The AFP Community Blog

How do family physicians provide cost-effective care?

2013-05-14T10:53:00.003-04:00

- Kenny Lin, MD

Research studies have documented strong associations between U.S. primary care physician supply, better population health outcomes, and lower health care spending. Among adult primary care specialties, national survey data suggest that family physicians provide more cost-effective care. However, little research has examined how family physicians provide effective care at lower cost than other physicians. Is it because we are more likely to follow evidence-based guidelines? Order fewer inappropriate imaging tests? Are less likely to offer non-beneficial tests and treatments?

In the May issue of Family Medicine, Dr. Richard Young and colleagues reported a qualitative analysis of interviews with 38 Texas family physicians about decision-making practices that may contribute to delivery of cost-effective care. Participants provided examples of experiences that they felt exemplified differences in the ways they approached patients compared to approaches of less cost-effective specialists. Two major themes emerged from these interviews: 1) cost-effective care is an inherent value in family medicine; 2) knowledge of the whole patient through continuous relationships enabled efficient decision-making.

Family physicians in this study emphasized the importance of the history and physical examination, conservative testing strategies in low-risk patients, being comfortable with managing complexity, and assigning less importance to "making the diagnosis" than relieving patients' symptoms. Physicians were also attuned to potential behavioral causes of physical symptoms and placed considerable weight on financial and medical harms that could result from aggressive care.

As the authors point out, these findings are limited by the relatively small number of participants, who may or may not represent the general attitudes of family physicians in other areas of the U.S. Do you think that Dr. Young and colleagues identified all of the important ways that family physicians provide cost-effective care? If not, what other factors would you add from your own patient care experiences?

Skin procedures for the family physician: old and “new”

2013-05-06T10:38:00.001-04:00

- Jennifer Middleton, MD, MPH

Seeing a skin procedure on my schedule always makes my day. I enjoy providing patients with small epidermal (sebaceous) cysts and worrisome lesions the convenience of removal in the office.

Traditionally, epidermal cysts are removed by making an incision parallel to the skin lines over the widest part of the cyst. The cyst is dissected away from the subcutaneous tissue, and after it’s removed the incision is sutured.

Traditionally, worrisome skin lesions are removed by inking an ellipse (1:3 ratio of width to length ensures optimal closure) around the lesion. The ellipse is then incised and lifted away from the subcutaneous tissue and closed with sutures.

In the last year, I’ve learned about an alternative technique for each of these procedures. They are much faster than the traditional methods above.

Minimal excision technique for epidermal cysts

Make an incision of 2-3 mm over the cyst. Then use a hemostat to keep this incision open and squeeze out all of the cyst’s contents using your thumbs (wear eye protection!). Use the hemostat to lift out the cyst shell. No sutures are necessary given the tiny size of the incision.

(Avoid this technique for cysts that are/were infected or inflamed, as the adhesions surrounding the cyst will make lifting out the cyst shell impossible.)

Thorough technique description and excellent pictures here: http://www.aafp.org/afp/2002/0401/p1409.html

Saucerization (“scoop”) excision for worrisome skin lesions

This procedure uses a common shave biopsy (razor) blade but “scoops” deep into the skin. The blade should enter the skin at a 45-degree angle and penetrate to at least the mid-dermis.

Thorough technique description and excellent pictures here:

http://www.aafp.org/afp/2011/1101/p995.html

When described to me within the last year, both of these procedures were billed as “new,” yet the AFP articles above cite sources that are more than 10 years old. It was a bit disconcerting to find how out of date my surgical techniques were.

Given that the dissemination gap between research-based practice recommendations and the actual implementation into clinical practice is around 20 years, though, perhaps I shouldn’t have been so surprised.

Are you using the minimal excision technique and/or saucerization in your practice? I welcome comments about when you learned about these techniques and how they're working. Or, if not yet, would these techniques change your practice?

Pros and cons of vitamin D screening

2013-04-29T14:09:00.000-04:00

- Kenny Lin, MD

The U.S. Preventive Services Task Force recently announced its intent to review the evidence and issue recommendations about screening for vitamin D deficiency, after finding insufficient evidence to recommend routine supplementation for the prevention of fractures in adults. According to a 2009 review published in American Family Physician, up to half of U.S. adults 65 years and older have inadequate vitamin D levels, which places them at increased risk of falls and fractures. Two editorials in the April 15th issue of AFP debate the pros and cons of screening for vitamin D deficiency in asymptomatic persons.

Dr. Leigh Eck makes the case for targeted screening for vitamin D deficiency in at-risk populations, which include, but are not limited to, persons with malabsorption syndromes, persons with chronic kidney disease, pregnant and lactating women, and older persons with a history of falls. "Most of these factors put patients at risk of osteoporosis," Dr. Eck argues. "Given the role of vitamin D in bone mineralization, patients who are at risk of or who have osteoporosis should be considered as candidates for vitamin D screening."

On the other hand, Dr. Colin Kopes-Kerr identifies several problems with measurement of serum vitamin D levels in asymptomatic persons, regardless of risk level: lack of test standardization; disagreement about what constitutes a "normal" vitamin D level; unclear treatment implications; and uncertain cost-effectiveness. Finally, he points out, "No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone."

The Endocrine Society recommends against population-based screening for vitamin D deficiency, and the American Society for Clinical Pathology included this screening test in its list of "Five Things Physicians and Patients Should Question" for the Choosing Wisely campaign.

