Monday, June 23, 2014

Acute Complaints: 3 of The 2013 Top 20 AFP articles

- Jennifer Middleton, MD, MPH

AFP recently posted its 20 most-read articles from last year here. The topics run through much of the full spectrum of Family Medicine, from health maintenance to acute complaints, from initial work-up to chronic management. Here are three articles that explore acute complaints:

1. Approach to Acute Headache in Adults (5/15/2013)
This article provides a practical approach to differentiating benign headaches (age <30, "features typical of primary headaches," prior similar headaches, normal neurologic exam, no high-risk comorbidities) from dangerous headaches (worst headache ever, headache triggered by exertion, mental status change, age > 50, papilledema, sudden onset, systemic illness, temporal artery tenderness). The authors review the classic "primary" headache syndromes (tension, migraine, cluster) and include a helpful table regarding choice of radiographic testing should 1 or more dangerous headache signs be present.

2. Diagnosis and Management of Acute Diverticulitis (5/1/2013)
This article provides likelihood ratios for common physical exam findings that can help to rule in or rule out diverticulitis (LLQ tenderness + absence of vomiting + CRP >50 = LR+ of 18). The authors review guidelines for laboratory and radiographic evaluation as well as recent evidence arguing against antibiotic use in patients with mild, uncomplicated diverticulitis. Weight loss, smoking cessation, fiber, and exercise help to prevent recurrences but avoidance of seeds, nuts, etc. does not.

3. Outpatient Diagnosis of Acute Chest Pain in Adults (2/1/2013)
Only 1.5% of patients presenting to a primary care office with chest pain have unstable angina or acute coronary syndrome, but identifying who these patients are can be challenging. The authors review likelihood ratios of clinical symptoms more likely to be associated with serious cardiac disease (among others, radiating pain and use of a term other than "pain" - such as "tightness" or "squeezing" increase the pre-test probability). Pleuritic chest pain and "sharp" or "stabbing" chest pain, on the other hand, are less likely to be due to acute coronary syndrome. The authors also present a validated clinical decision rule to assist with diagnosis (Table 2). They review the more common, and typically less serious, diagnoses of chest wall pain, GERD, and anxiety along with the less common, but more serious, possibilities of pericarditis, pneumonia, CHF, or pulmonary embolism.

By my count, half of the Top 20 articles from 2013 dealt with evaluation of new and/or acute complaints. Given how much of 21st century Family Medicine is chronic disease care, it's interesting that acute complaints caught so much of the attention of AFP readers, though certainly family doctors experience both on a daily basis.

What AFP articles dealing with acute issues have changed your practice lately?

Monday, June 16, 2014

Guest Post: The Future of Family Medicine - Some Sacrifices Required

- Matthew Loftus, MD

The American Academy of Family Physicians is collecting thoughts now on the future of Family Medicine in America; I shared mine and thought that I would post them here for discussion.

Right now the health care cost curve is being broken across the backs of hospitals & specialists. I think that they'll come for primary care next. If we're not prepared, we'll find our payments decreased and our specialty torn apart as the hospital systems that own us realize that the reimbursable services provided by physicians can often be provided by other types of health professionals. Fighting against nurse practitioner independence wastes time, money, & energy — we need to do more and define all of the roles that work together to create a vigorous primary care system. We're calling on some of our specialist colleagues to sacrifice some of their income and independence for the good of our patients as we try to restrict unnecessary or harmful procedures and tests. However, we have to lead the way by sacrificing a few things of our own — and if we do it now, we’ll get to do it on our terms.

I think that Family Medicine needs to recognize that most primary preventive care doesn't belong in the medical silo at all. While all of us are family physicians because we recognize the value of preventive care, it is important to recognize that our value to our patients and to the population does not come from our ability as physicians to deliver preventive care. Routine preventive care and basic primary care for simple diseases can be done thoughtfully and efficiently by other providers. Rather, our role as physicians is best used doing things that no other provider can do — coordinating care across inpatient and outpatient systems, guiding patients through difficult decisions, managing complex medical problems involving multiple organ systems, and helping to shape policies affecting whole communities. These are challenges uniquely suited for family physicians to address, which give us unique satisfaction even as we give up the often comfortable routine tasks of preventive care. When we are being paid for these services and have the systems in place to support this work, we can expect both our satisfaction with our jobs and our value to our patients to increase.

To this end, we should support the development of community health worker programs made up of residents local to a particular area who are responsible for giving vaccinations, doing basic health education for simple chronic diseases, and following the protocols for screening that clutter our computer screens. While providing preventive care and talking to patients who don't have very many medical problems is an enjoyable part of practice, we must recognize that our medical degrees overqualify us for such tasks and we should be doing them about as often as we are teaching our patients how to give themselves insulin —  it happens and we can do it well because we understand how it works, but it shouldn't be our bread and butter.

Family physicians should then focus on mastering the knowledge and expertise that we have acquired during our medical education and embrace our role as experts at managing multiple complex chronic diseases, especially with psychosocial co-morbidities. We should be supervising and leading teams of community health workers, health coaches, care coordinators, nurses, pharmacists, physician assistants, and nurse practitioners who are managing the simpler medical issues, as is often the case in many other countries around the world. We should also embrace a more active role in coordinating care across the inpatient/outpatient divide; more family doctors should seek inpatient privileges and care for their patients in the hospital. This is one of the ways that we can avoid becoming aloof consultants ourselves. We should learn as much as possible about diseases such as sickle cell anemia & cystic fibrosis so that we can help transition these patients from their pediatric specialists to adult ones.

