Wednesday, October 22, 2014

The natural history of symptoms in primary care

- Kenny Lin, MD, MPH

Not long ago, I was sitting in my office catching up on some electronic charting when I began to feel chilly, achy, and weak. I went home, skipped dinner, and went straight to bed. Although I felt mostly better the next morning, my appetite didn't fully return until later in the day. My self-diagnosis: probable viral infection. But the truth was that I had no idea if my symptoms were related to any kind of disease.

Medical education trains physicians to approach patients' symptoms foremost as manifestations of an underlying cause. Only "treating the symptoms," in contrast, can often feel like a sort of failure. But as Dr. Kurt Kroenke reported in a narrative review published in the Annals of Internal Medicine, at least one-third of common physical symptoms evaluated in primary care (including pain, fatigue, dizziness, sleep disturbances, and gastrointestinal symptoms) are "medically unexplained," meaning that they are never connected to a disease-based diagnosis after an appropriate history, physical examination, and testing.

Dr. Kroenke further asserted that viewing symptoms as purely disease-oriented influences the language physicians use to describe them:

The lack of a definitive explanation for many symptoms is further underscored by the use of adjectival modifiers indicating what a symptom is not ("noncardiac" chest pain or "nonulcer" dyspepsia) or implying causal explanations that are weakly defensible ("tension" headache, "mechanical" low back pain, or "irritable" bowel syndrome).

Not only do some symptoms have no obvious causes, but others have multiple possible causes which may be unproductive to approach separately. For example, why does a patient with congestive heart failure, anemia and depression feel tired all the time? Also, symptoms usually occur in a group, rather than in isolation; for example, a classic symptom cluster in cancer patients is SPADE (sleep  / pain / anxiety / depression / energy).

Studies show that about a quarter of symptoms that present to primary care eventually become chronic. Fortunately, very few of these patients harbor a serious missed diagnosis such as an occult infection or cancer. As family physicians know, even if we are uncertain about if or when a particular symptom might improve, communication still has great therapeutic value. "Is this normal, doctor?" is the question I hear most frequently from my patients who have persistent symptoms without diagnoses. I usually respond that there is a wide range of "normal," and what's more important to me is working with him or her to make these particular symptoms more manageable.

Monday, October 13, 2014

ADHD spotlight: treatment adherence issues and effects of meds on adult height

- Jennifer Middleton, MD, MPH

The October 1 AFP included a useful review article on ADHD in children, and not long after I read it, I saw two more articles on ADHD that got me thinking even more about this subject: one on adherence to ADHD medication and one on the effect of psychostimulant medication on height.

The AFP article on "Diagnosis and Management of ADHD in Children" reviews the diagnostic criteria for ADHD, the differential diagnoses for common presenting complaints, and initial treatment options. The authors review the data for various treatments and conclude that psychostimulants are still the most effective class of medications for those children in whom meds are indicated.

A recent article published earlier this year in Patient Preference and Adherence reviewed how adolescent patient beliefs affected treatment adherence to ADHD medications. The author reviewed several studies, both qualitative and mixed-methods, that investigated adolescent attitudes toward their ADHD medications. Multiple studies found that the strongest predictors of non-adherence were either adverse medication effects, lack of perceived benefit, and/or "changes to the patient's sense of self." Teens with ADHD rated the perceived efficacy of medications higher than behavioral interventions, yet adolescents themselves are more likely to stop their medications on their own than to involve a parent in that decision.

Another recent article, this one from Pediatrics, seeks to lay to rest concerns about psychostimulant medications' effect on final adult height. The researchers obtained medication and growth histories from around 1000 children born between 1976-1982 in a town in Minnesota; for every 1 child identified with ADHD, they matched 2 control children without ADHD. The researchers obtained growth records on these children along with their final adult height, and they found no difference in growth patterns or final adult height between children with ADHD and children without ADHD; they also found no difference between children with ADHD on medication compared to children with ADHD who were not on medication. This study followed only one geographically-limited cohort, though, and the authors acknowledge the impossibility of knowing whether these children's physicians adjusted their medications due to changes in their growth curves. Despite these limitations, this study's years of longitudinal data are still compelling.

I spend significant time reviewing growth charts with parents of children or teens with ADHD on stimulant medication, but I don't ask questions about medication adherence the way I do, for example, with my patients with other chronic conditions. These two articles suggest that my priorities need reversing.

According to the AFP article, "children with ADHD [on a stimulant] are less likely to be held back a grade." Being held back a grade is definitely Patient-Oriented-Evidence-that-Matters! Since adolescents typically make the decision to stop their medication, centering discussions related to medication issues on them, instead of their parents, during office visits makes sense. And it is nice to be able to share with adolescents and their parents the recent Pediatrics study that was reassuring regarding possible height loss due to long-term stimulant use.

Certainly, as Dr. Lin wrote about earlier this year, medication is not always the right course for treating ADHD. But when it is, these two articles will change my practice. If you'd like to read more, there's an AFP By Topic on ADHD.