Shared decision making

2013-04-22T10:02:00.000-04:00

- Jennifer Middleton, MD, MPH

Let’s say you’re seeing a healthy 21-year-old woman in your office for contraception management. She takes no other medicines, has no personal or family history of blood clots, and has no contraindications to estrogen. She is interested in a long-acting contraceptive that she won’t have to worry about remembering every day. IUD, subdermal progesterone implant, q 3 months injectable progesterone – how do you choose?

Or, how about this: a 45-year-old man presents with frequent migraine headaches. You review the best evidence for migraine prophylaxis in adults and are stuck deciding between propranolol and amitriptyline. Which do you use?

Gray areas like these abound in Family Medicine, even with the ever-growing primary care evidence base. In both of these scenarios, no one option is clearly superior to the other. All of those contraceptive options would be efficacious for the 21-year-old woman, and, likewise, the efficacy of propranolol versus amitriptyline for the migraineur is probably a toss-up.

These types of situations, where multiple reasonable treatment options exist, provide an opportunity to involve the patient in the decision. Shared decision making (SDM) brings the patient’s preferences into the conversation and gives them some ownership over the final choice.

I wish that I could tell you that SDM has a rigorous evidence base behind it, but like many behavioral interventions, few quality studies exist to suggest patient benefit. A study last week in the Annals of Internal Medicine, however, may help to reinforce SDM’s value. Weiner et al engaged patients who surreptitiously recorded their office visits with Internal Medicine residents. The residents who adapted their care plan to meet their specific patient’s preferences had, in return, improved compliance from their patients.

This study was small and needs to be replicated in bigger settings, but its finding makes intuitive sense: patients invited to be involved in treatment decisions tend to have better adherence with those treatments.

You can ease the loss of the extra time it takes to do SDM by billing for the time spent in counseling (10 min = 99212, 15 min = 99213, and 25 min = 99214). Just be sure to document as such in your encounter note.

In 2010, AFP also published a nice SDM review, along with a helpful framework for the office. You can find that Curbside Consultation here: http://www.aafp.org/afp/2010/0301/p645.html.

I welcome your thoughts on the practical use of SDM in the busy family doc’s practice.

Guidance for Choosing Wisely in diagnostic imaging

2013-04-16T12:13:00.000-04:00

- Kenny Lin, MD

Many of the primary care-relevant recommendations in the Choosing Wisely campaign advise physicians to think twice before reflexively ordering diagnostic imaging tests in certain clinical situations. Inappropriate imaging increases radiation exposure, leads to overdiagnosis and detection of incidentalomas, and increases costs for patients and health systems. In addition, as Drs. Brian Crownover and Jennifer Bepko observe in the April 1st issue of AFP, increasing radiation exposure is likely to lead to higher rates of cancer diagnoses and deaths:

In 2006, 380 million radiologic procedures (including 67 million computed tomography [CT] scans) and 18 million nuclear medicine procedures were performed in the United States. To highlight the disproportionate use, U.S. patients received approximately one-half of all nuclear medicine procedures worldwide while making up only 4.6 percent of the global population. The volume represents a sixfold increase (from 0.5 to 3.0 mSv [millisieverts]) in annual per capita radiation exposure from 1980 to 2006. ... Increasing recognition of future cancer risk from radiation exposure was illustrated in a 2009 study showing that 2 percent of all future cancer cases will likely come from previous CT exposure, resulting in approximately 15,000 deaths annually.

This article on the appropriate and safe use of diagnostic imaging goes on to review consensus indications for imaging in the central nervous system, chest, abdomen, and lumbar spine based on American College of Radiology appropriateness criteria. It includes a helpful Table on the average effective radiation doses of medical imaging procedures that clinicians may use to weigh the harm versus the potential benefit of a particular diagnostic imaging test. In general, the authors recommend discouraging patients from undergoing whole body scanning, which is associated with numerous health risks and no proven benefits.

Meet AFP Community Blog's new contributor

2013-04-08T19:49:00.001-04:00

- Jennifer Middleton, MD, MPH

Hello! I’m thrilled to accept AFP’s invitation to join Dr. Lin on this blog. I thought I’d use this first entry to share a little bit about myself and what you can expect from my posts.

For about 2 and ½ years, I’ve been blogging at The Singing Pen of Doctor Jen. Many good Family Medicine bloggers were already hard at work when I started in November of 2010, but I thought as a residency educator I might have something different to add to the mix. I did a two-year full time faculty development fellowship in Pittsburgh before starting my career. In my fellowship, I learned how to teach and create curricula, how to write and edit, and how to design and implement research. During my fellowship, I also studied for a Master’s Degree in Public Health (MPH). Between my faculty development background and my MPH training, I see the world of Family Medicine with a detached eye at times.

You can expect musings from me about my experiences as a family doctor, a teacher, and even sometimes, a patient. These stories will hopefully be a backdrop for us to share the challenges and joys of day-to-day Family Medicine. You will also hear me stridently advocating for Family Medicine as the solution to many of our current healthcare woes.

I am grateful for the opportunity to share some of these thoughts with you going forward.

New inpatient medicine resource in AFP By Topic

2013-03-25T13:50:00.002-04:00

- Kenny Lin, MD

Although some family physicians choose to transfer the primary care of hospitalized patients to other specialists, nearly two-thirds of physicians surveyed by the American Academy of Family Physicians in 2011 reported having hospital admission privileges, with similar proportions among recent residency graduates and physicians with 15 or more years of practice experience. In recognition of the essential role of family medicine in the inpatient setting, our newest AFP By Topic collection features links to key clinical content on 23 common conditions in hospitalized patients.

