Monday, August 31, 2015

Identifying female patients' sexual health concerns

- Jennifer Middleton, MD, MPH

Talking with patients about sex can be uncomfortable for physicians, yet many of our patients have concerns about their sexual functioning. "Sexual Dysfunction in Women: A Practical Approach" in the current issue of AFP provides pragmatic advice to enable family physicians to assist these women.

The authors differentiate between sexual health concerns and dysfunction, discuss three categories of sexual dysfunction, and describe treatment options. They suggest using the PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model when discussing sexual health with women and give examples of supportive, normalizing statements to use with patients (Table 5).

All of this excellent advice is of little use, though, if female patients' concerns are not voiced. Few women will initiate a discussion about sexual concerns with a physician, and many women will not seek care at all for sexual concerns due to embarrassment. Also, the greater the age difference between female patient and clinician, the less likely female patients will bring up sexual health issues. Most women will not ask questions about sex to physicians.

Physicians, then, need to directly solicit concerns. Most women, regardless of age, are willing to answer questions about their sexual functioning, and many would like for their physicians to ask them questions about this area of their health. A multi-specialty survey of physicians, however, found that few physicians initiate conversations about sexual health. We must overcome our reticence to discuss sex with our female patients; the questions in Table 3 of the AFP article referenced above provide a starting point for these conversations. Automated patient history software is another potential solution; in one study, patients were more comfortable disclosing sexual health concerns when giving their history on an electronic tablet compared to verbally giving their history to a physician.

Regardless of how we do so, inquiring about sexual functioning is important for women of all ages. A study in the current issue of Annals of Family Medicine examines the factors associated with sexual activity and satisfaction in older women; those authors found that the majority of partnered women remain sexually active throughout the life span. As a healthy sex life correlates highly with quality of life measures, especially as people age, family physicians need to be willing to discuss sexual issues with their patients.

Monday, August 24, 2015

Interacting with the arts in medicine: a web-based repository for teaching and learning

- Caroline Wellbery, MD, PhD

A cadre of physicians and other health practitioners, mostly educators in medical schools, believe in the healing power of the arts. Many of these clinicians find ways of incorporating the arts into their practice. Although hard evidence is lacking, the arts can be used to improve clinical observation, deepen the doctor-patient relationship and prevent physician burnout. Playing music for and with patients, listening to and re-telling stories, and spending time looking at art all have a role in teaching medical trainees and caring for patients.

Over the years, I have developed a rich web-based resource from which physicians and students can draw—the website “Interacting with the arts in medicine.” This repository of visual, auditory and narrative art covers many relevant topics—from learning anatomy to patients’ experience of illness to challenges faced at the end of life.

Winthrop Chandler - Dr. William Gleason, 1785 Oil Ohio Historical Society

Many of the works included in the site are the result of personal relationships I’ve cultivated with artists around a mutual interest in medicine. Once while reading the newspaper, I came across an article about a dancer, Ciao-Ping Li, who had choreographed a work entitled “Painkillers.” The article described how Ciao-Ping Li created this work in response to a serious car accident that had among other injuries crushed her foot. The performance chronicles her ordeal as she tried unsuccessfully to return to dance. Seeing that Ciao-Ping was in town to premiere this work, I attended her event and afterwards introduced myself. I asked if I could post her story on my website and she graciously agreed. She not only sent me pictures of her surgeries, but included clips from her choreographic work as well. In a similar way, I have connected with musicians, photographers, poets and storytellers, all of whom have generously allowed me to share their work on the site. I have always joked that my greatest talent is recognizing the talent of others and indeed, the website casts me as a kind of impresario of the arts-in-medicine.

Many of the features on the website address common clinical scenarios. In that, they complement the humanities features we publish in American Family Physician, notably Curbside Consultation, which addresses clinical dilemmas, and Close-ups, a patient page which gives patients a forum in which to tell their stories. So, for example, I’ve included in my website my colleague Heike Bailin’s humorous ruminations on caring for challenging patients, which complements many of Curbside’s themes. Or, as mentioned on the website’s page on social isolation featuring Anne Sexton’s poem, “The Touch,” I include as an additional resource one of our earliest Close-ups on the patient-physician contact during the physical exam as described in a patient’s reflection on “The Importance of Touch.”

While most medical journals provide a space for reflective writing, and some feature visual art, the pieces they publish must conform to each journal’s didactic agenda. The “Interacting with the arts in medicine” website celebrates a more open-ended approach to the arts and their application. Most features begin with a series of questions I have asked to challenge the user. Each visitor must decide how he or she wishes to engage with the site’s resources: for entertainment, to share with a patient, to pass on to a student, or to help mend a personal wound.

