For the past few days, I participated in the annual Northeast Region meeting of the Family Medicine Education Consortium in Hershey, Pennsylvania. In addition to presenting a well-received session on social media tools in family medicine (including the AFP Community Blog), I attended a thought-provoking seminar on "Reinventing Journal Club: Innovations in the Internet Age" led by faculty and residents from the University of Rochester. This seminar demonstrated their program's successful experience with increasing residents' use of AAFP-recommended evidence-based medicine resources such as reports from the Agency for Healthcare Research and Quality, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus to answer clinical questions.
At the end of the seminar, I asked the presenters if they encouraged their residents to read American Family Physician, and what role the journal plays in their evidence-based medicine curriculum, if any. (After all, we require AFP's clinical review authors to consult the same types of EBM resources as part of their literature searches and to label key clinical recommendations using the rigorous Strength-of-Recommendation Taxonomy.) Their response was that everyone reads AFP, so they didn't necessarily see a need to promote the journal as a resource.
In a previous editorial, AFP Deputy Editor Mark Ebell, MD, MS argued that rather than focusing on the skills needed to analyze original research studies, the typical family physician should instead aim to be an "informed consumer of the secondary literature" and "an expert at assessing the quality of an information source." Since medical school and residency are the best times for family physicians to develop skills in answering clinical questions, we would like to know how teachers of family medicine are using the journal for this purpose. Are there any particular AFP features that you find especially useful for teaching EBM, or areas where you feel we could improve? We welcome your feedback and suggestions.
Minggu, 31 Oktober 2010
Senin, 25 Oktober 2010
Complementary and alternative medicine: what should FPs and patients know?
Since 2003, AFP has published an occasional series of articles evaluating the evidence for complementary and alternative medicine (CAM) therapies, ranging from ecinachea to probiotics to yoga and meditation for anxiety and depression. In an editorial introducing the series, associate medical editor Sumi Sexton, MD wrote:
The intent of this new AFP series is to summarize and label the evidence behind various alternative therapies, starting with the most frequently prescribed and well-researched herbal remedies and supplements. ... Currently, an abundance of information on CAM exists in textbooks, journals, newsletters, and Web sites. The purpose of the series is not to replace the existing information or to encourage physicians to prescribe CAM therapies, but rather to extract the most important data in the literature and present it as concisely as possible.
However, as an exchange of letters in the October 15th issue of AFP about an article on acupuncture for pain demonstrates, drawing conclusions about the effectiveness of CAM therapies can be challenging. Dr. Paul Delaney asserts that "in a desire to present information regarding treatments designated as complementary and alternative medicine (CAM), the editors of American Family Physician seem willing to suspend the usual criteria for evidence-based medicine." In rebuttal, Dr. Robert Kelly cites a Cochrane review that supports the effectiveness of acupuncture in relieving chronic low back pain, and Dr. Sexton notes that the article's supporting references "included several RCTs, systematic reviews, and a meta-analysis, which would warrant an evidence level A for any review article."
A recent report from the National Center for Health Statistics found that U.S. adults spent nearly $34 billion in out-of-pocket costs for CAM practitioners and purchases of CAM therapies, classes, and educational materials in 2007. What do you think family physicians and patients should know about CAM, and how would you rate AFP's CAM series at meeting these needs?
The intent of this new AFP series is to summarize and label the evidence behind various alternative therapies, starting with the most frequently prescribed and well-researched herbal remedies and supplements. ... Currently, an abundance of information on CAM exists in textbooks, journals, newsletters, and Web sites. The purpose of the series is not to replace the existing information or to encourage physicians to prescribe CAM therapies, but rather to extract the most important data in the literature and present it as concisely as possible.
However, as an exchange of letters in the October 15th issue of AFP about an article on acupuncture for pain demonstrates, drawing conclusions about the effectiveness of CAM therapies can be challenging. Dr. Paul Delaney asserts that "in a desire to present information regarding treatments designated as complementary and alternative medicine (CAM), the editors of American Family Physician seem willing to suspend the usual criteria for evidence-based medicine." In rebuttal, Dr. Robert Kelly cites a Cochrane review that supports the effectiveness of acupuncture in relieving chronic low back pain, and Dr. Sexton notes that the article's supporting references "included several RCTs, systematic reviews, and a meta-analysis, which would warrant an evidence level A for any review article."
A recent report from the National Center for Health Statistics found that U.S. adults spent nearly $34 billion in out-of-pocket costs for CAM practitioners and purchases of CAM therapies, classes, and educational materials in 2007. What do you think family physicians and patients should know about CAM, and how would you rate AFP's CAM series at meeting these needs?
