John Hickner, MD, MSc

When I was training to become a family physician, my mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation. I am not sure where that figure came from, but my 40 years of experience in family medicine supports that prediction. Of course, the flip-side of that coin is having the wisdom to make those referrals for patients who really need a specialist’s diagnostic or treatment skills. The “rub,” of course, is that when I do need a specialist’s help, the wait for an appointment is often unacceptably long—both for me and my patients.

One way to help alleviate the logjam of referrals is to manage more medical problems ourselves. Now I don’t mean holding on to patients who definitely need a referral. But I do think we should avoid being too quick to hand off a patient. Let me explain.

When I was Chair of Family Medicine at Cleveland Clinic, I asked my specialty colleagues what percentage of the referred patients they saw in their offices could be managed competently by a well-trained family physician. The usual answer—from a variety of specialists—was “about 30%.” If we took care of that 30% of patients ourselves, it would go a long way toward freeing up specialists’ schedules to see the patients who truly require their expertise.

My mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation.

Some public health systems, such as the University of California San Francisco Medical Center,¹ have implemented successful triage systems to alleviate the referral backlog. Patients are triaged by a specialist and assigned to 1 of 3 categories: 1) urgent—the patient will be seen right away, 2) non-urgent—the patient will be seen as soon as possible (usually within 2 weeks), or 3) phone/email consultation—the specialist provides diagnostic and management advice electronically, or by phone, but does not see the patient.

Continue to: The issue of referral comes to mind...

The issue of referral comes to mind this month in light of our cover story on migraine headache management. Migraine is one of those conditions that is often referred for specialist care, but can, in many cases, be competently managed by family physicians. The diagnosis of migraine is made almost entirely by history and physical exam, and there are many treatments for acute attacks and prevention that are effective and can be prescribed by family physicians and other primary health care professionals.

Yes, patients with more severe migraine may need a specialist consultation. But let’s remain cognizant of the fact that a good percentage of our patients will be best served staying right where they are—in the office of their family physician.

When I was training to become a family physician, my mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation. I am not sure where that figure came from, but my 40 years of experience in family medicine supports that prediction. Of course, the flip-side of that coin is having the wisdom to make those referrals for patients who really need a specialist’s diagnostic or treatment skills. The “rub,” of course, is that when I do need a specialist’s help, the wait for an appointment is often unacceptably long—both for me and my patients.

One way to help alleviate the logjam of referrals is to manage more medical problems ourselves. Now I don’t mean holding on to patients who definitely need a referral. But I do think we should avoid being too quick to hand off a patient. Let me explain.

When I was Chair of Family Medicine at Cleveland Clinic, I asked my specialty colleagues what percentage of the referred patients they saw in their offices could be managed competently by a well-trained family physician. The usual answer—from a variety of specialists—was “about 30%.” If we took care of that 30% of patients ourselves, it would go a long way toward freeing up specialists’ schedules to see the patients who truly require their expertise.

My mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation.

Some public health systems, such as the University of California San Francisco Medical Center,¹ have implemented successful triage systems to alleviate the referral backlog. Patients are triaged by a specialist and assigned to 1 of 3 categories: 1) urgent—the patient will be seen right away, 2) non-urgent—the patient will be seen as soon as possible (usually within 2 weeks), or 3) phone/email consultation—the specialist provides diagnostic and management advice electronically, or by phone, but does not see the patient.

Continue to: The issue of referral comes to mind...

The issue of referral comes to mind this month in light of our cover story on migraine headache management. Migraine is one of those conditions that is often referred for specialist care, but can, in many cases, be competently managed by family physicians. The diagnosis of migraine is made almost entirely by history and physical exam, and there are many treatments for acute attacks and prevention that are effective and can be prescribed by family physicians and other primary health care professionals.

Yes, patients with more severe migraine may need a specialist consultation. But let’s remain cognizant of the fact that a good percentage of our patients will be best served staying right where they are—in the office of their family physician.

