Periodic Health Assessment/Screening on the CCFP exam

Approach

• Check vaccines and due screening at every visit, including visits for something else.
• Give due vaccines during a mild illness, such as a cold or an ear infection, with or without fever. Mild illness does not raise the risk of side effects.
• With moderate or severe illness, weigh the risks and benefits of vaccinating today.
• Never restart a broken series. Finish the schedule for the patient's current age. Give all rotavirus doses before 8 months of age.
• A fragility fracture mentioned in passing needs a bone health assessment. Screening limits do not apply. From age 50, a past hip or spine fracture calls for medicine.
• Do not screen adults for depression with a questionnaire. Ask how they are, and assess anyone with symptoms or a history of depression.

Approach

• Check each test's entry rules before you order it: age, sex, risk and life expectancy.
• No yearly blood tests unless the patient's risk calls for one. No vitamin D in low-risk adults. No thyroid tests in well adults who are not pregnant.
• No screening chest X-ray or electrocardiogram (ECG) for low-risk outpatients.
• Cervical screening: not under 25 or over 69, not more often than advised, and not after a hysterectomy for a benign cause.
• Mammography, by the Canadian Task Force on Preventive Health Care's 2024 draft: every 2 to 3 years at 50 to 74. At 40 to 49, offer it to women who want it after hearing benefits and harms.
• That draft does not apply to breast symptoms, a known gene change, a strong family history or past breast cancer.
• Bone density: the two Canadian positions differ (table below). Name the one you follow.

Approach

• Name the framework. The Canadian Task Force on Preventive Health Care recommends against PSA screening: weak at 55 to 69, strong at other ages.
• The Canadian Urological Association (CUA) suggests offering PSA to men expected to live more than 10 years, after a shared decision.
• Explain overdiagnosis. Up to 67% of prostate cancers found by screening would likely never have caused harm.
• Give the benefit in numbers. In the main European trial, 781 men were screened for each prostate cancer death prevented over 13 years.
• Explain what a high result starts: repeat tests, perhaps a magnetic resonance imaging (MRI) scan, a biopsy, then watching or treatment. Each step carries harm and worry.
• If he chooses testing, his PSA level sets the next test. Consider stopping at 60 if PSA is below 1 µg/L.
• Otherwise stop at 70, or sooner if he is not expected to live 10 more years.

Approach

• Human papillomavirus (HPV) vaccine since 2024: one dose for healthy people aged 9 to 20. Two doses, at least 6 months apart, at 21 to 26.
• Three HPV doses are now only for people who are immunocompromised or living with HIV.
• Depression: the Task Force's 2025 update advises against questionnaire screening in adults, even those at higher risk. Keep watching for symptoms.
• Check whether advice is final. The Task Force's 2024 breast cancer draft is now archived and has no final version yet.
• Read the strength and the certainty, not only the headline. The depression advice is strong but rests on very low certainty evidence.
• Lists change too. Choosing Wisely Canada's family medicine list dropped its mammography item in May 2024.
• When Canadian bodies disagree, as on PSA or bone density, know both and name the one you follow.