The most popular posts of 2012

- Kenny Lin, MD

Although page views are only a surrogate measure of reader engagement, in a year that saw American Family Physician review the "Top 20 Research Studies of 2011 for Primary Care Physicians," I thought it appropriate to share the top 10 most popular AFP Community Blog posts of 2012. The top post, on screening intervals for osteoporosis, has been viewed more than 600 times.

1. How often should you screen for osteoporosis? (January 25)

Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.

2. The spiritual assessment in family medicine: unnecessary or essential? (September 20)

Since 80 percent of patients and family physicians perceive religion to be important, acknowledging and supporting spiritual beliefs is a key component of holistic, patient-centered care.

3. Curbing overuse of CT scans (January 11)

Use computed tomography only when it is likely to enhance patient health or change clinical care.

4. Prescribing opioids for chronic pain: avoiding pitfalls (August 22)

National surveys show that chronic pain is undertreated, but opioids often have serious adverse effects and can lead to dependence, addiction, and abuse.

5. Doctors should trust their clinical judgments (March 5)

What drives doctors to order tests that, in their hearts, they must know have a remote chance of being helpful?

6. Electronic health records may improve preventive care (July 11)

After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users.

7. Rhythm or rate control for atrial fibrillation? (June 28)

Management of newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.

8. Cancer screening in men: flexible sigmoidoscopy works, PSA does not (May 21)

How long will take to change both of these practices to reflect the best evidence?

9. The state of family medicine is ... ? (February 13)

There aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform.

10. Counterintuitive findings on quality incentives and patient satisfaction (April 9)

Is it possible that patient satisfaction is driven by receiving more care, but not better care?

Live from NAPCRG: how long does a cough last?

- Kenny Lin, MD

Although American Family Physician focuses on providing readers with clinical reviews and features that synthesize evidence into guidance for practice, our medical editors wear a variety of hats. In addition to serving as Deputy Editor of Evidence-Based Medicine at AFP, Dr. Mark Ebell is also an accomplished primary care researcher. Earlier today, at the annual meeting of the North American Primary Care Research Group (NAPCRG), he presented the findings from a study that provided an original take a seemingly simple question: how long does a cough last? This study compared patient expectations with a systematic review of the medical literature.

Dr. Ebell and his colleagues surveyed a sample of patients and consulted "Dr. Google" to determine public perceptions of how long a cough from an acute upper respiratory infection is supposed to last. Although estimates varied, the most common answer was one to two weeks. His team then proceeded to review the medical literature for studies of the natural history of acute cough, using the control groups from randomized trials testing an intervention such as an antibiotic. The weighted mean duration of cough in these patients was actually 17.8 days.

Since antibiotics are prescribed for at least 50 percent of patients who visit doctors for acute cough, Dr. Ebell suggested that the substantial discrepancy between patients' expectations and the actual duration of acute cough caused by respiratory infections may be a driver of excessive antibiotic prescribing. If more patients knew that a cough could normally last for two weeks or more, perhaps fewer of them would seek medical care for self-limited illness. An article in the November 1st issue of AFP provides evidence-based guidance on appropriate antibiotic use in upper respiratory tract infections.

Is family medicine an affordable career choice?

- Kenny Lin, MD

The inexorable yearly rise of medical school tuition has led to corresponding increases in medical student indebtedness. According to the American Medical Association, 86 percent of graduating medical students in 2011 had loans to repay, and their average debt was more than $160,000. The greater long-term income potential from choosing a subspecialist rather than a primary care career is only one of many factors that influence medical students' specialty choices. That being said, my students increasingly ask if they will be able to repay their loans, support spouses and children, and save enough for retirement on a family physician's income - a question that would have been unlikely to come up a generation ago.

In an innovative analysis published in Academic Medicine, researchers from the American Association of Medical Colleges and Boston University concluded that the answer is "yes." Using economic modeling software, they examined variety of loan amounts and repayment scenarios projected against average household expenses in a high-cost urban area (Boston) and income levels for primary care and subspecialist physicians. The bottom line:

Our economic modeling of a physician's household income and expenses across a range of medical school borrowing levels in high- and moderate-cost living areas shows that physicians in all specialties, including primary care, can repay the current median level of education debt. At the most extreme borrowing levels, even for physicians in comparatively lower-income primary care specialties, options exist to mitigate the economic impact of education debt repayment.

The authors defined "extreme" borrowing levels as $250,000 or greater, and noted that options for these highly indebted physicians include extended repayment terms and federal loan forgiveness programs such as the National Health Service Corps. They also noted that physicians who choose to live in rural or low-cost areas will have considerably more discretionary income after expenses.

Although this analysis did not address the equally important question of why the primary care-subspecialist income gap exists and what can be done to reduce it, these findings should be reassuring to students considering family medicine careers.

Fasting lipids study: potential practice-changer?

- Kenny Lin, MD

When I last saw my personal physician for a checkup, she recommended that I undergo screening for lipid disorders, per the guidelines of the U.S. Preventive Services Task Force. Although the office had a phlebotomist on site, my appointment was in the afternoon, and I had already eaten breakfast and lunch. Consequently, she instructed me to make a separate morning appointment to have my blood drawn after an overnight fast. Due to my hectic schedule, several months passed before I finally got around to doing this (fortunately, the results were normal). As family physicians know, many patients who are sent for fasting tests never have those tests done at all.

A recent study published in the Archives of Internal Medicine suggests that there may be little reason for most patients to endure the inconvenience of fasting before lipid testing. The authors analyzed the relationship of fasting duration to variations in cholesterol levels obtained in more than 200,000 patients in and around Calgary (Alberta, Canada). In this population, the time since one's last reported meal had no effect on mean total cholesterol and high-density lipoprotein (HDL) cholesterol levels. Mean low-density lipoprotein (LDL) levels varied by up to 10 percent, while mean trigylceride levels varied by up to 20 percent. The authors and two editorialists conclude that for most purposes in primary care, including global cardiovascular risk assessment and monitoring response to pharmacologic treatment, nonfasting cholesterol measurements are likely to yield equivalent information to measurements from traditional fasting samples.

Rare is the single study in the medical literature that changes usual clinical practice on its own, and for good reason. Consistent evidence from multiple studies is usually needed to verify or refute impressive initial findings. Further, the cross-sectional design of this particular study might have masked unmeasured variables that would have been better controlled for in a randomized clinical trial. That being said, if any single study should be called a practice-changer, I think this one fits the bill. What's your opinion?