When I was training to become a family physician, my mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation. I am not sure where that figure came from, but my 40 years of experience in family medicine supports that prediction. Of course, the flip-side of that coin is having the wisdom to make those referrals for patients who really need a specialist’s diagnostic or treatment skills. The “rub,” of course, is that when I do need a specialist’s help, the wait for an appointment is often unacceptably long—both for me and my patients.

One way to help alleviate the logjam of referrals is to manage more medical problems ourselves. Now I don’t mean holding on to patients who definitely need a referral. But I do think we should avoid being too quick to hand off a patient. Let me explain.

When I was Chair of Family Medicine at Cleveland Clinic, I asked my specialty colleagues what percentage of the referred patients they saw in their offices could be managed competently by a well-trained family physician. The usual answer—from a variety of specialists—was “about 30%.” If we took care of that 30% of patients ourselves, it would go a long way toward freeing up specialists’ schedules to see the patients who truly require their expertise.

My mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation.

Some public health systems, such as the University of California San Francisco Medical Center,¹ have implemented successful triage systems to alleviate the referral backlog. Patients are triaged by a specialist and assigned to 1 of 3 categories: 1) urgent—the patient will be seen right away, 2) non-urgent—the patient will be seen as soon as possible (usually within 2 weeks), or 3) phone/email consultation—the specialist provides diagnostic and management advice electronically, or by phone, but does not see the patient.

Continue to: The issue of referral comes to mind...

The issue of referral comes to mind this month in light of our cover story on migraine headache management. Migraine is one of those conditions that is often referred for specialist care, but can, in many cases, be competently managed by family physicians. The diagnosis of migraine is made almost entirely by history and physical exam, and there are many treatments for acute attacks and prevention that are effective and can be prescribed by family physicians and other primary health care professionals.

Yes, patients with more severe migraine may need a specialist consultation. But let’s remain cognizant of the fact that a good percentage of our patients will be best served staying right where they are—in the office of their family physician.

Twenty years ago, the American Journal of Preventive Medicine published Felitti and colleagues’ seminal publication on the relationship between adverse childhood experiences (ACEs) and poor mental and physical health.¹ It is astonishing that mainstream medicine is only now taking this finding seriously under the current banner of “trauma informed care.” Better late than never.

In this issue of JFP, Stillerman provides a cogent summary of the research on diagnosis and treatment of ACEs performed over the past 20 years. There are good data supporting the effectiveness of identifying and treating ACEs to lessen the adverse health outcomes that can result. More important, however, is taking a public health approach to preventing the adverse health effects of ACEs by staging community interventions and providing support to new mothers and families.

Research strongly supports a causal relationship between ACEs and a host of mental and physical ailments. Felitti found that adults with 4 or more ACEs compared with none had a 4- to 12-fold increased health risk for alcoholism, drug abuse, depression, and suicide attempt. ACEs also increased the risk of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.¹

The research strongly supports a causal relationship between adverse childhood experiences and a host of mental and physical ailments.

There is need for further research on screening for, and treating, ACEs. A large randomized trial using one of the practical brief screeners would help us learn more about the impact that screening can have on the mental and physical health of those affected. Does the identification and empathetic acknowledgement of the traumatic events lead to improved health? If it does not, what type of treatment is most effective?

Continue to: Pending further research...

Pending further research, here are 3 steps that family physicians can take today:

1. Be aware of the strength of the relationship between ACEs and health problems.
2. Begin screening adults and children for ACEs using one of the simple, validated screening tools described by Stillerman. In a large follow-up study, screening along with discussion of the results with the patient’s physician led to remarkable decreases in health care utilization in the year following screening, which suggests that there are therapeutic benefits to bringing ACEs to light and fostering discussion.²
3. Remain ever compassionate in your interactions with all patients, knowing that many have significant childhood scars.

