- Kenny Lin, MD
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. As a previous article in American Family Physician observed, patients' beliefs regarding health and disease causation may pose obstacles to communication even when physicians and patients speak the same language. Using medical interpreters is another skill that takes practice to achieve proficiency, but has clear benefits, according to the author of a Curbside Consultation: "The skills of a medical interpreter or translator include cultural sensitivity and awareness of and respect for all parties, as well as mastery of medical and colloquial terminology, which make possible conditions of mutual trust and accurate communication that lead to effective provision of medical health services."
In the review article "Caring for Latino Patients" in the January 1st issue of AFP, Dr. Gregory Juckett notes that this population faces a number of special medical concerns:
Approximately 43 percent of Mexican Americans older than 20 years are obese, compared with 33 percent of the non-Latino white population. Diabetes and hypertension are closely linked with obesity; 11.8 percent of Latinos older than 20 years have type 2 diabetes (13.3 percent of Mexican Americans), making it the foremost health issue in this population. A higher-calorie diet, a more sedentary lifestyle, and genetic factors contribute to this problem. Because of less access to health care, Latinos with diabetes are often diagnosed later and have a greater risk of complications.
To navigate and resolve cultural differences that may impede understanding and effective treatment, Dr. Juckett advises that clinicians use the LEARN technique for cross-cultural interviewing:
1. Listen sympathetically to the patient's perception of the problem,
2. Explain his or her perception of the problem to the patient,
3. Acknowledge and discuss any differences and similarities between the two views,
4. Recommend a treatment plan, and
5. Negotiate agreement.
For practices that see sizable numbers of Latino patients, the article also includes a helpful list of strategies for creating a culturally sensitive office environment.
Jumat, 25 Januari 2013
Selasa, 15 Januari 2013
Is there a looming family physician shortage, or not?
- Kenny Lin, MD
Researchers at the American Academy of Family Physicians' Robert Graham Center (which produces the Policy One-Pagers series for AFP) recently predicted in the Annals of Family Medicine that a combination of population growth, aging, and insurance expansion from the Affordable Care Act will create the need for an additional 52,000 primary care physicians by the year 2025 - an increase of nearly 25 percent over the current workforce. Since the vast majority of internal medicine residents plan to pursue subspecialty rather than generalist careers, family medicine will be called on to supply the bulk of this looming gap in physician supply and demand. Recent efforts to increase the supply of family physicians include emphasizing community-based clinical training in medical school and temporarily increasing Medicaid and Medicare primary care fees.
Another strategy for bolstering the family medicine pipeline, contained in the Affordable Care Act, is mandating redistribution of unused residency positions to primary care programs. Unfortunately, an analysis published this month in Health Affairs concluded that a similar Medicare graduate medical education reform in 2005 not only failed to significantly boost primary care, but actually resulted in training twice as many new subspecialists. Dr. Candace Chen and colleagues conclude:
Our findings suggest that redistribution [of unused residency positions] largely supported hospitals in growing their specialty training. Some hospitals even converted primary care positions to specialty positions after receiving newly redistributed positions. ... This shifting collectively perpetuates the nation's physician workforce maldistribution, and our analysis demonstrates that Medicare continues to support these hospitals and even increases its support for them, regardless of the specialty mix of residents trained.
Not everyone agrees that meeting the future health needs of the U.S. population will require a massive influx of family physicians, however. Other researchers have argued that the widespread adoption of team-based care, "advanced access" scheduling, and replacing some in-person with electronic visits could provide enough new patient capacity to prevent a family physician shortage. Still, much uncertainty surrounds this and other projections. What steps is your practice taking, if any, to meet the anticipated needs of so many new patients? Hiring more physicians? Re-designing how you provide care? Please feel free to share your stories.
Researchers at the American Academy of Family Physicians' Robert Graham Center (which produces the Policy One-Pagers series for AFP) recently predicted in the Annals of Family Medicine that a combination of population growth, aging, and insurance expansion from the Affordable Care Act will create the need for an additional 52,000 primary care physicians by the year 2025 - an increase of nearly 25 percent over the current workforce. Since the vast majority of internal medicine residents plan to pursue subspecialty rather than generalist careers, family medicine will be called on to supply the bulk of this looming gap in physician supply and demand. Recent efforts to increase the supply of family physicians include emphasizing community-based clinical training in medical school and temporarily increasing Medicaid and Medicare primary care fees.
