Monday, May 21, 2018

Tips for caring for persons with developmental disabilities

- Jennifer Middleton, MD, MPH

Two articles in the current issue of AFP, along with other recent primary care literature, contain a wealth of practical tips and techniques for successfully - and respectfully - caring for persons with developmental disabilities.

"Adults with Developmental Disabilities: A Comprehensive Approach to Medical Care" provides an overview of office accessibility pointers, communication techniques, approaches to preventive care and acute illnesses, and end-of-life planning. It also includes a discussion on the medical versus neurodiversity models of diversity, asserting that accepting patients as they are is preferable to trying to "normalize" them:
The goal of health care for patients with developmental disabilities is to improve their well-being, function, and participation in family and community. It is not always necessary or desirable to try to change a person's traits and characteristics to make them appear or behave more normally. 
Along those lines, the patient in this issue's Close-up, "Persons with Disabilities: I'm the Expert About the Body," says, "[T]here are many things they cannot know about me just by observing the way I look or the way I communicate." Avoiding the temptation to make assumptions can go a long way toward communicating respect. This website, quoted within the feature article, includes brief video examples of engaging with patients with no or limited speaking ability. An AFP Curbside Consultation from 2017 reinforces the importance of grounding medical decision making within the patient's definition of quality of life - which may not always align with physicians' assumptions.

Improving our ability to care for persons with developmental disabilities is critically important to reducing health care disparities between them and the non-disabled population. A 2017 statewide study across Ohio found that, compared with persons with no disability, persons with a disability (and/or their supporters) were more likely to report their health status as being "fair" or "poor," had more hospital and Emergency Department (ED) visits, and had more problems "getting needed care." Disabled persons reported more frequent "delayed treatment[s]," problem[s] getting care," and "problem[s] seeing a specialist." A study from the United Kingdom examining hospital admissions found similarly: hospitalizations were double that of non-disabled persons, even after controlling for "higher levels of comorbidity." The authors of both studies call for further studies to explore solutions to minimize these disparities; improving communication between persons with developmental disabilities and physicians, as detailed in the AFP articles above, may be an important first step.

These AFP articles also include a collection of online toolkits and resources on "Supported Decision Making." You can read more in the AFP By Topic on Care of Special Populations. Since family physicians often care for supporters, too, the CDC has tips for caregivers of persons with a disability, and so does FamilyDoctor.org.

Monday, May 14, 2018

Few family physicians are delivering babies, and few women are having VBACs. What's stopping them?

- Kenny Lin, MD, MPH

In 2017, fewer than one in five members of the American Academy of Family Physicians (AAFP) reported providing obstetric care. In a previous Graham Center Policy One-Pager in AFP, Dr. Tyler Barreto and colleagues reported that between 2009 and 2016, the percentage of family physicians practicing high-volume obstetrics (more than 50 deliveries per year) fell from 2.1% to 1.1%. A subsequent study in Family Medicine by Dr. Sebastian Tong and colleagues found that 51% of recent family medicine residency graduates intended to provide prenatal care, and 23% intended to deliver babies; however, less than 10% were delivering after 1 to 10 years in practice.

In a recent policy brief in the Journal of the American Board of Family Medicine, Dr. Barreto and colleagues analyzed data from the 2016 Family Medicine National Graduate Survey to identify barriers faced by residency graduates who stated interest in delivering babies but did not do so in practice. Almost 60% of respondents cited the lack of opportunity to do deliveries in the practice they joined and lifestyle considerations as the most important factors. Fewer than 10% felt that inadequate training or reimbursement were major issues.

Although these recent studies did not specifically focus on family physicians who perform surgical deliveries, prior research has established that Cesarean delivery outcomes are comparable whether performed by family physicians or obstetrician-gynecologists. To support women who choose to attempt labor and vaginal birth after Cesarean delivery (VBAC), the AAFP published a 2015 guideline that was largely based on an Agency for Healthcare Research and Quality review of the benefits and harms of VBAC versus elective repeat Cesarean. I summarized the key findings of this review in AFP's "Tips From Other Journals":

The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). ... The evidence suggests that most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant.

As mentioned previously on the Community Blog, access to VBAC remains limited or nonexistent in many parts of the U.S., and debates continue about its safety for mothers and babies. This month in CMAJ, Dr. Carmen Young and colleagues analyzed a Canadian hospital database containing information on women with a single prior Cesarean between 2003 and 2015 and a second singleton birth at 37 to 43 weeks gestation. They found that rates of the composite outcomes "severe maternal morbidity and mortality" and "serious neonatal morbidity and mortality" were significantly higher after attempted VBAC compared to elective repeat Cesarean. However, absolute differences in these outcomes were low, with NNTs of 184 and 141, respectively.

This new study may give some hospitals and maternity care providers pause about continuing to support women who desire VBAC, and, together with the dwindling numbers of family physicians providing delivery services, could push the overall U.S. Cesarean rate of 32% higher in future years.