For example, a clinician managing a patient with diabetic ketoacidosis can consult a review article published in AFP earlier this month, while another recent article provides current information on the evaluation and treatment of patients with acute kidney injury. The Inpatient Medicine collection will be regularly updated with new content as it is published in all areas of the journal.

Less is more in preoperative testing

2013-03-18T16:17:00.001-04:00

- Kenny Lin, MD

Family physicians are often asked for preoperative consultations prior to elective surgical procedures. Traditionally, the process of "clearing" patients for surgery has included performing an electrocardiogram, chest x-ray, and numerous laboratory tests. However, as Dr. Molly Feely and colleagues point out in the cover article of AFP's March 15th issue, there is little evidence that routine preoperative testing is beneficial: "these tests often do not change perioperative management, may lead to follow-up testing with results that are often normal, and can unnecessarily delay surgery, all of which increase the cost of care." Instead, current guidelines recommend selective testing based on risk factors identified during the history or physical examination.

The following Choosing Wisely campaign recommendations from several medical specialty groups identify unwarranted preoperative tests to reduce waste and prevent harm to patients:

1. Avoid routine preoperative testing for low-risk surgeries without a clinical indication.
2. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
3. Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to noncardiac thoracic surgery.
4. Avoid cardiovascular stress testing for patients undergoing low-risk surgery.
5. Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.
6. Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk.
7. Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.
8. Prior to cardiac surgery there is no need for pulmonary function testing in the absence of respiratory symptoms.

Extra diagnostic tests don't reassure: another reason to Choose Wisely

2013-03-04T13:42:00.002-05:00

- Kenny Lin, MD

Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality family medicine. The March 1st issue of AFP includes two articles that reflect this philosophy as embodied in the American Board of Internal Medicine Foundation's Choosing Wisely campaign. Four of the American Geriatrics Society's "Five Things Patients and Physicians Should Question" refer to medications that can be harmful to older patients in certain settings: antipsychotics, hypoglycemics, benzodiazepines, and antibiotics. In this issue, Dr. Richard Pretorius and colleagues echo this advice and provide additional guidance and systematic approaches to reducing the risk of adverse drug events in older adults.

Sudden hearing loss is a distressing symptom that may prompt a physician to order a CT scan to look for a brain tumor or other cranial mass lesion. However, the American Academy of Otolaryngology - Head and Neck Surgery Foundation advises against ordering this diagnostic test in patients without focal neurologic findings, since the CT scan provides no useful information and exposes the patient to radiation and an expensive medical bill. More information on the evaluation and management of sudden hearing loss is available in AFP's Practice Guidelines summary of the AAO-HNSF's recent clinical guideline.

One reason that clinicians often give for ordering diagnostic tests in patients with a low pretest probability of serious disease is to "reassure the patient." This rationale is used to justify performing endoscopy in patients with dyspepsia but no alarm symptoms; x-rays or magnetic resonance imaging in patients with uncomplicated low back pain; or electrocardiography in patients with chest pain and a low likelihood of cardiac disease. It turns out, though, that negative tests aren't reassuring at all. A recent systematic review and meta-analysis of 14 randomized trials in JAMA Internal Medicine found that diagnostic tests did not reduce patients' illness worry, nonspecific anxiety, or symptom persistence. The only effect of the tests was a small reduction in subsequent primary care visits. Given the adverse effects of diagnostic testing in general, including false positives and overdiagnosis, this "benefit" does not warrant making unwise choices about non-indicated medical tests.

Choosing Wisely's notable omissions

2013-02-25T11:24:00.001-05:00

- Kenny Lin, MD

Last week, the American Board of Internal Medicine Foundation's Choosing Wisely Initiative announced the release of a second round of lists of 5 things that physicians and patients should question, based on evidence that certain tests or procedures are not beneficial in specific clinical situations. AFP will soon be updating our list of primary care-relevant items from the Choosing Wisely campaign, and our Facebook and Twitter accounts will highlight old and new entries daily over the next few months. This AAFP News Now article provides more information about the American Academy of Family Physicians' most recent items, which include elective labor inductions and unnecessary cervical cancer screenings.

Notably absent from the lists of the primary care specialty societies and the American Urological Association is routine prostate-specific antigen (PSA) testing, which both the Cochrane Collaboration and the U.S. Preventive Services Task Force have concluded does not improve men's health outcomes. Even though the American Cancer Society and the AUA still support selective use of the PSA test in older men who have been adequately informed of its potential harms, no medical group supports the still-common practice of ordering PSA screening without first discussing it with the patient.

Another curious omission from the top 5 lists of cardiology and thoracic surgery organizations is angioplasty or coronary artery bypass surgery for stable coronary artery disease, which are frequently performed in the U.S. but have no clinical advantages over initial medical management.

Shared decisions in screening for breast cancer

2013-02-17T20:02:00.002-05:00

- Kenny Lin, MD

In the February 15th issue of AFP, Dr. Maria Tirona reviews areas of agreement and disagreement in major organizational guidelines on screening for breast cancer. There is widespread consensus that annual or biennial mammography should be offered to women 50 to 74 years of age, and that teaching breast self-examination does not improve health outcomes. For women 40 to 49 years of age, in whom the risks and benefits of mammography are closely balanced on a population level, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommend shared decision making, taking into account individual patient risk and patients' values regarding benefits and harms of screening.

