Monday, January 15, 2018

Supporting family physicians who provide maternity care

- Jennifer Middleton, MD, MPH

An editorial on Immediate Postpartum LARC: An Underused Contraceptive Option in the current issue of AFP has generated a lot of interest. Several comments have been left online, and (as of this writing), all of them are quite positive. At a time when family physicians' interest in obstetrics (OB) continues to wane, these commenters exemplify the vibrant community of family physicians who do choose to provide OB care; as a specialty, we should support these physicians and the often underserved communities they care for.

Family physicians who attend deliveries are a critical component of improving the health of rural communities. Obstetrician/gynecologists (OB/GYNs) tend to cluster in metropolitan areas, with many rural counties in the United States reporting that family physicians are their only source for OB care. Supporting training opportunities in residency is critical to encouraging future family physicians to consider including OB in their practices; exposure to models of care like prenatal group visits and physician group coverage models may reduce concerns about the feasibility of doing so.

Even those of us who do not attend deliveries, however, have an obligation to advocate for those who do. Several of the comments left on the current AFP LARC editorial point to the need for state and national advocacy efforts to eliminate reimbursement barriers to providing this valuable service. This advocacy does not have to be time-consuming or burdensome; it's easy to send messages to your state AFP chapter and/or state legislators.

We also have an obligation to support preconception and prenatal care. All family physicians should discuss contraception and family planning with not only our expecting patients but all of our patients of child-bearing age. We should encourage folic acid supplementation for all women capable of pregnancy. We should discuss healthy birth spacing intervals at well child visits. There's an AFP By Topic on Family Planning and Contraception if you'd like to read more.

The comments regarding the LARC editorial enriched future readers' experience with their ideas and references. The ability to comment on articles online is one way you can directly engage with AFP; find us on Facebook and Twitter to join those conversations. Don't forget, too, about the opportunity to comment below here on the Community Blog every week.

Monday, January 8, 2018

The top ten AFP Community Blog posts of 2017

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

For the first time since we started putting together lists of the year's most-read posts, three guest posts made the 2017 list, including the top two. We welcome submissions of guest posts from readers on topics of interest to family physicians; please send inquiries and submissions to

1. Guest Post: I have a new patient (January 3) - 1952 page views

I realize, again, that sometimes we family physicians are called to comfort and not cure. I see how filling her remaining days by helping others continues to bring her a sense of purpose. I have learned a great deal from her in a short time and am grateful that I accepted a new patient.

2. Guest Post: On the front lines of the opioid epidemic (February 21) - 1843 page views

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus.

3. What's in a name? Obesity, ABCD, and prediabetes (January 10) - 1558 page views

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.

4. The 2017 ACC/AHA Clinical Practice Guideline for High Blood Pressure (November 27) - 1281 page views

It's difficult to argue with this CPG's emphasis on nonpharmacologic treatment, ambulatory BP monitoring, team-based care, integration of QI efforts, and population health advocacy. Its new BP diagnosis definitions and treatment goals, however, may be more open to discussion, especially as no primary care societies were involved in their development.

5. Strategies to limit antibiotic resistance and overuse (June 26) - 1170 page views

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more.

6. Safety net doesn't shield patients from low-value care (April 17) - 1147 page views

The study authors found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.

7. After emergency contraception: what next? (January 21) - 1011 page views

Discussions about EC should include options for initiating a regular form of contraception along with information about ulipristal's effectiveness and possible interactions. Providing this information to women will allow them to choose both an EC method and a regular contraceptive method that best fit their priorities and wishes.

8. Simplifying treatment of acute asthma (March 27) - 978 page views

For the time being, we'll need to use patient-centered decision making to arrive at the best treatment plan for each patient with acute asthma, though it certainly seems reasonable to consider shorter durations of oral corticosteroids in uncomplicated pediatric and adult patients.

9. Guest post: innovating connections in family medicine (February 6) - 970 page views

While I delight in new technology that enhances our care for patients, some aspects of family medicine won’t change. Technology won’t change the reassuring words we can offer to a worried parent or acutely ill patient. It won’t alter the power of our receptive ears being present for a scared patient. And it definitely won’t replace the wisdom, laughs, perspectives, and connections we encounter with our patients each day.

10. Vaccines in the news: controversies & updated recommendations (February 15) - 970 page views

Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.

Tuesday, January 2, 2018

Supporting patients' New Year's resolutions

- Jennifer Middleton, MD, MPH

The beginning of a new calendar year often sparks plans to improve health behaviors. When patients share these goals with us, we have many tools and resources available to help them succeed.

