Screening for developmental dysplasia of the hip: when organizations disagree

- Jennifer Middleton, MD, MPH

If your medical education was anything like mine, chances are you learned to incorporate hip testing into every newborn exam, but the evidence base to support that common practice is uncertain. "Common Questions About Developmental Dysplasia of the Hip," an article in the December 15 issue of AFP, includes a discussion about the varied hip dysplasia screening recommendations by the United States Preventive Service Task Force (USPSTF), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the Pediatric Orthopaedic Society of North America (POSNA).

The USPSTF gives screening for developmental dysplasia of the hip (DDH) an "I" recommendation:

There is poor evidence (poor quality studies) of the effectiveness of both surgical and non-surgical interventions; avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and harms of screening for DDH but was concerned about the potential harms associated with treatment of infants identified by routine screening.

The AAFP concurs with the USPSTF:

The AAFP concludes that the evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. 

Although the AAP agrees that the quality of available studies was low, they came to a different conclusion:

There were few controlled trials and few studies of the follow-up of infants for whom the results of newborn examinations were negative. When the evidence was poor or lacking entirely, extensive discussions among members of the committee and the expert opinion of outside consultants were used to arrive at a consensus....All newborns are to be screened by physical examination. [emphasis in original]

And, the POSNA aligns with the AAP:

The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. 

When medical organizations' recommendations differ, family physicians can be left wondering who to follow and what to do. Considering each organization's goals and process for developing recommendations can help. The USPSTF and AAFP typically will not make a recommendation in the absence of high-quality studies, therefore setting the bar high to receive anything but an "I" (insufficient evidence) recommendation. The AAP and Pediatric Orthopaedic Society, however, are more comfortable providing a recommendation based on expert opinion and lower-quality studies.

We strive, in this age of evidence based medicine (EBM), to base our clinical decisions on high-quality evidence. When high-quality evidence is lacking, however, we must rely on what we do have to make decisions; in this case, on expert opinion and lower-quality studies. In the absence of high-quality studies, reasonable physicians may also be expected to disagree about how to interpret what is available. The practice of EBM does not seek to eliminate individual clinician judgment, and each of us is left to determine how to put into practice what evidence and expert opinion currently exists. There's an AFP By Topic on Neonatology/Newborn Issues if you'd like to read more.

What is your practice regarding screening infants for DDH?

What should doctors do at well-child visits?

- Kenny Lin, MD, MPH

As a family physician who provides care to children, and as a father of four ranging in age from 6 months to 8 years, I have a professional and personal interest in the content of well-child visits beyond childhood immunizations. Not only can health maintenance and counseling vary from practice to practice, previous reviews have found large gaps in the evidence to support preventive services recommended by government health agencies and medical groups. Also, clinicians who compare the Bright Futures / American Academy of Pediatrics "Recommendations for Preventive Pediatric Health Care" to the clinical recommendations for children published by the American Academy of Family Physicians (AAFP) will find that groups sometimes disagree about which services should be offered at well-child visits.

To provide perspective on how the AAFP evaluates evidence regarding the net benefit of individual preventive services in children, I recently wrote an editorial in American Family Physician that reviewed the guideline process and discussed why there is insufficient evidence to recommend screening children for autism spectrum disorders, high blood pressure, and cholesterol levels. (Note to readers: although I am a member of the Commission on the Health of the Public and Science and verified that this editorial reflects current AAFP recommendations, it should not be considered an official statement of the AAFP.) Here is the bottom line:

Time is a precious clinical resource. Clinicians who spend time delivering unproven or ineffective interventions at health maintenance visits risk “crowding out” effective services. For example, a national survey of family and internal medicine physicians regarding adult well-male examination practices found that physicians spent an average of five minutes discussing prostate-specific antigen screening, but one minute or less each on nutrition and smoking cessation counseling. Similarly, family physicians have limited time at well-child visits and therefore should prioritize preventive services that have strong evidence of net benefit.

Desmopressin works for adults with nocturia, too

- Jennifer Middleton, MD, MPH

Desmopressin has been a staple in the treatment of pediatric nocturia for years, and the December 1 issue of AFP reviews a recent systematic review describing desmopressin's effectiveness for adults as well.

The systematic review examined 10 randomized controlled trials (RCTs) of varied quality with approximately 2200 patients in total. The average age of participants ranged from 55-74 years, and men and women were both represented. All of the RCTs compared desmopression to placebo (1 compared desmopression plus furosemide to placebo).

Here is the decrease in the mean number of voids for each dose:

25 mcg = 0.38 [95% CI 0.09, 0.48] fewer voids/night
50 mcg = 0.44 [95% CI 0.16, 0.72] fewer voids/night
100 mcg = 0.72 [95% CI 0.48, 0.96] fewer voids/night

And, here is the increase in time until first waking to void:
"low dose" (less than 100 mcg) = 42.18 more minutes [95% CI 19.94, 64.42]
"high dose" (100 mg or higher) = 68.30 more minutes  [95% CI 39.42, 97.17]

Desmopressin does reduce nocturia, and it is a reasonable option to offer adult patients. The included RCTs did not, however, assess participant satisfaction. Did participants feel more rested the next morning? Was their quality of sleep better? How about their quality of life? Is an extra 42-68 minutes of sleep before waking up to go to the bathroom meaningful to patients? Without participant satisfaction studies, physicians are left to interpret for themselves the clinical significance of this data.

After all, statistical significance doesn't always equal clinical significance. To the authors' credit, they broach these same questions in their discussion section. Studies looking specifically at participant satisfaction could aid patient-physician decision making. Using desmopression may involve some patient-centered decision making; physicians may choose to share the above data with patients, perhaps also with the number needed to harm (NNH) of 20 for the side effect of hyponatremia, and let patients decide if it is worthwhile to give desmopressin a try.

Evidence-based medicine is the intersection of evidence, clinician expertise, and patient preference. Desmopressin decreases nocturia, but will patients be happy with the difference?  The answer will likely vary from patient to patient and from clinician to clinician. There's an AFP article on "Sleep Problems in the Elderly" if you'd like to read more broadly about this topic.

