Tobacco quitlines suffer from budget cuts

An editorial in the July 15th issue of AFP by Drs. Stephen Rothemich and Scott Strayer extols the value of telephone quitlines in helping family physicians convince patients to stop smoking. Noting that many practices "lack the time and resources to provide effective counseling," the authors recommend that busy clinicians refer patients to the national toll-free quitline number (800-QUIT-NOW) to fill in these gaps. In addition, they review high-quality evidence that quitlines improve smoking cessation rates over counseling or medications alone:

The effectiveness of quitline counseling is well established. A Cochrane review reported successful cessation in patients who received counseling from quitlines (number needed to treat = 32). Quitline counseling combined with smoking cessation medications is particularly effective, with a cessation rate of 28.1 percent (more than three times the rates with minimal or no counseling or with self-help).

Unfortunately, funding for quitlines has recently fallen victim to budget cuts in at least two states. In Ohio and Washington State, quitlines that were once free to all smokers now only serve patients with certain types of insurance. State officials attributed their inability to continue to fully fund the quitlines to ending of federal grants and the need to divert funds from the 1998 Master Settlement Agreement with tobacco companies to other non-tobacco-related programs.

These cuts could not have come at a worse time, as the U.S. Food and Drug Administration's new requirement that cigarette packs display graphic health warning labels by September 2012 seems to have increased smokers' interest in using quitlines. For information about any eligibility limitations on your state's quitline, you can consult the website of the North American Quitline Consortium at http://www.naquitline.org/.

Diagnosing patients who itch

In a fascinating 2008 New Yorker article, "The Itch," Harvard surgeon Atul Gawande told the story of a patient who experienced a nearly fatal complication from treatment-resistant pruritis of her scalp following an episode of herpes zoster:

One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, “this fluid came down my face, this greenish liquid.” She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain.

Although this sort of complication is highly unusual, pruritis - far from being only a "nuisance" symptom - is often associated with underlying systemic conditions, Dr. Brian Reamy and colleagues observe in "A Diagnostic Approach to Pruritis" in the July 15th issue of AFP. Clinicians should consider evaluating patients who present with generalized, unexplained pruritis for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes. Many dermatoses of pregnancy can cause intense pruritis. Also, some psychiatric disorders are associated with pruritic sensations, leading to "neurotic excorations." Certain historical findings, including recent travel, exposure to animals, and constitutional symptoms such as weight loss and fatigue, can help to narrow the extensive differential diagnosis of this common and troublesome symptom.

Making informed choices about family planning and contraception

For reproductive-age women who have medical comorbidities such as epilepsy, diabetes, and hypertension, choosing a family planning method can be challenging. The September 1, 2010 issue of AFP reviewed the risks and benefits of hormonal contraceptives for these patients, based on guidelines from the American College of Obstetricians and Gynecologists. However, the scope of that article did not include nonpharmacologic options such as barrier or fertility awareness-based methods, also known as natural family planning (NFP). Two letters in the July 1st issue of AFP remind readers that NFP is an effective family planning option for appropriately educated couples and provide helpful training resources for clinicians. As Drs. Robert Conkling and Leslie Chorun observe:

Counseling in natural methods of fertility regulation is currently being provided by a growing number of trained physicians, nurse practitioners, and allied health professionals. ... These family planning methods should not be confused with calendar rhythm method and are not dependent on the regularity of a woman's cycle. Population-based surveys have shown a significant interest in NFP—approximately 25 percent of women and 40 percent of men are interested in using NFP to avoid pregnancy, and 33 percent of women are interested in using NFP to conceive. This interest is not associated with religion, education, age, or income level.

For further reading on patient outcomes associated with various fertility awareness-based methods, family physicians can consult a clinical review published in the Journal of the American Board of Family Medicine. Also, a recent AFP By Topic collection compiles the journal's current online content on all aspects of family planning and contraception, including preconception care, the infertility evaluation, and advantages and disadvantages of hormonal and non-hormonal methods.