Strategies for physicians to prevent burnout

- Kenny Lin, MD

Although they probably came as little surprise to most of us who practice primary care, the results of a national survey of physician burnout in the Archives of Internal Medicine earlier this year made headlines in The New York Times and The Atlantic. This study found that 1) physicians are more likely to experience symptoms of burnout than similarly educated workers in the U.S. general population; and 2) physicians on the "front line of care access" - family physicians, general internists, and emergency medicine physicians - had the highest rates of burnout.

A Curbside Consultation in the November 1st issue of AFP discussed the distinct but closely related problem of demoralization in a family physician who serves as the part-time medical director for a financially troubled clinic for children with developmental disorders. This physician was forced to accept layoffs of several key staff members without a corresponding decrease in workload:

She recognized the great need of these children and families, and had talked with other staff and administration about additional programs she wanted to develop. She now would have to say good-bye to coworkers and abandon her hopes for a larger and more robust program. She realized that the remaining staff, herself included, would have to work harder, and that she would have less time to spend with patients, the part of the work she found most fulfilling. Patients who needed the most help would, in fact, get less help. ... Over the next week, she became dejected and sad.

In the accompanying commentary, Dr. Stewart Gabel connected the often temporary state of demoralization to the more serious and persistent state of burnout:

Demoralization is a state of hopelessness and helplessness that is akin to, but separable from, depression. It is associated with a sense of subjective incompetence, the belief that a person is unable to express his or her values and achieve his or her goals. Demoralization has an existential dimension that is associated with the affected person's experienced losses. ... Moving past demoralization involves remoralization, or the renewal of one's personal values and the activities that stem from these values. ... However, if not addressed, persistent feelings of demoralization are likely to result in or contribute to burnout.

How can physicians prevent the demands of practicing present-day medicine from leading them down the road to burnout? An article in Family Practice Management suggested eight ideas, including joining a physician support group; strengthening interpersonal communication skills; and making it a priority to address the spiritual needs of patients and themselves.

New treatments for head lice

- Kenny Lin, MD

Pediculosis is a distressing diagnosis that frequently causes children to be sent home from school or day care. In the September 15th issue of American Family Physician, Dr. Karen Gunning and colleagues provided a treatment update for pediculosis and scabies. Permethrin 1% lotion or shampoo is the recommended first-line treatment for head lice infestation (see illustration below). However, permethrin resistance is increasingly common in many communities, and second-line therapies have substantial disadvantages: malathion is flammable, and lindane is neurotoxic and cannot be used in young children. Additional safe, effective treatments are now being developed.

Yesterday, researchers reported in the New England Journal of Medicine the results of two randomized trials evaluating a single 10-minute home application of topical 0.5% ivermectin lotion for head lice in patients 6 months of age or older. Compared to the control groups, patient assigned to receive ivermectin were significantly more likely to be louse-free at day 2 (95% vs. 31%) and day 15 (74% vs. 18%), with no difference in adverse events. A major limitation of these studies is that topical ivermectin was compared to a placebo rather than to established head lice treatments.

Often, new treatments are no better than old ones

- Kenny Lin, MD

A recent systematic review and meta-analysis from the Cochrane Collaboration broke new ground in evaluating not one intervention or group of interventions for a single health condition, but the more general question of whether new treatments are more effective than established ones. The authors analyzed data from four cohorts of publicly funded trials of cancer treatments, treatments for neurological problems, and treatments for mixed diseases. In this sample, they found that slightly more than half of new treatments turned out to be better than old ones, but not by much: primary outcomes were just 9 percent better with the new treatments, and mortality fell by only 5 percent.

To make it easier for family physicians to compare new treatments to old ones, AFP publishes the STEPS (Safety, Tolerability, Effectiveness, Price, and Simplicity) series of new drug reviews. The October 15th issue includes a STEPS review of rivaroxaban (Xarelto), a new oral anticoagulant that is indicated to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. Under Effectiveness, the review notes: "Rivaroxaban was as effective as warfarin at preventing stroke and systemic embolism, and reduced annual stroke rates to 2.1 percent, compared with 2.4 percent for warfarin. No trials have compared rivaroxaban with dabigatran (Pradaxa), a direct thrombin inhibitor, or with fondaparinux (Arixtra), an injectable factor Xa inhibitor." Rivaroxaban does not require laboratory INR monitoring like warfarin, but costs more than 40 times as much. Family physicians and patients will need to decide whether this relatively small benefit is worth the increased cost of this new drug compared to the old.

Why don't comparative effectiveness studies change clinical practice?

- Kenny Lin, MD

The October 1st issue features the third article in AFP's new series "Implementing Effective Health Care Reviews," a summary of the Agency for Healthcare Research and Quality's comparative effectiveness report on treatments for gastroesophageal reflux disease. Notably, the report found no differences in efficacy between proton pump inhibitors; better symptom relief from continuous daily compared with on-demand dosing; and limited data on endoscopic treatments. What are the chances that results from this and other high-quality comparative effectiveness studies will quickly change your practice? Not very good, unfortunately. As I wrote in an editorial that introduced the series:

To date, the track record of translating comparative effectiveness research findings into clinical practice has been mixed, at best. For example, several years after a landmark randomized controlled trial demonstrated the superiority of thiazide diuretics compared with other first-line medications for hypertension, prescribing of thiazide diuretics had increased only modestly. An evaluation of diabetes practice guidelines produced after the publication of an Effective Health Care review of oral treatments found numerous inconsistencies between guideline recommendations and evidence-based conclusions. Despite extensive evidence that initial coronary stenting provides no advantages over optimal medical therapy for stable coronary artery disease, more than one-half of patients who undergo stenting in the United States have not had a prior trial of medical therapy.

In the October issue of Health Affairs, Justin Timbie and colleagues propose five reasons that scientific evidence is slow to change how physicians practice:

1) Misalignment of financial incentives - e.g., fee-for-service payment systems tend to reward invasive therapies, such as surgery for back pain, that may be no better than conservative management.

2) Ambiguity of results - "Without consensus on evidentiary standards prior to the release of comparative effectiveness results, ambiguous results become fuel for competing interpretations, making it difficult for providers, insurers, and policy makers to act on the evidence."

3) Cognitive biases in interpreting new information - e.g., a tendency to reject evidence that contradicts previous strongly held beliefs, such as the superiority of atypical to conventional antipsychotics.

4) Failure to address the needs of end users - e.g., designing a study to compare the benefits of two therapeutic strategies, but not the harms.

5) Limited use of decision support - e.g., poorly designed electronic or paper patient decision aids that do not fit into the workflow of primary care practices.

Do these reasons sound about right to you? How do you think these obstacles could be overcome in order for front-line family physicians to rapidly incorporate the best scientific evidence into their practices?

Who should receive medications for influenza?