How does your office care for adults with nocturia?

Right-sizing care of patients with serious illnesses

- Kenny Lin, MD, MPH

Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Value Task Force of the American College of Physicians (ACP) recently published a synthesis of best practices on patient-centered communication about serious illness care goals. Although these conversations can sometimes be uncomfortable for clinicians or patients, the authors offered several reasons that they should occur early and often:

An understanding of patients’ care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress.

What clinical situations should trigger discussions about end-of-life preferences? The authors recommended making time for a conversation in the setting of worsening symptoms or frequent hospitalizations in patients with COPD, congestive heart failure, and end-stage renal disease; in all patients with non-small cell lung cancer, pancreatic cancer, and glioblastoma; in patients older than 70 years with acute myelogenous leukemia; in patients receiving third-line chemotherapy; and in hospitalized patients older than 80 years. The ePrognosis website offers useful tools for clinicians to estimate prognoses in older persons with serious illnesses.

According to the ACP, key elements to address in these conversations include understanding of prognosis; decision making and information preferences; prognostic disclosure; patient goals; patient fears; acceptable function; trade-offs; and family involvement. Additional guidance for discussing end-of-life care and eliciting patient preferences has been published in American Family Physician and Family Practice Management. Previous AFP Community Blog posts have also discussed misconceptions about palliative care, progressive disability in older adults, and gaps in end-of-life planning.

USPSTF: strategies to stop smoking initiation of moderate benefit

- Jennifer Middleton, MD, MPH

We have an impressive array of medical technology to diagnose and treat tobacco-related illness, but we should not let that technology keep us from the vital task of stopping people from smoking before they start. Last week on the AFP Community Blog, Dr. Lin wrote about shared decision making regarding low-dose CT screening for lung cancer in current and former smokers. He quoted Dr. Gates from his November 1st AFP article:

"[C]onvincing persons to quit smoking (or to not start) is far more effective in preventing lung cancer deaths than low-dose CT screening."

Cigarette smoking is linked to hundreds of thousands of deaths in the United States every year, with thousands more afflicted with COPD, cardiovascular disease, or one of the many cancers that smoking can cause. One of the great triumphs of public health in the U.S. has been the dramatic reduction in smoking over the last several decades; in 1965, 42% of US adults smoked tobacco, compared with 19% in 2011 (latest year for which data is available).

19%, however, still leaves still plenty of room for improvement. The benefits to the individuals who never start smoking, as well as the resources saved from not treating the many serious sequelae that can arise from smoking, are innumerable. Most individuals who smoke begin before age 18, making our offices an ideal place to provide counseling to children and teens to keep them from picking up the habit. The USPSTF recently weighed in on the usefulness of office strategies to prevent tobacco initiation among children and adolescents, and the November 15 AFP issue reviews this new "B" recommendation:

"The USPSTF found adequate evidence that behavioral counseling interventions, such as face-to-face or phone interaction with a health care professional, print materials, and computer applications, can reduce the risk of smoking initiation in school-aged children and adolescents."

The first step for clinicians is to assess the adolescent's risk of initiating smoking, the most powerful being parental tobacco use. Other important risk factors include peer smoking, low parental involvement, and exposure to tobacco ads. Medical offices don't have to go to great lengths to provide a meaningful intervention for these at-risk teens; although some of the interventions the USPSTF studied were quite intensive, even pre-printed anti-tobacco messages decreased tobacco initiation in one study. 

We can all have a role to play in stopping the initiation of tobacco use in children and adolescents. You can get more ideas, along with patient education materials, at the AFP By Topic for Tobacco Abuse and Dependence. If every family physician's office in the U.S. adopted one or more of these interventions, how many cases of COPD, cardiovascular disease, and cancer might we prevent?

How does your office discourage smoking among the kids and teens that you care for?

Shared decision-making for lung cancer screening: will it work?

- Kenny Lin, MD, MPH

Last week, the Centers for Medicare & Medicaid Services (CMS) officially proposed coverage for annual low-dose computed tomography (LDCT) screening for lung cancer in current or former smokers age 55 to 74 years with at least a 30 pack-year history. In doing so, CMS followed the lead of the U.S. Preventive Services Task Force, which had previously given a "B" grade recommendation for screening in a similar population through age 80 years.

In the November 1st American Family Physician cover article, Dr. Thomas Gates reviewed concepts and controversies in cancer screening. Dr. Gates observed that in the 1960s and 1970s, physicians were misled by lead-time and length-time bias into believing that screening smokers for lung cancer with chest radiography saved lives, when in fact, it did not. He also noted that although LDCT screening has reduced lung cancer and all-cause mortality in a randomized controlled trial, adverse effects include a high false-positive rate, uncertain harms from radiation exposure, and overdiagnosis (leading to potentially unnecessary treatment). For these reasons, the American Academy of Family Physicians decided not to endorse the USPSTF recommendation. In an editorial published earlier this year, AFP Contributing Editor Dean Seehusen, MD, MPH elaborated on arguments against routine LDCT screening.

Notably, CMS has proposed to pay for not only the LDCT itself, but also for a "counseling and shared decision making visit" with a physician to review benefits and harms of lung cancer screening and emphasize smoking cessation (in current smokers) and continued smoking abstinence (in ex-smokers). This element is critical, as Dr. Gates observed in his article:

Perhaps the most important issue with low-dose CT screening is that it is a costly, high-tech response to what is essentially a behavioral and lifestyle problem. Smoking is responsible for 85% of lung cancers; convincing persons to quit smoking (or to not start) is far more effective in preventing lung cancer deaths than low-dose CT screening.

Shared decision-making is increasingly recommended by screening guidelines, but I worry that these difficult discussions may not actually take place, even if family physicians are paid to initiate them with patients eligible for LDCT screening. Will clinicians merely go through the motions and just order the test, as happened with prostate-specific antigen testing for prostate cancer and screening mammography for women in their 40s? What do you think?

