+ Periodic Health Examinations

The periodic health examination is often better known to patients as the ‘Annual Physical’, ‘Complete Physical’, or ‘Routine Physical’. An annual physical in most cases is not warranted although periodic screening examinations are essential.

The primary focus of a periodic health examination is screening for disease pathologies. Screening, by medical definition, is the identification of an individual with disease (through physical assessment or diagnostic testing), in the pre-symptomatic stage. Put more plainly, screening is ‘looking for disease, prior to the onset of symptoms. This should be clearly distinguished from diagnosing, which is the process of evaluating patients in the symptomatic stage of their illness. Performing a chest X-ray in a chronic smoker to look for lung cancer is screening. Performing the same chest X-ray in a chronic smoker who presents coughing up blood is diagnosing.

The argument in favor of screening is that if disease can be detected early, medical treatment interventions would be more successful. It is fair to say that in past years, the medical community adopted the MORE IS BETTER approach, almost universally. A new philosophy is emerging in medicine however. Medical evidence strongly supports NOT screening for some conditions. This body of evidence, has in fact, documented harm from screening. In some instances, screening will discover patients with early disease, though this same disease would never evolve into a state that would be physically symptomatic or negatively affect the course of an individual’s life. In this context, the treatments (which are not benign) would inflict harm.

During a periodic health examination, a head-to-toe physical examination is typically performed by most physicians. This head-to-toe examination is not an all-encompassing evaluation for every potential disease. Rather, the exam focuses on common areas of potential pathology. While frequently performed, this examination is usually low-yield in detecting abnormalities.

Current screening guidelines will specify a target age group for screening, though cancer occasionally occurs in individuals who are not within this target age group. This makes it crucial for those individuals to be evaluated for symptoms of uncertainty. Never assume that a symptom is benign on the basis of age alone. It is a part of my routine practice to educate patients on symptoms related to the more frequent cancers. Remember that screening does not equal diagnosing and that ALL patients should see their physician regarding concerning symptoms, irrespective of age. Younger individuals who are not within the screening age are not immune to cancer.

A family history of disease will undeniably impact an individual’s chance of developing that particular disease. This is taken into strong consideration when evaluating when an individual should start screening. Please inform your physician of relevant family history.

Unfortunately, good screening tests are not available for many conditions and disease is discovered at the time of symptom onset.

Please note, it is strongly encouraged that the screening examination NOT be used as a visit to voice other MAJOR concerns; doing this will detract from the primary intention of this examination.

+ Callbacks To Office

Most patients are met with feelings of alarm and fear when called back to the doctor’s office. Please keep in mind that callbacks are quite common and the majority of office callbacks are for NOT for serious issues. A callback to office does not necessarily mean ‘cancer’ or some other life-threatening illness.

Family practices today generate a massive amount of test results such that it is not viable to address laboratory or imaging results via telephone. On occasion, a physician may call a patient directly to discuss results over the phone; this is done as a courtesy to patients and should not be the routine expectation.

Generally, if a laboratory result is concerning, you will be contacted and asked to come in. However, the general expectation would be for you to book an appointment to discuss the results following any test if you have concerns. Occasionally, patients can be called back for normal results, particularly in the setting of more advanced investigations such as CT scans or MRIs. This is to discuss potential future investigations and/or provide patients with some closure.

Please note it is strictly against office policy for office staff to divulge the specific nature of the callback over the phone. The office staff may indicate urgent or non-urgent and whether the abnormality pertains to lab testing or imaging.

+ Colon Cancer Screening

For most individuals, screening for colon cancer generally begins at the age of 50 and is performed through a stool test called a FIT test. This is recommended every one to two years. At the time of routine blood testing, the lab will supply a sample collection kit for patients to take home. It is important that collection instructions are followed carefully.

A ‘POSITIVE’ test does not indicate colon cancer. Rather, it means that the patient should then proceed with a colonoscopy as the risk of colon cancer is higher. Some individuals will be asked to start this test at the age of 40, due to a slightly higher risk.

FIT testing may not be appropriate for those at higher risk of colon cancer. In many cases, a colonoscopy is recommended as the primary screening method. Factors such as family history of colon cancer and/or high-risk polyps will influence the screening modality. Some medical conditions such as Crohn’s Disease, HNPCC, or FAP will also significantly increase risk, and a colonoscopy is the most appropriate screening test in this setting.

Symptoms of colon cancer include persistent thin-caliber stool, unintentional weight loss, bloody stool, or a persistent change (> 4 weeks) in bowel movement consistency.

It is important to remember that screening does not equal diagnosing. Individuals who present with concerning symptoms should consult their physician.

+ Skin Cancer Screening

All patients should evaluate their skin regularly. Many new skin marks/lesions are benign. Any lesion that is changing, bleeding, or poorly healing should be evaluated by a physician. It is helpful and recommended to have a partner or family member regularly evaluate your back for new skin lesions.

+ Vitamin D

The overwhelming majority of Canadians are deficient in Vitamin D, irrespective of dietary practices and level of sun exposure. It is generally recommended that all Canadians take daily Vitamin D. A reasonable dose for all Canadians is 2000 international units (IUs) per day. As of May 2015, routine vitamin D level testing is no longer available at the lab.

+ Women’s Health

The key areas of focus specific to women’s’ health include breast and cervical cancer screening.

Cervical Cancer: Screening for cervical cancer occurs by way of a Papanicolaou smear, or Pap smear. Cervical cancer screening should begin at age 25 or approximately 3 years after first intimate sexual activity, whichever occurs later. (May 2016 recommendation)

If within 5 years, three negative Pap tests at least 12 months apart are obtained, then screening can be extended to every 3 years.