- Kenny Lin, MD

Flu season is coming soon, and in addition to familiarizing themselves with the Advisory Committee on Immunization Practices vaccination guidelines for the 2012-13 season (offer influenza vaccine to everyone 6 months of age or older), physicians should consider how they plan to diagnose patients with suspected influenza. Despite the availability of multiple antiviral medications for influenza, whom to treat remains a challenging question.

In a 2010 Cochrane for Clinicians commentary, Dr. William E. Cayley observed that the neuraminidase inhibitors oseltamivir and zanamivir provided limited benefits for prevention and treatment of otherwise healthy persons with influenza. However, this conclusion was based on incomplete data - that is, results from published trials only. Subsequently, the Cochrane review authors were able to access several unpublished "clinical study reports" from the manufacturers and modified the review to reflect these additional data. In an updated Cochrane for Clinicians, published in the October 1st issue of AFP, Dr. Cayley finds that the evidence no longer supports using neuraminidase inhibitors to prevent influenza transmission:

The authors found that, based on clinical study reports, treatment with oseltamivir reduced the likelihood of an antibody response to influenza, the diagnostic marker that is typically used to determine the effectiveness of prophylaxis. In the absence of another way to measure the effectiveness of oseltamivir prophylaxis, it is uncertain whether the medication reduces the risk of influenza transmission.

Even for treatment of persons with influenza, the benefits of antivirals are modest: oseltamivir reduced the duration of symptoms by less than one day and had no effect on hospitalizations. Since these medications have side effects, physicians may reserve their use for persons at higher risk of complications, such as those with asthma or other chronic respiratory problems. As Dr. Cayley notes, existing guidelines are only as good as the evidence that supports them - and in the case of influenza treatments, not very good at all:

The contrast between the limited positive findings of this review and the strong support for treatment with neuraminidase inhibitors in public health guidelines (such as those from the CDC) highlights the importance of ongoing assessment of such recommendations and related educational materials, especially when evidence to support widespread implementation of an expensive intervention is lacking.

The spiritual assessment in family medicine: unnecessary or essential?

- Kenny Lin, MD

Since it became possible to post online comments on AFP content earlier this year, no single article has prompted as many comments as "The Spiritual Assessment," published in the September 15th issue. The range of comments thus far reflects family physicians' diversity of views on this topic. For example, while one reader opined that spiritual concerns have "little to do with improving the health of our patients," another countered, "I do not think this article goes far enough in promoting this type of spiritual health assessment." Another reader argued that the spiritual assessment should "not be elevated to the status of another vital sign we must always take." Some readers expressed concerns that physicians might seek to impose their religious beliefs on vulnerable patients, while another suggested that "many physicians seem to have more fear of [discussing] spiritual issues than the patients do."

In the article, Drs. Aaron Saguil and Karen Phelps suggest assessing older patients, hospitalized patients, and patients with worsening or terminal illness, who are more likely to be interested in sharing their spiritual or religious beliefs. Other patients may bring up their faith or spiritual practices without prompting in the course of a normal conversation. Since 80 percent of patients and family physicians perceive religion to be important, according to the authors, acknowledging and supporting spiritual beliefs is a key component of holistic, patient-centered care:

The spiritual assessment allows physicians to support patients by stressing empathetic listening, documenting spiritual preferences for future visits, incorporating the precepts of patients' faith traditions into treatment plans, and encouraging patients to use the resources of their spiritual traditions and communities for overall wellness. Conducting the spiritual assessment also may help strengthen the physician-patient relationship and offer physicians opportunities for personal renewal, resiliency, and growth.

We invite other readers to share their perspectives on the role of the spiritual assessment in family medicine by posting a comment on the article, posting a comment to this blog, or sending an e-mail to afpcomment@aafp.org.

What works for patients with irritable bowel syndrome?

- Kenny Lin, MD

A lot of treatments do, according to a review article by Thad Wilkins, MD and colleagues in the Sept. 1 issue of American Family Physician. Most effective appear to be regular exercise, antibiotics, antispasmodics, peppermint oil, and probiotics. Less effective (increase stool frequency but not pain) are over-the-counter antidiarrheals and laxatives. Fiber is no more effective than placebo. Other treatments that can provide some benefit include antidepressants, psychological therapies, and lubiprostone. With this many options to choose from, the challenge for physicians is selecting treatments that are most likely to benefit individual patients. The authors suggest classifying irritable bowel syndrome as diarrhea-predominant, constipation-predominant, or mixed presentation to guide initial and subsequent choices. Forming a therapeutic alliance with patients is critical, since IBS symptoms often recur despite treatment, and "a positive patient-physician interaction is associated with fewer return visits for IBS and is a key component in the treatment of these patients." A freely accessible handout for patients summarizes the most common treatments and provides additional informational resources.

Screening for chronic kidney disease

- Kenny Lin, MD

In patients without diabetes or hypertension, there is not enough evidence to assess benefits and harms of screening for chronic kidney disease with a serum creatinine level or urine albumin testing, the U.S. Preventive Services Task Force reported yesterday. A 2011 AFP article on chronic kidney disease detection and evaluation noted that multiple organizations recommend screening in patients with cardiovascular disease or diabetes, and a systematic review performed to support the USPSTF recommendation found that angiotensin-converting enzyme inhibitors slowed progression to end-stage renal disease and decreased mortality if prescribed in the early stages of this condition. However, few studies included patients without diabetes or hypertension.

For family physicians, the bottom line from this recommendation is that there is no clinical indication for ordering a basic metabolic profile or urinalysis in an asymptomatic patient as part of a preventive health evaluation. Ordering such unnecessary tests frequently does more harm than good, and has been discouraged by the AAFP-supported Choosing Wisely initiative and a previous AFP editorial.

Prescribing opioids for chronic pain: avoiding pitfalls

- Kenny Lin, MD

For years, family physicians who treat patients with chronic nonterminal pain have been caught between a rock and a hard place: national surveys show that chronic pain is undertreated, but opioids often have serious adverse effects and can lead to dependence, addiction, and abuse. A recent AFP review article advised comprehensive assessments for patients with chronic pain, careful patient selection using an opioid risk tool, and use of written agreements that "outline appropriate intervals for follow-up, refill policies, participation in any indicated multimodal management plan (e.g., physical therapy, psychological treatment), use of only one prescriber and one pharmacy for all controlled medications, and prohibition of illicit substance use or prescription diversion." In July, the U.S. Food and Drug Administration, in consultation with the AAFP, required that manufacturers of prescription opioids pay to support new voluntary educational programs for clinicians and patient education materials designed to reduce opioid misuse and its consequences.