Bronchodilators don't help bronchiolitis

- Jennifer Middleton, MD, MPH

Autumn brings the start of another Respiratory Syncytial Virus (RSV) season in the U.S., a virus that can cause bronchiolitis in younger children. The wheezing - and sometimes decreased oxygen saturation - of bronchiolitis can be scary for parents and physicians alike; since bronchodilators like albuterol help many older kids and adults with wheezing, it seems intuitive that they would help bronchiolitis as well. The November 1 issue of AFP discusses a Cochrane update, however, demonstrating that bronchodilators don't improve outcomes in most kids aged less than 2 years with bronchiolitis.

The Cochrane reviewers found that, in children less than 24 months old with bronchiolitis who were wheezing for the first time, bronchodilators didn't improve oxygen saturation, didn't keep children in the Emergency Department from getting admitted to the hospital, and didn't reduce the length of stay in children already admitted to the hospital. Unfortunately, bronchodilators also caused harm; children who received them were more likely to have tachycardia and decreased oxygen saturation.

It can be frustrating to see child suffering with bronchiolitis and not be able to offer treatment with a medication, but a recent AFP article on RSV infection reinforces that no studied pharmaceutical interventions have demonstrated a meaningful impact on patient-oriented outcomes. Hydration and supplemental oxygen remain the treatments of choice for the more than 90,000 children admitted with bronchiolitis in the U.S. every year; fewer children are being admitted in recent years than in the past, but the children who are being admitted are more likely to have high-risk conditions and require mechanical ventilation.

3 of the 5 Choosing Wisely recommendations from the Society of Hospital Medicine - Pediatric Hospital Medicine relate to bronchiolitis and/or respiratory tract infections in young children:

1. Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.
2. Don't routinely use bronchodilators in children with bronchiolitis.
3. Don't use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.

Pediatrics just published a clinical practice guideline on bronchiolitis that reinforces those points. 

If you'd like to read more, there's an AFP By Topic on Upper Respiratory Tract Infections that includes this risk stratification point-of-care guide for treatment of infants with bronchiolitis. You can follow RSV infection rates specific to your region of the U.S. at this CDC website. 

Will this Cochrane review change how you treat young children with bronchiolitis?

For homeless patients, housing is preventive health care

- Kenny Lin, MD, MPH

Every year, a medical school course that I teach invites two speakers to tell students their compelling stories about how being homeless negatively affected their health. Conversely, I care for patients whose declining health led to homelessness because they were unable to work and fell too far behind on mortgage or rent payments. The American Academy of Family Physicians and other professional societies, such as the American College of Obstetricians and Gynecologists, encourage their members to provide compassionate and unbiased care to homeless persons, and a recent article in American Family Physician reviewed strategies for managing clinical conditions that commonly occur in this population.

The standard approach to chronically homeless persons with mental illness and/or substance dependence has been to improve control of these underlying medical problems before placing them in permanent housing. The trouble is that not knowing where one will eat or sleep from day to day is about the worst possible environment to improve mental health or recover from addiction. Dr. Kelly Doran and colleagues reported in the New England Journal of Medicine on a pilot program that used New York State Medicaid funds to house high-risk homeless patients:

Placing people who are homeless in supportive housing — affordable housing paired with supportive services such as on-site case management and referrals to community-based services — can lead to improved health, reduced hospital use, and decreased health care costs, especially when frequent users of health services are targeted.

New York health officials hope that much of its investment will pay for itself by reducing acute and emergency care visits, but so far has been unable to convince the Centers for Medicare and Medicaid Services (which only pays for nursing homes through Medicaid) to make a similar investment. Despite a lack of federal support, this "Housing First" approach has been successful in other states too, notably Utah, as James Surowiecki recently described in The New Yorker. Like it because it's the decent thing to do, because it saves money, or both, Housing First has garnered support across the political spectrum.

Some may view advocating for Housing First policies to improve the health of homeless persons to be outside of the scope of family medicine, but I don't. I have come to realize that some of my patients will not be able to fully address their chronic health issues until they have roofs over their heads and the stability and security that comes with having a place to call home. As Surowiecki observed, this approach can be viewed as a cost-effective form of preventive health care:

Our system has a fundamental bias toward dealing with problems only after they happen, rather than spending up front to prevent their happening in the first place. We spend much more on disaster relief than on disaster preparedness. And we spend enormous sums on treating and curing disease and chronic illness, while underinvesting in primary care and prevention. This is obviously costly in human terms. But it’s expensive in dollar terms, too. The success of Housing First points to a new way of thinking about social programs: what looks like a giveaway may actually be a really wise investment.

Bariatric surgery for diabetes: does it work?

- Jennifer Middleton, MD, MPH

I can't remember the last time I referred a patient for weight loss surgery. I precept residents, and I can't remember the last time one of them told me that they'd like to refer their patient for bariatric surgery. I hear colleagues say, not infrequently, that they will not refer patients for bariatric surgery, usually alluding to its risks. Three recently published studies, though, describe the benefits of bariatric surgery to maintain weight loss and potentially reverse co-morbid disease.

The October 15 issue of AFP includes a POEM describing a recent study that compared diabetes outcomes in patients who underwent bariatric surgery compared with those who continued with conventional medication treatment. The study was published in the New England Journal of Medicine in March 2014 and randomized 150 patients with diabetes to either intensive medical management alone or intensive medical management with bariatric surgery (Roux-en-Y bypass or sleeve gastrectomy). Participants had A1Cs > 7.0% (average = 9.3%) at the study onset, had body mass indexes (BMI) that ranged from 27-43, and were between 20 and 60 years old. The researchers studied participants for 3 years and found bariatric surgery + medication superior to medication alone; the number needed to treat (NNT) to get A1Cs less than 6.0% was 3 for Roux-en-Y and 5 for sleeve gastrectomy.