A recent AFP article reviews evidence showing that weight loss may be more successful in patients who set simple dietary goals as opposed to attempting to follow a complex diet regimen. Setting permissive (eat more vegetables) instead of restrictive (eat less sweets) goals may also be more effective for meaningful weight loss. Increasing consumption of nutrient-dense foods (whole grains, vegetables, fruits) benefits all patients, and motivational interviewing by a physician can help patients lose an average of an additional 3.3 pounds. A comprehensive review of available medications for weight loss along with when to consider a referral to bariatric surgery can be found in this article and in the AFP By Topic on Obesity.

Another recent AFP article reminds us that many smokers want to quit and have failed quit attempts in the past. This article reviews the 5 A's framework (ask - advise - assess - assist - arrange) as well as the stages of change model to increase our counseling effectiveness. Just one minute spent in tobacco cessation counseling can increase quit rates. The article also reviews nicotine replacement therapies, which have been shown to increase the success of a quit attempt by 50-70%, and encourages use of dual therapy (for example, patch and gum) for those patients smoking more than 1 pack a day. Calling or contacting patients at least 4 times after their planned quit date increases quit rates; AAFP's Office Champions model is one way of involving the entire office in providing this follow-up and helping patients stay smoke-free for good. The AFP By Topic on Tobacco Abuse and Dependence provides many more helpful resources.

A final recent AFP article cites the disappointing statistic that most individuals do not report ever receiving counseling from their physicians regarding physical activity. Engaging in shared decision making with patients, writing an exercise prescription, and providing handouts with exercise instructions have all been shown to increase physical activity. Patients who feel that they don't have the time for prolonged periods of exercise may be glad to know that even 10-minute bursts of exercise can be beneficial. Patients intimidated by demanding exercise regimens may be relieved to learn that the overall time spent in exercising seems to be more important than overall intensity. Individuals should aim for no more than 2 days off between exercising to prevent losses in metabolic activity gains from a regular exercise program. The AFP By Topic on Health Maintenance and Counseling includes this recent review regarding the United States Preventive Services Task Force (USPSTF)'s report on the benefits of behavioral counseling interventions for physical activity.

Perhaps one of your new year's resolutions is to increase your office's capacity for supporting patients' behavior change efforts; this Family Practice Management article describing the AAFP's "AIM-HI" office intervention model might provide some inspiration. Or, perhaps your office has a successful model already in place that you might share with other AFP Community Blog readers in the comment space below.

Here's to a healthy 2018!

Monday, December 18, 2017

In defense of forbidden words and evidence-based medicine

- Kenny Lin, MD, MPH

I was a federal employee in the Department of Health and Human Services (HHS) during the George W. Bush and Obama administrations. Although the current era of "fake news" and "alternative facts" lay in the future, some subjects were inherently more sensitive than others, depending on which party controlled Congress and the White House. For example, breast cancer screening with mammography made political waves when the U.S. Preventive Services Task Force released updated recommendations in 2009 (while Congress was debating the Affordable Care Act) and again in 2015 (as the House of Representatives repeatedly voted to repeal it).

Over the weekend, the Washington Post, STAT, and multiple other news outlets reported that the Centers for Disease Control and Prevention (CDC) and another unidentified HHS agency were recently provided with a list of seven "words to avoid" when writing budget proposals. These banned or forbidden words are: "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." Although CDC director Dr. Brenda Fitzgerald e-mailed agency staff and tweeted yesterday that "there are no banned words at CDC," neither she nor an HHS agency spokesperson denied the reports.

The unprecedented news created a firestorm on Twitter and elicited an immediate response from Dr. Michael Munger, President of the American Academy of Family Physicians (AAFP), who said in a statement:

The American Academy of Family Physicians, which represents 129,000 family physicians and medical students, is both surprised and concerned by the Administration’s clear disregard for the importance of science and evidence-based medicine. ... This action is an obvious attempt to politicize the most fundamental tenets of medicine and research, which will have a chilling effect on the CDC’s ability to rely on science to justify the work it does to protect public health.

American Family Physician is editorially independent from the AAFP, but the journal's editors stand with the organization in urging the Administration to "fully assess the broader implications of this purely political maneuver and reconsider its recent directive to the CDC." Further, we condemn censorship of science and public health in any form and will not allow it to infiltrate our content, which includes and will continue to include all of the seven forbidden words. Finally, we consider evidence-based medicine to be the essential foundation for ethical patient care, by distinguishing effective health care from tests and treatments that are unnecessary and harmful.