Twenty years ago, the American Journal of Preventive Medicine published Felitti and colleagues’ seminal publication on the relationship between adverse childhood experiences (ACEs) and poor mental and physical health.¹ It is astonishing that mainstream medicine is only now taking this finding seriously under the current banner of “trauma informed care.” Better late than never.

In this issue of JFP, Stillerman provides a cogent summary of the research on diagnosis and treatment of ACEs performed over the past 20 years. There are good data supporting the effectiveness of identifying and treating ACEs to lessen the adverse health outcomes that can result. More important, however, is taking a public health approach to preventing the adverse health effects of ACEs by staging community interventions and providing support to new mothers and families.

Research strongly supports a causal relationship between ACEs and a host of mental and physical ailments. Felitti found that adults with 4 or more ACEs compared with none had a 4- to 12-fold increased health risk for alcoholism, drug abuse, depression, and suicide attempt. ACEs also increased the risk of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.¹

The research strongly supports a causal relationship between adverse childhood experiences and a host of mental and physical ailments.

There is need for further research on screening for, and treating, ACEs. A large randomized trial using one of the practical brief screeners would help us learn more about the impact that screening can have on the mental and physical health of those affected. Does the identification and empathetic acknowledgement of the traumatic events lead to improved health? If it does not, what type of treatment is most effective?

Continue to: Pending further research...

Pending further research, here are 3 steps that family physicians can take today:

1. Be aware of the strength of the relationship between ACEs and health problems.
2. Begin screening adults and children for ACEs using one of the simple, validated screening tools described by Stillerman. In a large follow-up study, screening along with discussion of the results with the patient’s physician led to remarkable decreases in health care utilization in the year following screening, which suggests that there are therapeutic benefits to bringing ACEs to light and fostering discussion.²
3. Remain ever compassionate in your interactions with all patients, knowing that many have significant childhood scars.

Twenty years ago, the American Journal of Preventive Medicine published Felitti and colleagues’ seminal publication on the relationship between adverse childhood experiences (ACEs) and poor mental and physical health.¹ It is astonishing that mainstream medicine is only now taking this finding seriously under the current banner of “trauma informed care.” Better late than never.

In this issue of JFP, Stillerman provides a cogent summary of the research on diagnosis and treatment of ACEs performed over the past 20 years. There are good data supporting the effectiveness of identifying and treating ACEs to lessen the adverse health outcomes that can result. More important, however, is taking a public health approach to preventing the adverse health effects of ACEs by staging community interventions and providing support to new mothers and families.

Research strongly supports a causal relationship between ACEs and a host of mental and physical ailments. Felitti found that adults with 4 or more ACEs compared with none had a 4- to 12-fold increased health risk for alcoholism, drug abuse, depression, and suicide attempt. ACEs also increased the risk of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.¹

The research strongly supports a causal relationship between adverse childhood experiences and a host of mental and physical ailments.

There is need for further research on screening for, and treating, ACEs. A large randomized trial using one of the practical brief screeners would help us learn more about the impact that screening can have on the mental and physical health of those affected. Does the identification and empathetic acknowledgement of the traumatic events lead to improved health? If it does not, what type of treatment is most effective?

Continue to: Pending further research...

Pending further research, here are 3 steps that family physicians can take today:

1. Be aware of the strength of the relationship between ACEs and health problems.
2. Begin screening adults and children for ACEs using one of the simple, validated screening tools described by Stillerman. In a large follow-up study, screening along with discussion of the results with the patient’s physician led to remarkable decreases in health care utilization in the year following screening, which suggests that there are therapeutic benefits to bringing ACEs to light and fostering discussion.²
3. Remain ever compassionate in your interactions with all patients, knowing that many have significant childhood scars.