An editorial in this week's Archives of Internal Medicine questioned whether there is a true difference between opioid "dependence" and "addiction," noting that a Washington state law that limited the amount of opioid that can be prescribed for chronic pain led to many patients experiencing persistent withdrawal effects after being tapered to lower doses. The authors concluded: "Dependence on opioid pain treatment is not, as we once believed, easily reversible; it is a complex physical and psychological state that may require therapy similar to addiction treatment, consisting of structure, monitoring, and counseling, and possibly continued prescription of opioid agonists." What has been your experience in prescribing opioids for patients with chronic nonterminal pain?

Screening for hepatitis C in Baby Boomers

- Kenny Lin, MD

Today, the Centers for Disease Control and Prevention finalized new recommendations for one-time screening for the hepatitis C virus (HCV) in all persons born between 1945 and 1965, a generation better known as the "Baby Boomers." The CDC's new recommendations are published in the Annals of Internal Medicine. Previously, the CDC only recommended that persons with behavioral or medical risk factors for HCV be routinely tested. The rationale for expanded screening in persons age 47 to 67 is that more than 75% of persons with antibodies to HCV (demonstrating evidence of prior infection) belong to this age group,  due to a higher prevalence of injection drug use. Since more than half of adults with HCV are unaware that they are infected, the CDC recently estimated that routine screening and treatment of infected persons in this "birth cohort" would be cost-effective.

It remains unclear what impact the new CDC recommendations will have on primary care, given that the American Academy of Family Physicians continues to follow the U.S. Preventive Services Task Force's 2004 guideline, which states that there is insufficient evidence to screen persons at high risk of HCV infection, and recommends against screening adults in the general population. The CDC's and USPSTF's contrasting views previously provoked a lively debate in the editorial pages of American Family Physician, with the USPSTF arguing that screening had not been shown to reduce morbidity or mortality from HCV, and the CDC countering that disease-oriented benefits should eventually translate into positive long-term health outcomes for patients. In fact, the new CDC guideline makes it a point to explain why the two organizations may continue to differ in their recommendations:

The USPSTF prefers data from randomized, controlled trials that begin with randomization into screened and nonscreened groups and follow participants through to morbidity and mortality, yet these data are not available. Although these types of studies provide the most conclusive evidence about the benefits and harms of a screening intervention, they also are resource-intensive and require long periods of follow-up. The CDC based its HCV testing recommendations on the prevalence in the target population, the many persons who are unaware of their infection status, potential benefits of care and treatment, and projections of increasing morbidity and mortality in the absence of an intervention.

According to a recent AFP review article, chronic HCV infection "leads to cirrhosis in about 10 to 20 percent of patients, increasing the risk of complications of chronic liver disease, including portal hypertension, ascites, hemorrhage, and hepatocellular carcinoma." Due to the increased risk of alcohol-induced liver damage in patients with HCV, the CDC also recommends brief screening and intervention for alcohol misuse at the time of HCV diagnosis, a position supported by the USPSTF.

Checking the resurgence of pertussis

- Kenny Lin, MD

According to several news stories, more than twice as many cases of pertussis (whooping cough) have already been reported in the U.S. this year than in all of 2011. Although some of the disease resurgence may be due to increasing rates of vaccine refusal, experts are concerned that another culprit may be waning immunity from the acellular pertussis vaccine that has been used in the U.S. since the 1980s. Although a recent Cochrane review concluded that acellular pertussis vaccines (preferred due to their lower incidence of side effects) were as effective as whole-cell vaccines, the review relied mostly on indirect comparisons and limited follow-up intervals. In contrast, an Australian study published in the August 2nd issue of JAMA found that acellular vaccines were clearly inferior to whole-cell vaccines in preventing pertussis 10 to 12 years after vaccination.

In order to prevent new pertussis infections, especially in infants who are too young to be immunized, all adolescents and adults should receive Tdap immunizations instead of the traditional Td booster. To encourage patients to receive age-appropriate immunizations, parents should be counseled about vaccine safety, and standing orders and patient reminders instituted to prompt physicians and support staff when immunizations are recommended. Additional information on immunizations for pertussis and other vaccine-preventable diseases is available in the AFP By Topic collection.

Treating common ailments of Olympic athletes

- Kenny Lin, MD

As I write, competitors at Summer Olympic Games in London are pushing their bodies to their physical and mental limits, leading to plenty of work for family physicians and other sports medicine clinicians. Elite endurance cyclists and long-distance runners encounter a host of common problems, ranging from overuse injuries to heat-related illnesses. Runners and gymnasts also are at increased risk for lower extremity stress fractures. Tennis players traditionally suffer from lateral epicondylitis, while basketball and soccer players are vulnerable to ankle sprains and anterior cruciate ligament injuries when they step on to the court or field of play. Beach volleyball star Kerri Walsh recently underwent multiple surgeries for acute shoulder injuries suffered during championship-level competitions. Swimmer Jessica Hardy, competing in several events at the current Games, also qualified for the 2008 Summer Games in Beijing but withdrew and served a one-year ban from the sport after testing positive for a banned sports supplement.

With such an extensive variety of ailments that might surface during the Summer Games, U.S. team physicians and medical personnel can at least breathe a sigh of relief that the athletes' medical records are, for the first time, being stored digitally. As Alice Park recently wrote in Time magazine:

While fans can follow their favorite Olympian via Twitter and texts, and get real-time updates on their activities, until this Games, medical records were handled in a conspicuously old-school way — shipped, in dozens of palettes, to the Games. For Beijing, the files literally took a slow boat to China, says Dr. Bill Moreau, managing director of sports medicine at the USOC. “Heaven forbid that an athlete would actually need something from their record while it’s being shipped, or on the ocean, or stuck in a harbor,” he says. With the electronic records, anyone caring for an Olympic athlete, from a trainer to a physical therapist to a physician treating an emergency injury, can get a quick look at the athlete’s medical history at a glance, and update it with the latest developments.

That's medical progress that all of us watching from home can cheer about!

Making wiser choices about medical tests and treatments

- Kenny Lin, MD

The July 15th issue of AFP features an special online editorial by AFP editor Jay Siwek, MD that compiles family medicine-relevant items from the multi-specialty Choosing Wisely campaign that aims to reduce the provision of "unnecessary" care, defined as medical tests and treatments that offer no health benefits and may result in harm to patients. Based on trusted sources of evidence-based medicine such as the U.S. Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus, these "don't do" recommendations have the potential to save both lives and money, if they can be effectively put into practice. To inform patients about the campaign, Consumer Reports has created fact sheets about many of the included items.

