious sedation, recognize a difficult airway, plan for back-up methods/cricothyrotomy).
5. In a patient with signs and symptoms of shock:
   1. Recognize the shock.
   2. Define the severity and type (neurogenic, hypovolemic, septic).
   3. Treat the shock.
6. In trauma patients, rule out hypothermia on arrival and subsequently (as it may develop during treatment).
7. Suspect certain medical problems (ex: seizure, drug intoxication, hypoglycemia, attempted suicide) as the precipitant of the trauma.
8. Do not move potentially unstable patients from treatment areas for investigations (e.g., computed tomography, X-ray examination).
9. Determine when patient transfer is necessary (ex: central nervous system bleeds, when no specialty support is available).
10. Transfer patients in an appropriate manner (i.e., stabilize them before transfer and choose the method, such as ambulance or flight).
11. Find opportunities to offer advice to prevent or minimize trauma (ex: do not drive drunk, use seatbelts and helmets).
12. In children with traumatic injury, rule out abuse. (Carefully assess the reported mechanism of injury to ensure it corresponds with the actual injury.)

urinary tract infection

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).
2. Appropriately investigate all boys with urinary tract infections, and young girls with recurrences (ex: ultrasound).
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).
4. In a patient with a diagnosed urinary tract infection, modify the choice and duration of treatment according to risk factors (ex: pregnancy, immunocompromise, male extremes of age); and treat before confirmation of culture results in some cases (ex: pregnancy, sepsis, pyelonephritis).
5. Given a non-specific history (ex: abdominal pain, fever, delirium) in elderly or very young patients, suspect the diagnosis and do an appropriate work-up.
6. In a patient with dysuria, exclude other causes (ex: sexually transmitted diseases, vaginitis, stones, interstitial cystitis, prostatitis) through an appropriate history, physical examination, and investigation before diagnosing a urinary tract infection.

vaginal bleeding

1. In any woman with vaginal bleeding, rule out pregnancy.
2. In pregnant patients with vaginal bleeding
   1. Consider worrisome causes (ex: ectopic pregnancy, abruption, abortion), and confirm or exclude the diagnosis through appropriate interpretation of test results.
   2. Do not forget blood typing and screening, and offer rH immunoglobulin treatment, if appropriate.
   3. Diagnose (and treat) hemodynamic instability.
3. In a non-pregnant patient with vaginal bleeding:
   1. Do an appropriate work-up and testing to diagnose worrisome causes (ex: cancer), using an age-appropriate approach.
   2. Diagnose (and treat) hemodynamic instability.
   3. Manage hemodynamically stable but significant vaginal bleeding (ex: with medical versus surgical treatment).
4. In a post-menopausal woman with vaginal bleeding, investigate any new or changed vaginal bleeding in a timely manner (ex: with endometrial biopsy testing, ultrasonography, computed tomography, a Pap test, and with a pelvic examination).

VAGINITIS

1. In patients with recurrent symptoms of vaginal discharge and/or perineal itching, have a broad differential diagnosis (ex: lichen sclerosus et atrophicus, vulvar cancer, contact dermatitis, colovaginal fistula), take a detailed history, and perform a careful physical examination to ensure appropriate investigation or treatment. (Do not assume that the symptoms indicate just a yeast infection.)
2. In patients with recurrent vaginal discharge, no worrisome features on history or physical examination, and negative tests, make a positive diagnosis of physiologic discharge and communicate it to the patient to avoid recurrent consultation, inappropriate trreatment, and investigation in the future.
3. When bacterial vaginosis and candidal infections are identified through routine vaginal swab or Pap testing, ask about symptoms and provide treatment only when it is appropriate.
4. In a child with a vaginal discharge, rule out sexually transmitted infections and foreign bodies. (Do not assume that the child has a yeast infection.)
5. In a child with a candidal infection, look for underlying illness (ex: immunocompromised, diabetes). 

violent/aggressive patient

1. In certain patient populations (ex: intoxicated patients, psychiatric patients, patients with a history of violent behaviour):
   1. Anticipate possible violent or aggressive behaviour.
   2. Recognize warning signs of violent/aggressive behaviour.
   3. Have a plan of action before assessing the patient (ex: stay near the door, be accompanied by security or other personnel, prepare physical and/or chemical restraints if necessary).
2. In all violent or aggressive patients, including those who are intoxicated, rule out underlying medical or psychiatric conditions (ex: hypoxemia, neurologic disorder, schizophrenia) in a timely fashion (i.e., don't wait for them to sober up, and realize that their calming down with or without sedation does not necessarily mean they are better).
3. In a violent or aggressive patient, ensure the safety (including appropriate restraints) of the patient and staff before assessing the patient.
4. In managing your practice environment (ex: office, emergency department), draw up a plan to deal with patients who are verbally or physically aggressive, and ensure your staff is aware of this plan and able to apply it.

WELL-BABY CARE

1. ​Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record.
2. Modify the routine immunization schedule in those patients who require it (ex: those who are immunocompromised, those who have allergies).
3. Anticipate and advise on breast-feeding issues (ex: weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired.
4. At each assessment, provide parents with anticipatory advice on pertinent issues (ex: feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues).
5. Ask about family adjustment to the child (ex: sibling interaction, changing roles of both parents, involvement of extended family).
6. With parents reluctant to vaccinate their children, address the following issues so that they can make an informed decision:
   1. Their understanding of vaccinations.
   2. The consequences of not vaccinating (ex: congenital rubella, death).
   3. The safety of unvaccinated children (ex: no Third World travel).
7. When recent innovations (ex: new vaccines) and recommendations (ex: infant feeding, circumcision) have conflicting, or lack defined, guidelines, discuss this information with parents in an unbiased way to help them arrive at an informed decision.
8. Even when children are growing and developing appropriately, evaluate their nutritional intake (ex: type, quality, and quantity of foods) to prevent future problems (ex: anemia, tooth decay), especially in at-risk populations (ex: the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations)

Procedures