BETTER HEALTH
Health Information
Information To Know
The field of medicine and medical information is in constant change. By the time a medical textbook is published and printed, its information is generally out of date. The following information is intended to be a general reference for patients on a few frequently addressed issues. The information provided may not be applicable to all patients and is not a substitute for direct medical care.
The periodic health examination is often better known to patients as the ‘Annual Physical’, ‘Complete Physical’, or ‘Routine Physical’.
The primary focus of a periodic health examination is screening for disease pathology. 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.
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.
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.
Bone Mineral Density Testing is recommended for certain individuals age 50 or older. This includes those with:
• Fragility fractures which are defined as low trauma fractures (e.g., from a fall from a standing height or less), or fractures presenting in the absence of obvious trauma.
• Vertebral compression fracture or osteopenia identified on radiography
• Parental hip fracture
• Prolonged use of oral steroid medications
• Use of other high risk medications (specific cancer drugs)
• Rheumatoid arthritis, malabsorption syndromes, other disorders strongly associated with osteoporosis
• Current smoker
• High alcohol intake (>3 units/day)
• Major weight loss (10% below their body weight at age 25)
It is crucial that patients repeat ALL future follow-up bone density examinations at the exact same facility. Patients should strongly consider this when scheduling their first bone density test.
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.
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)
In most women, yearly pap smears are not necessary, and women can wait up to three years for a repeat pap smear, but no later. 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 45-74. These can be performed every 2 years, unless otherwise recommended by the radiologist.
In women between the ages of 40-44, 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.
The key area of focus specific to men’s health is prostate cancer screening.
Prostate Cancer:
Prostate cancer screening is accomplished by performing a blood test known as the PSA (Prostate Specific Antigen) in conjunction with a digital rectal examination (DRE). This is an area in medicine that has spurred much controversy. Local and world screening experts feel that screening for prostate cancer can cause more harm than good. Patients are often surprised at the notion or suggestion that a blood test can cause harm.
Approximately 16% of all men will develop prostate cancer. However, only around 2% of all men will develop aggressive (metastatic) prostate cancer. Thus, there is an estimated 14% of men who will develop prostate cancer and yet never develop any clinically relevant progression. We presently have no effective way of differentiating between aggressive and non-aggressive prostate cancer and therefore all men are treated the same. Treatment of prostate cancer can lead to permanent erectile dysfunction and urinary incontinence in men, and the 14% of men with non-aggressive prostate cancer suffer unnecessarily.
PSA blood testing is recommended for some men based on their family history or ethnic background. Men with a first-degree relative with prostate cancer diagnosed under the age of 65, as well as black men, are recommended to have routine PSA testing.
The symptoms of prostate cancer are non-specific and therefore a symptom-based approach is also difficult. The symptoms of prostate cancer are quite similar to benign prostate enlargement that will occur in the majority of men. These are mainly urinary in nature (low pressure stream, feelings of incomplete emptying, waking up multiple times a night to urinate, excessive dribbling after voiding, and trouble initiating a void).
Current recommendations stipulate that if an individual chooses to proceed with PSA testing, they should get a rectal examination. An individual in favor of PSA testing hopes to detect cancer, regardless of implications. In order to increase the chances of detecting cancer, a rectal examination is performed.
Testicular Cancer:
There is no evidence that has shown that routine screening through clinical examination or self-examination is of benefit. There is likely no harm to performing self-examination at home. The physician should perform a testicular exam if a mass is discovered by the patient.
Erectile Dysfunction:
It is now widely accepted that age-onset Erectile Dysfunction is associated with increased cardiovascular risk. Erectile dysfunction is a symptom of atherosclerosis which is hardening of the arteries. Patients with erectile dysfunction must remain vigilant in adopting healthy lifestyle choices.
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 Calgary. 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.
It is recommended that infants and young children be evaluated at the following ages: 1 week, 1 month, 2 months, 4 months, 6 months, 12 months, 18 months, 24 months, 3 years, 4 years, 5 years.
Beyond 5 years of age, there are no clear recommendations on how often to have your child assessed for a routine evaluation.
Parents generally request an evaluation in the setting of medical issues and this is a reasonable approach.
Evaluations typically consist of a clinical assessment, developmental screen, and discussion on age-specific issues.
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 (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.
The driver’s medical examination is a requirement for some individuals.
Alberta Transportation’s statement on Driver Fitness and Monitoring is as follows:
“Alberta Transportation aims to strike a balance between an individual’s transportation needs and the public’s right to road safety. Through monitoring drivers’ fitness, safety records and medical conditions, Alberta’s roads will be safe for all road users.
Note: Physical and medical conditions, as well as changes in health, that could affect your driving ability must be reported. All medical reports are kept confidential and will only be used by Alberta Transportation to determine a person’s qualifications to drive. Decisions regarding a person’s ability to drive are based on the Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards.”
Alberta Transportation requires a medical examination be performed in drivers 75 years and older. Physicians are legally required to report any condition that my impact an individual’s ability to drive safely. If a physician has concerns, this will prompt additional evaluations. It is Alberta Transportation that makes the final decision about fitness to drive. This is not a physician decision.
Cognitive impairment invariably impacts an individual’s ability to drive safely. Even the most experienced drivers with a clean driving record become unsafe when cognitively impaired. Individuals who are cognitively impaired require additional evaluation. Special in-office testing, completed through a Certified Geriatric Nurse, can be performed to determine a patient’s cognitive status specific to driving ability. This testing will give the patient and/or their family some estimation of the likelihood of approval by Alberta Transportation.
The Driver’s Medical Examination is free for those individuals who are within 6 months of their 75th birthday and older. For individuals who require a driver’s medical evaluation for employment/occupational reasons, this is a non-insured (patient-pay) service.
DriveAble is a private organization that offers patient-pay testing for individuals with cognitive impairment. This will allow individuals to achieve confidence in their decision to continue or stop driving. Visit www.driveable.com for more information.
• 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.
• Respectfully, 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. A doctor’s office visit is much more effective when patients 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.
Ask Your Family Doctor For A Referral
