Monday, February 1, 2016

Myth-busting and fact-sharing about Family Medicine

- Jennifer Middleton, MD, MPH

What career options exist for family physicians?
Can I afford to be a family physician?
How do family physicians keep up with the evidence base?

Medical students, other specialists, and even the lay public often have questions about Family Medicine. Kozakowski et al answer these questions and many more in "Responses to Medical Students' Frequently Asked Questions About Family Medicine" in the current issue of AFP. They provide information that debunks common myths about Family Medicine and also demonstrate Family Medicine's incredible breadth of career options:

Myth 1. Family physicians only work in outpatient settings seeing simple/boring problems like colds and minor injuries.

The authors review the numerous practice options available for family physicians:
As a family physician, you will be uniquely trained to provide comprehensive care for acute and chronic conditions, provide wellness care and disease prevention, perform a variety of procedures, and manage care through collaboration with other specialties.
True, most family physicians primarily practice in an outpatient setting, but many also provide inpatient and/or maternity care. Some work part- or full-time in urgent care centers or emergency departments. Most incorporate at least some procedures into their work, and some do a lot of them (see Table 2 for a comprehensive list). On average, we deal with a greater number of patient issues per visit than other specialists, and we're experts in understanding how co-morbid diseases affect each other. One of the reasons that I became a family doctor is the incredible variety of patients and conditions I see; I am never bored!

Myth 2. There's too much to keep up with in Family Medicine; I can't possibly know it all!

The authors tackle this one adeptly:
Family medicine residencies give you the core skills to manage most patient concerns comfortably, acknowledge your limitations, use your resources, and give you lifelong learning skills that allow you to grow and evolve with your patients and interests.
Students should actively seek Family Medicine residency programs that offer a comprehensive evidence-based medicine curriculum; the days where a monthly journal club might suffice are long past. Make sure that you will learn how to critically evaluate new studies, along with having ample mentoring regarding your personal reading plan. Using high-quality secondary literature review resources like AFP, it's more than possible to keep abreast of changes in the evidence base that should affect your practice, and residency is the perfect time to determine what resources you like and how you will integrate reviewing them into your schedule. Many family physicians also rely on social media to stay current with changes in medicine; AFP has a strong Facebook and Twitter presence, as do many other medical journals.

Myth 3. I won't be able to pay off my student loans if I become a family physician.

Family physician salaries are growing quickly in response to the increased need for primary care physicians in the United States. In addition, many health systems are offering sizable loan repayment benefits in their zeal to recruit family physicians (try putting "loan repayment family medicine" into your internet search engine and see what pops up). Fears about loan repayment should not keep individuals passionate about primary care out of our specialty.

On the flip side, here are some powerful facts about our specialty from the article:

Fact 1. A strong primary care infrastructure = higher quality health care at lower cost.

The authors review data showing that countries with a strong primary care base deliver better care for less cost; counties in the U.S. with the right proportion of primary care providers compared to other specialists show the same. Yes, we will always need the assistance of our colleagues in other specialties at times, but if you want to be part of the solution to improve health outcomes in the U.S., you can't go wrong choosing Family Medicine.

Fact 2. Training in Family Medicine provides excellent preparation for global health work.

Global health is about more than tropical diseases and unmet acute care needs; the authors point out that, increasingly, providing care for chronic diseases is equally important. No other specialty provides the breadth of training to prepare for the multitude of acute and chronic conditions at every age and stage of life that you may see across the globe besides Family Medicine.

Fact 3. Family physicians make great health care leaders.

Because we deal with whole human beings, and not isolated disease states, we are uniquely trained to look at the big picture with all of its inherent complexities. Besides this natural inclination to think broadly about challenges, no other specialty devotes as much time in residency training to understanding systems of care than Family Medicine. In addition, if you are passionate about advocating for your patients, AAFP provides a myriad of outlets to do so.

In an accompanying editorial to this special feature, Dr. Winklerprins and AFP's editor, Dr. Siwek, encourage all family doctors to share this article widely, especially with any medical students that you might mentor, since rotating with a family physician is often the most important factor influencing students' decision to join our specialty.