Another strategy for bolstering the family medicine pipeline, contained in the Affordable Care Act, is mandating redistribution of unused residency positions to primary care programs. Unfortunately, an analysis published this month in Health Affairs concluded that a similar Medicare graduate medical education reform in 2005 not only failed to significantly boost primary care, but actually resulted in training twice as many new subspecialists. Dr. Candace Chen and colleagues conclude:
Our findings suggest that redistribution [of unused residency positions] largely supported hospitals in growing their specialty training. Some hospitals even converted primary care positions to specialty positions after receiving newly redistributed positions. ... This shifting collectively perpetuates the nation's physician workforce maldistribution, and our analysis demonstrates that Medicare continues to support these hospitals and even increases its support for them, regardless of the specialty mix of residents trained.
Not everyone agrees that meeting the future health needs of the U.S. population will require a massive influx of family physicians, however. Other researchers have argued that the widespread adoption of team-based care, "advanced access" scheduling, and replacing some in-person with electronic visits could provide enough new patient capacity to prevent a family physician shortage. Still, much uncertainty surrounds this and other projections. What steps is your practice taking, if any, to meet the anticipated needs of so many new patients? Hiring more physicians? Re-designing how you provide care? Please feel free to share your stories.
Rabu, 02 Januari 2013
Questioning the need for annual pelvic examinations
- Kenny Lin, MD
New Year, time for women to schedule their annual pelvic examinations? Not so fast. An editorial that accompanies AFP's Jan. 1 cover article on health maintenance in women challenges this longstanding tradition. This is not the first time that this topic has appeared in the journal; a Curbside Consultation published in 2003 raised similar concerns:
My patients seem comfortable when I tell them they don’t need annual Pap smears. Yet, in teaching settings and among colleagues, I often hear the question, “If we’re not doing Paps, shouldn’t we be doing something?” Sexually transmitted infection screening, contraceptive counseling, safe-sex advice, and clinical breast examination are opportunities that are missed if patients don’t come to the office for annual Pap tests.
In their editorial, Drs. Giang Nguyen and Peter Cronholm observe that the reasons that clinicians commonly provide for continuing to perform these "routine" examinations are inconsistent with evidence-based recommendations. Cervical cancer screening should be performed no more often than every 3 years; ovarian cancer screening is ineffective and likely harmful; contraceptive prescriptions need not be preceded by a pelvic examination; and urine samples are highly accurate at detecting asymptomatic sexually transmitted diseases. The authors conclude:
Taking into account the time required for the patient to undress, the time to obtain the necessary equipment, and the time to perform the procedure, a screening pelvic examination can conservatively add an extra 10 minutes to an office encounter. In addition, because many physicians also require a nurse or medical assistant in the room during this examination, there is an opportunity cost associated with the other work that could have been done by the support staff during this time (e.g., stocking supply cabinets, performing immunizations, making phone calls to patients). Given the lack of evidence to support annual pelvic examinations, it would be better for patients if we spend that time addressing screening, counseling, and other preventive services for which strong evidence exists.
Although evidence supporting an unequivocal benefit of routine examinations (pelvic examination or no) remains elusive, many effective clinical preventive services for women can be provided at health maintenance-oriented visits or in the context of care for other health concerns. The review and patient education handout by Dr. Margaret Riley and colleagues, along with additional content in the AFP By Topic collection on Health Maintenance and Counseling, provide excellent summaries of these services.
New Year, time for women to schedule their annual pelvic examinations? Not so fast. An editorial that accompanies AFP's Jan. 1 cover article on health maintenance in women challenges this longstanding tradition. This is not the first time that this topic has appeared in the journal; a Curbside Consultation published in 2003 raised similar concerns:
My patients seem comfortable when I tell them they don’t need annual Pap smears. Yet, in teaching settings and among colleagues, I often hear the question, “If we’re not doing Paps, shouldn’t we be doing something?” Sexually transmitted infection screening, contraceptive counseling, safe-sex advice, and clinical breast examination are opportunities that are missed if patients don’t come to the office for annual Pap tests.
