Announcing the AFP mobile app edition

- Matthew Neff, Senior Editor, AFP Online

Now you can keep up with American Family Physician in a format that's as mobile as you are. AFP is pleased to announce the new mobile app edition of the journal. This app provides a digitally enhanced replica of AFP for tablets and smartphones. Other features include downloading for offline reading; quick links to full articles; bookmarking content; sharing articles with colleagues; and real-time news and content feeds from the American Academy of Family Physicians (AAFP) and the AFP Community Blog.

The apps are free for AAFP members, print and online paid subscribers, and individuals who currently receive the journals in their own name; all others can purchase individual issues within the app. The app is now available in the Apple App Store and will be coming soon to Google Play. Search the App Store for “AAFP” or “American Family Physician” to download the app, and then sign in using the e-mail address associated with your AAFP account to start downloading issues.

Are calcium supplements bad for the heart?

- Kenny Lin, MD

Until recently, the idea that calcium-containing supplements, which more than half of older adults in the U.S. consume regularly, could be harmful would have seemed absurd. Primary care clinicians have long recommended calcium supplements to reduce the risk of osteoporotic fractures in adults who are unable to meet the Institute of Medicine's Dietary Reference Intakes through diet alone. However, a large prospective study published this week in JAMA Internal Medicine demonstrated a statistically significant association between supplemental calcium (as opposed to dietary calcium) intake and a 20 percent higher relative risk of death from cardiovascular disease in men.

This troubling finding adds to the evidence base that suggests harmful cardiovascular effects of calcium-containing supplements. A timely pair of editorials in the February 1st issue of AFP debates the population-level risk of widespread calcium supplementation. Arguing that this potential risk should be a serious concern, Drs. Ian Reid and Mark Bolland review the results of their previous randomized trial and meta-analysis that found 20 to 30 percent increases in the incidence of acute myocardial infarction in adults taking calcium supplements. In their view, these adverse effects are not worth the potential benefits to bone health:

In both of our meta-analyses, calcium supplementation was more likely to cause vascular events than to prevent fractures. Therefore, the bolus administration of this micronutrient should be abandoned in most circumstances, and patients should be encouraged to obtain their calcium intake from an appropriately balanced diet. For those at high risk of fracture, effective interventions with a fully documented safety profile superior to that of calcium are available. We should return to seeing calcium as an important component of a balanced diet and not as a low-cost panacea to postmenopausal bone loss.

In the second editorial, Dr. Rajib Bhattacharya points out that the Women's Health Initiative and other randomized trials did not indicate that calcium supplements increased cardiovascular risk. He argues that secondary analyses of trials designed with other primary outcomes in mind may have predisposed these analyses to unforeseen bias, and that there is "no compelling evidence" that calcium supplements at usual doses pose dangers to heart health.

Notably, a draft recommendation statement released by the U.S. Preventive Services Task Force last June stated that there was insufficient evidence that vitamin D and calcium supplementation prevent fractures or cancer in otherwise healthy older adults. Although the only adverse effects of supplements mentioned in the Task Force's evidence review were renal and urinary tract stones, none of the reviewed studies were specifically designed to assess cardiovascular harms. Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence might make you change your practice?

Providing culturally competent health care

- 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.

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.

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.

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.

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)

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.

8. Cancer screening in men: flexible sigmoidoscopy works, PSA does not (May 21)

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.

10. Counterintuitive findings on quality incentives and patient satisfaction (April 9)

Is it possible that patient satisfaction is driven by receiving more care, but not better care?

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.