In an accompanying editorial, however, Drs. Russell Harris and Linda Kinsinger argue that shared decision making regarding breast cancer screening need not be limited to younger women:

More and more, the goal for breast cancer screening is not to maximize the number of women who have mammography, but to help women make informed decisions about screening, even if that means that some women decide not to be screened. ... The goal of improving patient decision making should be expanded to all women eligible for breast cancer screening (i.e., those 40 to 75 years of age who are in reasonable health), because the benefits and harms of screening are not very different among these age groups.

The primary benefit of screening mammography is an estimated 15 percent relative reduction in deaths from breast cancer; harms of mammography include false positive results, overdiagnosis, and overtreatment. A recent study published in BMJ explored the impact of overdiagnosis on attitudes toward mammography in several focus groups of Australian women 40 to 79 years of age. Few women had ever been informed about overdiagnosis as a potential harm of screening. Most women continued to feel that mammography was worthwhile if overdiagnosis was relatively uncommon (30 percent or less of all breast cancers detected). However, a higher estimate of overdiagnosis (50 percent) "made some women perceive a need for more careful personal decision making about screening."

Notably, a 2011 Cochrane Review estimated that 30 percent of breast cancers detected through screening are overdiagnosed:

This means that for every 2,000 women invited for screening over 10 years, one will have her life prolonged, and 10 healthy women who would not have been diagnosed if there had not been screening will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false-positive findings.

Given this information, what approach do you take to screening mammography? Do you believe that this test should be routine for women of eligible ages, a shared decision for some, or (as Drs. Harris and Kinsinger advocate), a shared decision for all? Why is it often difficult to promote shared decision making in clinical practice?

Announcing the AFP mobile app edition

2013-02-08T11:34:00.001-05:00

- Matthew Neff, Senior Editor, AFP Online

Now you can keep up with American Family Physician in a format that's as mobile as you are. AFP is pleased to announce the new mobile app edition of the journal. This app provides a digitally enhanced replica of AFP for tablets and smartphones. Other features include downloading for offline reading; quick links to full articles; bookmarking content; sharing articles with colleagues; and real-time news and content feeds from the American Academy of Family Physicians (AAFP) and the AFP Community Blog.

The apps are free for AAFP members, print and online paid subscribers, and individuals who currently receive the journals in their own name; all others can purchase individual issues within the app. The app is now available in the Apple App Store and will be coming soon to Google Play. Search the App Store for “AAFP” or “American Family Physician” to download the app, and then sign in using the e-mail address associated with your AAFP account to start downloading issues.

Are calcium supplements bad for the heart?

2013-02-05T10:51:00.002-05:00

- Kenny Lin, MD

Until recently, the idea that calcium-containing supplements, which more than half of older adults in the U.S. consume regularly, could be harmful would have seemed absurd. Primary care clinicians have long recommended calcium supplements to reduce the risk of osteoporotic fractures in adults who are unable to meet the Institute of Medicine's Dietary Reference Intakes through diet alone. However, a large prospective study published this week in JAMA Internal Medicine demonstrated a statistically significant association between supplemental calcium (as opposed to dietary calcium) intake and a 20 percent higher relative risk of death from cardiovascular disease in men.

This troubling finding adds to the evidence base that suggests harmful cardiovascular effects of calcium-containing supplements. A timely pair of editorials in the February 1st issue of AFP debates the population-level risk of widespread calcium supplementation. Arguing that this potential risk should be a serious concern, Drs. Ian Reid and Mark Bolland review the results of their previous randomized trial and meta-analysis that found 20 to 30 percent increases in the incidence of acute myocardial infarction in adults taking calcium supplements. In their view, these adverse effects are not worth the potential benefits to bone health:

In both of our meta-analyses, calcium supplementation was more likely to cause vascular events than to prevent fractures. Therefore, the bolus administration of this micronutrient should be abandoned in most circumstances, and patients should be encouraged to obtain their calcium intake from an appropriately balanced diet. For those at high risk of fracture, effective interventions with a fully documented safety profile superior to that of calcium are available. We should return to seeing calcium as an important component of a balanced diet and not as a low-cost panacea to postmenopausal bone loss.

In the second editorial, Dr. Rajib Bhattacharya points out that the Women's Health Initiative and other randomized trials did not indicate that calcium supplements increased cardiovascular risk. He argues that secondary analyses of trials designed with other primary outcomes in mind may have predisposed these analyses to unforeseen bias, and that there is "no compelling evidence" that calcium supplements at usual doses pose dangers to heart health.

Notably, a draft recommendation statement released by the U.S. Preventive Services Task Force last June stated that there was insufficient evidence that vitamin D and calcium supplementation prevent fractures or cancer in otherwise healthy older adults. Although the only adverse effects of supplements mentioned in the Task Force's evidence review were renal and urinary tract stones, none of the reviewed studies were specifically designed to assess cardiovascular harms. Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence might make you change your practice?