These recommendations are not universal and those individuals with previous high-risk findings or cervical cancer are encouraged to be screened yearly.

Breast Cancer: Screening for breast cancer is performed through mammography. Mammograms are typically performed in women between the ages of 50-74. These can be performed every 2 years, unless otherwise recommended by the radiologist.

In women between the ages of 40-49, the balance of benefits and risks is not great enough to recommend routine screening and should be guided by a patient’s preference.

Routine self-breast examination, performed by the patient, is not recommended. Additionally, the clinical breast examination performed by the physician is also not recommended for screening purposes.

Endometrial Cancer: Endometrial Cancer is more common in women who are menopausal. Vaginal bleeding after menopause should prompt further evaluation. Heavy and/or irregular vaginal bleeding prior to menopause may also be a symptom of endometrial cancer.

Ovarian Cancer: Screening for ovarian cancer is not recommended as there are currently no good screening tests. The symptoms of ovarian cancer are vague and non-specific.

If a patient develops irregular or heavy vaginal bleeding, a pelvic examination should be performed. If a patient develops ANY unusual breast changes, the physician should perform a breast examination.

It is important to remember that screening does not equal diagnosing. Individuals who present with concerning symptoms should consult their physician.

+ Traveller Health

Patients travelling to other countries are encouraged to be aware of their own vaccination needs well in advance of their trip.

I generally direct all of my patients to the Centre for Disease Control travel website: http://wwwnc.cdc.gov/travel

This website provides up to date infectious disease information for every country. Patients are advised to have their itinerary on hand when evaluating their vaccination needs.

Some travel vaccinations can only be administered by medical personnel with specific training and certification in travel medicine.

There are various travel-health clinics in Victoria. A list of these can be found at www.travelhealthclinics.ca

All individuals should store their vaccination history in a safe place. There is no universal vaccination history record. Patients are responsible for recording/tracking their vaccination history.

Travel-related health visits are a non-insured (patient-pay) service.

+ Complex Care Plans

For eligible patients, a physician may complete a Complex Care Plan for the patient on an annual basis. Eligibility is based on medical conditions (irrespective of severity) including hypertension, diabetes, chronic kidney disease, asthma, COPD, and history of cardiovascular events.

The goal of the care plan is to outline well-established targets for specific chronic diseases (mild to severe) in order to assist the patient in meeting their targets. For some diseases (ex. Asthma), many patients deem their condition to be mild when they are in fact poorly controlled and not meeting targets. This care plan will clarify this. There are no penalties for failing to meet these targets. It is simply intended as a reference for patients. At the very least, the document will provide an overview of their medical history. There is no cost to the patient.

+ Choosing Wisely Canada

“Choosing Wisely Canada (CWC) is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care.

Unnecessary tests and treatments do not add value to care. In fact, they take away from care by potentially exposing patients to harm, leading to more testing to investigate false positives and contributing to stress for patients. And of course unnecessary tests and treatments put increased strain on the resources of our health care system.”

Visit http://www.choosingwiselycanada.org for more information.

Patients sometimes feel that they are being shorted when not offered an evaluation. Some patients feel that campaigns such as this are designed only with the intention of saving health care dollars. As a practicing family physician, I am in support of the philosophy that MORE IS NOT ALWAYS BETTER. I can also attest to the fact that investigations beget investigations, and that these investigations do not alter the course of patient’s health. In many cases, these investigations do lead to patient anxiety and consume a patient’s time unnecessarily.

+ Helpful Tips For Patients

• If you cannot remember the names and dosages of your pills, bring your medications to the office. Describing a pill by its physical appearance is rarely helpful for the physician. Physicians are not trained in learning the appearance of the medications they prescribe and many medications appear the same. • Learn the names of the medication, and why you take them. You are your best health advocate. A prefix before a proper medication name refers to the generic manufacturer of that medication (ex. Apo-, Ratio-, Ran-, Teva-). Sometimes patients tolerate some generics over others. • Always ensure the pharmacy has indicated the correct number of refills on your medication. On a pill bottle, this will appear as “Refills:” or “Ref:”. On occasion, these refills are omitted at the pharmacy. • If you are having your blood pressure checked in the office, engage in deep breathing for several minutes before the physician enters the exam room. Avoid talking during this time as this can elevate your BP. • Writing out the history of a medical complaint before the office visit can help patients convey their symptoms more effectively. Some patients frequently repeat themselves when they have difficulty further characterizing a symptom. This does not add value to the visit. • If you have several concerns that cannot be addressed in a single visit, choose the item(s) of highest concern. If you are unsure, indicate a brief list of your concerns to the physician and the physician will direct you accordingly. • Sometimes the best response to a physician’s question is a simple “YES” or “NO”. Physicians will ask about all the information that they require, so don’t worry about missing an important detail. The easiest patients to treat are ones that answer questions succinctly, though we do appreciate that not all questions can be answered this way. • Bringing a family member into the office is a good idea if you often forget important details about the visit, or if you feel you need a family member to explain things to you. • Inform the staff if you will be travelling and the dates you will be away if you are expecting a referral or have pending laboratory testing/diagnostic imaging. This will help them coordinate your appointments. • Notify the physician at your next appointment if a family member has been recently diagnosed with a new condition. This may impact the way in which you are evaluated. • Inform the physician during your appointment if you have recently been assessed in the emergency department, admitted to a hospital, or have had recent surgery. Hospital communications can be delayed.