Reactions to the Choosing Wisely campaign in the blogosphere have been varied. Calling it "the health reform we need," cardiologist John Mandrola writes, "I hope it sticks like super glue." On the other side, emergency physician William Sullivan argues that the campaign "has good intentions, but isn't a good idea," noting that "there isn’t a Suing Wisely campaign for attorneys and there isn’t a Legislating Wisely campaign for Congress." Similarly, family physician Mike Sevilla contends that while Choosing Wisely may "score political points" for sponsoring physician organizations, it is unlikely to change their members' behavior, which is also driven by patient demands and fears of lawsuits over interventions not taken. Where do you stand on this spectrum? Is the Choosing Wisely campaign good or bad for family medicine, or perhaps some of both?

Which test should be used for TB screening?

- Kenny Lin, MD

The tuberculin skin test has a long and venerable history as the screening test of choice for latent tuberculosis infection in the United States. A 2009 AFP article called it "the most acceptable method" of tuberculosis screening. However, the tuberculin skin test has limitations: it requires 2 patient visits, and may be difficult to interpret in persons from other countries that have received bacille Calmette-Guerin (BGC) vaccinations. In contrast, interferon-gamma release assays (IGRAs) performed on blood samples require only a single patient visit, do not cross-react with BCG, and according to a recent systematic review, have comparable specificity to TSTs. The Centers for Disease Control and Prevention now recommends that IGRAs be the preferred test for patients with prior BCG vaccinations and those who are unlikely to return for a TST reading (e.g. homeless persons). But why not go one step further and abandon the tuberculin skin test entirely?

In an editorial in this week's JAMA, Drs. Phillip LoBue and Kenneth Castro examine the case for replacing traditional skin with blood tests for tuberculosis. They note that although the evidence is limited, positive IGRAs are able to predict which patients will eventually develop active tuberculosis in the absence of treatment at a rate similar to TSTs, albeit poorly (5 to 10 percent). It is also uncertain if having a single positive cutoff value for IGRAs will produce additional false-positive results, compared to the 3 values for a positive TST based on a person's health status and tuberculosis risk. Finally, an IGRA costs 3 times as much as TST, even factoring in costs associated with a follow-up visit.

What test or tests does your practice currently use to screen patients for latent tuberculosis infections? Do you think the convenience and ease of interpretation of the blood test is worth the additional cost? Please let us know your thoughts.

Electronic health records may improve preventive care

- Kenny Lin, MD

In an editorial in the May 15th issue of AFP, I summarized the mixed evidence that using electronic health records with clinical decision support systems (CDSSs) improves processes and outcomes of preventive care. Most of the literature supporting a positive effect of EHRs with CDSSs is either anecdotal, observational, or limited to specific settings (namely, practices of employed physicians in large, integrated health systems). I concluded that it remained uncertain if these results could be duplicated in randomized trials in typical private practices.

Uncertain, that is, until this week, following a study by Alex Krist and colleagues, "Interactive Preventive Health Record to Enhance Delivery of Recommended Care: A Randomized Trial," in the Annals of Family Medicine. The authors randomized 4500 patients from 8 primary care practices in Virginia to usual care versus an invitation to use MyPreventiveCare, an interactive personal health record (IPHR) that generates a list of screening and counseling recommendations based on guidelines from the U.S. Preventive Services Task Force, as well as links to more detailed explanations of these preventive services and relevant decision aids. When patients used the IPHR, their physicians also received a summary of the recommendations in their EHRs.

Although only about 1 in 6 invited patients had actually used the personal health record 16 months later, it was enough to show a statistically significant difference between the proportion of patients in that group who were up-to-date on all recommended services, compared to the control group. After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users. The authors concluded: "Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefits." A how-to guide on the use of personal health records to promote preventive services is available on the Agency for Healthcare Research and Quality website.

Rhythm or rate control for atrial fibrillation?

- Kenny Lin, MD

For many years, the standard thinking regarding treatment of patients with atrial fibrillation was that drug therapy to restore sinus rhythm (rhythm control) was superior to drug therapy to slow the ventricular response rate (rate control). That all changed in 2002, when a clinical trial found no difference in survival between patients randomized to rhythm or rate control, and a higher incidence of adverse effects in the rhythm control group.

This trial and other evidence led the American Academy of Family Physicians to issue a guideline that recommended rate control with chronic anticoagulation as the preferred strategy for most patients with atrial fibrillation. A recent AFP review article echoed this guidance, assigning an "A" strength of evidence rating to the following statement:  "Rate control is the recommended treatment strategy in most patients with atrial fibrillation. Rhythm control is an option for patients in whom rate control is not achievable or who remain symptomatic despite rate control."

On occasion, however, evidence-based interventions achieve different results in primary care than in clinical trials. A study published earlier this month in the Archives of Internal Medicine used administrative databases in Quebec, Canada to compare mortality between older patients with atrial fibrillation who were initially prescribed rhythm or rate control therapy after their diagnoses. After experiencing similar mortality through 4 years of follow-up, patients in the rhythm control group had a significantly lower risk of death, with 23% lower relative mortality than patients in the rate control group at 8 years. These surprising results beg the question: was this new study somehow flawed? If not, as the subtitle of an accompanying editorial asked, can observational data trump randomized trial results?

Although it is unlikely that treatment guidelines will change any time soon, this study should remind clinicians that management of patients with newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.

Family physicians and Communities of Solution

Every so often, AFP reviews a public health topic, such as outdoor air pollutants, disaster preparedness and response, or reducing the effects of climate change. And occasionally we receive feedback from readers who suggest that these topics are not appropriate for a family medicine journal, since family physicians are practicing clinicians who provide direct care to individual patients, not public health professionals responsible for large populations. However, this view of the limited role of family physicians is by no means unanimous.

In response to concerns about the shrinking scope of family medicine, Dr. Joseph Scherger wrote on the Society of Teachers of Family Medicine blog that "family medicine today is more complex and expansive in some ways than ever before." Family physicians must learn advanced motivational counseling and information management skills to practice excellent preventive and chronic care. Also, the patient-centered medical home requires family physicians to take population-based approaches to managing chronic illnesses.

In March, the Institute of Medicine published a report on opportunities for integrating primary care and public health. Notably, the report did not advocate for large numbers of family physicians to obtain formal public health degrees. Just as an editorial in the Annals of Internal Medicine argued that the subspecialty of geriatric medicine would be best served by incorporating its unique resources and skills into primary care training, a group of family medicine leaders convened by the American Board of Family Medicine recently declared:

The modern primary care physician, who values “community participation, political involvement, and collective advocacy," can, in effect, be a true public health professional, forming partnerships with community-based organizations that facilitate healthy change. This paradigm shift includes the transition from treating individuals in isolation to treating people in the context of their lives in their communities, indeed, culminating in community-centered care.

