Clinical problem-solving is a strength of family medicine

Working with family physicians since 1978, I have noticed two things in particular.

First, they take great pride in their interest in relationship-based care. They talk about the value of continuity. They tell stories that describe how much they treasure relationships with patients. They tell these stories in their teaching. They write books about it. It's a powerful force that energizes their work and their career satisfaction.

They rarely, if ever, mention the power of their clinical problem-solving abilities. Why is that? The absence of mention and the seeming lack of pride (my assumption) in this area makes me wonder if FPs really believe they are effective in the area of clinical problem-solving.

From my earliest days in family medicine, I came to believe that FPs' impact as physicians was a result of their patient/relationship-centered approach that included effective communication skills, their fund of knowledge, and their clinical problem-solving skills. All three are essential; any two working alone, except in special circumstances, will not lead to the best results.

Family physicians embraced the work of Barbara Starfield, MD, MPH, who told the world that FPs, in particular, and primary care clinicians, in general, had a positive effect on population health while reducing the cost of care. When I hear FPs take pride in their relationship centered approach to care but never mention their approach to clinical problem-solving, it leads me to believe they think that continuity alone produces the impact documented by Dr. Starfield.

I put this issue to a number of colleagues and heard the following.

"Because of the variety of patients and undefined illnesses that family physicians see, they become better at development of realistic differential diagnosis than any other medical specialty." - Doug Smith, MD, Orono Family Medicine, Orono, Minnesota

Shantie Harkisoon, MD, director of the Phelps Family Medicine Residency Program in Sleepy Hollow, New York, told me that she thinks the strength of FPs is strong skill with differential diagnosis of the patient as person while sub-specialists are generally more effective at differential diagnosis of a disease.

I have been talking to a documentary film maker who wants to tell a story about family medicine and primary care innovation. In his interviews with FPs, all he hears about is the value of relationship centered care. He can't understand how the care provided by FPs costs less money. When I told him that FPs are effective clinical problem-solvers and their approach to decision making is a key piece of this story, he almost did not believe me. When he interviewed FPs, he was not hearing about this. Why do we not hear more about family physicians' clinical problem-solving prowess?

Laurence Bauer, MSW, MEd

Chief Executive Officer

Family Medicine Education Consortium

Laurence.Bauer@gmail.com

Compromising the medical literature

To ensure that our clinical review articles reflect current medical literature, American Family Physician requires prospective authors to consult several evidence-based resources that synthesize the best available evidence from clinical trials and other high-quality studies. The goal of this process is to produce unbiased recommendations for primary care physicians. But what if the authors of clinical reviews are actually professional scientific writers paid by pharmaceutical companies, rather than the physicians whose names are listed as authors?

In fact, drug-company funded "ghostwriters" have been publishing articles in the medical literature for years. A study by the editors of JAMA found that from 2 to 11 percent of articles published in 2008 in six major journals (including the New England Journal of Medicine) were actually written by people who were not named as authors. While the study could not establish that these ghostwriters had been directly financed by industry, the practice of writing up a scientific study and then recruiting a lead author (usually an academic physician under pressure to "publish or perish") has been well-documented in the case of previous "blockbuster" drugs that were taken by millions of patients for common conditions but later turned out to have dangerous or fatal side effects, including Wyeth's Prempro and Merck's Vioxx.

Ghostwriting is not the only way that the pharmaceutical industry is able to influence the interpretation of evidence in its favor. A Letter to the Editor in the Sept. 1 issue points out that a 2005 Cochrane Review on medications for diabetic neuropathic pain (cited in a 2010 AFP article on this topic) unintentionally exaggerated the effectiveness of gabapentin in treating this condition due to the manufacturer's selective publication of favorable trials and suppression of unfavorable ones. In an accompanying editorial, Drs. Adriane Fugh-Berman and Jay Siwek review these and other "stealth marketing" tactics that can potentially compromise the medical literature, along with ways that readers can help correct these biases:

Distorted information, once ensconced in the medical literature, is propagated by industry and by well-intentioned authors who unwittingly cite these studies. The medical literature is a permanent record that scientists and physicians rely on for decisions that ultimately affect patient care. Although the scientific process is never linear, the self-correcting process by which evidence is continually refined can be corrupted by the infiltration of medical journals with research studies and review articles distorted by a hidden marketing agenda.