A few months after this NEJM study, Cochrane published a systematic review evaluating the evidence regarding benefits of bariatric surgery. They included all randomized controlled trials (RCTs) comparing either surgery to non-surgical obesity management or different surgical procedures to each other. They looked at several outcomes, including maintenance of weight loss, quality of life, and remission of diabetes. They found that bariatric surgery, overall, "results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used." They also found, however, that studies did not adequately report complication rates.

Another group of researchers published a slightly different systematic review in the Journal of the American Medical Association (JAMA) a month later. These researchers only included studies whose participants had a BMI of at least 35 and who had at least 2 years of follow-up data, and they did not limit included studies to RCTs. And, although the researchers noted the overall lack of long-term follow-up studies, their findings from the available evidence base to date are in line with the Cochrane reviewers'.

Bariatric surgery is certainly not a zero-risk proposition. But given these outcomes, we should at least be presenting it to appropriate patients as an option among others for obesity and diabetes treatment. The AFP By Topic on Obesity contains further references if you'd like to read more.

How do you discuss bariatric surgery with your patients?

The natural history of symptoms in primary care

- Kenny Lin, MD, MPH

Not long ago, I was sitting in my office catching up on some electronic charting when I began to feel chilly, achy, and weak. I went home, skipped dinner, and went straight to bed. Although I felt mostly better the next morning, my appetite didn't fully return until later in the day. My self-diagnosis: probable viral infection. But the truth was that I had no idea if my symptoms were related to any kind of disease.

Medical education trains physicians to approach patients' symptoms foremost as manifestations of an underlying cause. Only "treating the symptoms," in contrast, can often feel like a sort of failure. But as Dr. Kurt Kroenke reported in a narrative review published in the Annals of Internal Medicine, at least one-third of common physical symptoms evaluated in primary care (including pain, fatigue, dizziness, sleep disturbances, and gastrointestinal symptoms) are "medically unexplained," meaning that they are never connected to a disease-based diagnosis after an appropriate history, physical examination, and testing.

Dr. Kroenke further asserted that viewing symptoms as purely disease-oriented influences the language physicians use to describe them:

The lack of a definitive explanation for many symptoms is further underscored by the use of adjectival modifiers indicating what a symptom is not ("noncardiac" chest pain or "nonulcer" dyspepsia) or implying causal explanations that are weakly defensible ("tension" headache, "mechanical" low back pain, or "irritable" bowel syndrome).

Not only do some symptoms have no obvious causes, but others have multiple possible causes which may be unproductive to approach separately. For example, why does a patient with congestive heart failure, anemia and depression feel tired all the time? Also, symptoms usually occur in a group, rather than in isolation; for example, a classic symptom cluster in cancer patients is SPADE (sleep  / pain / anxiety / depression / energy).

Studies show that about a quarter of symptoms that present to primary care eventually become chronic. Fortunately, very few of these patients harbor a serious missed diagnosis such as an occult infection or cancer. As family physicians know, even if we are uncertain about if or when a particular symptom might improve, communication still has great therapeutic value. "Is this normal, doctor?" is the question I hear most frequently from my patients who have persistent symptoms without diagnoses. I usually respond that there is a wide range of "normal," and what's more important to me is working with him or her to make these particular symptoms more manageable.

ADHD spotlight: treatment adherence issues and effects of meds on adult height

- Jennifer Middleton, MD, MPH

The October 1 AFP included a useful review article on ADHD in children, and not long after I read it, I saw two more articles on ADHD that got me thinking even more about this subject: one on adherence to ADHD medication and one on the effect of psychostimulant medication on height.

The AFP article on "Diagnosis and Management of ADHD in Children" reviews the diagnostic criteria for ADHD, the differential diagnoses for common presenting complaints, and initial treatment options. The authors review the data for various treatments and conclude that psychostimulants are still the most effective class of medications for those children in whom meds are indicated.

A recent article published earlier this year in Patient Preference and Adherence reviewed how adolescent patient beliefs affected treatment adherence to ADHD medications. The author reviewed several studies, both qualitative and mixed-methods, that investigated adolescent attitudes toward their ADHD medications. Multiple studies found that the strongest predictors of non-adherence were either adverse medication effects, lack of perceived benefit, and/or "changes to the patient's sense of self." Teens with ADHD rated the perceived efficacy of medications higher than behavioral interventions, yet adolescents themselves are more likely to stop their medications on their own than to involve a parent in that decision.

Another recent article, this one from Pediatrics, seeks to lay to rest concerns about psychostimulant medications' effect on final adult height. The researchers obtained medication and growth histories from around 1000 children born between 1976-1982 in a town in Minnesota; for every 1 child identified with ADHD, they matched 2 control children without ADHD. The researchers obtained growth records on these children along with their final adult height, and they found no difference in growth patterns or final adult height between children with ADHD and children without ADHD; they also found no difference between children with ADHD on medication compared to children with ADHD who were not on medication. This study followed only one geographically-limited cohort, though, and the authors acknowledge the impossibility of knowing whether these children's physicians adjusted their medications due to changes in their growth curves. Despite these limitations, this study's years of longitudinal data are still compelling.

I spend significant time reviewing growth charts with parents of children or teens with ADHD on stimulant medication, but I don't ask questions about medication adherence the way I do, for example, with my patients with other chronic conditions. These two articles suggest that my priorities need reversing.

According to the AFP article, "children with ADHD [on a stimulant] are less likely to be held back a grade." Being held back a grade is definitely Patient-Oriented-Evidence-that-Matters! Since adolescents typically make the decision to stop their medication, centering discussions related to medication issues on them, instead of their parents, during office visits makes sense. And it is nice to be able to share with adolescents and their parents the recent Pediatrics study that was reassuring regarding possible height loss due to long-term stimulant use.

Certainly, as Dr. Lin wrote about earlier this year, medication is not always the right course for treating ADHD. But when it is, these two articles will change my practice. If you'd like to read more, there's an AFP By Topic on ADHD.

How do you counsel parents and their children and/or teens about ADHD treatment?