Some sections of the site are still being built. The visitor is invited to offer feedback, connections and additional materials or ideas. I hope you will enjoy browsing the site and finding stories, poems or images that resonate with you.

**

Note: Dr. Wellbery is Associate Deputy Editor of AFP.

Monday, August 17, 2015

Announcing the #AFPTop20 Tweet Chat on August 26th

- Kenny Lin, MD, MPH

For the past four years, American Family Physician has published a summary review of the top 20 clinically relevant research articles of the preceding year, as selected by a survey of Canadian Medical Association members using a validated tool. Each of these summary articles draws on material from POEMs (patient-oriented evidence that matters) written by experts in primary care and evidence appraisal at Essential Evidence Plus. This year's compilation, authored by AFP deputy medical editor Mark Ebell and McGill University family physician Roland Grad, features the top 20 research studies published in 2014 judged to be most likely to change primary care practice.

On Wednesday, August 26th at 4 PM Eastern, @AFPJournal will hold its first #AFPTop20 Tweet Chat to take a deeper dive into the findings of some of these POEMs and their ramifications for family physicians. Contributing medical editor Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will serve as moderators, and we will be joined by Dr. Ebell (@markebell). To focus the discussion, we have selected three studies that we found to be the most challenging and/or potentially controversial. If you want to read the POEMs ahead of time (helpful, but definitely not essential), they are available at the links below:

Opioids for Chronic Back Pain: Short-Term Effectiveness, Long-Term Uncertain

Low-Carb Diet Better Than Low-Fat Diet to Reduce CV Risk Factors and Cause Weight Loss (or, listen to the podcast)

New Anticoagulants vs Warfarin in A Fib: No Clear Winner

For those who can't tune in to #AFPTop20 live, we plan to make the highlights available on Storify. Either way, please follow us at @AFPJournal and re-tweet this announcement (with the #AFPTop20 hashtag) far and wide!

Monday, August 10, 2015

Ruling out acute MI in 2 hours, not 2 days

- Jennifer Middleton, MD, MPH

Since the current troponin assay used in the U.S. may not be positive until several hours after myocardial damage has occurred, many patients presenting to emergency departments (EDs) with chest pain will spend a night in the hospital to obtain serial troponin measurements. A POEM in the current issue of AFP, however, demonstrates that ruling out acute MI can be done in only 2 hours with a new high-sensitivity cardiac troponin assay.

The high-sensitivity cardiac troponin assay has several advantages over the troponin assay currently used in the United States. It detects myocardial damage within 90 to 180 minutes after an acute MI, allowing for both faster diagnosis and treatment along with faster rule out, allowing for quicker discharge home. The high sensitivity assay is also more specific for myocardium cell death compared with the current assay.

The researchers for this POEM's study enrolled approximately 1600 patients from participating hospitals in Europe and Australia who presented to EDs complaining of chest pain. Included participants had normal electrocardiograms (ECG) that did not show ST-segment elevation. They had routine serial troponins followed but also had high-sensitivity troponins drawn at 0 and 2 hours of presentation. Participants were managed independently according to their clinical presentations. After discharge, blinded cardiologists reviewed the lab work and patient courses to determine which patients did and did not have acute MI. Comparing the high-sensitivity assay against the current gold standard troponin test, the researchers found a specificity of 99% for the high-sensitivity assay with a negative predictive value of 99.5%.

This study is predated by several others seeking to improve the efficiency of ED chest pain evaluation. A 2002 study found that a 6 to 12 hour observation in the ED, with stress tests in higher risk patients, was equivalent to care with hospital admission for patients at lower risk of acute MI. A 2007 study suggested that low risk patients with normal ECGs can reasonably be discharged home. A 2009 study found that, in patients with normal ECGs, the presence of active chest pain did not confer additional risk of acute MI. Even the idea of a two-hour window is not new; in 2002, a group of researchers studied an "accelerated evaluation protocol" and found that they could rule out acute MI in 2 hours for low risk patients. Despite these studies, though, an overnight stay to rule out MI remains the standard of care in many hospitals across the U.S. in 2015, perhaps partially due to high rates of malpractice suits against ED physicians for missed MI diagnoses, but perhaps also due to the significant risk of missed MI given the limitations of the current troponin assay.

Challenges exist with the new assay as well, though. The high sensitivity of the test may lead to false positives, especially in patients with a prior history of coronary artery disease. Clinicians currently disagree about what cut-off levels to use with the high-sensitivity assay to rule in MI. And, although cost-effectiveness models in Europe suggest overall savings with use of the new assay, it's unclear how expensive it will be in the United States. It's possible that we won't realize any cost savings if the new assay is significantly more expensive than the current one.

