How can social media help Family Medicine?

-Jennifer Middleton, MD, MPH

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

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

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

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

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

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

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

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

The demise of the small practice has been greatly exaggerated

- Kenny Lin, MD, MPH

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

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

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

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

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

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

An evidence-based alternative to antibiotics for acute sinusitis

- Jennifer Middleton, MD, MPH

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

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

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

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

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

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

Why is anyone still prescribing bed rest in pregnancy?

- Kenny Lin, MD, MPH

Maternity care providers have traditionally prescribed "bed rest," or activity restriction, for a host of pregnancy complications (including preterm contractions, short cervix, multiple gestation, and preeclampsia) despite evidence that it does not improve maternal or neonatal outcomes. On the other hand, prolonged activity restriction in pregnancy increases risk for muscle atrophy, bone loss, thromboembolic events, and gestational diabetes. Although it did not include this practice in its Choosing Wisely "Five Things Physicians and Patients Should Question" list, the Society of Maternal and Fetal Medicine (SMFM) recently published a strongly worded position paper recommending against activity restriction in pregnancy for any reason.

This isn't the first time reviewers have examined the evidence for activity restriction and found it lacking; a 2013 summary of several Cochrane reviews of therapeutic bed rest in pregnancy also found such poor data to support the practice that the authors concluded its use should be considered unethical outside of the context of a randomized controlled trial.

The message isn't getting through to physicians or patients, though. A 2009 survey of SMFM members found that 71 percent would recommend bed rest to patients with arrested preterm labor, and 87 percent would advise bed rest for patients with preterm premature rupture of membranes at 26 weeks gestation, even though most of them did not believe it would make make any difference in the outcome (the most common answers were "minimal benefit" and "minimal risk"). Unfortunately, the risk may be more than minimal. Not only does activity restriction expose pregnant women to harm, a secondary analysis of a randomized trial of preterm birth prevention found that nulliparous women with short cervices whose activity was restricted were actually more likely to deliver before 37 weeks' gestation than those who were not.

Similarly, a search of the terms "bed rest" on popular pregnancy websites Babyzone and Pregnancy.org yielded the following statements that fly in the face of evidence: "Changing the force of gravity usually helps minimize preterm labor." "It [bed rest] helps keep blood pressure stable and low." "In most cases, bed rest is used to help the body have the best chance to normalize." A handout on WebMD provided a more balanced assessment:

Bed rest has been a way of treating pregnancy complications for more than a hundred years. But there's a problem. While bed rest is a common treatment, there's no proof that it helps. It doesn't seem to protect your health or your baby's. In fact, bed rest has risks itself. Doctors still prescribe it, but more because of tradition than good evidence that it works.

The handout went on to advise patients to question their physicians closely or get a second opinion if bed rest is recommended. That's sensible advice. Physicians who are reluctant to abandon this useless and potentially harmful maternity practice should consult the SMFM paper or the American Family Physician By Topic collections on Prenatal Care and Labor, Delivery, and Postpartum Issues, where no articles recommend activity restriction for pregnancy complications.