In their editorial, Drs. Giang Nguyen and Peter Cronholm observe that the reasons that clinicians commonly provide for continuing to perform these "routine" examinations are inconsistent with evidence-based recommendations. Cervical cancer screening should be performed no more often than every 3 years; ovarian cancer screening is ineffective and likely harmful; contraceptive prescriptions need not be preceded by a pelvic examination; and urine samples are highly accurate at detecting asymptomatic sexually transmitted diseases. The authors conclude:
Taking into account the time required for the patient to undress, the time to obtain the necessary equipment, and the time to perform the procedure, a screening pelvic examination can conservatively add an extra 10 minutes to an office encounter. In addition, because many physicians also require a nurse or medical assistant in the room during this examination, there is an opportunity cost associated with the other work that could have been done by the support staff during this time (e.g., stocking supply cabinets, performing immunizations, making phone calls to patients). Given the lack of evidence to support annual pelvic examinations, it would be better for patients if we spend that time addressing screening, counseling, and other preventive services for which strong evidence exists.
Although evidence supporting an unequivocal benefit of routine examinations (pelvic examination or no) remains elusive, many effective clinical preventive services for women can be provided at health maintenance-oriented visits or in the context of care for other health concerns. The review and patient education handout by Dr. Margaret Riley and colleagues, along with additional content in the AFP By Topic collection on Health Maintenance and Counseling, provide excellent summaries of these services.
Senin, 17 Desember 2012
The most popular posts of 2012
- Kenny Lin, MD
Although page views are only a surrogate measure of reader engagement, in a year that saw American Family Physician review the "Top 20 Research Studies of 2011 for Primary Care Physicians," I thought it appropriate to share the top 10 most popular AFP Community Blog posts of 2012. The top post, on screening intervals for osteoporosis, has been viewed more than 600 times.
1. How often should you screen for osteoporosis? (January 25)
Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.
Since 80 percent of patients and family physicians perceive religion to be important, acknowledging and supporting spiritual beliefs is a key component of holistic, patient-centered care.
3. Curbing overuse of CT scans (January 11)
Use computed tomography only when it is likely to enhance patient health or change clinical care.
4. Prescribing opioids for chronic pain: avoiding pitfalls (August 22)
National surveys show that chronic pain is undertreated, but opioids often have serious adverse effects and can lead to dependence, addiction, and abuse.
What drives doctors to order tests that, in their hearts, they must know have a remote chance of being helpful?
6. Electronic health records may improve preventive care (July 11)
After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users.
7. Rhythm or rate control for atrial fibrillation? (June 28)
Management of newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.
How long will take to change both of these practices to reflect the best evidence?
9. The state of family medicine is ... ? (February 13)
There aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform.
Is it possible that patient satisfaction is driven by receiving more care, but not better care?
Although page views are only a surrogate measure of reader engagement, in a year that saw American Family Physician review the "Top 20 Research Studies of 2011 for Primary Care Physicians," I thought it appropriate to share the top 10 most popular AFP Community Blog posts of 2012. The top post, on screening intervals for osteoporosis, has been viewed more than 600 times.
1. How often should you screen for osteoporosis? (January 25)
Armed with this new information, family physicians and other primary care clinicians can now work to redirect testing resources to where they are needed most.
2. The spiritual assessment in family medicine: unnecessary or essential? (September 20)
Since 80 percent of patients and family physicians perceive religion to be important, acknowledging and supporting spiritual beliefs is a key component of holistic, patient-centered care.
3. Curbing overuse of CT scans (January 11)
Use computed tomography only when it is likely to enhance patient health or change clinical care.
4. Prescribing opioids for chronic pain: avoiding pitfalls (August 22)
National surveys show that chronic pain is undertreated, but opioids often have serious adverse effects and can lead to dependence, addiction, and abuse.
5. Doctors should trust their clinical judgments (March 5)
6. Electronic health records may improve preventive care (July 11)
After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users.
7. Rhythm or rate control for atrial fibrillation? (June 28)
Management of newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.
How long will take to change both of these practices to reflect the best evidence?
9. The state of family medicine is ... ? (February 13)
There aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform.
Is it possible that patient satisfaction is driven by receiving more care, but not better care?
Minggu, 02 Desember 2012
Live from NAPCRG: how long does a cough last?
- Kenny Lin, MD
Although American Family Physician focuses on providing readers with clinical reviews and features that synthesize evidence into guidance for practice, our medical editors wear a variety of hats. In addition to serving as Deputy Editor of Evidence-Based Medicine at AFP, Dr. Mark Ebell is also an accomplished primary care researcher. Earlier today, at the annual meeting of the North American Primary Care Research Group (NAPCRG), he presented the findings from a study that provided an original take a seemingly simple question: how long does a cough last? This study compared patient expectations with a systematic review of the medical literature.
