Praise youth and it will prosper.
Irish proverb
I think age is a very high price to pay for maturity.
Tom Stoppard
Recently I saw 19-year-old Christina, a new patient referred to me by her grandmother, whose family doctor I have been for more than 25 years. Christina had not seen her previous family physician since the age of 15. She came to see me that day because of low mood—much of the time she felt anxious, tearful, and depressed. She was struggling in her first year at university. Although living at home and financially dependent on her parents, there was conflict between them as she fought to assert her autonomy against their more traditional values. There was a lot of difficult ground to cover in that first visit.
Later that same day I also saw Paul, a healthy 76-year-old man with a history of mild hypertension (well controlled on 1 medication) and gout, for his periodic health examination. At the end of such visits I like to review all appropriate screening tests, including screening for colorectal cancer, and to discuss the risks and benefits of screening. For screening for colorectal cancer after age 75, most clinical practice guidelines recommend that the decision to screen be an individual one. Such guidance is based on the absence of clinical trial data to quantify the benefits and harms for people who outlive the recommended age for screening. Without such evidence, it is hard to quantify the net benefit of screening in this age group. How, then, to help Paul make a decision?
This month’s issue of Canadian Family Physician features 2 articles that provide valuable guidance for dealing with both these common, but challenging, practice scenarios.
Preventive care in young adults
In “Greig Health Record for Young Adults. Preventive health care for young adults aged 18 to 24 years,” Greig and Tellier provide a practical and comprehensive approach, along with links to appropriate resources, for family physicians and other primary health care providers caring for this potentially tricky population (page 539).1
As they point out, there has been recent recognition of the unique health care needs of the 18- to 24-year age group, known as emerging adults.2 What is unique about this age group is that it represents a transitional period from the dependence of adolescence (living at home, attending school, financially dependent, employed part time or unemployed, not in a committed long-term relationship, etc) to the autonomy of adulthood. Not surprisingly it is a period of great vulnerability—young adults in transition are at greater risk of physical, mental, and emotional health problems,1 just like my new patient Christina.
Screening beyond the guidelines
In “Age to stop? Appropriate screening in older patients” (part of Canadian Family Physician’s Prevention in Practice series: www.cfp.ca/content/by/section/Prevention%20in%20Practice), Grad and colleagues provide valuable and practical guidance on how to avoid overscreening in older patients through evidence-informed shared decision making (page 543).3
They make the case that the top consideration in guiding the conversation about screening in older patients should be life expectancy, buttressed by patient values and preferences, and downstream thinking about the possible outcomes of screening.3 They point out that many older adults might not consider life expectancy important in screening and might not welcome a discussion of their life expectancy when addressing screening, but Grad et al provide data that can help family physicians estimate life expectancy among older patients, as well as appropriate and sensitive language to begin the conversation. In discussing values and preferences and downstream thinking about the possible outcomes of screening, they provide practical tips on the appropriate ways to communicate the risks and benefits to patients in a way that allows for real shared decision making.
Using the tools and the language provided by Grad and colleagues, it will be much easier to have that conversation with Paul at his next periodic health examination.
In previous editorials I have likened providing preventive care in family practice to “holding a wolf by the ears.”4 These practical articles make that job a little bit easier.
Footnotes
Cet article se trouve aussi en français à la page 529.
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