Another important aspect to our role as family doctors is embracing public health and population health; we should be spending our time not just in seeing very sick patients but also addressing the structural issues pertaining to our local neighborhoods where our patients live. Capitation-based payment may be one way to help tie particular doctors to particular communities, but it is not necessary if we are living in the same places as our patients and getting to know their neighborhoods & leaders. Our residency programs should emphasize leadership training as well as opportunities to engage local communities. I wrote about this in my Family Medicine Educational Consortium "This We Believe" essay titled Proximity, Vulnerability, Faith, & Love.

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care. This is not just about surviving health care reform — it’s about leading it so that our patients get the best care possible.


Matthew Loftus (@matthew_loftus) is a recent graduate of Medstar Franklin Square Family Medicine Residency. He lives with his wife and daughter in Baltimore, MD, where he will soon begin practicing at Healthcare for the Homeless.

Monday, June 9, 2014

Helmets don't help infant skull deformations

- Jennifer Middleton, MD, MPH

If you're a family physician, chances are you've seen your fair share of infants with skull deformations. Whether it's plagiocephaly (unilateral occipital flattening) or brachycephaly (symmetrical occipital flattening), approximately 1 in 5 infants will have one of these two conditions by age 4 months. Repositioning (especially "tummy time" to help with the flattening due to placing infants on their backs to sleep) often helps, but many infants with persistent plagiocephaly or brachycephaly will end up with a helmet (cranial orthosis) by age 6 months if these deformations persist.

The British Medical Journal published a randomized controlled trial (RCT) from the Netherlands this month investigating the utility of these helmets. The researchers enrolled 84 infants between the ages of 5-6 months with plagiocephaly and brachycephaly who were born after 36 weeks gestation and who didn't have any other dysmorphic features. 42 of them wore a cranial orthosis for 6 months, and 42 of them did not wear a helmet or do any other sort of treatment. Follow-up measurement at ages 8,12, and 24 months showed no difference between groups in the number of infants who had resolution of their skull deformation: 26% of helmet group infants vs 23% of non-helmet group infants for an odds ratio of 1.2 (95% confidence interval 0.4-3.3). Motor developmental outcomes were identical between groups, quality of life scores were the same for both groups, and parents' satisfaction with the shape of their child's head were also the same for both groups. Additionally, every single parent of an infant in the helmet group reported at least one side effect (discomfort, itching, sweating, helmet odor, and/or "feeling hindered from cuddling their child").

This RCT's primary outcome, skull measurement, is admittedly a disease-oriented outcome. Several of the secondary outcomes, though, were patient-oriented evidence that matters: motor development, quality of life, parental satisfaction, and side effect frequency. An accompanying editorial states that this RCT is the first to compare helmets to observation.

AFP published an article on "Diagnosis and Management of Positional Head Deformity" in 2003. While the BMJ RCT provides an updated perspective on the use of helmets, the AFP article still provides some excellent pictures and references to aid family physicians in counseling parents. Another AFP article (this one from 2004), "Craniosynotosis," provides a useful review of how to differentiate plagiocephaly and brachycephaly from craniosynotosis (premature fusion of the cranial sutures) which necessitates surgical referral.

Will this RCT change how you counsel parents about treatment for infant skull deformations?

Sunday, June 1, 2014

For sepsis, protocol-driven care is not superior to clinical judgment

- Kenny Lin, MD, MPH

Unwarranted variations in medical care contribute to poor health outcomes in the United States. In many cases, following a standard management protocol is likely to produce as good or better results than clinical judgment alone. For example, American Family Physician's Point-of-Care Guides provide high-quality clinical decision rules and tools designed to improve quality of care for problems encountered by family physicians in outpatient and inpatient settings.

Similar principles have guided the management of patients presenting to emergency departments with severe sepsis and septic shock since a 2001 randomized trial found that early goal-directed therapy, or EGDT (including central venous catheterization, intravenous fluids, vasopressors, inotropes, and blood transfusions) improved mortality compared to usual care. A 2013 AFP review, "Early Recognition and Management of Sepsis in Adults: The First Six Hours," recommended using the EGDT protocol and concluded that "timely initiation of evidence-based protocols should improve sepsis outcomes."

This conclusion was recently put to the test in a multicenter trial published in The New England Journal of Medicine. 1,341 patients presenting to 31 emergency departments in the U.S. were randomly assigned to protocol-based EGDT, procotol-based standard therapy, or usual care. Surprisingly, the trial found no statistically significant differences between the three groups in 60-day mortality, longer-term mortality, or the need for organ support. An accompanying perspective cautioned policymakers against rushing to implement regulatory mandates to adhere to sepsis protocols in light of the increasing incidence of this diagnosis and potential harms of protocol-based care:

Protocols that force physician behavior risk promoting inappropriate prescribing of broad-spectrum antibiotics for noninfectious conditions, unnecessary testing, overuse of invasive catheters, diversion of scarce ICU capacity, and delayed identification of nonsepsis diagnoses.

Two lessons from this study for the management of sepsis and other areas of family medicine are that decision rules and protocols should be derived from replicable studies conducted in multiple settings; and that these tools can sometimes enhance, but should not supplant, best clinical judgment.