Dr. Ebell and his colleagues surveyed a sample of patients and consulted "Dr. Google" to determine public perceptions of how long a cough from an acute upper respiratory infection is supposed to last. Although estimates varied, the most common answer was one to two weeks. His team then proceeded to review the medical literature for studies of the natural history of acute cough, using the control groups from randomized trials testing an intervention such as an antibiotic. The weighted mean duration of cough in these patients was actually 17.8 days.
Since antibiotics are prescribed for at least 50 percent of patients who visit doctors for acute cough, Dr. Ebell suggested that the substantial discrepancy between patients' expectations and the actual duration of acute cough caused by respiratory infections may be a driver of excessive antibiotic prescribing. If more patients knew that a cough could normally last for two weeks or more, perhaps fewer of them would seek medical care for self-limited illness. An article in the November 1st issue of AFP provides evidence-based guidance on appropriate antibiotic use in upper respiratory tract infections.
Although American Family Physician focuses on providing readers with clinical reviews and features that synthesize evidence into guidance for practice, our medical editors wear a variety of hats. In addition to serving as Deputy Editor of Evidence-Based Medicine at AFP, Dr. Mark Ebell is also an accomplished primary care researcher. Earlier today, at the annual meeting of the North American Primary Care Research Group (NAPCRG), he presented the findings from a study that provided an original take a seemingly simple question: how long does a cough last? This study compared patient expectations with a systematic review of the medical literature.
Dr. Ebell and his colleagues surveyed a sample of patients and consulted "Dr. Google" to determine public perceptions of how long a cough from an acute upper respiratory infection is supposed to last. Although estimates varied, the most common answer was one to two weeks. His team then proceeded to review the medical literature for studies of the natural history of acute cough, using the control groups from randomized trials testing an intervention such as an antibiotic. The weighted mean duration of cough in these patients was actually 17.8 days.
Since antibiotics are prescribed for at least 50 percent of patients who visit doctors for acute cough, Dr. Ebell suggested that the substantial discrepancy between patients' expectations and the actual duration of acute cough caused by respiratory infections may be a driver of excessive antibiotic prescribing. If more patients knew that a cough could normally last for two weeks or more, perhaps fewer of them would seek medical care for self-limited illness. An article in the November 1st issue of AFP provides evidence-based guidance on appropriate antibiotic use in upper respiratory tract infections.
Rabu, 28 November 2012
Is family medicine an affordable career choice?
- Kenny Lin, MD
The inexorable yearly rise of medical school tuition has led to corresponding increases in medical student indebtedness. According to the American Medical Association, 86 percent of graduating medical students in 2011 had loans to repay, and their average debt was more than $160,000. The greater long-term income potential from choosing a subspecialist rather than a primary care career is only one of many factors that influence medical students' specialty choices. That being said, my students increasingly ask if they will be able to repay their loans, support spouses and children, and save enough for retirement on a family physician's income - a question that would have been unlikely to come up a generation ago.
In an innovative analysis published in Academic Medicine, researchers from the American Association of Medical Colleges and Boston University concluded that the answer is "yes." Using economic modeling software, they examined variety of loan amounts and repayment scenarios projected against average household expenses in a high-cost urban area (Boston) and income levels for primary care and subspecialist physicians. The bottom line:
Our economic modeling of a physician's household income and expenses across a range of medical school borrowing levels in high- and moderate-cost living areas shows that physicians in all specialties, including primary care, can repay the current median level of education debt. At the most extreme borrowing levels, even for physicians in comparatively lower-income primary care specialties, options exist to mitigate the economic impact of education debt repayment.
The authors defined "extreme" borrowing levels as $250,000 or greater, and noted that options for these highly indebted physicians include extended repayment terms and federal loan forgiveness programs such as the National Health Service Corps. They also noted that physicians who choose to live in rural or low-cost areas will have considerably more discretionary income after expenses.
Although this analysis did not address the equally important question of why the primary care-subspecialist income gap exists and what can be done to reduce it, these findings should be reassuring to students considering family medicine careers.
The inexorable yearly rise of medical school tuition has led to corresponding increases in medical student indebtedness. According to the American Medical Association, 86 percent of graduating medical students in 2011 had loans to repay, and their average debt was more than $160,000. The greater long-term income potential from choosing a subspecialist rather than a primary care career is only one of many factors that influence medical students' specialty choices. That being said, my students increasingly ask if they will be able to repay their loans, support spouses and children, and save enough for retirement on a family physician's income - a question that would have been unlikely to come up a generation ago.