If U.S. EDs adopt this new test, outpatient family doctors will need to complete the evaluations for these patients after they are discharged. This 2013 AFP article discusses outpatient chest pain evaluation. You can also find several resources regarding acute coronary syndrome diagnosis in the AFP By Topic on Coronary Artery Disease/Coronary Heart Disease.

Sunday, August 2, 2015

Improving the likelihood of a successful vaginal delivery

- Kenny Lin, MD, MPH

Two of the most important questions that pregnant women have are: 1) How can I improve my chances of having a normal (vaginal) delivery? and 2) Does where I plan to have my baby make a difference in birth outcomes? In the August 1st issue of AFP, Drs. Lee Dresang and Nicole Yonke review the management of spontaneous vaginal delivery by family physicians. The authors note that the following practices are associated with positive maternal and neonatal birth outcomes:

1) Encouraging patients to walk and stay in upright positions
2) Waiting until at least 6 cm dilation to diagnose active stage arrest
3) Providing continuous labor support (e.g., doulas)
4) Using intermittent auscultation in low-risk deliveries
5) Group B streptococcus prophylaxis
6) Active management of the third stage of labor

Guidelines from the American Academy of Family Physicians and American College of Obstetricians and Gynecologists encourage women with a previous low transverse uterine incision to consider a trial of labor after cesarean delivery, as most will be able to deliver vaginally.

Although obstetricians and family physicians remain the most common birth attendants in the U.S., pregnant women at low risk of complications have been increasingly turning to midwives practicing in birth centers or other out-of-hospital settings. A United Kingdom prospective cohort study that examined perinatal and maternal outcomes by planned place of birth in 64,000 healthy women with low-risk pregnancies found no differences in the odds of a composite outcome of perinatal mortality and intrapartum neonatal morbidities in freestanding midwifery centers compared to obstetric hospital units. Planned home births were associated with worse neonatal outcomes for women delivering for the first time, but not for women in subsequent pregnancies. As one might expect, labor interventions occurred most frequently in hospital settings.

Monday, July 27, 2015

Did eliminating annual pap tests worsen chlamydia screening rates?

- Jennifer Middleton, MD, MPH

Despite the USPSTF's recommendation to screen all sexually active women aged 15-24 for chlamydia annually (along with women over age 24 at increased risk), many women do not receive this testing. Even worse, a recent study in the Annals of Family Medicine found that the rate of annual chlamydia screening in young women in one health care system decreased after 2009, the year the American College of Obstetrics and Gynecology (ACOG) updated their cervical cancer screening recommendations and increased both the initial age of screening and the recommended screening interval for cervical cancer (which is consistent with the United States Preventive Services Task Force [USPSTF]'s current recommendations). Given that asymptomatic chlamydia infections can cause serious, potentially permanent complications in women, this study should prompt each of us to examine how and when we are screening for chlamydia in our offices.

The study researchers obtained data from 5 outpatient family medicine offices in a university-based health care system. They looked at the number of visits made by women aged 15-21 for any reason and calculated the percentage of women who had received chlamydia screening during two 13-month intervals, the first spanning 2008-2009 and the second 2011-2012. The total number of office visits for each cohort was similar. The odds ratio for having chlamydia screening done in the 2008-2009 group compared to the 2011-2012 group was 13.97 (95% confidence interval 9.17-21.29); in these offices, at least, chlamydia screening happened significantly more often when annual gyn exams were still the norm.

As discussed in the current issue of Family Practice Management, the Choosing Wisely campaign's goal is to eliminate medical overuse - unnecessary, potentially harmful care. Annual cervical cancer screening certainly falls into this category, as do annual screening pelvic examinations. Many of us family physicians currently practicing, however, learned to associate sexually transmitted disease (STD) screening with these no-longer annual visits; a decrease in chlamydia screening may be an unintended consequence of scaling back on cervical cancer screening.

The importance of this screening regarding our female patients' reproductive health cannot be overstated; the Centers for Disease Control (CDC) estimates that 60% of female infertility could be eliminated with appropriate chlamydia screening. Family physicians may find it helpful to measure the rate of chlamydia screening in their own practices, and, if suboptimal, consider implementing an office quality improvement initiative to increase screening. Using a urine sample to screen, which is as accurate as a cervical sample, may be one way to reduce barriers for both patients and clinicians. The National Committee for Quality Assurance (NCQA) has a publication addressing chlamydia screening which includes several additional strategies to try.

There's an AFP By Topic on STDs if you'd like to read more, and the collection contains this 2012 article on chlamydia infection screening, diagnosis, and management.

How is your office screening women for chlamydia?