Why do clinical questions go unanswered?

- Kenny Lin, MD, MPH

What do you do when you have a clinical question that ideally requires an answer before the patient leaves your office? Do you flip through a textbook or a back issue of American Family Physician? Look up the topic in a online reference? Consult an smartphone app? Ask a colleague in the office or curbside a specialist by telephone?

Family physicians take many approaches to answering clinical questions, some more efficient and effective than others. For example, using AFP By Topic or the journal website search function is more likely to yield relevant results than hunting through a stack of print issues for that article on community-acquired pneumonia that you remembered reading at some point. Unfortunately, Deputy Editor Mark Ebell, MD, MS reported in a 2009 article that on average, 15-20 clinical questions come up each day, and most of these go unanswered.

A recent study published in JAMA Internal Medicine examined barriers to answering clinical questions at the point of care. Researchers affiliated with the Mayo Clinic conducted several focus groups with a total of 50 family and internal medicine physicians in academic medical center and community settings. Not surprisingly, the barrier most commonly mentioned by physicians was insufficient time. Some physicians with convenient access to computers and online references complained of not knowing which resource to search, and having doubts about whether the search was likely to yield an answer. Others were concerned that looking up information while in the examination room might diminish a patient's confidence in them. Finally, some physicians found that available resources simply did not contain the answers they needed.

The editors of AFP are interested in learning more about how you use our journal - in its print, online, and mobile versions - to answer your clinical questions. Are you able to find current, relevant answers at the point of care, or do you prefer to browse AFP at home and subsequently incorporate what you learn into practice? What could we do to improve your searching and reading experiences?

You don't snooze, you lose

- Jennifer Middleton, MD, MPH

The consequences of insufficient sleep can be significant.  Children and teens who don't get enough sleep not only get worse grades in school but are also more likely to have parents who worry about their mood and behavior.  Sleep-deprived adults are more likely to be involved in a motor vehicle or work accident, are more likely to have hypertension, and are more likely to be obese (even controlling for changes in diet patterns).  Perhaps logically, then, sleep-deprived adults incur higher health care costs than adults who get at least 6 hours of sleep a night.

The August 15, 2013 AFP featured an article regarding the Management of Common Sleep Disorders. The first section of this article dealt with insomnia; I don't know about you, but I see a lot of patients in the office who are struggling with falling and staying asleep at night. The authors wisely suggest reframing patients' thoughts about sleep using Cognitive Behavioral Therapy (CBT), and Table 4 contains most of the advice that I routinely dispense to patients: limit caffeine and stop nicotine, only use the bedroom for sleep and sex, get up if you haven't fallen asleep within 20 minutes, etc. I liked how the authors cited evidence showing that these simple physician interventions can be quite effective.

Decreasing time with electronics (TV, computers, tablets, mobile phones) may also help.  The American Sleep Foundation's annual poll in 2011 found that use of a smartphone, computer, and/or television the in hour before falling asleep correlated with lower quality sleep.  They also reported that the average number of caffeinated beverage servings among adolescents and adults was around 3 a day - perhaps to make up for the fatigue from decreased sleep quality?

I recommend that patients get television sets and other electronics out of the bedroom if at all possible, and spend the last hour of the day disconnected from technology.  You can probably imagine how my patients often respond to that advice; smartphones, computers, and televisions seem to be ubiquitous in the US, and certainly have many positives regarding inter-connectivity and just plain old entertainment.

But, as the above studies demonstrate, helping our patients to get restful sleep may help prevent a lot of problems.  There are AFP by Topics on sleep disorders for both adults and children if you'd like to check out more resources about this issue.

Do you have any special advice for your patients regarding sleep?

The most popular posts of January - July 2013

- Kenny Lin, MD, MPH

Following up on our successful previous collection of the most popular posts of 2012 (which has been viewed more than 1300 times), here are the AFP Community Blog's top 5 most viewed posts from the first seven months of 2013.

1. Are IUDs a reasonable option for birth control in adolescents? (May 21)

What are your thoughts about the intrauterine device for teens? If you are recommending it, what spurred you to do so? If not, what is making you hesitate?

2. Pros and cons of vitamin D screening (April 29)

No study has demonstrated that measurement of serum 25-hydroxyvitamin D levels offers outcome benefits over clinical assessment alone.

3. Providing culturally competent health care (January 25)

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.

4. USPSTF: Diet and exercise counseling not routinely recommended (June 17)

Given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective? Is something more than just counseling necessary to effect behavior change?

5. Is routine stress testing necessary for resolved chest pain? (May 29)

Are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?

Does acetaminophen help nasal congestion from the common cold?

- Jennifer Middleton, MD, MPH

I don't know about you, but when I get a upper respiratory tract infection (URI or "cold"), one of the first things that I reach for is acetaminophen. I've never thought that it did much for the nasal congestion, but it at least seems to take the edge off of the headache, muscle aches, and fever.

Cold and flu season is right around the corner - except for my household, where it unfortunately arrived this weekend.  So, I am finding Cochrane's recent review of acetaminophen for the common cold rather timely.  The reviewers only found 4 small studies of "low to moderate quality," but 2 of these studies did show that acetaminophen reduced nasal congestion, and 1 showed that it reduced rhinorrhea.