In a publication in the Annals of Family Medicine, this group re-examined and updated the 1967 Folsom Report, which provided a blueprint for connecting the personal physician with community resources in "Communities of Solution." What do you think of this ambitious vision of the family physician as a public health professional? Is this a desirable goal, and if so, what would it take to achieve it?

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.

Opposing views on spinal manipulation for low back pain

Low back pain is a distressing, and distressingly common, problem encountered in family medicine. Although this symptom is usually self-limited in otherwise healthy patients, there are few truly effective treatments other than time. Seeking faster relief, many patients visit chiropractors or osteopathic physicians who provide spinal manipulative therapy. Three pro/con editorials in the April 15th issue of AFP debate the effectiveness of spinal maniplation relative to other commonly used treatments for low back pain.

In the first editorial, Drs. James Arnold and Shannon Ehleringer point out that "in two large systematic reviews, manipulation decreased pain and improved range of motion in patients with chronic neck pain and in patients with acute and chronic back pain. Manipulation improved symptoms more effectively than placebo and was as effective as nonsteroidal anti-inflammatory drugs, home exercises, physical therapy, and back school." Dr. Melicien Tettambel concurs in the second editorial, arguing that since "it is unrealistic to expect any single treatment modality to be universally effective across all patients," manipulation has a useful role as an adjunct therapy.

On the other hand, Drs. Peter Cronholm and David Nicklin contend in a third editorial that much of the evidence supporting spinal manipulation for low back pain consists of low-quality studies that demonstrate statistical but not clinical benefit. Since the benefits of manipulation are comparable to watchful waiting, they argue that the latter option should generally be preferred:

Patients in pain are unhappy, and they want relief. The evidence shows that taking acetaminophen or a nonsteroidal anti-inflammatory drug and resting as needed is as effective as spinal manipulation. However, patients attribute pain resolution to active treatment. Although a course of spinal manipulation, or physical therapy, may keep the patient happy (and occupied) while his or her pain spontaneously resolves, the improvement in pain and function is not based on large, quality studies. Whether improved patient satisfaction with spinal manipulation versus watchful waiting is worth the cost of the therapy depends on who pays and how the paying party values satisfaction. As controlling costs becomes more important, incentives make watchful waiting with nonsteroidal anti-inflammatory drugs or acetaminophen the preferred approach.

What do you say when patients ask if seeing a specialist in spinal manipulation will relieve their low back pain?

Counterintuitive findings on quality incentives and patient satisfaction

They've been repeated so often that many health care quality gurus take them for granted: 1) paying physicians for performance will improve quality of care; 2) increasing patient satisfaction will reduce care costs and improve outcomes.

Not necessarily, two recent studies suggest.

A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of AFP concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes Dr. Elizabeth Salisbury-Afshar, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from AFP readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.

In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:

Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.

Patents versus patients? Revisiting the Journal Club on donepezil 23 mg

In the March 15, 2011 issue of AFP, Drs. Mark Graber, Robert Dachs, and Andrea Darby-Stewart analyzed an industry-funded trial that compared the effects of two daily doses of the Alzheimer's disease drug donepezil (Aricept): a new 23 mg version and the existing 10 mg version that would soon lose its patent protection. Despite the trial authors' finding that the higher dose of donepezil slightly improved cognitive outcomes, AFP Journal Club commentators determined that this difference was clinically unimportant, and was greatly outweighed by the higher frequency of adverse effects in patients using the higher dose:

First, the authors did four comparisons. Three were negative and only one was positive. And the one that was positive was only two points different on a 100-point scale. So, although this is statistically significant, it is clinically meaningless. There is no discernible benefit for the patient or caregivers. ... Also, the drop-out rate in this study was an astounding 30 percent in the higher-dose group and 18 percent in the lower-dose group.

Adverse effects of donepezil include bradycardia, falls, nausea, diarrhea, and anorexia. In fact, a recent study demonstrated that community-dwelling older persons with dementia who are taking currently available cholinesterase inhibitors have higher rates of hospitalization for syncope, bradycardia, pacemaker insertion, and hip fractures compared with similar patients with Alzheimer disease who are not taking these medications. So, the idea of increasing the dose to 23 mg, potentially resulting in more serious adverse events while achieving no clinical gain, is ill-conceived at best.

Nonetheless, based on this study, the U.S. Food and Drug Administration eventually approved the 23 mg dose of donepezil against the advice of its own medical reviewers. One year later, though, the Journal Club on donepezil has proved to be prescient. Last week, in a scathing editorial published in BMJ, noted physician-researchers Lisa Schwartz and Steven Woloshin echoed AFP's earlier critique. They also rebuked the FDA for allowing Eisai, the manufacturer of donepezil, to include a false statement on the drug label and physician advertisements that touted "important clinical benefits" on measures of cognition (which, as noted, were clinically meaningless) and global function (which were not even statistically significant). Schwartz and Woloshin concluded by calling on the FDA to exercise greater oversight of such ethically questionable practices:

Alzheimer's is an awful disease. Sadly, the available drugs don't work well. But that is no excuse for emotionally manipulating vulnerable patients, desperate family members, and their doctors to use a product that is more likely to add harm than benefit. Nowhere - not in the direct to consumer or the physician advertisements, nor even in the FDA approved label - are the great uncertainties about this drug explained. ... That it is so easy to send doctors and patients incomplete and distorted messages about drugs is depressing. To make good decisions about drugs, doctors and patients need the evidence. The FDA should not forget to give it to them.

Smoking cessation: what works, and what doesn't

In the cover article of the March 15th issue of AFP, Drs. Michele Larzelere and Dave Williams review evidence-based strategies to promote smoking cessation, including the five A's framework (Ask, Advise, Assess, Assist, and Arrange), stages of behavior change, and motivational interventions. In addition, they provide practical information about first-line medical therapies that improve smoking cessation rates in adults: nicotine replacement, sustained-release bupropion, and varenicline.

Despite the existence of well-established guidelines for clinicians on applying these effective interventions in practice, however, one in five adults in the U.S. continues to smoke. This fact has led researchers to explore other ways to motivate smokers to quit, such as using imaging technology to show them the personal consequences of tobacco use. In a randomized trial recently published in the Archives of Internal Medicine, researchers tested the "pictures are worth a thousand words" theory by comparing cessation rates between smokers who received standard therapy plus carotid plaque ultrasonographic screening to smokers receiving standard therapy alone. Even though 58 percent of smokers in the intervention group were found to have carotid plaques, there was no statistical difference in cessation rates between the groups after one year, and patients with plaques were not more likely to quit smoking than those with normal ultrasound results.