Selasa, 19 Oktober 2010
Putting depression guidelines into practice
It's difficult to find time to ask about depressive symptoms in practice, and family physicians who want to make screening a priority must also ensure access to follow-up resources that improve patient outcomes. Recently, the U.S. Preventive Services Task Force and the AAFP both updated their clinical recommendations on screening adults for depression. Both organizations now recommend screening only "when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up." The October 15th issue of AFP contains several valuable depression care resources, including a clinical review of postpartum major depression, an abridged version of the USPSTF statement, a case study and quiz questions on applying the USPSTF and AAFP recommendations in practice, and an editorial about the experience of the integrated delivery system MaineHealth in improving depression screening and care for its members.
Readers seeking to remodel their care management processes to be consistent with the latest depression guidelines will find the editorial to be a good start. In addition, AFP and its sister publication, Family Practice Management, offer helpful online content on proven staff-assisted depression care supports, including validated screening tools, patient registries, and communication strategies to encourage self-management. Finally, you can find links to these resources and more in the AFP By Topic collection on depression and bipolar disorder.
Readers seeking to remodel their care management processes to be consistent with the latest depression guidelines will find the editorial to be a good start. In addition, AFP and its sister publication, Family Practice Management, offer helpful online content on proven staff-assisted depression care supports, including validated screening tools, patient registries, and communication strategies to encourage self-management. Finally, you can find links to these resources and more in the AFP By Topic collection on depression and bipolar disorder.
Kamis, 14 Oktober 2010
ACL injury and musculoskeletal care resources
The cover article of the October 15th issue of AFP reviews the diagnosis, management, and prevention of anterior cruciate ligament (ACL) injuries. Although we have always recognized the importance of including high-quality illustrations of relevant anatomy and physical examination maneuvers in articles like these, this article also includes short videos of diagnostic and prognostic tests that you can watch on the AFP web page or on the AFPJournal YouTube channel. Click on the image below to see a demonstration of the Lachman test, which the authors note is the most accurate test for detecting an ACL injury. Eventually, we hope to build a library of online videos of common examination skills and procedures in family medicine. In the meantime, don't miss the AFP By Topic collection on Musculoskeletal Care, which contains links to online content on joint injections, fracture management, and approaches to musculoskeletal problems organized by region of the body.
Rabu, 06 Oktober 2010
Feedback from the AAFP Scientific Assembly
We were delighted to meet many of you at the AAFP Publications Booth during the Scientific Assembly in Denver last week and listen to your thoughtful comments and suggestions about how to improve AFP's online experience. We received some valuable feedback on the new AFP By Topic feature, and are working to make it available as a mobile app within the next several months.
Our 40th topic collection on Menopause includes an updated review from the October 1st issue on how to counsel menopausal patients about hormone therapy and alternatives for vasomotor symptoms. Future topic collections will organize current AFP content on thyroid disorders, sleep disorders, and gastrointestinal conditions. Please let us know if you have suggestions for other topics that you commonly encounter in your practice, by posting a comment on this blog, AFP's Facebook page, or sending a tweet to @AFPJournal.
Our 40th topic collection on Menopause includes an updated review from the October 1st issue on how to counsel menopausal patients about hormone therapy and alternatives for vasomotor symptoms. Future topic collections will organize current AFP content on thyroid disorders, sleep disorders, and gastrointestinal conditions. Please let us know if you have suggestions for other topics that you commonly encounter in your practice, by posting a comment on this blog, AFP's Facebook page, or sending a tweet to @AFPJournal.
Rabu, 29 September 2010
Cultural competency training should not rely on stereotypes
Two physician readers submitted the following post about a topic that is becoming increasingly important to family physicians. In addition to the Curbside Consultation discussed below, AFP has also previously published clinical reviews of cross-cultural medicine and cultural diversity at the end of life.
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While we appreciate Dr. Gupta’s insights into culturally specific care for Indian patients in the July 1, 2010 Curbside Consultation, “Improving Sensitivity to Patients from Other Cultures,” we feel that the article's emphasis on learning culturally specific stereotypes can be potentially misleading for clinicians. Cultural competency training has traditionally involved memorizing culturally specific “rules” (e.g., Muslims don’t shake hands). Although learning about a particular group’s cultural norms can be helpful, it may also lead to stereotyping and false assumptions. Because clinicians are caring for increasingly diverse populations, including growing numbers of immigrants and refugees, there are too many cultural groups with too many norms to become familiar with.