Eliciting patients' lifestyle habits can be difficult

A physician reader of AFP submitted the following post.

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It is an unwritten law of medicine that patients tend to be less than entirely forthcoming when responding to queries regarding their intake of alcohol. I would guess that most physicians double or triple the number of alcoholic beverages patients admit to drinking daily. Similarly, when counseling patients with diabetes or obesity, I generally hear what I take to be gross underestimates of the amount of carbohydrates and total calories consumed. An individual might state with complete confidence (and often, indignation), "I eat almost nothing." He then might list his total food consumption for the previous day as "nothing for breakfast, an apple for lunch, a piece of chicken and a salad for dinner; that’s it."

I suspect that we all have an unintentional, perhaps uncontrollable, drive to appear better than we are in the presence of health professionals; we want to pass the test, so to speak. As a result, it is quite difficult to obtain accurate information regarding lifestyle habits such as diet, amount of exercise, tobacco use, substance abuse, sexual activity, etc. I congratulate patients who "come clean" and provide me with true descriptions of their daily habits. When asking them to keep food diaries, I explain that I am not grading them but, rather, collecting information about unhealthy aspects of their diet so that I can help them make adjustments.

Sometimes this approach works; often, it does not. After hearing another improbable tale of conscientious eating habits in a patient whose physical examination and laboratory tests suggest otherwise, I generally explain, “the laws of thermodynamics cannot be broken."

Bob Schwartz, MD
Chester Family Medicine
Chester, Vermont

Advice for physicians on using social media

The Mayo Clinic's Center for Social Media recently posted a short video of prominent physician bloggers Bryan Vartabedian (a gastroenterologist), Wendy Sue Swanson (a pediatrician), and Katherine Chretien (an internist) giving advice to young physicians on the potential and perils of social media use.

The advice and additional resources these experts provide should be helpful to family physicians at all stages of training who are new to using social media tools. Dr. Chretien also writes an insightful commentary in the July 1st issue of AFP in response to the question, "Should I be 'friends' with my patients on social networking web sites?" (Short answer: no, but there are less ethically questionable ways to interact with one's patients online.) As Dr. Chretien points out, the American Medical Association has recently published guidance on professionalism in the use of social media.

We encourage family physicians to explore the health care social media landscape through posts and comments on the AFP Community Blog and the journal's Facebook and Twitter accounts, as well as by visiting our links to blogs written by and for family physicians.

Preparing for bioterrorism and other medical emergencies

In the aftermath of 9/11 and the anthrax attacks of 2001, AFP published a review article on "Recognition and Management of Bioterrorism," recognizing that primary care clinicians would be on the front lines of any future bioterrorist attack. Other critical resources for family physicians now include the Centers for Disease Control and Prevention's Bioterrorism resource page, the MedlinePlus collection on Biodefense and Bioterrorism, and the American Academy of Family Physicians' Preparedness Manual for Disasters and Public Health Emergencies.

Although the unpredictable threat of bioterrorism can seem distant from day-to-day practice, Drs. Mark Harris and Kevin Yeskey remind us in an editorial in the July 1st issue of AFP that family physicians continue to play a "vital role" in protecting all Americans from the consequences of these attacks:

The first diagnosis of anthrax in the 2001 attack was in an emergency department. A salmonella outbreak in Oregon in 1984 that was later found to be bioterrorism-related was discovered after primary care physicians reported to their health department large numbers of patients with diarrhea who had eaten at two local restaurants. This type of passive surveillance is the early warning system for naturally occurring outbreaks, and for bioterrorism events. An astute physician who diagnoses a reportable illness and alerts the local health department may be detecting a bioterrorism attack, possibly saving his or her patient and many others.

Additional free AFP online resources to help physicians prepare for a variety of natural and man-made medical emergencies include a clinical review of emergency preparedness in office practice and a Curbside Consultation on professional training for emergency situations.