Known and unknown: putting Ebola in perspective

- Kenny Lin, MD, MPH

At a recent morning huddle, I noticed that the hanging file of emergency protocols at my practice nurse's station held a new folder, labeled "Ebola." That same day, a patient who had returned from West Africa was isolated at a nearby hospital for symptoms consistent with infection with the virus. I had been following news about the Ebola epidemic for months, since its re-emergence in Guinea, rapid spread to neighboring Nigeria and other parts of West Africa, through the critical illness and miraculous recovery of family physician Kent Brantly. But until that day, I hadn't actually confronted the question, "As a family physician, what do I need to know about this?"

Many have pointed out that even though this is by far the largest and most lethal Ebola outbreak in history, it pales in importance next to more common and contagious viruses such as influenza or measles, or emerging infections closer to home, such as the enterovirus respiratory illness that has stricken children in 43 states. Family physician blogger Mike Sevilla expressed skepticism that patients who continue to decline influenza vaccines in droves would be willing to receive a vaccine against Ebola even if it could be produced quickly, and given our abysmal track record with pandemic flu vaccination, I tend to agree.

What terrifies health professionals and laypersons about Ebola, despite its thus-far limited impact in the United States, is that so much about it is unknown. Clinicians are prepared to tackle influenza, a known quantity from past years. We don't know what to expect from Ebola, a nebulous threat to cause disaster at any time, like bioterrorism. Until more is known, family physicians should remember that fever in returning international travelers is far more likely to be due to malaria (which turned out to be the diagnosis of the hospitalized patient I mentioned earlier), and to always ask and communicate about recent travel, rather than depending on an electronic medical record to do it.

**

Postscript: In an October 15th editorial on "Management of Influenza in the 2014-15 Season," Dr. Ronald Goldschmidt noted that the overlap between the international Ebola outbreak and the U.S. influenza season may lead to concerns about confusing these two viral diagnoses. He pointed out, however, that "influenza generally features rhinorrhea and upper respiratory symptoms (rare with the Ebola virus) and Ebola generally features gastrointestinal symptoms (not prominent with influenza),"and more importantly, a travel and contact exposure history should identify patients at risk for Ebola infection.

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.

Who is defining Family Medicine?

- Jennifer Middleton, MD, MPH

Perhaps you've already heard - a cardiologist raised the profile of family physicians last week.

National Public Radio's Fresh Air program interviewed Dr. Sandeep Jauhar, a cardiologist working in New York City, August 19 and he had this to say about family physicians:

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not coordinated....no one is really talking and trying to coordinate this care, so it makes it very difficult for the physician who is trying to manage the whole patient...

This particular piece of the interview reminded me of a powerful editorial written a few years ago in the Annals of Family Medicine by Dr. Kurt Stange. Published in 2009, Dr. Stange tells the story of a patient with unresolved low back pain in whom he diagnosed with a large abdominal aortic aneurysm, esophageal cancer, and incidental renal cancer. 

A narrowly focused approach is fine when an obvious problem is linked to a clear solution. When multiple problems are woven into the fabric of life, however, the generalist approach is critical.

In a recent guest post for the Community Blog, Dr. Loftus takes this idea of the generalist's role a step further:

Family physicians should then focus on mastering the knowledge and expertise that we have acquired during our medical education and embrace our role as experts at managing multiple complex chronic diseases, especially with psychosocial co-morbidities. We should be supervising and leading teams of community health workers, health coaches, care coordinators, nurses, pharmacists, physician assistants, and nurse practitioners who are managing the simpler medical issues, as is often the case in many other countries around the world. 

The struggles of our health care system are bringing our specialty to a critical juncture. Who will we be as family physicians 5, 10, 15 years from now? Will we continue to passively accept employment and reimbursement models that push us to see as many patients in as little time as possible? Will we continue to spend time counseling patients on topics that a well-trained medical assistant, nurse, or pharmacist could probably do more effectively? 

Dr. Stange ends the editorial mentioned above with a call for action to rebuild our health care system with primary care at its core. He provides a long list of concrete steps we can each take; here is just an excerpt:

We can cultivate the courage to take on the narrow self-interest that fuels our system dysfunctions. We can be willing to sacrifice in the short term for a larger good in the long term. We can develop relationships with individuals and groups and societies that are different from us, and thus develop a broader sense of community.As individuals, groups, systems, and society, we can strive to be humble, connected, and open....Think and act in ways that bring meaning to apparently low-level tasks that develop relationships, and iterate between the parts and the whole to foster a larger good.

Maybe just keeping abreast of how others are championing Family Medicine is another worthy first step. Trying to keep up with everything that is happening in the larger world of healthcare policy and legislation might feel burdensome to already overworked family docs, but AAFP News Now provides concise updates in your AFP journals. Supporting and being involved with AAFP, our specialty's advocacy organization, is an easy way to support those efforts.

Sometimes changing the world can feel too big for one person. But maybe if each of us worked within our sphere of influence on just one of Dr. Stange's action steps, our health care system could get back to serving patients instead of payors and companies. Maybe then we wouldn't need cardiologists to raise our specialty's profile.

ACC/AHA cholesterol guideline: summary and perspectives

- Kenny Lin, MD, MPH

As previewed in a previous blog post, the August 15th issue of AFP features a concise summary of the American College of Cardiology / American Heart Association updated cholesterol treatment guideline. Key points include an expansion of the role of statins in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); elimination of specific low-density lipoprotein cholesterol (LDL-C) target levels; and a new tool for assessing of 10-year and lifetime risk for ASCVD. An accompanying POEM notes that full implementation of the new guideline would increase the number of U.S. adults eligible to take statins by nearly 13 million, with the percentage of adults 60 to 75 years of age for whom statins are recommended rising from 47.8% to 77.3%.

