Does your practice function as an effective team?

Two recent commentaries in the Annals of Family Medicine and the New England Journal of Medicine argue that the performance of modern primary care physicians can only be as good as their practice teams. In "The Myth of the Lone Physician: Toward a Collaborative Alternative," George Saba and colleagues explain why the myth that a physician can do it all alone is dysfunctional and outdated, and should be replaced with the paradigm of a "highly functioning health care team":

What will be the roles and responsibilities of each team member? What systems and skills are needed to ensure effective communication? How will decisions be shared? How will conflict be resolved? How will the team foster trust and respect? How will the team promote the development of meaningful healing relationships? How will the team evolve over time? The specific answers to these questions define the roles and tasks of each team member, and the collaborative process of working through these challenges strengthens team relationships.

Similarly, in "Sharing the Care to Improve Access to Primary Care," Amireh Ghorob and Thomas Bodenheimer assert that the only way for family physicians to meet the health care needs of a burgeoning and increasingly complex patient population is to delegate many of their traditional responsibilities - such as "patient education, lifestyle counseling, medication titration, and medication-adherence counseling" - to other health professionals:

The paradigm (culture) shift transforms the practice from an “I” to a “we” mindset. Unlike the lone-doctor-with-helpers model, in which the physician assumes all responsibility, makes all decisions, and delegates tasks to team members, but the capacity to see more patients does not increase, the “we” paradigm uses a team comprising clinicians and nonclinicians to provide care to a patient panel, with a reallocation of responsibilities, not only tasks, so that all team members contribute meaningfully to the health of their patient panel. Nonclinician team members must add capacity in order to bring demand and capacity into balance.

In the current issue of Family Practice Management, Berdi Safford and Cynthia Manning discuss "Six Characteristics of Effective Practice Teams," which include shared goals; clearly defined roles; shared knowledge and skills; effective, timely communication; mutual respect; and an optimistic, can-do attitude. How many of these characteristics does your practice embody? Would your practice's other members agree that you and they currently function as an effective team?

Cancer screening in men: flexible sigmoidoscopy works, PSA does not

The cover article of AFP's May 15th issue reviews evidence-based components of the adult well male examination. Among the recommended tests for men (and women) age 50 years and older is screening for colorectal cancer via periodic fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy. Yesterday, the lead researchers of the National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial reported in the New England Journal of Medicine that flexible sigmoidoscopy every 3 to 5 years reduced deaths from colorectal cancer by 26 percent, a very impressive result given that nearly half of the participants in the control group were also screened at least once.

Today, the U.S. Preventive Services Task Force finalized its provisional recommendation to assign PSA-based screening for prostate cancer a "D" (don't do) grade in men of any age. The USPSTF's conclusion from five randomized, controlled trials that PSA-based screening produces no health benefits is consistent with a Cochrane for Clinicians review that AFP published more than a year ago. Evaluating the entire body of evidence, the Task Force concluded:

The reduction in prostate cancer mortality after 10 to 14 years [from PSA-based screening] is, at most, very small, even for men in what seems to be the optimal age range of 55 to 69 years. ... In contrast, the harms associated with the diagnosis and treatment of screen-detected cancer are common, occur early, often persist, and include a small but real risk for premature death. ...The inevitability of overdiagnosis and overtreatment of prostate cancer as a result of screening means that many men will experience the adverse effects of diagnosis and treatment of a disease that would have remained asymptomatic throughout their lives. ... The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms.

Few family physicians still perform screening flexible sigmoidoscopies, and PSA is one of the most commonly ordered blood tests in men over 50. How long will take to change both of these practices to reflect the best evidence?

A primer on medical apps

The current issue of Family Practice Management features an indispensable article on "Medical Apps: Making Your Mobile Device a Medical Device," by David Walsworth, MD. This concise guide to the expanding world of medical apps advises that family physicians evaluate apps much as they evaluate the medical literature:

It's good to ask the following questions, which I've adapted from a similar set of questions in a 1993 JAMA article on using the medical literature: Will I use this app frequently? If not, does it do its job so well that it has value for me? Do I trust the results? Do I trust the source? Does the value justify the cost? Your answers to these questions will determine whether a given app is for you.

Dr. Walsworth goes on to highlight his recommended apps in the categories of drug databases, point-of-care references, library tools, research tools, and online communities. Included among these is the AFP By Topic app, which allows readers to access up-to-date content on 50 commonly sought clinical topics. Hopefully you already have this app on your smartphone; if not, you can download it for free at the Android or ITunes stores. We would appreciate any feedback on how we could improve the app's usefulness in future versions.

Effective health care for children with autism spectrum disorders

A recent report from the Centers for Disease Control and Prevention found that the prevalence of autism spectrum disorders (ASDs), estimated at 1 in 110 children in a 2010 AFP article, may now have risen as high as 1 in 88. Previous AFP Community Blog posts have discussed potential explanations for the continuing increase in autism diagnoses, from the phenomenon of "diagnosis shift" to increased screening for ASDs at well-child visits, a controversial practice.

Although the etiology of ASDs remains unknown, there is evidence to support some treatments for affected children. In the May 1st issue of AFP, Dr. Corey Fogleman launched our "Implementing AHRQ Effective Health Care Reviews" series by summarizing key points from an Agency for Healthcare Research and Quality-sponsored review of the effectiveness, benefits, and harms of therapies for core and associated symptoms of ASDs in children two to 12 years of age. The review found that the antipsychotic drugs risperidone and aripiprazole reduce challenging behaviors in children with ASDs, but are associated with significant adverse effects. Also, intensive one-on-one behavioral interventions appear to improve outcomes if begun before four years of age.

The AHRQ review's conclusion that there is insufficient evidence to assess the benefits and harms of other treatments for ASD-associated repetitive behaviors was supported by a recent study published in Pediatrics. Dr. Melisa Carrasco and colleagues analyzed published and unpublished data on selective serotonin receptor inhibitors (SSRIs) and initially found that SSRIs were modestly helpful in reducing repetitive behaviors in children with ASDs. However, after they adjusted for the effect of publication bias (i.e., the tendency for trials showing a benefit to be published while those showing no benefit are not), the improvement was no longer statistically significant. This study illustrated how difficult it is for even the highest-quality reviews to determine what constitutes effective health care for patients when important data are unavailable for review.