Monday, August 26, 2013

You don't snooze, you lose

- Jennifer Middleton, MD, MPH

The consequences of insufficient sleep can be significant.  Children and teens who don't get enough sleep not only get worse grades in school but are also more likely to have parents who worry about their mood and behavior.  Sleep-deprived adults are more likely to be involved in a motor vehicle or work accident, are more likely to have hypertension, and are more likely to be obese (even controlling for changes in diet patterns).  Perhaps logically, then, sleep-deprived adults incur higher health care costs than adults who get at least 6 hours of sleep a night.

The August 15, 2013 AFP featured an article regarding the Management of Common Sleep Disorders. The first section of this article dealt with insomnia; I don't know about you, but I see a lot of patients in the office who are struggling with falling and staying asleep at night. The authors wisely suggest reframing patients' thoughts about sleep using Cognitive Behavioral Therapy (CBT), and Table 4 contains most of the advice that I routinely dispense to patients: limit caffeine and stop nicotine, only use the bedroom for sleep and sex, get up if you haven't fallen asleep within 20 minutes, etc. I liked how the authors cited evidence showing that these simple physician interventions can be quite effective.

Decreasing time with electronics (TV, computers, tablets, mobile phones) may also help.  The American Sleep Foundation's annual poll in 2011 found that use of a smartphone, computer, and/or television the in hour before falling asleep correlated with lower quality sleep.  They also reported that the average number of caffeinated beverage servings among adolescents and adults was around 3 a day - perhaps to make up for the fatigue from decreased sleep quality?

I recommend that patients get television sets and other electronics out of the bedroom if at all possible, and spend the last hour of the day disconnected from technology.  You can probably imagine how my patients often respond to that advice; smartphones, computers, and televisions seem to be ubiquitous in the US, and certainly have many positives regarding inter-connectivity and just plain old entertainment.

But, as the above studies demonstrate, helping our patients to get restful sleep may help prevent a lot of problems.  There are AFP by Topics on sleep disorders for both adults and children if you'd like to check out more resources about this issue.

Do you have any special advice for your patients regarding sleep?

Monday, August 19, 2013

The most popular posts of January - July 2013

- Kenny Lin, MD, MPH

Following up on our successful previous collection of the most popular posts of 2012 (which has been viewed more than 1300 times), here are the AFP Community Blog's top 5 most viewed posts from the first seven months of 2013.

1. Are IUDs a reasonable option for birth control in adolescents? (May 21)

What are your thoughts about the intrauterine device for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?

2. Pros and cons of vitamin D screening (April 29)

No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone.

The increasing diversity of the U.S. population has made it more likely that family physicians will care for many patients with cultural backgrounds, beliefs, and practices that are dissimilar to their own.

Given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is something more than just counseling necessary to effect behavior change?

5. Is routine stress testing necessary for resolved chest pain? (May 29)

Are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?

Monday, August 12, 2013

Does acetaminophen help nasal congestion from the common cold?

- Jennifer Middleton, MD, MPH

I don't know about you, but when I get a upper respiratory tract infection (URI or "cold"), one of the first things that I reach for is acetaminophen. I've never thought that it did much for the nasal congestion, but it at least seems to take the edge off of the headache, muscle aches, and fever.

Cold and flu season is right around the corner - except for my household, where it unfortunately arrived this weekend.  So, I am finding Cochrane's recent review of acetaminophen for the common cold rather timely.  The reviewers only found 4 small studies of "low to moderate quality," but 2 of these studies did show that acetaminophen reduced nasal congestion, and 1 showed that it reduced rhinorrhea.

I had never thought of acetaminophen as a treatment for nasal symptoms before, but the Cochrane reviewers wisely recommend caution in interpreting these small studies, stating that they are insufficient "to reach a conclusion."

Does this mean that I will be less likely to use and recommend acetaminophen for cold symptoms? Nope. A lack of high-quality studies supporting its efficacy isn't the same as a high-quality study showing that it doesn't work.  I still like recommending acetaminophen for headache, myalgias, and fever, and if it gets some of those nasal symptoms, that'd be a nice bonus.  What this review will hopefully spark, though, is some higher-quality prospective studies to more precisely define acetaminophen's utility for URI symptoms.

So, we'll keep on using acetaminophen in our house until this current virus runs its course.  AFP also recently reviewed "Treatment of the Common Cold in Children and Adults" with pragmatic evidence-based recommendations for patients (and doctors) with URIs.  And, when all of those over-the-counter options for colds get overwhelming, this AFP Cochrane for Clinicians article can provide guidance.  We're also drinking plenty of fluids, resting when possible, and my husband is taking zinc lozenges (though the taste isn't worth it to me, given zinc's only modest effect on URIs).

Will Cochrane's review change your recommendations for acetaminophen use in the common cold?

Monday, August 5, 2013

Is prevention or treatment the heart of family medicine?

- Kenny Lin, MD, MPH

The comprehensive scope of family medicine has always made it a challenge to describe, in a nutshell, what family physicians do. Unlike subspecialists or general internists, surgeons, or pediatricians, family physicians do not define their patient populations by age, gender, or organ system. A series of editorials published a few years ago in the Annals of Family Medicine argued that family physicians practice a "science of connectedness" that includes a distinct approach to clinical problem-solving. A more recent study in Family Medicine asserted that the training and attitudes of family physicians make them uniquely qualified to provide cost-effective health care. The emergence of the Patient-Centered Medical Home model has emphasized the role of the family physician as a facilitator and leader of care teams for patients with multiple preventive and chronic care needs.

Dr. John Hickner, editor of The Journal of Family Practice, worries that well-intentioned initiatives to improve family physicians' skills at providing screening tests and facilitating behavioral change may come at the cost of neglecting patients' acute concerns. He wrote in a recent editorial:

At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”

Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.

As a family physician who teaches public health and preventive medicine, I appreciate the tension between prevention and treatment in my own practice. Previous studies concluded that paying exclusive attention to providing guideline-recommended preventive and chronic disease services would leave literally no time to address the many other reasons that patients come into the office. As Dr. Hickner noted, "The 'number needed to treat' to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!" So is prevention or treatment the heart of family medicine? Is the answer to this question different today than it would have been a generation ago, and is it likely to be different a generation from now?