Because of the high prevalence of obesity and diabetes, bariatric surgery has become very popular. In the United States alone, there were an estimated 228,000 weight loss surgical procedures performed in 2017.¹

But I must confess that for many years, I was skeptical about the value of surgery to treat obesity. Yes, everyone who had a bariatric procedure lost weight, but did the long-term benefits really outweigh the harms? I wondered if most people gradually gained back the weight they lost. And the harms can be significant, including dumping syndrome, hypoglycemia, and malabsorption—in addition to the potential for surgical complications and repeat surgery. And, I must confess that my views were likely affected by the death of a friend from complications of gastric bypass 25 years ago.

My skepticism, however, has changed to cautious optimism for carefully selected patients.

My skepticism, however, has changed to cautious optimism for carefully selected patients. I say this because we now have long-term follow-up studies demonstrating the value of bariatric procedures—especially for people with type 2 diabetes.

Most studies have been cohort studies that compare results to similar patients with obesity who did not have surgery, and the outcomes have been consistently better in patients who underwent surgery. Two recent meta-analyses summarized these results; one for all patients with obesity and the other for patients with type 2 diabetes.

Continue to: The first meta-analysis

The first meta-analysis included 11 randomized trials, 4 nonrandomized controlled trials, and 17 cohort studies and showed probable reductions in all-cause mortality and possible reductions in cancer and cardiovascular events.² The second demonstrated significant improvements in microvascular and macrovascular disease and reduced mortality.³ The data were limited, however, because of the lack of large randomized trials with long-term follow-up.

The Stampede trial is one of a few bariatric surgery randomized trials focusing on patients with diabetes.⁴ The 5-year follow-up results are impressive. Nearly 30% of patients who had gastric bypass and 23% who had sleeve gastrectomy had an A1C ≤6 at 5 years compared to only 5% of those treated medically. Some patients discontinued all medications for diabetes, hypertension, and hyperlipidemia.

There is now adequate research to show that bariatric surgery provides significant benefits to properly selected patients who understand the risks. I no longer hesitate to refer patients for bariatric surgery who have been unsuccessful with weight loss—despite their best efforts.

Where do you stand?

Because of the high prevalence of obesity and diabetes, bariatric surgery has become very popular. In the United States alone, there were an estimated 228,000 weight loss surgical procedures performed in 2017.¹

But I must confess that for many years, I was skeptical about the value of surgery to treat obesity. Yes, everyone who had a bariatric procedure lost weight, but did the long-term benefits really outweigh the harms? I wondered if most people gradually gained back the weight they lost. And the harms can be significant, including dumping syndrome, hypoglycemia, and malabsorption—in addition to the potential for surgical complications and repeat surgery. And, I must confess that my views were likely affected by the death of a friend from complications of gastric bypass 25 years ago.

My skepticism, however, has changed to cautious optimism for carefully selected patients.

My skepticism, however, has changed to cautious optimism for carefully selected patients. I say this because we now have long-term follow-up studies demonstrating the value of bariatric procedures—especially for people with type 2 diabetes.

Most studies have been cohort studies that compare results to similar patients with obesity who did not have surgery, and the outcomes have been consistently better in patients who underwent surgery. Two recent meta-analyses summarized these results; one for all patients with obesity and the other for patients with type 2 diabetes.

Continue to: The first meta-analysis

The first meta-analysis included 11 randomized trials, 4 nonrandomized controlled trials, and 17 cohort studies and showed probable reductions in all-cause mortality and possible reductions in cancer and cardiovascular events.² The second demonstrated significant improvements in microvascular and macrovascular disease and reduced mortality.³ The data were limited, however, because of the lack of large randomized trials with long-term follow-up.

The Stampede trial is one of a few bariatric surgery randomized trials focusing on patients with diabetes.⁴ The 5-year follow-up results are impressive. Nearly 30% of patients who had gastric bypass and 23% who had sleeve gastrectomy had an A1C ≤6 at 5 years compared to only 5% of those treated medically. Some patients discontinued all medications for diabetes, hypertension, and hyperlipidemia.