Monday, December 11, 2017

What's new with flu?

- Jennifer Middleton, MD, MPH

We're starting to see our first few cases of influenza where I practice, and the Centers for Disease Control and Prevention (CDC) confirms that the 2017-18 influenza season is off and running in the United States. The predominant activity thus far has been influenza A(H3N2), which is included in all formulations of the influenza vaccine available in the US. Less than 40% of eligible children and adults in the US have received this year's vaccine, but it's not too late to increase our practices' vaccination rates. Here are some simple tips and tools to help do so from the primary care literature.

The Annals of Family Medicine's latest issue includes a randomized controlled trial using text messages to encourage influenza vaccination that had modest success in an Australian multi-center trial. The researchers chose to focus on high-risk populations within these 10 practices including the elderly, young children, pregnant women, individuals with co-morbid health conditions, and certain ethnic minorities. An average of 29 patients (or parents) received text messages for every patient who was vaccinated, costing the practices $3.48 per additional vaccinated patient (at $0.12/text message). That "number needed to text" (my wording) may seem unimpressive, but the cost and time investment that resulted in those vaccinations was modest. The greatest increase in vaccination rates was in children under the age of 5.

An article from Family Practice Management reviews five simple steps to improving vaccination rates: find a champion, use standing orders, optimize your documentation, provide regular reminders to providers, and give ongoing feedback. The authors describe a template for their vaccination standing order, tips for documenting vaccines received elsewhere and vaccine refusals, the use of electronic health record (EHR) and visual reminder systems, and tracking vaccination numbers with simple office metrics. They review the evidence base behind each of these five steps and provide specifics regarding how to implement each one.

A recent AFP Practice Guideline reviews the CDC's Advisory Committee on Immunization Practices' (ACIP) recommendations for the current season. It includes descriptions of the currently available vaccination products and also provides guidance regarding vaccinating persons with a history of Guillain-Barre syndrome (only in individuals at high risk of complications from influenza) or egg allergy (closely monitor persons with a history of anaphylactic egg allergy immediately after vaccination).

The AFP By Topic on Influenza provides many more resources, including patient information handouts and tips for conversing with vaccine-adverse individuals. The CDC's weekly FluView report is another useful tool that I recently added to my AFP Favorites page.

What strategies has your practice used to encourage influenza vaccination?

Monday, December 4, 2017

A simple test to rule out pathologic heart murmurs in kids

- Kenny Lin, MD, MPH

It happens all the time to family physicians at well-child visits: we listen to the heart, hear a murmur that wasn't documented as being there before, and wonder if it's necessary to obtain an echocardiogram and/or refer the child to a cardiologist. A previous review in American Family Physician by Drs. Jennifer Frank and Kathryn Jacobe listed several "red flags" that make a pathologic murmur more likely:

- Holosystolic or diastolic murmur
- Grade 3 or higher murmur
- Harsh quality
- Abnormal S2
- Maximum murmur intensity at the upper left sternal border
- A systolic click
- Increased intensity when the patient stands

The authors also recommended referral to a pediatric cardiologist if historical findings suggest structural heart disease, if cardiac symptoms are present, or if the family physician is unable to identify a specific innocent (physiologic) murmur. Even though innocent murmurs share several characteristics, some of these are subjective or difficult to distinguish, and the fear of missing a heart disease diagnosis may still lead to unnecessary referrals.

In an important study published in the November/December issue of Annals of Family Medicine, Dr. Bruno Lefort and colleagues prospectively evaluated 194 consecutive children aged 2 or older referred for heart murmur evaluations at 2 French medical centers to test the hypothesis that a simple, objective clinical test could exclude serious cardiac disease. 100 children had a murmur that was present when supine but completely disappeared when they stood up, per the pediatric cardiologists' examinations. Of these children, only two had an abnormal echocardiogram result, and only one required further evaluation and treatment for a non-trivial problem (an atrial septal defect that required percutaneous closure). The authors calculated that the complete disappearance of the heart murmur on standing had a positive predictive value of 98%, specificity of 93%, and sensitivity of 60% for innocent murmurs in children. This clinical standing test had superior predictive value compared to traditionally taught clinical features of physiologic murmurs, such as change in murmur intensity, location, or timing.

The investigators concluded that the complete disappearance of the murmur on standing may be a valuable test to rule out pathologic heart murmurs in children and prevent unnecessary imaging and referrals. They recommended that a larger study confirm the value of this test and its reproducibility between pediatric cardiologists and primary care physicians (whose assessments were not evaluated in this study).