Monday, January 25, 2016

Managing hypertension with home blood pressure measurements

- Kenny Lin, MD, MPH

Several of my hypertensive patients always have significantly higher blood pressures at the office than at home. Even after verifying the appropriate size cuff, and re-measuring blood pressure several minutes into the visit, the numbers don't change. Since treating these patients based solely on office blood pressures risks overtreatment (prescribing too high a dose or too many drugs), I encourage them to keep logs of their home blood pressures for us to review at each followup visit. However, as outlined in this home blood pressure measurement protocol from a previous AFP article, interpreting the results can be complex and challenging to carry out in a time-constrained primary care visit.

In a recent study published in the Annals of Family Medicine, a team of Australian researchers monitored 286 patients with uncomplicated hypertension to determine a more efficient method for interpreting home blood pressure measurements. They found that participants with 3 or more of their last 10 home systolic blood pressures greater than or equal to 135 mm Hg were the most likely to have elevated 24-hour ambulatory blood pressures and signs of end organ disease on echocardiography. This correlation held even if patients did not follow the recommended home monitoring protocol. The researchers concluded that using this "3 in 10" threshold may be a more practical way to assess blood pressure control with home measurements.

Although this study only included patients with established hypertension diagnoses, the U.S. Preventive Services Task Force has emphasized the importance of obtaining blood pressure measurements outside of the clinical setting in its 2015 recommendation statement on screening for high blood pressure in adults. According to this Figure, 6 studies found that home blood pressure monitoring confirmed elevated office blood pressure readings only 45 to 84 percent of the time.

In light of recent trial findings that setting lower blood pressure goals may improve outcomes in patients at high risk for cardiovascular events, it will be even more critical to verify office blood pressure measurements with measurements outside of the office to maximize treatment benefits and minimize adverse effects.

Monday, January 18, 2016

Who should be screened for type 2 diabetes - and when?

- Jennifer Middleton, MD, MPH

The current issue of AFP reviews screening recommendations for type 2 diabetes in both a review article ("Diabetes Mellitus: Screening and Diagnosis") and a discussion of the United States Preventive Service Task Force (USPSTF)'s recommendation to screen all overweight and obese adults aged 40-70 for diabetes. These screening recommendations are at odds, however, of the practices of many employers and health insurers seeking to gather more data about their insured employees. 

Last year, the USPSTF released a "B" recommendation that non-pregnant adults aged 40-70 who are also overweight or obese should be screened for type 2 diabetes. A fasting glucose, a glucose tolerance test, or a serum hemoglobin A1C are all reasonable options for screening. The USPSTF recommends repeating screening, if initial results are normal, every 3 years. Treatment of patients with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) can forestall the development of type 2 diabetes, and identifying asymptomatic individuals with IGT or IFG is a laudable goal. 

These recommendations, however, are quite different than the practice of my current employer regarding biometric screenings. Once a year, I either submit to a fasting glucose level and lipid profile or forfeit several hundred dollars in health insurance premiums. These biometric screenings do not take into account risk factors, and they don't care what the evidence base says about whom we should be screening and when. (For the record, I do not meet USPSTF guidelines to be screened for diabetes or lipid disorders.) Employers and health insurers are indiscriminately testing everyone as a way to measure its insured population, assess its risks, and encourage individuals with abnormal results to engage in treatment and lifestyle changes

Those aims are not unreasonable, but they come at a cost. Applying these screening tests more often than currently recommended is not inexpensive and can also create the risk of false positive results. It also requires employees to share what should be protected health data with employers; although these screenings are often touted as "optional," the risk of forfeiting what may be hundreds of dollars may border on coercive

These complex issues can put family physicians in a difficult spot. Although I don't want to order annual lipid profiles and fasting glucose levels for my patients who don't need them, I also don't want my patients to suffer unnecessary healthcare costs. It seems unlikely that these programs are going away, but what can we, as family physicians and healthcare providers, do to orient these programs more in the direction of the evidence base? It may be time for us to speak up on this issue, both as individuals and our organized medical societies.

Efforts to do so to date have had mixed results. Last year, employees at one university protested vehemently against their employers' new biometric screening and health survey policy, and, in 2014, the United States Equal Employment Opportunity Commission brought a lawsuit against a large U.S. employer for their penalty-heavy requirement for employees to undergo biometric screenings. Although the EEOC lost their suit, those university employees succeeded in delaying the new biometric screening policy and creating a task force to examine the issue in greater depth

Certainly, there can be benefits to employees of incentivizing healthy lifestyles. Providing coverage for smoking cessation classes and medications, for weight loss programs and gym memberships, even for lactation support services are all worthwhile. Ensuring that employer health programs are meeting both employees' and employers' needs, however, will likely continue to be a balancing act. As long as the financial power of the equation lies with the employers, we will need to advocate for our patients, the employees.