Providing culturally competent health care

2013-01-25T15:55:00.000-05:00

- Kenny Lin, MD

The increasing diversity of the U.S. population has made it more likely that family physicians will care for many patients with cultural backgrounds, beliefs, and practices that are dissimilar to their own. As a previous article in American Family Physician observed, patients' beliefs regarding health and disease causation may pose obstacles to communication even when physicians and patients speak the same language. Using medical interpreters is another skill that takes practice to achieve proficiency, but has clear benefits, according to the author of a Curbside Consultation: "The skills of a medical interpreter or translator include cultural sensitivity and awareness of and respect for all parties, as well as mastery of medical and colloquial terminology, which make possible conditions of mutual trust and accurate communication that lead to effective provision of medical health services."

In the review article "Caring for Latino Patients" in the January 1st issue of AFP, Dr. Gregory Juckett notes that this population faces a number of special medical concerns:

Approximately 43 percent of Mexican Americans older than 20 years are obese, compared with 33 percent of the non-Latino white population. Diabetes and hypertension are closely linked with obesity; 11.8 percent of Latinos older than 20 years have type 2 diabetes (13.3 percent of Mexican Americans), making it the foremost health issue in this population. A higher-calorie diet, a more sedentary lifestyle, and genetic factors contribute to this problem. Because of less access to health care, Latinos with diabetes are often diagnosed later and have a greater risk of complications.

To navigate and resolve cultural differences that may impede understanding and effective treatment, Dr. Juckett advises that clinicians use the LEARN technique for cross-cultural interviewing:

1. Listen sympathetically to the patient's perception of the problem,
2. Explain his or her perception of the problem to the patient,
3. Acknowledge and discuss any differences and similarities between the two views,
4. Recommend a treatment plan, and
5. Negotiate agreement.

For practices that see sizable numbers of Latino patients, the article also includes a helpful list of strategies for creating a culturally sensitive office environment.

Is there a looming family physician shortage, or not?

2013-01-15T11:30:00.002-05:00

- Kenny Lin, MD

Researchers at the American Academy of Family Physicians' Robert Graham Center (which produces the Policy One-Pagers series for AFP) recently predicted in the Annals of Family Medicine that a combination of population growth, aging, and insurance expansion from the Affordable Care Act will create the need for an additional 52,000 primary care physicians by the year 2025 - an increase of nearly 25 percent over the current workforce. Since the vast majority of internal medicine residents plan to pursue subspecialty rather than generalist careers, family medicine will be called on to supply the bulk of this looming gap in physician supply and demand. Recent efforts to increase the supply of family physicians include emphasizing community-based clinical training in medical school and temporarily increasing Medicaid and Medicare primary care fees.

Another strategy for bolstering the family medicine pipeline, contained in the Affordable Care Act, is mandating redistribution of unused residency positions to primary care programs. Unfortunately, an analysis published this month in Health Affairs concluded that a similar Medicare graduate medical education reform in 2005 not only failed to significantly boost primary care, but actually resulted in training twice as many new subspecialists. Dr. Candace Chen and colleagues conclude:

Our findings suggest that redistribution [of unused residency positions] largely supported hospitals in growing their specialty training. Some hospitals even converted primary care positions to specialty positions after receiving newly redistributed positions. ... This shifting collectively perpetuates the nation's physician workforce maldistribution, and our analysis demonstrates that Medicare continues to support these hospitals and even increases its support for them, regardless of the specialty mix of residents trained.

Not everyone agrees that meeting the future health needs of the U.S. population will require a massive influx of family physicians, however. Other researchers have argued that the widespread adoption of team-based care, "advanced access" scheduling, and replacing some in-person with electronic visits could provide enough new patient capacity to prevent a family physician shortage. Still, much uncertainty surrounds this and other projections. What steps is your practice taking, if any, to meet the anticipated needs of so many new patients? Hiring more physicians? Re-designing how you provide care? Please feel free to share your stories.

Questioning the need for annual pelvic examinations

2013-01-02T12:17:00.001-05:00

- Kenny Lin, MD

New Year, time for women to schedule their annual pelvic examinations? Not so fast. An editorial that accompanies AFP's Jan. 1 cover article on health maintenance in women challenges this longstanding tradition. This is not the first time that this topic has appeared in the journal; a Curbside Consultation published in 2003 raised similar concerns:

My patients seem comfortable when I tell them they don’t need annual Pap smears. Yet, in teaching settings and among colleagues, I often hear the question, “If we’re not doing Paps, shouldn’t we be doing something?” Sexually transmitted infection screening, contraceptive counseling, safe-sex advice, and clinical breast examination are opportunities that are missed if patients don’t come to the office for annual Pap tests.

In their editorial, Drs. Giang Nguyen and Peter Cronholm observe that the reasons that clinicians commonly provide for continuing to perform these "routine" examinations are inconsistent with evidence-based recommendations. Cervical cancer screening should be performed no more often than every 3 years; ovarian cancer screening is ineffective and likely harmful; contraceptive prescriptions need not be preceded by a pelvic examination; and urine samples are highly accurate at detecting asymptomatic sexually transmitted diseases. The authors conclude:

Taking into account the time required for the patient to undress, the time to obtain the necessary equipment, and the time to perform the procedure, a screening pelvic examination can conservatively add an extra 10 minutes to an office encounter. In addition, because many physicians also require a nurse or medical assistant in the room during this examination, there is an opportunity cost associated with the other work that could have been done by the support staff during this time (e.g., stocking supply cabinets, performing immunizations, making phone calls to patients). Given the lack of evidence to support annual pelvic examinations, it would be better for patients if we spend that time addressing screening, counseling, and other preventive services for which strong evidence exists.