Two editorials in the same issue further explore the implications of the new guideline. Writing for the members of the guideline panel, Dr. Patrick McBride and colleagues emphasize that the recommendations are largely based on high-quality evidence from randomized controlled trials that measured patient-oriented outcomes. They argue that "these changes should simplify the approach to clinical practice by reducing titration of medication, the addition of other medications, and the frequency of follow-up laboratory testing." In a second editorial, Dr. Rodney Hayward concurs with the panel's decision to abandon LDL-C targets, but disagrees with setting a universal 10-year ASCVD risk threshold of 7.5% for treatment with a statin:

My biggest criticism of the new guideline is that it does not acknowledge a specific gray zone—a range in which the potential benefits and harms of a statin make the “right decision” predominantly a matter of individual patient circumstances and preferences. It may be reasonable to set 7.5% as a starting point for discussion (e.g., for every 33 patients treated for 10 years, roughly one heart attack will be prevented [i.e., number needed to treat = 33]). But these risks and benefits are estimates with a nontrivial margin of error. The guideline does note that shared decision making should be used, but it provides no clear direction on when statins should be recommended rather than just discussed.

A similar debate is taking place in the United Kingdom, where its National Institute for Health and Care Excellence (NICE) recently recommended offering a statin to all persons with a 10-year cardiovascular event risk of 10% or more. An editorial in BMJ observed that doctors need better shared decision making tools to help patients understand the tradeoffs involved in taking medications that have potentially large population health benefits but are unlikely to prevent a bad outcome in an individual patient:

Doctors are unlikely to start giving patients clear numerical information simply because they are told to do so. They might do so if NICE can recommend information tools with the same force as when it recommends drugs, and if it becomes as easy to give contextual numerical advice as it is to print a prescription. ... We will need better data, from bigger trials, and better risk communication than for conventional medical treatment. ... Without such innovation in the use of medical data, we can say only that statins are—broadly speaking—likely to do more good than harm. That is not good enough.

Have you already integrated the ACC/AHA cholesterol guideline into your practice? If so, how do you decide whether to "recommend" versus "discuss" statins with patients? If not, what reservations or workflow issues have prevented you from transitioning to the new guideline?

More evidence against initiation of perioperative beta blockers in non-cardiac surgeries

- Jennifer Middleton, MD, MPH

Patients undergoing intermediate- or high-risk non-cardiac surgeries often get a perioperative beta blocker, and the American College of Cardiology Fellows (ACCF) and the American Heart Association (AHA)'s 2007 guideline advises as such. The ACCF/AHA's 2009 update, though, recommends perioperative beta blockers only in patients with a history of coronary artery disease (CAD) and/or at least 2 CAD risk factors. A 2014 meta-analysis additionally found that perioperative beta blockade in patients not chronically on beta blockers increased mortality -- even if they had CAD or at least 2 CAD risk factors.

JFP reviewed this 2014 meta-analysis recently in an online article. This article discussed serious methodological problems regarding a group of Dutch studies that heavily informed the ACCF/AHA 2007 guideline and 2009 update. These studies failed to consistently obtain written informed consent for subjects, recruited inappropriate patients, and could not produce their raw data when requested by a review panel. These flawed studies are the backbone for the ACCF/AHA's current recommendation to add a perioperative beta blocker to patients with at least 2 CAD risk factors and/or a history of CAD*.

Perioperative beta blockers were certainly controversial even prior to these studies' public disgrace; a 2012 AFP article on Perioperative Cardiac Risk Reduction cited several of the studies included in the 2014 meta-analysis and advised caution in using perioperative beta blockers in patients without known cardiac disease.

The 2014 meta-analysis examined post-operative outcomes for patients who were not taking a beta blocker prior to surgery (including patients with CAD and/or risk factors) and who were undergoing non-cardiac surgeries. The researchers included 9 high quality randomized controlled trials (RCTs) and excluded the suspect data from the Dutch trials. They found that beta blockers did decrease perioperative non-fatal myocardial infarctions (RR = 0.73 [0.61-0.88]), but they also increased the risk of stroke (RR = 1.73 [1.00-2.79]), hypotension (RR = 1.51[1.37-1.67]), and 30-day all cause mortality (RR = 1.27 [1.01-1.60]). For patients not previously on a beta blocker prior to intermediate- or high-risk surgery, adding one causes more harm than good (NNH for 30-day all cause mortality = 160).

When newer studies conflict with previously published guidelines, physicians have an important decision to make. Assuming the new study is methodologically sound, should we abandon the earlier guideline because of the updated evidence? Or, should we wait until the original recommending body assesses the new evidence?

The answer probably involves multiple variables: the amount of trust in the earlier guidelines, the degree to which our colleagues are changing their practice, and, perhaps, even our level of comfort in assessing the study's quality. Maybe it feels like the stakes are too high to change our practice based on one study, especially if larger recommending bodies have yet to weigh in.

Our specialty is fortunate to have high quality journals whose editorial experts sift through new studies and assist us with interpreting and applying them. AFP recently reviewed the ACCF/AHA guidelines for management of congestive heart failure, for example, and handily summarized the high points of this 300 page document into a brief article geared toward busy family docs. Although we should use our evidence-based medicine skills to reach our own independent conclusions about newly published studies, we can also rely on AFP and others to help confirm our assessments.

How comfortable are you changing your practice when new studies conflict with prior recommendations?

* Admittedly, most patients with CAD should be on a beta blocker chronically, but I suspect I'm not the only family doc with a couple of patients who either can't tolerate them or refuse to take one. Several of the studies included in this 2014 meta-analysis included this group of patients in their RCTs.

The most popular posts of January - June 2014

- Kenny Lin, MD, MPH

Diabetes, weight loss, the future of family medicine, antibiotic safety, and athlete's foot were the topics of the AFP Community Blog's top 5 most viewed posts from the first six months of 2014. Each of these posts has been viewed between 500 and 650 times to date.

1. Does metformin prevent recurrent events in diabetic patients with CAD? (January 20)

This study helps to reinforce that metformin (rather than a sulfonylurea) is the right choice when initiating treatment for type 2 diabetes. What to add when additional glycemic control is needed, however, remains up to each physician's clinical judgment.

