Eliciting patients' lifestyle habits can be difficult

A physician reader of AFP submitted the following post.

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It is an unwritten law of medicine that patients tend to be less than entirely forthcoming when responding to queries regarding their intake of alcohol. I would guess that most physicians double or triple the number of alcoholic beverages patients admit to drinking daily. Similarly, when counseling patients with diabetes or obesity, I generally hear what I take to be gross underestimates of the amount of carbohydrates and total calories consumed. An individual might state with complete confidence (and often, indignation), "I eat almost nothing." He then might list his total food consumption for the previous day as "nothing for breakfast, an apple for lunch, a piece of chicken and a salad for dinner; that’s it."

I suspect that we all have an unintentional, perhaps uncontrollable, drive to appear better than we are in the presence of health professionals; we want to pass the test, so to speak. As a result, it is quite difficult to obtain accurate information regarding lifestyle habits such as diet, amount of exercise, tobacco use, substance abuse, sexual activity, etc. I congratulate patients who "come clean" and provide me with true descriptions of their daily habits. When asking them to keep food diaries, I explain that I am not grading them but, rather, collecting information about unhealthy aspects of their diet so that I can help them make adjustments.

Sometimes this approach works; often, it does not. After hearing another improbable tale of conscientious eating habits in a patient whose physical examination and laboratory tests suggest otherwise, I generally explain, “the laws of thermodynamics cannot be broken."

Bob Schwartz, MD
Chester Family Medicine
Chester, Vermont

Advice for physicians on using social media

The Mayo Clinic's Center for Social Media recently posted a short video of prominent physician bloggers Bryan Vartabedian (a gastroenterologist), Wendy Sue Swanson (a pediatrician), and Katherine Chretien (an internist) giving advice to young physicians on the potential and perils of social media use.

The advice and additional resources these experts provide should be helpful to family physicians at all stages of training who are new to using social media tools. Dr. Chretien also writes an insightful commentary in the July 1st issue of AFP in response to the question, "Should I be 'friends' with my patients on social networking web sites?" (Short answer: no, but there are less ethically questionable ways to interact with one's patients online.) As Dr. Chretien points out, the American Medical Association has recently published guidance on professionalism in the use of social media.

We encourage family physicians to explore the health care social media landscape through posts and comments on the AFP Community Blog and the journal's Facebook and Twitter accounts, as well as by visiting our links to blogs written by and for family physicians.

Preparing for bioterrorism and other medical emergencies

In the aftermath of 9/11 and the anthrax attacks of 2001, AFP published a review article on "Recognition and Management of Bioterrorism," recognizing that primary care clinicians would be on the front lines of any future bioterrorist attack. Other critical resources for family physicians now include the Centers for Disease Control and Prevention's Bioterrorism resource page, the MedlinePlus collection on Biodefense and Bioterrorism, and the American Academy of Family Physicians' Preparedness Manual for Disasters and Public Health Emergencies.

Although the unpredictable threat of bioterrorism can seem distant from day-to-day practice, Drs. Mark Harris and Kevin Yeskey remind us in an editorial in the July 1st issue of AFP that family physicians continue to play a "vital role" in protecting all Americans from the consequences of these attacks:

The first diagnosis of anthrax in the 2001 attack was in an emergency department. A salmonella outbreak in Oregon in 1984 that was later found to be bioterrorism-related was discovered after primary care physicians reported to their health department large numbers of patients with diarrhea who had eaten at two local restaurants. This type of passive surveillance is the early warning system for naturally occurring outbreaks, and for bioterrorism events. An astute physician who diagnoses a reportable illness and alerts the local health department may be detecting a bioterrorism attack, possibly saving his or her patient and many others.

Additional free AFP online resources to help physicians prepare for a variety of natural and man-made medical emergencies include a clinical review of emergency preparedness in office practice and a Curbside Consultation on professional training for emergency situations.

Aspirin for primary CVD prevention: the continuing debate

In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that primary care clinicians discuss preventive aspirin use with adults at increased risk of cardiovascular events. Four years later, the National Commission on Prevention Priorities (NCPP) ranked counseling for aspirin use the number one priority on its list of the most effective clinical preventive services. According to the NCPP, if the percentage of eligible patients using aspirin (then estimated to be about 50 percent) increased to 90 percent, 45,000 additional lives could be extended each year.

At that time, the benefits of aspirin use in men and women were assumed to be the same. However, an updated USPSTF recommendation statement published in the June 15th issue of AFP indicates that aspirin use actually prevents heart attacks in men, but ischemic strokes in women. In addition, physicians and patients must weigh the benefits of reduced cardiovascular risk with the risk of gastrointestinal bleeding events, and use shared decision making when these risks are closely balanced.