A more practical approach to cultural competency has emphasized not the patient’s background, but instead, the “implementation of the principles of patient-centered care, including exploration, empathy, and responsiveness to patients’ needs, values, and preferences.” In the words of another useful definition, cultural competence involves an “examination of one’s own attitude and values, as well as the acquisition of the values, knowledge, skills and attributes that will allow an individual to work appropriately in cross cultural situations.” Published tools aid in learning and teaching these skill sets. Busy clinicians are better served by using these tools to practice culturally sensitive and individualized patient-oriented care, rather than memorizing lists of cultural norms and “rules."
Bernadette Kiraly, MD
Peter Weir, MD
Hartland Refugee Clinic
Department of Family & Preventive Medicine
University of Utah School of Medicine
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While we appreciate Dr. Gupta’s insights into culturally specific care for Indian patients in the July 1, 2010 Curbside Consultation, “Improving Sensitivity to Patients from Other Cultures,” we feel that the article's emphasis on learning culturally specific stereotypes can be potentially misleading for clinicians. Cultural competency training has traditionally involved memorizing culturally specific “rules” (e.g., Muslims don’t shake hands). Although learning about a particular group’s cultural norms can be helpful, it may also lead to stereotyping and false assumptions. Because clinicians are caring for increasingly diverse populations, including growing numbers of immigrants and refugees, there are too many cultural groups with too many norms to become familiar with.
A more practical approach to cultural competency has emphasized not the patient’s background, but instead, the “implementation of the principles of patient-centered care, including exploration, empathy, and responsiveness to patients’ needs, values, and preferences.” In the words of another useful definition, cultural competence involves an “examination of one’s own attitude and values, as well as the acquisition of the values, knowledge, skills and attributes that will allow an individual to work appropriately in cross cultural situations.” Published tools aid in learning and teaching these skill sets. Busy clinicians are better served by using these tools to practice culturally sensitive and individualized patient-oriented care, rather than memorizing lists of cultural norms and “rules."
Bernadette Kiraly, MD
Peter Weir, MD
Hartland Refugee Clinic
Department of Family & Preventive Medicine
University of Utah School of Medicine
Kamis, 23 September 2010
Autism: recognition and management
The September 15th edition of AFP Journal Club reviews an analysis of evidence behind the persistent but scientifically discredited hypothesis that the measles, mumps, and rubella (MMR) vaccine causes children to develop autism. Since a 1998 case series published in The Lancet first suggested this hypothesis, 13 large ecologic and observational studies performed worldwide have shown no association between the receipt of MMR vaccine and autism. Nonetheless, many parents continue to believe that delaying or refusing MMR vaccine and other immunizations will protect their children from harm. Dr. Andrea Darby-Stewart notes that this is a critical educational opportunity:
A national survey conducted in 2003 to 2004 indicated that more than one fourth of all U.S. parents were either unsure of vaccine safety or refused or delayed vaccination of their children because of safety concerns. However, the most important take-home point from that survey was that the parents who changed their minds and immunized their children did so because of information and assurance provided by their health care professional. Indeed, we do make a difference!
An AFP article published earlier this year reviews guidance for family physicians on how to coordinate medical and behavioral care for children who have been diagnosed with an autism spectrum disorder. More controversial is a 2007 practice guideline from the American Academy of Pediatrics that recommends that primary care clinicians routinely screen children at nine, 18, 24, and 30 months of age using an autism-specific screening tool. In light of the uncertain evidence for improved outcomes in children identified by screening, the American Academy of Family Physicians recently nominated "Screening for Autism in Children" as a new topic for review by the U.S. Preventive Services Task Force.
Given the steadily rising prevalence of autism spectrum disorders (approaching 1 in 100 U.S. children) and that autism can present with subtle symptoms in its early stages, what approach do you take to identify this condition in practice, if any?
A national survey conducted in 2003 to 2004 indicated that more than one fourth of all U.S. parents were either unsure of vaccine safety or refused or delayed vaccination of their children because of safety concerns. However, the most important take-home point from that survey was that the parents who changed their minds and immunized their children did so because of information and assurance provided by their health care professional. Indeed, we do make a difference!
An AFP article published earlier this year reviews guidance for family physicians on how to coordinate medical and behavioral care for children who have been diagnosed with an autism spectrum disorder. More controversial is a 2007 practice guideline from the American Academy of Pediatrics that recommends that primary care clinicians routinely screen children at nine, 18, 24, and 30 months of age using an autism-specific screening tool. In light of the uncertain evidence for improved outcomes in children identified by screening, the American Academy of Family Physicians recently nominated "Screening for Autism in Children" as a new topic for review by the U.S. Preventive Services Task Force.
Given the steadily rising prevalence of autism spectrum disorders (approaching 1 in 100 U.S. children) and that autism can present with subtle symptoms in its early stages, what approach do you take to identify this condition in practice, if any?
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