2. Weight loss medications: how much of a solution are they? (March 10)

Frankly, I'd prefer to see us work to lessen biologic and environmental pressures instead of adding another pill to our patients' regimens. Our commitment as 21st century family physicians must be to our communities as well as our individual patients if we are ever to turn the tide of rising obesity rates.

3. The Future of Family Medicine - Some Sacrifices Required (June 16)

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care.

4. Azithromycin and levofloxacin safety concerns continue (March 24)

Although many physicians prefer basing practice change on a prospective study, retrospective studies are better suited than prospective studies to detect rare events.

5. What is the best topical antifungal for treating tinea pedis? (May 27)

Given that 1 week of therapy is preferable to most patients instead of 4, and the price difference is negligible (around $10-16 for 30 grams of either), I will still favor terbinafine over clotrimazole for treating tinea pedis.

Nebulizers: old habits die hard

- Jennifer Middleton, MD, MPH

Last week's JFP discussed an updated Cochrane review reasserting that nebulizers cost more, cause more side effects, and offer equivalent treatment compared with a metered dose inhaler (MDI) and a spacer (aerochamber). The Cochrane reviewers conducted a systematic review of 39 trials that included both children and adults as well as office and emergency department (ED) settings. They found no difference in hospital admission rates for adults or children who received albuterol via a MDI and spacer versus a nebulizer. Hospital length of stay was no different for adults who received albuterol via an MDI/spacer versus a nebulizer. Children's ED visit time was, on average, 33 minutes less for those who received albuterol with an MDI/spacer instead of a nebulizer. Children using an MDI/spacer had less tremor, and both children and adults using an MDI/spacer had less tachycardia.

(If you'd like to read more about asthma, check out this AFP By Topic on asthma. You can also brush up on spacer techniques here.)

This is not new information; several randomized controlled studies and the original 2003 Cochrane review demonstrated similar findings. If your office and/or hospital setting is anything like mine, though, nebulizers are everywhere, despite a decade's worth of research showing that MDIs offer equivalent therapy with fewer side effects and less cost. Why the continued love affair with nebulizers when they're not only therapeutically equivalent to MDIs with spacers but also cause more side effects, cost more per dose, and result in longer ED visits?

Well, a study from last year found that 80% of COPD patients and their families felt that using a nebulizer was better than using an MDI. A small study of pediatricians found that most would benefit from "better training" regarding spacer use. These small studies may not be generalizable to an American family medicine office, but it's still possible that patients like using nebulizers and that physicians are more comfortable ordering nebulizers. And, I have to confess that it's much more efficient in my office for my nurse to give an albuterol nebulizer treatment than it is to track down a clean spacer and educate a patient on how to use it.

UItimately, the nebulizer epidemic is part of a larger problem in medicine: physicians are slow to change their practice to accommodate new evidence-based findings. Debate exists as to how long it takes for evidence-based research to percolate into widespread physician behavior changes, but estimates around 10-20 years are not hard to believe. Physician leaders have hypothesized the reasons behind this lag, including this NEJM editorial likening local physicians' practices as "where the [information] highway reaches its end and divides into a number of smaller avenues and lanes, and it is also where...concepts may get lost." One team of researchers theorize that just reading about new evidence is insufficient for physicians to place that information in the proper context when applicable patient situations arise; they advocate for more case-based learning in continuing medical education (CME).

Perhaps the first step for each of us is to just acknowledge that the lag exists; perhaps the next step is to think about how each of our "avenues and lanes" might systematically ensure that evidence-based changes become routine care faster. Perhaps we also must advocate for innovation in how CME is delivered.

How do you translate evidence-based changes into your daily practice?

Palliative care consists of more than pain control

- Kenny Lin, MD, MPH

In inpatient settings, family physicians frequently care for patients with progressive, incurable conditions that cause severe pain. Interventions aimed at slowing the progress of a disease often add to patients' physical distress; therefore, pharmacologic management of pain is a key component of end-of-life care, as outlined in an article in the July 1st issue of American Family Physician. However, as Drs. Timothy Daaleman and Margaret Helton discuss in an accompanying editorial, providing analgesia is only the starting point for effective palliative care:

Palliative care generally begins with diagnosis of a life-limiting disease and initiation of an ongoing conversation on the goals of care and treatment. This often begins in patient-centered medical homes, continues through acute hospitalizations, and may conclude in long-term care facilities. At each point, family physicians may be called on to provide primary palliative care and can expect to encounter nonpharmacologic challenges in managing pain.

Misconceptions about palliative care are common. For example, many believe that palliative care, like hospice care, cannot be offered to patients who are still pursuing "aggressive" treatments such as chemotherapy for cancer. On the contrary, one of the American Academy of Hospice and Palliative Medicine's Choosing Wisely recommendations states, "Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment." Palliative care does not necessarily increase patient comfort at the cost of shortening life; in a randomized trial of patients with metastatic non-small-cell lung cancer, patients assigned to early palliative care not only experienced better quality of life and fewer symptoms of depression than patients receiving standard care, they actually lived more than two months longer.

The recent announcement by a large health insurance company in the Pacific Northwest that it will prioritize palliative care by training physicians and caregivers about having appropriate end-of-life conversations; and pay for previously unreimbursed home health services and counseling about advanced directive planning suggests that policymakers are finally recognizing the value of improving the availability of palliative care to appropriate patients. What have been your experiences with connecting patients or loved ones to palliative care services?

Behavioral interventions to help motion sickness

- Jennifer Middleton, MD, MPH

When my father tells the story of his parents' second honeymoon, which was a cruise, he relates how my grandmother had a delightful time sailing the seas while my grandfather sat in the cabin feeling irritable and dizzy in between bouts of emesis. (This story inevitably seemed to come up right after my sister had vomited in the car during a family road trip; a recent study estimated the prevalence of motion sickness in cars among children aged 7-12 at 43%.)