How do you counsel parents and their children and/or teens about ADHD treatment?

Monday, October 6, 2014

Known and unknown: putting Ebola in perspective

- Kenny Lin, MD, MPH

At a recent morning huddle, I noticed that the hanging file of emergency protocols at my practice nurse's station held a new folder, labeled "Ebola." That same day, a patient who had returned from West Africa was isolated at a nearby hospital for symptoms consistent with infection with the virus. I had been following news about the Ebola epidemic for months, since its re-emergence in Guinea, rapid spread to neighboring Nigeria and other parts of West Africa, through the critical illness and miraculous recovery of family physician Kent Brantly. But until that day, I hadn't actually confronted the question, "As a family physician, what do I need to know about this?"

Many have pointed out that even though this is by far the largest and most lethal Ebola outbreak in history, it pales in importance next to more common and contagious viruses such as influenza or measles, or emerging infections closer to home, such as the enterovirus respiratory illness that has stricken children in 43 states. Family physician blogger Mike Sevilla expressed skepticism that patients who continue to decline influenza vaccines in droves would be willing to receive a vaccine against Ebola even if it could be produced quickly, and given our abysmal track record with pandemic flu vaccination, I tend to agree.

What terrifies health professionals and laypersons about Ebola, despite its thus-far limited impact in the United States, is that so much about it is unknown. Clinicians are prepared to tackle influenza, a known quantity from past years. We don't know what to expect from Ebola, a nebulous threat to cause disaster at any time, like bioterrorism. Until more is known, family physicians should remember that fever in returning international travelers is far more likely to be due to malaria (which turned out to be the diagnosis of the hospitalized patient I mentioned earlier), and to always ask and communicate about recent travel, rather than depending on an electronic medical record to do it.

Monday, September 22, 2014

How can social media help Family Medicine?

-Jennifer Middleton, MD, MPH

I was thumbing through my issue of Family Medicine (the Society of Teachers of Family Medicine's journal) last week when I came across "Twitter Use at a Family Medicine Conference: analyzing #STFM13." I knew that this article was on its way; its lead author, Dr. Ranit Mishori, had contacted me to ask for some of my thoughts about using Twitter at conferences several months ago.

The study authors examined every tweet with the #STFM13 hashtag related to the 2013 Annual STFM conference from 3 days prior to the conference, during the conference, and for 3 days after the conference. They found that nearly 70% of the tweets were directly related to session content, about 14% were more social, and the remainder related to logistics and advertising. They also grouped the top reasons attendees gave for tweeting into four categories: information sharing, networking and connectedness, advocacy, and note taking.

Several of my comments made their way into the article about why I tweet at conferences. Tweeting allows me to simultaneously take notes and share interesting facts with the Twitter-verse. It's easy to read through my tweets when I get home and review what I learned along with the action steps I need to take. I also enjoy the dialogue and camaraderie that happens during the conference on Twitter; it's great to respond to other people's comments and factoids as well as see their responses to mine. By enabling supportive, meaningful dialogue among conference attendees, Twitter helps us to engage more deeply with the conference content.

Upon reading the article, I saw my Twitter handle (@SingingPenDrJen) named as the top tweeter for the conference. I was both a little proud and a little dismayed; it's nice to be an "influencer," but maybe I'm tweeting too much? Outside of what the article terms "social" tweets (which are not the majority of my tweets), I try to only tweet session content that is new, insightful, and/or practice changing. I'll definitely be more mindful of what I tweet at the next conference I attend.

Only a small percentage of STFM 2013 conference attendees were on Twitter; just 13% of conference attendees tweeted at least once, and over half of the total number of tweets were sent by 10 people. Many of the people sitting next to me in conference sessions asked me about tweeting and why I do it. When I offered to assist them with getting on Twitter, most politely declined, usually with comments about "I don't have the time" and the how intimidating new technology is ("I can't even figure out my EHR!" one person said).

I'd love to see more family docs on Twitter and other social media sites, but I'm not sure how realistic that is. From 2012 to 2013, the number of tweeters at the STFM conference didn't budge much. The diffusion of innovations theory postulates that a critical mass of early adopters have to embrace a change before the majority will follow suit; are we still waiting for that critical mass, or will this particular theory end up not applying to family docs and Twitter, with a significant number of docs not ever using it?

Spreading the word about the positives of an online presence may be a step in the right direction. A recent article in Family Practice Management reviews several social media platforms and discusses benefits of having a robust online presence. The article describes using social media to provide office updates and patient education. Perhaps equally valuable is proactively managing your online presence, so that patients see more than just third-party website patient reviews of you when they put your name into a search engine. At the end of the article is a list of simple, practical starting points for getting online in ways that benefit both patients and docs.

I hope to see more articles exploring how we as family docs connect and communicate online. The AFP social media presence -- with Facebook, Twitter, and the Community Blog -- provides a great way to engage with both our content and family docs in general. Keep the replies, retweets, and Facebook posts coming!