Tuesday, January 12, 2016

Is Vitamin D supplementation good for anything?

- Kenny Lin, MD, MPH

For as long as I can remember, throughout medical training and clinical practice, the message from my mentors and colleagues about vitamin D supplements was the same: the sooner patients started taking them, the better to prevent osteoporosis and fractures later in life. And that wasn't the only benefit: in 2012, the U.S. Preventive Services Task Force even recommended vitamin D supplementation in community-dwelling adults age 65 and older to prevent falls.

But the very same Task Force soon began to raise doubts about the value of vitamin D supplements. In 2014, it found insufficient evidence to recommend calcium and vitamin D to prevent fractures in premenopausal women or men, and recommended against postmenopausal women using daily vitamin D supplements containing 400 IU or less because these increased the risk of kidney stones without affecting fracture rates. What about a strategy of selective supplementation in vitamin D "deficient" persons? The USPSTF also found insufficient evidence that screening for vitamin D deficiency in adults improves health outcomes, and the American Society for Clinical Pathology recommended against screening for vitamin D deficiency in the Choosing Wisely campaign.

So what is vitamin D supplementation good for? Recognizing the vitamin D deficiency in older adults has been associated with functional decline, Dr. Heike Bischoff-Ferrari and colleagues recently performed a randomized controlled trial comparing high-dose (60,000 IU per month or 24,000 IU per month plus calcifediol, a liver metabolite of vitamin D) to low-dose (24,000 IU per month) vitamin D supplements in 200 community-dwelling men and women 70 years and older with a history of falls. After 12 months, participants receiving the high-dose supplement did not have better lower extremity function and were more likely to have experienced falls than participants in the low-dose group. The authors of an accompanying editorial noted that after many similar trials, vitamin D supplementation has only been shown to reduce fractures and falls in institutionalized older adults.

Putting this all together, the next time a healthy adult of any age asks me if he or she should be taking a vitamin D supplement, I plan to answer: we don't know for sure, but probably not - and we don't need to know what your vitamin D level is, either.

Monday, January 4, 2016

Predictions for 2016 practice-changers

- Jennifer Middleton, MD, MPH

2015 brought us many provocative medical headlines, and 2016 will likely continue to provide us with a lot to discuss here on the AFP Community Blog. Here are some headlines that we may see in 2016:

SPRINT part 2
Although enrollment in the Systolic Blood Pressure Intervention Trial (SPRINT) was halted last year, data collection is still ongoing regarding two components of the trial: the effect, if any, of intensive blood pressure control on dementia and cognitive function (SPRINT MIND), and continued follow-up on renal function in participants (as an increased rate in renal function decline was noted in participants in the trial's intensive treatment arm). According to the SPRINT website, the researchers plan to complete data collection for both by mid-2016. Given how quickly the initial SPRINT study went to press after enrollment was closed, I wouldn't be surprised to see SPRINT MIND and the follow-up renal function data publicized before the end of 2016.

New hypertension treatment guidelines (again)
The publication of SPRINT last year conflicts with some of the JNC 8 hypertension treatment recommendations from 2013; although JNC 8 advocates for a systolic blood pressure (SBP) goal of 140 for all patients under age 60 and for patients over 60 with CVD risk factors, SPRINT suggests that some patients at high risk of cardiovascular disease (CVD) may benefit from an SBP goal of 120. The National Heart, Lung, and Blood Institute (NHLBI), which sponsored the JNC, is no longer issuing treatment guidelines, but a task force from the American College of Cardiology (ACC) and the American Heart Association (AHA) is currently at work developing new recommendations. Though they've provided no expected publication date, I suspect the desire by many to resolve this SBP goal discrepancy will push them to finish their work sooner rather than later.

USPSTF: dyslipidemia screening & treatment
The United States Preventive Services Task Force (USPSTF) is currently soliciting public comment on 2 topics related to dyslipidemia: dyslipidemia screening and "Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication." While both of these topics will be relevant to primary care, the second may have the most far-reaching consequences. Dr. Kenny Lin has written before on this blog on the current conflicting recommendations regarding treatment with statins for the primary prevention of CVD; it will be interesting to see what the USPSTF determines.