In an accompanying editorial, Dr. Patrick O'Malley called for a renewed emphasis on developing communication skills throughout medical training:

We rely too much on technology and testing that are misapplied to problems that really should be addressed with cognitive, emotion handling, and relationship-centered skills. We need a paradigm shift in priorities and incentives to shift from excessive reliance on technologies, a terribly wasteful practice, to training and cultivation of communication- and relationship-based skills that are likely much more effective in the psychosocial domains of care.

The bottom line for family physicians: when it comes to promoting smoking cessation, talking to patients trumps technology.

Addressing gaps in end-of-life planning

A recent article by family physician Ken Murray in the Wall Street Journal, titled "Why Doctors Die Differently," observed that doctors are more likely than other people to decline end-of-life interventions that have little likelihood of benefit:

It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.


Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).

In a published survey of older physicians cited in the article, 64 percent of physicians had created an advanced directive, which Dr. Murray argues is essential to planning for end-of-life care: "Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements."

In the March 1st issue of AFP, Drs. G. David Spoelhof and Barbara Elliott review strategies for implementing advance directives in office practice. The authors recommend that family physicians have interactive discussions with patients regarding their end-of-life care preferences over multiple office visits, and they provide guidance for overcoming common patient- and physician-related barriers to completion of advance directives. A suggested approach for physicians is to bring up the topic of advance directives at routine visits for patients age 50 years or older and intensify discussions upon the diagnosis of a chronic and progressive illness such as cancer, heart failure, or dementia:

Following a realistic discussion of the patient's prognosis, the physician initiates a more in-depth discussion, including the proxy and family members as desired, that centers on the patient's care goals. Adding a values history to the advance directive may be helpful. After the discussion, the advance directive is updated and made as specific as possible. These issues should be readdressed periodically and as circumstances change. The last phase occurs with the onset of frailty or the need for long-term care. The discussion, centered on the patient's care goals, may result in consistent and specific physician orders regarding life-sustaining interventions.

To ensure that patients' end-of-life wishes are respected, advance directives should avoid vague language (e.g., "no heroics"), be shared with proxy decision-makers, and be made accessible in the medical record so that they are easily transferable to multiple levels of care.

Doctors should trust their clinical judgments

A physician reader of AFP submitted the following post.

**

Many doctors have lost, or never acquired, the ability to make decisions based on clinical judgment after a detailed history, physical examination and basic laboratory tests. Instead, they substitute expensive diagnostic tools for clinical competence.

A case in point: a friend recently asked my opinion after her primary care physician noted a moderately elevated eosinophil level on a complete blood count. I remembered the common causes of this abnormality (allergies and parasitic infections) and asked some questions about recent changes in diet, use of herbal products, and travel. I also recalled seeing eosinophilia in patients with Hodgkin's disease and systemic vasculitides, but she was completely asymptomatic and had been told that her physical exam was normal. In reviewing the topic online, I read about other rare causes of eosinophilia, but told her that in my judgment the chance that she had ovarian cancer or any of these other conditions was extremely low. This was, after all, a healthy 35 year-old woman who regularly ran marathons.

Our job as physicians should be to educate patients so that they can make informed decisions. Based on the information I gave, my friend seemed comfortable with a "wait and see" approach. She was not particularly concerned, as she recalled an aunt having been told for years that she had an elevated eosinophil count. However, her doctor pushed her to see a hematologist. After she endured CT scans of her chest, abdomen and pelvis, followed by a bone marrow biopsy, she wrote again to ask my opinion. It seems that the hematologist had found nothing and now wanted her to see an infectious disease specialist.

What drives doctors to order tests that, in their hearts, they must know have a remote chance of being helpful? For some, it may be medical-legal considerations. For others, there is a financial incentive. But at a deeper level, I think it is that too many doctors are unable to live with medical uncertainty. They want a definitive answer, even when it is unlikely that it would alter the patient's long-term well-being. We must learn to trust our clinical judgments, and to educate our patients and involve them in decision-making, if we ever hope to rein in health care costs.

Robert G. Brown, MD
Lovettsville, VA
E-mail: olddocbob@hotmail.com

What's in your health care shopping cart?

A few years ago, we received a letter from a physician reader who complained that the approximate prices of drugs provided in AFP were often quite different from the prices he found online or in his local drugstore. This letter ultimately led to a re-evaluation of the rationale and process for estimating drug costs in the journal, as AFP editor Jay Siwek, MD explained in this January 2010 editorial:

Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.

Although having information about the costs of drugs can be helpful, physicians are often unaware of the costs of common tests, procedures, and referrals. A recent commentary in JAMA argues that electronic medical records should incorporate such cost information to make clinicians aware of the overall costs generated by office visits and other health care encounters:

What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.

The American Academy of Family Physicians has partnered with the American Board of Internal Medicine and several other physician and consumer groups in the Choosing Wisely campaign, an initiative to promote more efficient use of limited health care resources. Although this campaign focuses on reducing use of tests or procedures that have no clinical benefits (e.g., imaging for uncomplicated low back pain, antibiotics for upper respiratory infections), it raises the question of whether physicians should take responsibility for controlling costs of health care beyond simply eliminating "waste." For example, should family physicians' virtual "shopping carts" drive more selective use of health services that have high costs and marginal benefits (e.g., coronary CT scans, cancer screening in patients over age 75 years)? Or is this type of thinking unjustified and unethical rationing? What's your view?

The state of family medicine is ... ?

A special report on "The State of Family Medicine" in the current issue of AFP's sister publication, Family Practice Management, reviews data from 2011 Residency Match and American Academy of Family Physicians' member surveys to arrive at a mixed conclusion about the current status of the specialty:

On the one hand, family medicine has its challenges, including administrative hassles, a lack of support in the health care system, and threats to its comprehensiveness and scope of practice. On the other hand, family medicine has a lot going for it, including recent efforts to create primary care incentives, incomes well above the national average, and solid evidence of its value to the health care system.

Although the glass may appear to be either half-full or half-empty for today's family physicians, depending on one's perspective, there is a widespread consensus that there aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform. An article published in last week's Washington Post quoted AAFP President Glen Stream, MD and Robert Graham Center for Policy Studies in Family Medicine and Primary Care director Robert Phillips, MD, MSPH on the urgent need to address the economic realities that drive many students away from careers in family medicine and primary care.

Since 2000, AFP has published a series of One-Pagers produced by the Graham Center that examine broad historical trends in the scope and practice of family medicine, the impact of policy changes on the primary care workforce, and the often underestimated benefits that primary care physicians bring to the U.S. health system. Collectively, they are an invaluable resource for illustrating the current "state of family medicine." The full text of each of these One-Pagers is available online without access restrictions from the date of publication.

How many referrals is too many?