I had never thought of acetaminophen as a treatment for nasal symptoms before, but the Cochrane reviewers wisely recommend caution in interpreting these small studies, stating that they are insufficient "to reach a conclusion."

Does this mean that I will be less likely to use and recommend acetaminophen for cold symptoms? Nope. A lack of high-quality studies supporting its efficacy isn't the same as a high-quality study showing that it doesn't work.  I still like recommending acetaminophen for headache, myalgias, and fever, and if it gets some of those nasal symptoms, that'd be a nice bonus.  What this review will hopefully spark, though, is some higher-quality prospective studies to more precisely define acetaminophen's utility for URI symptoms.

So, we'll keep on using acetaminophen in our house until this current virus runs its course.  AFP also recently reviewed "Treatment of the Common Cold in Children and Adults" with pragmatic evidence-based recommendations for patients (and doctors) with URIs.  And, when all of those over-the-counter options for colds get overwhelming, this AFP Cochrane for Clinicians article can provide guidance.  We're also drinking plenty of fluids, resting when possible, and my husband is taking zinc lozenges (though the taste isn't worth it to me, given zinc's only modest effect on URIs).

Will Cochrane's review change your recommendations for acetaminophen use in the common cold?

Is prevention or treatment the heart of family medicine?

- Kenny Lin, MD, MPH

The comprehensive scope of family medicine has always made it a challenge to describe, in a nutshell, what family physicians do. Unlike subspecialists or general internists, surgeons, or pediatricians, family physicians do not define their patient populations by age, gender, or organ system. A series of editorials published a few years ago in the Annals of Family Medicine argued that family physicians practice a "science of connectedness" that includes a distinct approach to clinical problem-solving. A more recent study in Family Medicine asserted that the training and attitudes of family physicians make them uniquely qualified to provide cost-effective health care. The emergence of the Patient-Centered Medical Home model has emphasized the role of the family physician as a facilitator and leader of care teams for patients with multiple preventive and chronic care needs.

Dr. John Hickner, editor of The Journal of Family Practice, worries that well-intentioned initiatives to improve family physicians' skills at providing screening tests and facilitating behavioral change may come at the cost of neglecting patients' acute concerns. He wrote in a recent editorial:

At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”

Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.

As a family physician who teaches public health and preventive medicine, I appreciate the tension between prevention and treatment in my own practice. Previous studies concluded that paying exclusive attention to providing guideline-recommended preventive and chronic disease services would leave literally no time to address the many other reasons that patients come into the office. As Dr. Hickner noted, "The 'number needed to treat' to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!" So is prevention or treatment the heart of family medicine? Is the answer to this question different today than it would have been a generation ago, and is it likely to be different a generation from now?

Is all substance misuse really abuse?

- Jennifer Middleton, MD, MPH

I appreciated AFP's article last week about "A Primary Care Approach to Substance Misuse" and its practical review of screening and treatment options for patients struggling with this issue.  The article appropriately included discussion about prescription drug abuse.

Prescription painkiller deaths have been on the rise in the United States. Drug overdose (60% of which are pharmaceutical drug overdoses) is now the number 1 cause of injury-related death in the U.S.  The Centers for Disease Control and Prevention (CDC) states that every 3 minutes a middle-aged woman presents to the Emergency Department for prescription opioid "misuse or abuse."   Every single one of those prescription medications originated from a doctor's prescription pad (paper or virtual).

I continue to ruminate, though, about the word "misuse" in the AFP article. Usually, when I think about problems with inappropriate substance use, I think of the word "abuse," not "misuse."  Clearly these words share a similar meaning, but, for me at least, the connotation of "misuse" is a bit gentler than "abuse."  "Misuse" sounds more like a mistake than the intentional impropriety of "abuse."

I have previously thought of the substance "abusers" as those who are inappropriately requesting prescription painkillers.  My office, as I'm sure many others do, has a controlled substance policy that supports frequent urine drug screens, and we discontinue prescribing for patients with discordant results.

But what about the "misusers?"  What about the patients who have some legitimate pain source but don't always use their prescription opioids as prescribed?  Or the patients who never tell me that they're borrowing someone else's prescription medications?  After all, the CDC found that 55% of the people misusing or abusing prescription pain medications obtain them for free from a friend or relative. Only 11% buy their pills from friends or family, and only 4% purchase their meds from a dealer.  Learning that most of my patients using these medications inappropriately are getting them at no cost from friends and family changes how I think about who those patients might be.

What I appreciate about the term "misuse" is its reminder that, as a prescriber of these medications, I need to be on the alert for more than just the "abusers."  I should probably be asking all of my patients the single question screen for substance disorders outlined in last week's AFP article (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) on a regular basis.  I need to broaden who I think of as at risk from problems related to substance misuse and abuse.

How often do thoughts of prescription medication misuse and abuse occur during your practice day? Does the term "misuse" help you to think more widely about prescription medication problems, or is it an unnecessary term?

Estimating osteoporosis risk in older men

- Kenny Lin, MD, MPH

According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."

Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.

In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.

Will the results of this study make you more likely to use MORES to assess the risk of osteoporosis in older men in your practice? Or would you prefer to screen all men older than a certain age with DXA to avoid missing any patients with osteoporosis?