In an innovative analysis published in Academic Medicine, researchers from the American Association of Medical Colleges and Boston University concluded that the answer is "yes." Using economic modeling software, they examined variety of loan amounts and repayment scenarios projected against average household expenses in a high-cost urban area (Boston) and income levels for primary care and subspecialist physicians. The bottom line:
Our economic modeling of a physician's household income and expenses across a range of medical school borrowing levels in high- and moderate-cost living areas shows that physicians in all specialties, including primary care, can repay the current median level of education debt. At the most extreme borrowing levels, even for physicians in comparatively lower-income primary care specialties, options exist to mitigate the economic impact of education debt repayment.
The authors defined "extreme" borrowing levels as $250,000 or greater, and noted that options for these highly indebted physicians include extended repayment terms and federal loan forgiveness programs such as the National Health Service Corps. They also noted that physicians who choose to live in rural or low-cost areas will have considerably more discretionary income after expenses.
Although this analysis did not address the equally important question of why the primary care-subspecialist income gap exists and what can be done to reduce it, these findings should be reassuring to students considering family medicine careers.
Rabu, 14 November 2012
Fasting lipids study: potential practice-changer?
- Kenny Lin, MD
When I last saw my personal physician for a checkup, she recommended that I undergo screening for lipid disorders, per the guidelines of the U.S. Preventive Services Task Force. Although the office had a phlebotomist on site, my appointment was in the afternoon, and I had already eaten breakfast and lunch. Consequently, she instructed me to make a separate morning appointment to have my blood drawn after an overnight fast. Due to my hectic schedule, several months passed before I finally got around to doing this (fortunately, the results were normal). As family physicians know, many patients who are sent for fasting tests never have those tests done at all.
A recent study published in the Archives of Internal Medicine suggests that there may be little reason for most patients to endure the inconvenience of fasting before lipid testing. The authors analyzed the relationship of fasting duration to variations in cholesterol levels obtained in more than 200,000 patients in and around Calgary (Alberta, Canada). In this population, the time since one's last reported meal had no effect on mean total cholesterol and high-density lipoprotein (HDL) cholesterol levels. Mean low-density lipoprotein (LDL) levels varied by up to 10 percent, while mean trigylceride levels varied by up to 20 percent. The authors and two editorialists conclude that for most purposes in primary care, including global cardiovascular risk assessment and monitoring response to pharmacologic treatment, nonfasting cholesterol measurements are likely to yield equivalent information to measurements from traditional fasting samples.
Rare is the single study in the medical literature that changes usual clinical practice on its own, and for good reason. Consistent evidence from multiple studies is usually needed to verify or refute impressive initial findings. Further, the cross-sectional design of this particular study might have masked unmeasured variables that would have been better controlled for in a randomized clinical trial. That being said, if any single study should be called a practice-changer, I think this one fits the bill. What's your opinion?
When I last saw my personal physician for a checkup, she recommended that I undergo screening for lipid disorders, per the guidelines of the U.S. Preventive Services Task Force. Although the office had a phlebotomist on site, my appointment was in the afternoon, and I had already eaten breakfast and lunch. Consequently, she instructed me to make a separate morning appointment to have my blood drawn after an overnight fast. Due to my hectic schedule, several months passed before I finally got around to doing this (fortunately, the results were normal). As family physicians know, many patients who are sent for fasting tests never have those tests done at all.
A recent study published in the Archives of Internal Medicine suggests that there may be little reason for most patients to endure the inconvenience of fasting before lipid testing. The authors analyzed the relationship of fasting duration to variations in cholesterol levels obtained in more than 200,000 patients in and around Calgary (Alberta, Canada). In this population, the time since one's last reported meal had no effect on mean total cholesterol and high-density lipoprotein (HDL) cholesterol levels. Mean low-density lipoprotein (LDL) levels varied by up to 10 percent, while mean trigylceride levels varied by up to 20 percent. The authors and two editorialists conclude that for most purposes in primary care, including global cardiovascular risk assessment and monitoring response to pharmacologic treatment, nonfasting cholesterol measurements are likely to yield equivalent information to measurements from traditional fasting samples.
Rare is the single study in the medical literature that changes usual clinical practice on its own, and for good reason. Consistent evidence from multiple studies is usually needed to verify or refute impressive initial findings. Further, the cross-sectional design of this particular study might have masked unmeasured variables that would have been better controlled for in a randomized clinical trial. That being said, if any single study should be called a practice-changer, I think this one fits the bill. What's your opinion?
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