To further complicate matters, a 2009 meta-analysis published in the journal The Lancet questioned the value of aspirin for primary prevention, concluding that for patients who without a history of cardiovascular disease, "aspirin is of uncertain net value." In response, family physicians and USPSTF members Ned Calonge and Michael LeFevre wrote an editorial that concluded, "There is not a simple message for aspirin prophylaxis as a primary preventive strategy, and we need to consider gender, age, and the associated balance of potential risks and benefits to provide the best advice and preventive care for our patients."

We pick up the continuing debate with two thought-provoking editorials in the June 15th issue. Alison L. Bailey and colleagues caution that routine aspirin use is not justified for primary prevention in adults at low risk of CVD. On the other hand, W. Fred Miser asserts that the main issue regarding aspirin for primary prevention continues to be underuse in appropriate-risk patients. Finally, a Putting Prevention Into Practice case study applies information from the USPSTF recommendation to a sample patient scenario.

FP Blog Roundup: Remembering Barbara Starfield

The recent passing of legendary primary care researcher Barbara Starfield, MD, MPH was the subject of many Family Medicine blog posts this week. At Medicine and Social Justice, Josh Freeman, MD called Dr. Starfield "the pre-eminent scholar on health workforce policy." At Family Medicine Rocks, Mike Sevilla, MD posted a video of her receiving the Family Medicine Education Consortium's Lifetime Achievement Award and commented on the surprising silence from family medicine organizations about Dr. Starfield, who, though a pediatrician by training, "gave this specialty [of family medicine] a voice." Finally, at The Singing Pen of Doctor Jen, Jennifer Middleton, MD, MPH pondered, "With all of the national chatter about [unsustainable] heath care costs, why hasn't the media broadcasted the message of primary care's cost-saving and health-prolonging benefits?"

Through her research, Dr. Starfield did more than perhaps any other individual to establish the essential role of family medicine in improving population health outcomes in the U.S. and abroad. In a 2009 interview for AAFP News Now, she observed:

The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality. [This] is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. Primary care everywhere in the world is most of the care, for most of the people, most of the time. We have done a reasonably good job at making subspecialty care available, but a lot of subspecialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily. If we followed what the evidence shows, we could do a whole lot better with a much better infrastructure of what we call primary health care.

Earlier that year, in a provocative editorial published in Family Practice Managment, Dr. Starfield had argued that the timeless principles of family medicine - first-contact care; comprehensive care; person-focused care over time; and care coordination - should be driving practice reforms such as the Patient-Centered Medical Home, rather than the other way around. To honor Dr. Starfield's career, Health Affairs is offering free access until June 28th to four landmark articles that she previously wrote in their journal.

Evaluation and management of heat-related illness

Last July, a record-breaking heat wave affected most of the Northern Hemisphere and led to many cases of heat-related illness in the U.S. and abroad. As the summer of 2011 approaches, Drs. Jonathan Becker and Lynsey Stewart from the University of Louisville, Kentucky present an updated review of the evaluation and management of heat cramps, heat exhaustion, and heat stroke in the June 1st issue of AFP. In addition to using the suggested evaluation algorithm, family physicians should also be aware of the many conditions and substances that may increase the risk of heat-related illness. As the authors note, heat stroke is a true medical emergency that requires immediate assessment and lowering of core body temperature, preferably through cold water immersion.

Addressing family medicine's "Top 5" list

Last week, the journal Archives of Internal Medicine published "The 'Top 5' Lists in Primary Care," a physician-authored consensus statement that recommended five activities each for the specialties of family medicine, internal medicine, and pediatrics to pursue to reduce waste and improve quality. Here is the top 5 list for family physicians, together with related online resources from AFP By Topic collections:

1) Don't do imaging for low back pain within the first 6 weeks unless "red flags" are present.

AFP By Topic: Muculoskeletal Care - Neck and Back

2) Don't routinely prescribe antibiotics for acute sinusitis.

AFP By Topic: Upper Respiratory Tract Infections - Treatment

3) Don't order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients.

AFP By Topic: Coronary Artery Disease - Screening and Diagnosis

4) Don't perform Pap tests on women younger than 21 years or in women status post hysterectomy for benign disease.

AFP By Topic: Cancer - Cervical Cancer

5) Don't use DEXA screening for osteoporosis in women under age 65 years or in men under 70 years with no risk factors.

AFP By Topic: Osteoporosis - Screening and Diagnosis

As a reminder, AFP By Topic is also available as a free mobile app in the Apple Store and the Android Market.