Diagnosing patients who itch

In a fascinating 2008 New Yorker article, "The Itch," Harvard surgeon Atul Gawande told the story of a patient who experienced a nearly fatal complication from treatment-resistant pruritis of her scalp following an episode of herpes zoster:

One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, “this fluid came down my face, this greenish liquid.” She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain.

Although this sort of complication is highly unusual, pruritis - far from being only a "nuisance" symptom - is often associated with underlying systemic conditions, Dr. Brian Reamy and colleagues observe in "A Diagnostic Approach to Pruritis" in the July 15th issue of AFP. Clinicians should consider evaluating patients who present with generalized, unexplained pruritis for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes. Many dermatoses of pregnancy can cause intense pruritis. Also, some psychiatric disorders are associated with pruritic sensations, leading to "neurotic excorations." Certain historical findings, including recent travel, exposure to animals, and constitutional symptoms such as weight loss and fatigue, can help to narrow the extensive differential diagnosis of this common and troublesome symptom.

Making informed choices about family planning and contraception

For reproductive-age women who have medical comorbidities such as epilepsy, diabetes, and hypertension, choosing a family planning method can be challenging. The September 1, 2010 issue of AFP reviewed the risks and benefits of hormonal contraceptives for these patients, based on guidelines from the American College of Obstetricians and Gynecologists. However, the scope of that article did not include nonpharmacologic options such as barrier or fertility awareness-based methods, also known as natural family planning (NFP). Two letters in the July 1st issue of AFP remind readers that NFP is an effective family planning option for appropriately educated couples and provide helpful training resources for clinicians. As Drs. Robert Conkling and Leslie Chorun observe:

Counseling in natural methods of fertility regulation is currently being provided by a growing number of trained physicians, nurse practitioners, and allied health professionals. ... These family planning methods should not be confused with calendar rhythm method and are not dependent on the regularity of a woman's cycle. Population-based surveys have shown a significant interest in NFP—approximately 25 percent of women and 40 percent of men are interested in using NFP to avoid pregnancy, and 33 percent of women are interested in using NFP to conceive. This interest is not associated with religion, education, age, or income level.

For further reading on patient outcomes associated with various fertility awareness-based methods, family physicians can consult a clinical review published in the Journal of the American Board of Family Medicine. Also, a recent AFP By Topic collection compiles the journal's current online content on all aspects of family planning and contraception, including preconception care, the infertility evaluation, and advantages and disadvantages of hormonal and non-hormonal methods.

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.