Although evidence supporting an unequivocal benefit of routine examinations (pelvic examination or no) remains elusive, many effective clinical preventive services for women can be provided at health maintenance-oriented visits or in the context of care for other health concerns. The review and patient education handout by Dr. Margaret Riley and colleagues, along with additional content in the AFP By Topic collection on Health Maintenance and Counseling, provide excellent summaries of these services.

The most popular posts of 2012

2012-12-17T13:32:00.000-05:00

- Kenny Lin, MD

Although page views are only a surrogate measure of reader engagement, in a year that saw American Family Physician review the "Top 20 Research Studies of 2011 for Primary Care Physicians," I thought it appropriate to share the top 10 most popular AFP Community Blog posts of 2012. The top post, on screening intervals for osteoporosis, has been viewed more than 600 times.

1. How often should you screen for osteoporosis? (January 25)

Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.

2. The spiritual assessment in family medicine: unnecessary or essential? (September 20)

Since 80 percent of patients and family physicians perceive religion to be important, acknowledging and supporting spiritual beliefs is a key component of holistic, patient-centered care.

3. Curbing overuse of CT scans (January 11)

Use computed tomography only when it is likely to enhance patient health or change clinical care.

4. Prescribing opioids for chronic pain: avoiding pitfalls (August 22)

National surveys show that chronic pain is undertreated, but opioids often have serious adverse effects and can lead to dependence, addiction, and abuse.

5. Doctors should trust their clinical judgments (March 5)

What drives doctors to order tests that, in their hearts, they must know have a remote chance of being helpful?

6. Electronic health records may improve preventive care (July 11)

After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users.

7. Rhythm or rate control for atrial fibrillation? (June 28)

Management of newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.

8. Cancer screening in men: flexible sigmoidoscopy works, PSA does not (May 21)

How long will take to change both of these practices to reflect the best evidence?

9. The state of family medicine is ... ? (February 13)

There aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform.

10. Counterintuitive findings on quality incentives and patient satisfaction (April 9)

Is it possible that patient satisfaction is driven by receiving more care, but not better care?

Live from NAPCRG: how long does a cough last?

2012-12-02T17:30:00.001-05:00

- Kenny Lin, MD

Although American Family Physician focuses on providing readers with clinical reviews and features that synthesize evidence into guidance for practice, our medical editors wear a variety of hats. In addition to serving as Deputy Editor of Evidence-Based Medicine at AFP, Dr. Mark Ebell is also an accomplished primary care researcher. Earlier today, at the annual meeting of the North American Primary Care Research Group (NAPCRG), he presented the findings from a study that provided an original take a seemingly simple question: how long does a cough last? This study compared patient expectations with a systematic review of the medical literature.

Dr. Ebell and his colleagues surveyed a sample of patients and consulted "Dr. Google" to determine public perceptions of how long a cough from an acute upper respiratory infection is supposed to last. Although estimates varied, the most common answer was one to two weeks. His team then proceeded to review the medical literature for studies of the natural history of acute cough, using the control groups from randomized trials testing an intervention such as an antibiotic. The weighted mean duration of cough in these patients was actually 17.8 days.

Since antibiotics are prescribed for at least 50 percent of patients who visit doctors for acute cough, Dr. Ebell suggested that the substantial discrepancy between patients' expectations and the actual duration of acute cough caused by respiratory infections may be a driver of excessive antibiotic prescribing. If more patients knew that a cough could normally last for two weeks or more, perhaps fewer of them would seek medical care for self-limited illness. An article in the November 1st issue of AFP provides evidence-based guidance on appropriate antibiotic use in upper respiratory tract infections.

Is family medicine an affordable career choice?

2012-11-28T12:10:00.000-05:00

- Kenny Lin, MD

The inexorable yearly rise of medical school tuition has led to corresponding increases in medical student indebtedness. According to the American Medical Association, 86 percent of graduating medical students in 2011 had loans to repay, and their average debt was more than $160,000. The greater long-term income potential from choosing a subspecialist rather than a primary care career is only one of many factors that influence medical students' specialty choices. That being said, my students increasingly ask if they will be able to repay their loans, support spouses and children, and save enough for retirement on a family physician's income - a question that would have been unlikely to come up a generation ago.

In an innovative analysis published in Academic Medicine, researchers from the American Association of Medical Colleges and Boston University concluded that the answer is "yes." Using economic modeling software, they examined variety of loan amounts and repayment scenarios projected against average household expenses in a high-cost urban area (Boston) and income levels for primary care and subspecialist physicians. The bottom line:

Our economic modeling of a physician's household income and expenses across a range of medical school borrowing levels in high- and moderate-cost living areas shows that physicians in all specialties, including primary care, can repay the current median level of education debt. At the most extreme borrowing levels, even for physicians in comparatively lower-income primary care specialties, options exist to mitigate the economic impact of education debt repayment.

The authors defined "extreme" borrowing levels as $250,000 or greater, and noted that options for these highly indebted physicians include extended repayment terms and federal loan forgiveness programs such as the National Health Service Corps. They also noted that physicians who choose to live in rural or low-cost areas will have considerably more discretionary income after expenses.

Although this analysis did not address the equally important question of why the primary care-subspecialist income gap exists and what can be done to reduce it, these findings should be reassuring to students considering family medicine careers.

Fasting lipids study: potential practice-changer?