Although there is no foolproof way for readers to detect undue industry influence, readers should be alert for marketing messages that disparage older, generically available drugs or that position newer branded (or upcoming) drugs as more effective, more convenient, safer, or filling an unmet need. The last sentence of the abstract is typically where the marketing spin is inserted. Readers should alert medical journals to suspicious articles by writing letters to the editor.

Convincing new mothers that "breast is best"

A recent report from the Centers for Disease Control and Prevention found that despite evidence that birthing environments strongly influence new mothers' feeding practices, only 3.5 percent of surveyed U.S. hospitals met most quality indicators of the Baby-Friendly Hospital Initiative, an international program that seeks to reduce obstacles to successful breastfeeding. Hospitals received low marks on items such as restricting pacifier use and supplemental infant formula, and only a minority permitted 24-hour "rooming in," which makes it easier for infants to breastfeed on demand.

Although the American Academy of Family Physicians and the American Academy of Pediatrics recommend that mothers exclusively breastfeed infants for the first 6 months of life, and supports continuing breastfeeding to at least one year of age, data from the 2004-2008 National Immunization Survey document that only 73% of U.S. women attempt to breastfeed after birth, and only 42% and 21% are still breasfeeding at 6 and 12 months of life. The percentages are even lower for Black women: only 54% attempt breastfeeding, and just 27% and 11% are still doing so at 6 and 12 months.

Family physicians can help convince expectant and new mothers that "breast is best" by applying a number of evidence-based interventions recommended by the U.S. Preventive Services Task Force. Patients should be informed that the Department of Health and Human Services mandates first dollar coverage of comprehensive lactation support and breastfeeding equipment (e.g., breast pumps) for insurance plans starting in August 2012. Recognizing that primary care clinicians have many opportunities to support breastfeeding throughout pregnancy and the newborn period, we have included related content in each of the AFP By Topic collections on Prenatal Care, Labor and Delivery, and Newborn Care.

Does aspirin prophylaxis improve health in older adults?

Every day, family physicians are confronted with the clinical question of whether or not to start a patient on aspirin for the primary prevention of cardiovascular disease. The editorials in the June 15th issue of AFP by Dr. W. Fred Miser ("Appropriate Aspirin Use") and Drs. Bailey, Smyth, and Campbell ("The Case Against Routine Aspirin Use") highlight the current difficulties in putting the 2009 U.S. Preventive Services Task Force recommendations on aspirin prophylaxis into practice. There is limited information available to inform benefit versus risk decisions regarding aspirin prophylaxis in healthy older adults. Given the significant projected growth of the elderly population, especially of older minorities, family physicians will need to address aspirin prophylaxis decisions more frequently in the future.



To address areas of uncertainty beyond the 2009 USPSTF guidelines, the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial aims to answer a simple question with significant public health relevance: Does daily low-dose aspirin use maintain longevity without cognitive and functional disability in healthy men and women age 70 years or older? Currently, recruitment of 19,000 older adults who do not require aspirin for a cardiovascular condition is ongoing at over 20 sites in the U.S. in addition to general practices in Australia. In the U.S., results from ASPREE should hopefully provide insight on how aspirin works in all older persons, including members of minority groups. In order to succeed, ASPREE will require the engagement of family physicians and other primary care clinicians. Family physicians can make a significant contribution by identifying healthy, older persons from minority communities and providing them with information about how to participate in the study. More information about the study and locations of study sites in the United States can be found at www.ASPREE.org.

Raj C. Shah, MD

Rush University Medical Center

Chicago, Illinois

Raj_C_Shah@rush.edu



Disclosure: The author is a co-investigator on the ASPREE study.

Autism: to screen or not screen?