Most AFP review articles about conditions that may require co-management of specialists contain a short section or Table titled "Indications for Referral." For example, the January 1st article on prevention and care of outpatient burns includes a list of criteria from the American Burn Association for considering the transfer of a patient to a burn center. This and other lists generally represent expert consensus on appropriate reasons to refer a patient in a typical primary care setting; obviously, availability and accessibility of specialists has a large influence on a family physician's practice with regard to management of "referable" conditions. Clinicians' training and expertise also affect their comfort levels in caring for patients with complex problems and, as previous studies have shown, these factors lead to variations in referral rates.

Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago. What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?

How often should you screen for osteoporosis?

Last year, AFP published the U.S. Preventive Services Task Force's updated recommendations on screening for osteoporosis, which advised dual-energy x-ray absorptiometry (DEXA) in "women 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors." However, the USPSTF statement left one important question unanswered: when should a woman be re-screened if her first test shows normal or slightly decreased bone mineral density (BMD)? Put another way, what are the chances that a woman without osteoporosis today will develop it in the future?

A research team led by former AFP medical editor Margaret Gourlay, MD, MPH recently shed light on this question by following nearly 5000 U.S. women age 67 years or older with normal BMD or osteopenia for up to 15 years. They defined the BMD re-testing interval as the estimated time it took for 10% of women to develop osteoporosis before having a hip or clinical vertebral fracture. According to their report in the January 19th issue of the New England Journal of Medicine, more than 90% of women with initially normal BMD or mild osteopenia did not develop osteoporosis after 15 years. As might be expected, women with moderate and advanced osteopenia progressed faster, with 10% of each group developing osteoporosis after 5 years and 1 year, respectively.

This study's results have substantial implications for family physicians and their patients. In the absence of new risk factors for osteoporosis (e.g., significant weight loss, corticosteroid use), a woman with normal BMD at age 65 may not need to be re-tested until age 80, an interval that is substantially longer than current clinical practice. That's good news, since as Dr. Gourlay pointed out in a previous AFP editorial, many U.S. women who are at risk for osteoporosis have yet to receive any screening at all. Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.

AFP Journal Club casts doubt on NEJM study

Do children younger than 2 years of age with acute otitis media (AOM) require antibiotics, or is a watchful waiting approach just as effective? A study designed to answer this question was published last year in the New England Journal of Medicine and concluded that a 10-day course of amoxicillin-clavulanate "tended to reduce the time to resolution of symptoms and reduced the overall symptom burden and the rate of persistent signs of acute infection on otoscopic examination." However, an analysis of this study by Drs. Andrea Darby-Stewart, Mark Graber, and Robert Dachs in the November 15, 2011 AFP Journal Club concluded that the results actually supported a watchful waiting strategy because the primary outcome (likelihood of treatment failure) was disease-oriented rather than patient-oriented:

The only clinically significant outcome was likelihood of treatment failure; yet, this was defined as the presence of any symptom of AOM and persistent otoscopic signs of AOM on day 10 to 12. Treatment did not fail in any children based on symptoms alone—all treatment failures were defined by persistent inflammation on examination. The treatment failed even if the patient was symptomatically better. Most of these asymptomatic children likely would never have presented for follow-up in routine practice. And, only four to six children had to be treated to cause diarrhea, rash, or diaper dermatitis.

The January 15th AFP Journal Club continues this story by reporting an apparent discrepancy between the predesignated primary outcomes in study's original protocol (published on ClinicalTrials.gov and posted to the NEJM's website) and those that were ultimately reported in the study abstract's conclusions:

There were only three primary outcomes planned and the fourth outcome, otoscopic resolution, was one of many planned secondary outcomes. ... What is even more concerning is that the otoscopic findings are only one of 22 secondary outcomes evaluated in this study. It amazes me that a significant number of these findings, the ones that just happen to support placebo, were never reported. The secondary outcomes that demonstrated no difference between placebo and amoxicillin/clavulanate were analgesia requirements in these children; number of needed follow-up visits to a primary care physician; number of visits to the emergency department; missed hours of work by the parents; and parental satisfaction. 

The bottom line: family physicians should not conclude that this NEJM study showed that antibiotics are superior to watchful waiting for acute otitis media in young children. In fact, by showing that only 6 children needed to be treated with antibiotics to cause one additional episode of diarrhea, it suggests that the opposite conclusion may be true.

Curbing overuse of CT scans

The urban public hospital where I completed most of my training as a medical student had a single CT scanner. To ensure that this precious resource was put to effective use, any physician ordering a non-emergent CT scan was required to personally present the patient's case to the on-call Radiology fellow and explain how the result of the scan would potentially change management. Since my attending surgeons were usually too busy to trudge down to the Radiology suite, they deputized their residents to do so, and most of the time my residents passed this thankless task down to the students. Thus, my classmates and I learned early on the difference between appropriate and inappropriate reasons for ordering CT scans.

Today, the widespread availability of CT scanners has made this sort of explicit rationing uncommon in the U.S. In fact, an editorial published last year in AFP reviewed the accumulating evidence that CT scans are highly overused in current medical practice, which puts patients at unnecessary risk of radiation-induced cancers and detection of incidental findings that can lead to overdiagnosis and overtreatment. Identifying overuse of CT scans often isn't easy, though. And some might argue that increasing use of CT scans may have the positive effect of improving diagnosis of common symptoms, allowing physicians to institute appropriate management of serious conditions more quickly.

Family physicians Andrew Coco and David O'Gurek investigated this possibility in a research study published recently in the Journal of the American Board of Family Medicine. They analyzed data on common chest symptom-related emergency department visits from the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 and 2005 to 2007. Unsurprisingly, the proportion of these visits in which a CT scan was performed rose from 2.1% to 11.5% during this time period. However, the proportion of visits that resulted in a clinically significant diagnosis (pulmonary embolism, acute coronary syndrome or MI, heart failure, pneumonia, pleural effusion) actually fell slightly, challenging that notion that increased CT utilization leads to improved detection and treatment of serious health conditions.

In their AFP editorial, Drs. Diana Miglioretti and Rebecca Smith-Bindman recommend that physicians and referring clinicians take several steps to reduce harms from CT scan overuse:

1. Use CT only when it is likely to enhance patient health or change clinical care.
2. When CT is necessary, apply the ALARA (as low as reasonably achievable) principle to radiation doses.
3. Inform patients of CT risks before imaging.
4. Monitor individual exposure over time and provide the information to patients.

Since 2007, AFP has published a series of articles in collaboration with the American College of Radiology on appropriate criteria for diagnostic imaging (including CT) in specific clinical situations. The ACR Appropriateness Criteria are periodically updated, and current versions are available on the ACR website.