What Residency Looks Like LXXIII: Screen-INGO!

Sometimes residency looks like playing bingo with health screening guidelines over lunch. The current Med-Peds fellow is writing his masters thesis in medical education on the "gamification" of medical training--in other words, the movement to make teaching more interesting (and effective!) than listening to a lecture by embedding learning points in recognizable games such as Jeopardy! or, in this case, bingo. The competitive feature doesn't hurt; even medical residents are easily motivated by candy, Starbucks gift cards, and bragging rights.

For the game of Screening-Bingo (aka Screen-INGO), we each designed our own bingo sheet by allocating the usual numbers. Then the fellow asked us questions about United States Preventive Services Task Force (USPSTF) guidelines for screening for things like high blood pressure and colon cancer. If you got the question right AND he drew a number you had, you could mark your board. If you got it right but didn't have that number, you could mark an earlier number that had been called OR ask to have a number re-entered into the cage if you had gotten an earlier question incorrect. At the end of the hour we ran out of time, so he just called numbers, and I was three ways away from winning before another resident got bingo.

Here is what I learned:

We're supposed to practice Evidence-Based Medicine (EBM), but not all evidence is created equally. Good evidence is Graded A (definitely do this), B (probably a good idea), C (it probably doesn't help, but at least it doesn't hurt), and Grade D (don't do it--dangerous!). Grade I recommendations are those for which there is insufficient evidence to determine whether it is good or harmful or not.

Q. Who should be screened by abdominal ultrasound for abdominal aortic aneurysm?
A. Men ages 60-75 years of who have smoked at least 100 cigarettes in their lifetime.

Stop screening for breast cancer at age 75, or when the patient has less than a 10-year life expectancy.

Screen for cervical cancer by testing for HPV every 5 years for patients who are over age 30. Anyone who has a cervix needs to be screened regularly for HPV, and even those who don't have a cervix due to hysterectomy for cervical cancer or a high-grade lesion (CIN 2 or 3) need continued surveillance.

Any young woman under the age of 25 who is sexually active needs annual testing for gonorrhea and chlamydia; from age 25, only those who have high-risk behaviors need annual testing. The level of evidence for testing men (who do not have high-risk behaviors) is I. (This topic is being updated for the latest research.)

Did you know? The PHQ2 (Patient Health Questionnaire, 2 questions) is a 97%-sensitive screen for major depression in the prior 2 weeks, with anhedonia being required for an eventual diagnosis with the PHQ9 (guess how many questions that form has?).

Q. When should you recommend discontinuing Colorectal Cancer (CRC) screening?
A. Most people should be screened for CRC until they are 75 years old, or a 10-year life expectancy. [In practice, the first colonoscopy has the highest yield, so getting one at 50 is the most important. I am more likely to encourage my patients to get that first scope than I am to lean on them to get the second or third.]

There's a great risk-assessment tool for the BRCA gene for breast and ovarian cancer: Gail. If a patient is determined to be high risk, the prudent thing to do is to refer to a genetic counselor, NOT order genetic testing.

Vitamin D for fall protection is OUT, physical therapy is IN.

All women of reproductive age, no matter their sexual practices, are recommended to be on 400mcg (0.4mg) of folic acid daily, as 50% of pregnancies are unintended, and this nutrient is required for early neural-tube development.

Did you know that patients who use intranasal drugs should be screened for Hepatitis C? (We assume they mean non-prescription drugs.)

Although we routinely order full "hepatitis panels," the USPSTF recommends we screen for Hepatitis B with only a surface antigen test (Hep B S Ag), not core antigen, PCV for viral titer, etc.

All adults at least 18 years old should be "screened" for hypertension by taking their blood pressure taken in the office, but you shouldn't officially diagnose them unless you have at least one value from outside the office, due to the prevalence of white-coat hypertension.

Hormone therapy for primary prevention of any chronic condition (such as cardiovascular disease) in post-menopausal women is a grade D recommendation.

All people aged 15-65 years old should be tested for HIV at least once in their lives. You can always re-test them, and test others, as necessary.

All women of reproductive age should be screened for intimate-partner violence (grade B), but the evidence is grade I for other kinds of patients. Many of my colleagues ask at every physical exam anyway, whether it's an adolescent or an elderly patient.

Finally, a baby aspirin every day. I don't remember what the question was--maybe how to reduce the risk of pre-eclampsia? That's been in the news the last week.

"Th-th-th-that's all folks!"


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