The August 15th issue of AFP features a pair of editorials that stake out opposite positions in the intensifying debate about the benefits of routinely screening young children for autism spectrum disorders (ASDs). Dr. Paul Lipkin and Susan Hyman argue that the rising incidence of ASDs and studies suggesting a benefit from early diagnosis and behavioral interventions make it imperative for pediatricians and family physicians to incorporate developmental screening tools into their practices. They assert that developmental screening does not impose significant time burdens on physicians, and that false-positive screening results can be minimized by scheduling follow-up interview visits.

On the other hand, Dr. Doug Campos-Outcalt counters that screening for ASDs has not yet met several critical criteria for establishing the effectiveness of a screening test. In particular, the following important questions remain unanswered:

1) What are the sensitivity and false-positive rate of the best screening test for ASDs available in an average clinical setting?



2) How much earlier can screening tests detect ASDs compared with an astute clinician who asks a few key questions about, and acts on, parental concerns regarding a child's communication and interactions?



3) What are the potential harms of testing?



4) Does earlier detection by screening result in meaningful and long-lasting improvements compared with detection through routine care?

Although a recent systematic review published in Pediatrics found limited evidence that early intensive behavioral interventions improve "cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs," it remains uncertain if routine screening leads to improved outcomes. Therefore, Dr. Campos-Outcalt recommends, "Family physicians who provide care for young children should ask parents about any concerns, be alert for the signs and symptoms of ASDs, and use available diagnostic testing tools to assist in making clinical decisions when an ASD is suspected."

AFP Community Blog: Top 10 most-read posts

This month, the AFP Community Blog celebrates its first anniversary. For those of you who started following us recently, or don't read regularly, here is a list of the blog's top 10 most-read posts:

1) AFP By Topic now available for IPhone and Android (4/20/11)

2) Dabigatran for stroke prevention in atrial fibrillation: is it worth it? (1/18/11)

3) Prostate-specific antigen screening is not effective (3/30/11)

4) Screening and treatment of hyperlipidemia in children (9/1/10)

5) Autism spectrum disorders: increasing prevalence or diagnosis shift? (5/22/11)

6) Antibiotics for acute bronchitis: just don't do it (12/9/10)

7) Screening colonoscopies performed more often than necessary (5/9/11)

8) Geriatric assessment tools (1/3/11)

9) Should pharma have unrestricted access to your prescribing profile? (4/25/11)

10) Advice for physicians on using social media (7/6/11)

Thank you all for continuing to make American Family Physician the best-read journal in primary care!

Climate change and family physicians

At first glance, the topic of the cover article of AFP's August 1st issue, "Slowing Global Warming: Benefits for Patients and the Planet," might seem out of place in a journal that aims to provide practical clinical guidance for family physicians. Past summer-themed articles have included clinical reviews of heat-related illness, medical advice for commercial air travelers, and even health issues for surfers. By addressing climate change, AFP joins other widely read medical journals such as The Lancet and BMJ in recognizing the essential role that physicians can play in mitigating the negative impacts of environmental stress on patients' health.

After summarizing the serious potential health effects of climate change, Dr. Cindy Parker recommends that primary care clinicians counsel patients regarding two lifestyle changes that are likely to improve personal health as well as slow global warming: reducing meat consumption and increasing "active transportation" (substituting bicycling or walking for short car trips). In addition, physician practices and larger medical organizations can positively affect climate change by "going green":

Medical offices and hospitals can help by recycling; using recycled items and Energy Star certified appliances and computers; minimizing waste and waste transport by replacing single-use items with sterilizable or washable items; purchasing wind-generated electricity; and reducing energy use by turning off appliances, computers, and lights when not in use. In 2008, the U.S. health care sector spent $8.8 billion on energy to meet patient needs, not including the transportation of employees or patients to and from health care facilities, resulting in 8 percent of all U.S. greenhouse gas emissions.

In an accompanying editorial, Dr. Robert Gould reviews several national and international initiatives that encourage hospitals and health systems to reduce greenhouse gas emissions, including the Healthier Hospitals Initiative and Health Care Without Harm.