Monday, May 7, 2018

Supporting our patients' health outside of the office

- Jennifer Middleton, MD, MPH

Our patients' incomes, neighborhoods, and educational levels impact their health at least as much, if not more, than the interventions we discuss with them within our practice settings. Identifying patients who are struggling with housing, bills, child care, and/or safety might feel like a daunting task, though, and connecting them to helpful resources can feel overwhelming. A new toolkit released by the AAFP can make these tasks manageable; The EveryONE Project provides screening tools to help family physicians screen for social determinants of health (SDOH) and also connect patients to local resources.

The EveryONE Project website contains links to screen patients for SDOH challenges, a guide to patient resources, and planning tools for your office (or practice setting) to implement these changes. Each of these links provides more in-depth background material, a robust list of specific suggestions, and references to resources like Aunt Bertha, an online search engine that lists social services by zip code. These resources simplify connecting individual patients to local resources. (If you're interested in community planning tools, check out the CDC's Tools for Putting Social Determinants of Health into Action.)

A 2017 AFP editorial, "Acting on Social Determinants of Health: A Primer for Family Physicians," includes additional suggestions to implement SDOH interventions and also gives examples of how doing so can benefit patients:
Rather than simply recommending that a patient eat better and exercise more, care teams can connect patients to a local community garden, low-cost exercise resources (e.g., YMCA), or neighborhood walking groups. As another example, knowing that a patient lives in a neighborhood with old housing may prompt a physician to proactively screen for lead exposure based on elevated community risk. 
Perhaps a staff member in your office, or a visiting nursing or medical student, might compile a list of local resources where you practice, starting with tools like Aunt Bertha. Perhaps your practice might identify a champion to work through The EveryONE Project's assessment checklist. Or, perhaps your practice has a best practice to share with other Community Blog readers - please do so in the comment section below. The AFP By Topic on Health Maintenance and Counseling includes tools to deepen your understanding of your patients' unique situation via an in-depth family history and spiritual assessment as well.

If our goal is whole person health, then including SDOH assessment into our practices is essential. No advanced training in public health or social work is necessary to use these tools. As Sir Michael Marmot said, quoted in the The EveryONE Project Guide to Social Needs Screening Tool and Resources, "Why treat people and send them back to the conditions that made them sick in the first place?"

Monday, April 30, 2018

Top research studies of 2017 for primary care practice

- Kenny Lin, MD, MPH

In the most recent installment in an ongoing series in American Family Physician, Drs. Mark Ebell and Roland Grad summarized research studies of 2017 that were ranked highly for clinical relevance by members of the Canadian Medical Association who received daily summaries of studies that met POEMs (patient-oriented evidence that matters) criteria. This year's top 20 studies included potentially practice-changing research on cardiovascular disease and hypertension; infections; diabetes and thyroid disease; musculoskeletal conditions; screening; and practice guidelines from the American College of Physicians and the U.S. Preventive Services Task Force.

The April issue of Canadian Family Physician, the official journal of the College of Family Physicians of Canada, also featured an article on "Top studies relevant to primary care practice" authored by an independent group that selected and summarized 15 high-quality research studies published in 2017. Not surprisingly, some POEMs ended up on both lists:

1) Home glucose monitoring offers no benefit to patients not using insulin

2) Treatment of subclinical hypothyroidism ineffective in older adults

3) Pregabalin does not decrease the pain of sciatica

4) Steroid injections ineffective for knee osteoarthritis

The common theme running through these four studies is "less is more": commonly provided primary care interventions were found to have no net benefits when subjected to close scrutiny.

On the other hand, in a randomized trial that appeared on CFP's but not AFP 's list, adults and children with small, drained abscesses who received clindamycin or trimethoprim-sulfamethoxazole were more likely to achieve clinical cure at 10 days than those who received placebo, although the antibiotics also caused more adverse events, particularly diarrhea (number needed to harm = 9 to 11). As Dr. Jennifer Middleton explained on this blog last year, these findings challenge a previous Choosing Wisely recommendation from the American College of Emergency Physicians that states, "Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up." More can sometimes be, well, more.

Speaking of the Choosing Wisely campaign, Drs. Grad and Ebell will highlight more primary care-relevant research studies from 2017 consistent with the principles of the campaign in AFP later this year.

Monday, April 23, 2018

Caring for agitated patients...and ourselves

- Jennifer Middleton, MD, MPH

A patient of mine, who works in healthcare, was allegedly assaulted by a patient last week with injuries serious enough to warrant an Emergency Department visit. I suspect many healthcare workers can tell stories of times when they, or a colleague, felt unsafe with a patient. Nearly 70% of workplace assaults in the U.S. occur in healthcare or social services settings. A 2010 study of family physicians in Canada found that 39% reported at least one serious assault at some point during their career. Although thoughtful preparation can't provide a complete guarantee of safety, it can help to reduce the risk of serious injury at the hands of an agitated patient.