Tuesday, September 16, 2014

The demise of the small practice has been greatly exaggerated

- Kenny Lin, MD, MPH

When I was in high school, a national hardware retailer opened a new franchise down the street from the mom-and-pop hardware store that had served my neighborhood for many years. Since the new store had the advantage of larger volumes and lower costs, it seemed to be only a matter of time before it drove its smaller competitor out of business, the way that big bookstore chains and fast-food restaurants had already vanquished theirs.

But a funny thing happened on the way to the inevitable. By the time I left for college, the new hardware store had folded, and the mom-and-pop operation had moved into their former building. How did this small business manage to retain its customers and win new ones without prior loyalties? The answer was quality of service. I remember visiting both stores when a classmate and I were working on a physics project. At the mom-and-pop store, the owner himself happily held forth for several minutes on the advantages and disadvantages of various types of epoxy adhesive. At the national hardware chain, the staff consisted mostly of kids my age who didn't know much more about glue than I did.

A few years ago, an editorial authored by White House officials in the Annals of Internal Medicine blithely predicted that small primary care practices would eventually be absorbed by "vertically integrated organizations" as a result of health reforms. The editorial prompted the American Academy of Family Physicians to send the White House a letter defending the ability of solo and small group practices to provide high-quality primary care. Despite the migration of recent family medicine residency graduates into employed positions, researchers from the Robert Graham Center estimated in the August 15th issue of American Family Physician that up to 45% of active primary care physicians in 2010 practiced at sites with five or fewer physicians.

The limited resources of small practices seem to put them at a disadvantage relative to integrated health systems and newly formed Accountable Care Organizations. Small practices have less capital to invest in acquiring and implementing technology such as patient portals, and fewer resources (dollars and personnel) to devote to quality improvement activities, such as reducing preventable hospital admission rates. Nonetheless, like the small hardware store of my youth, some small practices are not only surviving, but thriving in the new health care environment. Dr. Alex Krist and colleagues recently reported in the Annals of Family Medicine that eight small primary care practices in northern Virginia used proactive implementation strategies to achieve patient use rates of an interactive preventive health record similar to those of large integrated systems such as Kaiser Permanente and Group Health Cooperative. An analysis of Medicare data published in Health Affairs found that among primary care practices with 19 or fewer physicians, a smaller practice size was associated with a lower rate of potentially preventable hospital admissions.

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement. For example, Dr. Jennifer Brull reported how her practice and four others in north-central Kansas succeeded in improving hypertension control rates in an article and video in the September/October issue of Family Practice Management.

These examples illustrate that the demise of the small primary care practice has been greatly exaggerated. Whether small practices can continue to flourish in the post-Affordable Care Act era remains an open question, but I do know this: the small hardware store in my home town is still thriving, more than twenty years later.

Monday, September 8, 2014

An evidence-based alternative to antibiotics for acute sinusitis

- Jennifer Middleton, MD, MPH

It's that time of year when the kids go back to school and bring home colds, or viral upper respiratory tract infections (URIs), to their families. These viral infections can progress to acute bacterial sinusitis (ABS), and in my office we are starting to see the usual fall uptick in "sinus" complaints. The September 1st edition of AFP reviews a Cochrane meta-analysis of intranasal corticosteroids' effect on ABS symptoms.

AFP provides the key details from this 2013 Cochrane review, which examined 4 studies and included about 2000 children and adults in total. The studies included patients who were both prescribed and not prescribed antibiotics. The Cochrane reviewers deemed 1 of these studies to be of low quality and excluded it from the meta-analysis. From the remaining 3 studies, the number needed to treat (NNT) with an intranasal corticosteroid (fluticasone, mometasone, or budesonide) to resolve or improve symptoms was 15.

Most patients with ABS will recover without an antibiotic, and the Choosing Wisely campaign exhorts us to avoid prescribing antibiotics unless symptoms are severe and/or persistent. The Choosing Wisely materials provide several alternate treatment recommendations, but patients may still be getting antibiotic prescriptions because it's more satisfying for us to write one than advise patients about rest, fluids, and salt water gargles. Pressures to keep patients satisfied may also influence our prescribing; you may recall hearing about a study from 2012 that correlated higher patient satisfaction scores with increased prescription costs (along with increased emergency department visits and mortality).

An AFP Curbside Consultation from 2005 provides guidance for responding to patients who insist on receiving an antibiotic for sinusitis despite clinician advice against it. The article recommends centering discussions on the risk of future harm to patients and their loved ones related to antibiotic resistance. Providing brochures and posters throughout the office that educate on appropriate antibiotic use can also be helpful. There's an AFP By Topic on Upper Respiratory Tract Infections if you'd like to read more.

The duty of tackling antibiotic resistance belongs to all of us; perhaps having an evidence-based alternative to antibiotics in the form of intranasal corticosteroids will decrease inappropriate antibiotic use along with the office practices described above.

How do you treat ABS? Will this Cochrane review change your practice?