There is now adequate research to show that bariatric surgery provides significant benefits to properly selected patients who understand the risks. I no longer hesitate to refer patients for bariatric surgery who have been unsuccessful with weight loss—despite their best efforts.

Where do you stand?

Because of the high prevalence of obesity and diabetes, bariatric surgery has become very popular. In the United States alone, there were an estimated 228,000 weight loss surgical procedures performed in 2017.¹

But I must confess that for many years, I was skeptical about the value of surgery to treat obesity. Yes, everyone who had a bariatric procedure lost weight, but did the long-term benefits really outweigh the harms? I wondered if most people gradually gained back the weight they lost. And the harms can be significant, including dumping syndrome, hypoglycemia, and malabsorption—in addition to the potential for surgical complications and repeat surgery. And, I must confess that my views were likely affected by the death of a friend from complications of gastric bypass 25 years ago.

My skepticism, however, has changed to cautious optimism for carefully selected patients.

My skepticism, however, has changed to cautious optimism for carefully selected patients. I say this because we now have long-term follow-up studies demonstrating the value of bariatric procedures—especially for people with type 2 diabetes.

Most studies have been cohort studies that compare results to similar patients with obesity who did not have surgery, and the outcomes have been consistently better in patients who underwent surgery. Two recent meta-analyses summarized these results; one for all patients with obesity and the other for patients with type 2 diabetes.

Continue to: The first meta-analysis

The first meta-analysis included 11 randomized trials, 4 nonrandomized controlled trials, and 17 cohort studies and showed probable reductions in all-cause mortality and possible reductions in cancer and cardiovascular events.² The second demonstrated significant improvements in microvascular and macrovascular disease and reduced mortality.³ The data were limited, however, because of the lack of large randomized trials with long-term follow-up.

The Stampede trial is one of a few bariatric surgery randomized trials focusing on patients with diabetes.⁴ The 5-year follow-up results are impressive. Nearly 30% of patients who had gastric bypass and 23% who had sleeve gastrectomy had an A1C ≤6 at 5 years compared to only 5% of those treated medically. Some patients discontinued all medications for diabetes, hypertension, and hyperlipidemia.

There is now adequate research to show that bariatric surgery provides significant benefits to properly selected patients who understand the risks. I no longer hesitate to refer patients for bariatric surgery who have been unsuccessful with weight loss—despite their best efforts.

Where do you stand?

Musculoskeletal complaints are one of the top reasons patients visit family physicians, with more than 24 million encounters per year.¹ Two articles in this month’s issue of JFP discuss treatments for musculoskeletal pain.

The article by Drs. Stephen and Peter Carek summarizes the value of specific exercises for hip and knee osteoarthritis (OA), chronic back pain, chronic shoulder pain, Achilles tendinitis, and lateral epicondylitis. This month’s PURL summarizes a negative randomized trial of treatment of knee OA with the popular over-the-counter combination of glucosamine and chondroitin. The findings? The group taking placebo actually had superior pain relief at 6 months!

What else works … and doesn’t? You may find that the following 4 “pearls,” taken from the literature, are also useful to know as you seek to manage patients’ musculoskeletal pain.

Studies remind us to harness the placebo effect, rather than dismiss it.

Pearl #1. Don’t use diazepam (valium) for acute low back pain. It doesn’t improve pain or function for this back pain. One hundred fourteen patients with acute low back pain were randomized to naproxen 500 mg bid as needed plus either placebo or diazepam 5 mg, 1 or 2 tablets, every 12 hours prn. At 7 days, 32% of the diazepam group reported moderate to severe pain and 22% of the placebo group did.²

Pearl #2. Use naproxen alone when treating acute low back pain. Three hundred twenty-three patients with acute low back pain were randomized to receive naproxen 500 mg bid plus placebo; naproxen plus oxycodone/acetaminophen; or naproxen plus cyclobenzaprine.³ At 7 days and 3 months, pain and function scores did not differ between groups.