A recent AFP review of the American Psychiatric Association's (APA) Practice Guidelines on Psychiatric Evaluation in Adults includes taking a thorough mental health and social history, assessing for substance abuse, and assessing for risk of harm to self or others:
If the patient reports having aggressive ideas, the APA recommends that clinicians assess the patient's impulsivity, including anger management issues; determine the patient's access to firearms; identify specific persons toward whom homicidal or aggressive ideas or behaviors have been directed; and ask about the history of violent behaviors in the patient's biological relatives.
Patients can be agitated for reasons besides a mental health issue, according to a recent article in the Journal of Family Practice. Before determining whether a patient's agitation is due to a mental/behavioral health issue, metabolic/physiological cause, substance use, and/or perceptions of unfair treatment, though, we should employ the same de-escalation techniques: stay calm, be non-confrontational, assess the availability of help, and explore solutions. The article provides suggestions for maximizing safety with agitated patients in a variety of practice settings and also suggests the use of scales like the Agitated Behavior Scale to assess risk. It also includes a discussion on interventions to mitigate the development of post-traumatic stress disorder (PTSD) in healthcare workers including Critical Incident Stress Debriefing (CISD) and workplace support measures like Cleveland Clinic's "Code Lavender."

"What to Do When Emotions Run High" from the current issue of Family Practice Management centers on the importance of recognizing, and then addressing, patients' upset feelings before they escalate. The author encourages physicians to pay attention to nonverbal cues (such as "a blank stare or an angry tone") and respond to them by sharing your observation and making gentle inquiries ("'[I]t seems like something is really bothering you today,'" or "'I sense I may have done something to upset you, and if so I'd like for us to discuss it'"). Providing empathic statements can help to defuse tensions, and the author's advice to not "take it personally" reminds us that patients' upset feelings "are usually not about us."

Have you discussed workplace safety where you practice? What resources have you found helpful?

Monday, April 16, 2018

American Family Physician Podcast passes 1,000,000 downloads: why podcasts matter

- Steven R. Brown, MD, FAAFP

We released the first episode of the American Family Physician (AFP) Podcast in December 2015. AFP Podcast is a collaboration between American Family Physician, the most-read journal in primary care, and faculty and residents of the University of Arizona College of Medicine – Phoenix Family Medicine Residency.

Today the podcast passed a significant milestone: 1,000,000 episode downloads! We began counting downloads in May 2016, so this milestone was achieved in less than two years. The AFP Podcast audience continues to grow, and our listeners are now downloading episodes an average of over 45,000 times per month. A podcast with over 20,000 downloads per month, averaged over a year, is considered “high impact” for scholarly work. AFP Podcast is regularly a Top 10 medical podcast on iTunes, and has over 170 five star ratings on the platform. Listeners to the podcast are engaged. The credits at the end of each episode have been read by medical students, residents, and practicing physicians in 39 states and 4 countries. The @AFPPodcast Twitter account has over 1300 followers and an average of over 30,000 impressions per month.

Additionally, AFP Podcast has received a 2017 Gold EXCEL Award from Association Media & Publishing: Educational Podcast category.

Why podcasts matter

The role of podcasts in medical education is growing. With the emergence of new technology, changes in learning preferences, and resident work-hour restrictions, asynchronous methods of education are increasingly relevant. 89% of emergency medicine residents listen to podcasts regularly and 72% report podcasts change their clinical practice. 86% of these emergency residents report podcasts as their favorite form of medical education because of portability, ease of use, and ability to listen while doing sometime else.

We have received multiple comments from practicing family physicians that the AFP Podcast is useful as an American Board of Family Medicine preparation resource. Clerkship directors tell us they recommend AFP Podcast to students in required family medicine clerkships.

Podcasts are also a useful platform for exploring not just practice-changing clinical evidence, but the humanistic aspects of medical practice. The 2016 post “25 podcasts that every family physician should listen to” remains one of the most read articles on the AFP Community Blog. Recommendations from that post include podcasts related to public health, improving learning, patient stories, and medical economics.

The podcast Greyscale, produced by family physician Ben Davis, explores the physician – patient relationship and its impact on practice. Sawbones, hosted by family physician Sydnee McElroy and her husband Justin McElroy, discusses medical history and is regularly ranked as a Top 100 podcast in the iTunes “Comedy” category.

Podcasting quality

While many residents, medical students, and physicians are listening to medical podcasts, there is scant literature related to podcast quality. How do we know which podcasts should be recommended? How can the AFP Podcast be sure we are producing a quality product, worthy of family physicians and learners everywhere?

Two recent studies (published here and here) have examined medical education podcast quality. Both acknowledge that study of this topic is in its infancy. Key criteria for excellence include credibility (transparency, trustworthiness, avoidance of bias), content (professionalism, academic rigor), and design (aesthetics, interaction, functionality, ease of use).

Our editorial team will continue to strive to meet these metrics. Engagement from listeners is essential to these efforts. As we say on the credits at end of each episode: “Please send us your thoughts by emailing AFPPodcast@aafp.org or tweeting @AFPpodcast.” Engagement from listeners will help us improve AFP Podcast for the next million downloads and beyond.

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Dr. Brown is an AFP Contributing Editor and Editor, AFP Podcast.