2012-11-14T15:47:00.004-05:00

- Kenny Lin, MD

When I last saw my personal physician for a checkup, she recommended that I undergo screening for lipid disorders, per the guidelines of the U.S. Preventive Services Task Force. Although the office had a phlebotomist on site, my appointment was in the afternoon, and I had already eaten breakfast and lunch. Consequently, she instructed me to make a separate morning appointment to have my blood drawn after an overnight fast. Due to my hectic schedule, several months passed before I finally got around to doing this (fortunately, the results were normal). As family physicians know, many patients who are sent for fasting tests never have those tests done at all.

A recent study published in the Archives of Internal Medicine suggests that there may be little reason for most patients to endure the inconvenience of fasting before lipid testing. The authors analyzed the relationship of fasting duration to variations in cholesterol levels obtained in more than 200,000 patients in and around Calgary (Alberta, Canada). In this population, the time since one's last reported meal had no effect on mean total cholesterol and high-density lipoprotein (HDL) cholesterol levels. Mean low-density lipoprotein (LDL) levels varied by up to 10 percent, while mean trigylceride levels varied by up to 20 percent. The authors and two editorialists conclude that for most purposes in primary care, including global cardiovascular risk assessment and monitoring response to pharmacologic treatment, nonfasting cholesterol measurements are likely to yield equivalent information to measurements from traditional fasting samples.

Rare is the single study in the medical literature that changes usual clinical practice on its own, and for good reason. Consistent evidence from multiple studies is usually needed to verify or refute impressive initial findings. Further, the cross-sectional design of this particular study might have masked unmeasured variables that would have been better controlled for in a randomized clinical trial. That being said, if any single study should be called a practice-changer, I think this one fits the bill. What's your opinion?

Strategies for physicians to prevent burnout

2012-11-07T15:27:00.001-05:00

- Kenny Lin, MD

Although they probably came as little surprise to most of us who practice primary care, the results of a national survey of physician burnout in the Archives of Internal Medicine earlier this year made headlines in The New York Times and The Atlantic. This study found that 1) physicians are more likely to experience symptoms of burnout than similarly educated workers in the U.S. general population; and 2) physicians on the "front line of care access" - family physicians, general internists, and emergency medicine physicians - had the highest rates of burnout.

A Curbside Consultation in the November 1st issue of AFP discussed the distinct but closely related problem of demoralization in a family physician who serves as the part-time medical director for a financially troubled clinic for children with developmental disorders. This physician was forced to accept layoffs of several key staff members without a corresponding decrease in workload:

She recognized the great need of these children and families, and had talked with other staff and administration about additional programs she wanted to develop. She now would have to say good-bye to coworkers and abandon her hopes for a larger and more robust program. She realized that the remaining staff, herself included, would have to work harder, and that she would have less time to spend with patients, the part of the work she found most fulfilling. Patients who needed the most help would, in fact, get less help. ... Over the next week, she became dejected and sad.

In the accompanying commentary, Dr. Stewart Gabel connected the often temporary state of demoralization to the more serious and persistent state of burnout:

Demoralization is a state of hopelessness and helplessness that is akin to, but separable from, depression. It is associated with a sense of subjective incompetence, the belief that a person is unable to express his or her values and achieve his or her goals. Demoralization has an existential dimension that is associated with the affected person's experienced losses. ... Moving past demoralization involves remoralization, or the renewal of one's personal values and the activities that stem from these values. ... However, if not addressed, persistent feelings of demoralization are likely to result in or contribute to burnout.

How can physicians prevent the demands of practicing present-day medicine from leading them down the road to burnout? An article in Family Practice Management suggested eight ideas, including joining a physician support group; strengthening interpersonal communication skills; and making it a priority to address the spiritual needs of patients and themselves.

New treatments for head lice

2012-11-02T09:00:00.001-04:00

- Kenny Lin, MD

Pediculosis is a distressing diagnosis that frequently causes children to be sent home from school or day care. In the September 15th issue of American Family Physician, Dr. Karen Gunning and colleagues provided a treatment update for pediculosis and scabies. Permethrin 1% lotion or shampoo is the recommended first-line treatment for head lice infestation (see illustration below). However, permethrin resistance is increasingly common in many communities, and second-line therapies have substantial disadvantages: malathion is flammable, and lindane is neurotoxic and cannot be used in young children. Additional safe, effective treatments are now being developed.

Yesterday, researchers reported in the New England Journal of Medicine the results of two randomized trials evaluating a single 10-minute home application of topical 0.5% ivermectin lotion for head lice in patients 6 months of age or older. Compared to the control groups, patient assigned to receive ivermectin were significantly more likely to be louse-free at day 2 (95% vs. 31%) and day 15 (74% vs. 18%), with no difference in adverse events. A major limitation of these studies is that topical ivermectin was compared to a placebo rather than to established head lice treatments.

Often, new treatments are no better than old ones

2012-10-18T15:39:00.001-04:00

- Kenny Lin, MD

A recent systematic review and meta-analysis from the Cochrane Collaboration broke new ground in evaluating not one intervention or group of interventions for a single health condition, but the more general question of whether new treatments are more effective than established ones. The authors analyzed data from four cohorts of publicly funded trials of cancer treatments, treatments for neurological problems, and treatments for mixed diseases. In this sample, they found that slightly more than half of new treatments turned out to be better than old ones, but not by much: primary outcomes were just 9 percent better with the new treatments, and mortality fell by only 5 percent.