For as prevalent as motion sickness is, the recent AFP review article on this topic, Prevention and Treatment of Motion Sickness, reminds us that there is much we can do to help our patients overcome this discomfort. The article reminds us that prevention is the mainstay of treatment, and beyond the multiple pharmacologic options (nicely summarized in Table 3) the authors also point out important behavioral strategies (Table 2).

Two of the cited studies regarding behavioral interventions looked at how music and deep breathing may help. Denise et al investigated the use of controlled breathing as participants were upside-down, rightside-up again, and tilted to the side while watching an asynchronous 180 degree video screen; in all positions, controlled breathing lowered sickness ratings and prolonged participants' tolerance to movement.

In the second study, Sang et al had healthy participants listen "to a music audiotape designed to reduce motion sickness symptoms," do breathing exercises, or neither (control group) while undergoing a lab simulation to evoke motion sickness symptoms. The participants began the music or deep breathing after the onset of mild motion sickness symptoms, and both interventions prolonged the development of moderate motion sickness symptoms for about ten minutes compared with placebo. Another just published study found that "pleasant music" reduced motion sickness symptoms overall to participants exposed to symptom-inducing stimuli. While it's unclear in this latter study who decided what "pleasant music" was, it's probably reasonable to extrapolate that "pleasant" is in the ear of the beholder.

Listening to music and controlled breathing exercises are simple, zero-risk interventions that would require only brief counseling in the office to recommend to patients, and they may complement the prescription therapies described in the article.

How do you discuss motion sickness prevention with your patients?

Skip the annual pelvic examination? How about the whole checkup?

- Kenny Lin, MD, MPH

An American College of Physicians practice guideline released yesterday has garnered attention for recommending against clinicians performing screening pelvic examinations in asymptomatic, nonpregnant women. Although the new guideline has been called "controversial," its findings should not be a surprise to readers of American Family Physician. An editorial and blog post published in AFP early in 2013 argued that this longstanding tradition is "preventive time not well spent," since the pelvic examination doesn't actually prevent anything (screening for ovarian cancer does more harm than good and accurate testing for chlamydia and gonorrhea can be done on urine samples) and is associated with increased cost, inconvenience, and patient discomfort. With Pap smears only recommended every 3 to 5 years in most women, it also seems prudent to redirect time saved from not performing extra pelvic exams to effective preventive services such as counseling for tobacco and alcohol misuse.

But why stop at the pelvic examination? Last September, the Society of General Internal Medicine included the following item in its Choosing Wisely Top 5 List of potentially unnecessary tests or procedures: "Don't perform routine general health checks for asymptomatic adults." They cited a Cochrane review of 14 randomized controlled trials that found that the annual physical increases new diagnoses but "do not decrease total, cardiovascular-related, or cancer-related morbidity or mortality."

The physical examination may not improve outcomes in asymptomatic patients, but what about the cardiovascular risk assessment and lifestyle counseling that goes along with it? A randomized trial published this year in BMJ casts doubt on the benefits of this preventive service. In nearly 60,000 residents of Copenhagen, Denmark between the ages of 30 and 60 years, four or more sessions of individual lifestyle counseling over a 5-year period produced no effect on rates of coronary artery disease disease, stroke, or mortality after 10 years of followup. In an accompanying editorial, the Cochrane review authors state flatly: "General health checks don't work. It's time to let them go."

As the U.S. faces a worsening shortage of primary care clinicians, are today's family physicians prepared to abandon annual pelvic examinations and well-adult checkups in general? If not, why not?

Acute Complaints: 3 of The 2013 Top 20 AFP articles

- Jennifer Middleton, MD, MPH

AFP recently posted its 20 most-read articles from last year here. The topics run through much of the full spectrum of Family Medicine, from health maintenance to acute complaints, from initial work-up to chronic management. Here are three articles that explore acute complaints:

1. Approach to Acute Headache in Adults (5/15/2013)
This article provides a practical approach to differentiating benign headaches (age <30, "features typical of primary headaches," prior similar headaches, normal neurologic exam, no high-risk comorbidities) from dangerous headaches (worst headache ever, headache triggered by exertion, mental status change, age > 50, papilledema, sudden onset, systemic illness, temporal artery tenderness). The authors review the classic "primary" headache syndromes (tension, migraine, cluster) and include a helpful table regarding choice of radiographic testing should 1 or more dangerous headache signs be present.

2. Diagnosis and Management of Acute Diverticulitis (5/1/2013)
This article provides likelihood ratios for common physical exam findings that can help to rule in or rule out diverticulitis (LLQ tenderness + absence of vomiting + CRP >50 = LR+ of 18). The authors review guidelines for laboratory and radiographic evaluation as well as recent evidence arguing against antibiotic use in patients with mild, uncomplicated diverticulitis. Weight loss, smoking cessation, fiber, and exercise help to prevent recurrences but avoidance of seeds, nuts, etc. does not.

3. Outpatient Diagnosis of Acute Chest Pain in Adults (2/1/2013)
Only 1.5% of patients presenting to a primary care office with chest pain have unstable angina or acute coronary syndrome, but identifying who these patients are can be challenging. The authors review likelihood ratios of clinical symptoms more likely to be associated with serious cardiac disease (among others, radiating pain and use of a term other than "pain" - such as "tightness" or "squeezing" increase the pre-test probability). Pleuritic chest pain and "sharp" or "stabbing" chest pain, on the other hand, are less likely to be due to acute coronary syndrome. The authors also present a validated clinical decision rule to assist with diagnosis (Table 2). They review the more common, and typically less serious, diagnoses of chest wall pain, GERD, and anxiety along with the less common, but more serious, possibilities of pericarditis, pneumonia, CHF, or pulmonary embolism.

By my count, half of the Top 20 articles from 2013 dealt with evaluation of new and/or acute complaints. Given how much of 21st century Family Medicine is chronic disease care, it's interesting that acute complaints caught so much of the attention of AFP readers, though certainly family doctors experience both on a daily basis.

What AFP articles dealing with acute issues have changed your practice lately?