USPSTF: weight loss medications
I've written previously about the pros and cons of using prescription medications for weight loss on the blog, and the USPSTF is currently drafting its stance on this topic as well.  Will they be finished with this one before the end of 2016? Only time will tell.

Personal health tech goes mainstream?
Dr. Lin wrote last fall about the Family Medicine for America's Health (FMAH)'s technology "tactic team" and their strategies for increasing the use of technology to help patients. In that post, he described a study showing that text messaging to patients with heart disease helped them to reduce CVD risk factors. I'm hoping to see both a lot more studies like this one along with more from FMAH about how to practically implement these technologies in our offices.

Well, those are some of the stories I'll be watching for in 2016. What medical news are you anticipating in the next year?

Sunday, December 27, 2015

The top ten AFP Community Blog posts of 2015

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

Some themes that emerged from this year's list of most-read posts included avoiding overtreatment, challenging medical dogma in management of low back pain and myocardial infarction, and estimating efficacy and adverse effects of depression therapies in primary care settings. Happy holidays and best wishes for the New Year!

1. Advise patients to steer clear of these six orthopedic procedures (March 16) - 1804 views

What accounts for the continued popularity of ineffective orthopedic procedures? Excessive magnetic resonance imaging (MRI) plays a role. Patients who perceive surgery to be a "quick fix" may not have the patience to stick with physical therapy and rehabilitation. And there is the inescapable reality that, necessary or not, these procedures pay well.


2. Can treating mild hypertension be too much medicine? (January 2) - 935 views

Key take-home points are that the absolute benefits of treating otherwise healthy persons with mild hypertension are relatively small; lifestyle modification should generally precede medication; and blood pressure measurement should be performed and repeated carefully to ensure accurate identification of hypertensive patients.


3. ACC/AHA and Framingham calculators overestimate cardiovascular risk (March 3) - 841 views

Men in the Multi-Ethnic Study of Atherosclerosis cohort with a calculated ACC/AHA risk score of 7.5 to 10 percent had an actual event rate of only 3 percent; and just over 5 percent of women with a similar risk score experienced cardiovascular events.

4. Acetaminophen ineffective for chronic low back pain - now what? (April 6) - 826 views

Intuitively, acetaminophen seems like a reasonable choice for treating chronic LBP. It's inexpensive and relatively safe when used at recommended doses. This 2015 meta-analysis overturns that recommendation and should prompt a change in the clinical guidelines.


5. Stop beta-blockers 30 days after acute MI? (March 23) - 794 views

The greatest challenge for family physicians managing patients following up after an AMI admission may be the decision to stop a beta-blocker. Discontinuing therapies may be difficult for physicians.

6. Guest post: quality medical care makes patients feel at home (Sept. 7) - 766 views

In my view, the definition of good care includes communication, patience, concern, and perseverance. A high quality, "patient-centered" medical home is based on these human characteristics and not on outcome criteria, EHR meaningful use, or other measures.

7. Announcing the #AFPTop20 Tweet Chat on August 26th (August 17) - 760 views

On Wednesday, August 26th at 4 PM Eastern, @AFPJournal held its first #AFPTop20 Tweet Chat to take a deeper dive into the findings of some of the top POEMs of the year and their ramifications for family physicians.

8. Which antidepressants have the highest suicide risk? (July 6) - 748 views

In a United Kingdom cohort of 240,000 adult patients with depression, the adjusted hazard ratios for venlafaxine and mirtazapine for suicidal behavior were 1.70 (1.44 to 2.02) and 1.85 (1.61 to 2.13), respectively, compared with citalopram.

9. How to make sure your patients understand health information (July 15) - 713 views

A large body of evidence demonstrates strong associations between low health literacy and poorer health outcomes; compared to patients with high health literacy, patients with low literacy have more hospitalizations, more emergency department visits, and are less likely to receive appropriate preventive and chronic care services.

10. Depression treatment: the evidence base from a primary care perspective (Feb. 23) - 695 views

This systematic review provides guidance for family physicians treating patients with mild to moderate depression as well as severe depression; it provides reassurance to patients unable to attend multiple psychotherapy sessions that even a few sessions can provide benefit.