To make it easier for family physicians to compare new treatments to old ones, AFP publishes the STEPS (Safety, Tolerability, Effectiveness, Price, and Simplicity) series of new drug reviews. The October 15th issue includes a STEPS review of rivaroxaban (Xarelto), a new oral anticoagulant that is indicated to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. Under Effectiveness, the review notes: "Rivaroxaban was as effective as warfarin at preventing stroke and systemic embolism, and reduced annual stroke rates to 2.1 percent, compared with 2.4 percent for warfarin. No trials have compared rivaroxaban with dabigatran (Pradaxa), a direct thrombin inhibitor, or with fondaparinux (Arixtra), an injectable factor Xa inhibitor." Rivaroxaban does not require laboratory INR monitoring like warfarin, but costs more than 40 times as much. Family physicians and patients will need to decide whether this relatively small benefit is worth the increased cost of this new drug compared to the old.

Why don't comparative effectiveness studies change clinical practice?

2012-10-10T12:49:00.000-04:00

- Kenny Lin, MD

The October 1st issue features the third article in AFP's new series "Implementing Effective Health Care Reviews," a summary of the Agency for Healthcare Research and Quality's comparative effectiveness report on treatments for gastroesophageal reflux disease. Notably, the report found no differences in efficacy between proton pump inhibitors; better symptom relief from continuous daily compared with on-demand dosing; and limited data on endoscopic treatments. What are the chances that results from this and other high-quality comparative effectiveness studies will quickly change your practice? Not very good, unfortunately. As I wrote in an editorial that introduced the series:

To date, the track record of translating comparative effectiveness research findings into clinical practice has been mixed, at best. For example, several years after a landmark randomized controlled trial demonstrated the superiority of thiazide diuretics compared with other first-line medications for hypertension, prescribing of thiazide diuretics had increased only modestly. An evaluation of diabetes practice guidelines produced after the publication of an Effective Health Care review of oral treatments found numerous inconsistencies between guideline recommendations and evidence-based conclusions. Despite extensive evidence that initial coronary stenting provides no advantages over optimal medical therapy for stable coronary artery disease, more than one-half of patients who undergo stenting in the United States have not had a prior trial of medical therapy.

In the October issue of Health Affairs, Justin Timbie and colleagues propose five reasons that scientific evidence is slow to change how physicians practice:

1) Misalignment of financial incentives - e.g., fee-for-service payment systems tend to reward invasive therapies, such as surgery for back pain, that may be no better than conservative management.

2) Ambiguity of results - "Without consensus on evidentiary standards prior to the release of comparative effectiveness results, ambiguous results become fuel for competing interpretations, making it difficult for providers, insurers, and policy makers to act on the evidence."

3) Cognitive biases in interpreting new information - e.g., a tendency to reject evidence that contradicts previous strongly held beliefs, such as the superiority of atypical to conventional antipsychotics.

4) Failure to address the needs of end users - e.g., designing a study to compare the benefits of two therapeutic strategies, but not the harms.

5) Limited use of decision support - e.g., poorly designed electronic or paper patient decision aids that do not fit into the workflow of primary care practices.

Do these reasons sound about right to you? How do you think these obstacles could be overcome in order for front-line family physicians to rapidly incorporate the best scientific evidence into their practices?

Who should receive medications for influenza?

2012-10-04T08:39:00.004-04:00

- Kenny Lin, MD

Flu season is coming soon, and in addition to familiarizing themselves with the Advisory Committee on Immunization Practices vaccination guidelines for the 2012-13 season (offer influenza vaccine to everyone 6 months of age or older), physicians should consider how they plan to diagnose patients with suspected influenza. Despite the availability of multiple antiviral medications for influenza, whom to treat remains a challenging question.

In a 2010 Cochrane for Clinicians commentary, Dr. William E. Cayley observed that the neuraminidase inhibitors oseltamivir and zanamivir provided limited benefits for prevention and treatment of otherwise healthy persons with influenza. However, this conclusion was based on incomplete data - that is, results from published trials only. Subsequently, the Cochrane review authors were able to access several unpublished "clinical study reports" from the manufacturers and modified the review to reflect these additional data. In an updated Cochrane for Clinicians, published in the October 1st issue of AFP, Dr. Cayley finds that the evidence no longer supports using neuraminidase inhibitors to prevent influenza transmission:

The authors found that, based on clinical study reports, treatment with oseltamivir reduced the likelihood of an antibody response to influenza, the diagnostic marker that is typically used to determine the effectiveness of prophylaxis. In the absence of another way to measure the effectiveness of oseltamivir prophylaxis, it is uncertain whether the medication reduces the risk of influenza transmission.

Even for treatment of persons with influenza, the benefits of antivirals are modest: oseltamivir reduced the duration of symptoms by less than one day and had no effect on hospitalizations. Since these medications have side effects, physicians may reserve their use for persons at higher risk of complications, such as those with asthma or other chronic respiratory problems. As Dr. Cayley notes, existing guidelines are only as good as the evidence that supports them - and in the case of influenza treatments, not very good at all:

The contrast between the limited positive findings of this review and the strong support for treatment with neuraminidase inhibitors in public health guidelines (such as those from the CDC) highlights the importance of ongoing assessment of such recommendations and related educational materials, especially when evidence to support widespread implementation of an expensive intervention is lacking.