Pearl #3. Don’t inject knees with corticosteroids. Enroll these patients in exercise and walking programs, which do provide benefit. One hundred forty patients with moderately severe knee OA were randomized to saline or triamcinolone 40 mg intra-articular injections every 3 months for 2 years.⁴ There was no difference in pain or function scores measured every 3 months and there was more cartilage degeneration in the triamcinolone group.

Continue to: Pearl #4

Pearl #4. Don’t dismiss the placebo effect. Eighty-three patients with chronic low back pain were randomized to either continue their current pain medications or to continue their current pain medication plus a placebo tablet twice daily for 3 weeks.⁵ They were told that placebos can have significant pain-relieving qualities. At 3 weeks, the patients taking placebo had less pain than those not taking placebo.

I’m not sure if we should start prescribing placebos, but this study is a strong reminder that we should harness the placebo effect, rather than dismiss it.

Musculoskeletal complaints are one of the top reasons patients visit family physicians, with more than 24 million encounters per year.¹ Two articles in this month’s issue of JFP discuss treatments for musculoskeletal pain.

The article by Drs. Stephen and Peter Carek summarizes the value of specific exercises for hip and knee osteoarthritis (OA), chronic back pain, chronic shoulder pain, Achilles tendinitis, and lateral epicondylitis. This month’s PURL summarizes a negative randomized trial of treatment of knee OA with the popular over-the-counter combination of glucosamine and chondroitin. The findings? The group taking placebo actually had superior pain relief at 6 months!

What else works … and doesn’t? You may find that the following 4 “pearls,” taken from the literature, are also useful to know as you seek to manage patients’ musculoskeletal pain.

Studies remind us to harness the placebo effect, rather than dismiss it.

Pearl #1. Don’t use diazepam (valium) for acute low back pain. It doesn’t improve pain or function for this back pain. One hundred fourteen patients with acute low back pain were randomized to naproxen 500 mg bid as needed plus either placebo or diazepam 5 mg, 1 or 2 tablets, every 12 hours prn. At 7 days, 32% of the diazepam group reported moderate to severe pain and 22% of the placebo group did.²

Pearl #2. Use naproxen alone when treating acute low back pain. Three hundred twenty-three patients with acute low back pain were randomized to receive naproxen 500 mg bid plus placebo; naproxen plus oxycodone/acetaminophen; or naproxen plus cyclobenzaprine.³ At 7 days and 3 months, pain and function scores did not differ between groups.

Pearl #3. Don’t inject knees with corticosteroids. Enroll these patients in exercise and walking programs, which do provide benefit. One hundred forty patients with moderately severe knee OA were randomized to saline or triamcinolone 40 mg intra-articular injections every 3 months for 2 years.⁴ There was no difference in pain or function scores measured every 3 months and there was more cartilage degeneration in the triamcinolone group.

Continue to: Pearl #4

Pearl #4. Don’t dismiss the placebo effect. Eighty-three patients with chronic low back pain were randomized to either continue their current pain medications or to continue their current pain medication plus a placebo tablet twice daily for 3 weeks.⁵ They were told that placebos can have significant pain-relieving qualities. At 3 weeks, the patients taking placebo had less pain than those not taking placebo.

I’m not sure if we should start prescribing placebos, but this study is a strong reminder that we should harness the placebo effect, rather than dismiss it.

Musculoskeletal complaints are one of the top reasons patients visit family physicians, with more than 24 million encounters per year.¹ Two articles in this month’s issue of JFP discuss treatments for musculoskeletal pain.

The article by Drs. Stephen and Peter Carek summarizes the value of specific exercises for hip and knee osteoarthritis (OA), chronic back pain, chronic shoulder pain, Achilles tendinitis, and lateral epicondylitis. This month’s PURL summarizes a negative randomized trial of treatment of knee OA with the popular over-the-counter combination of glucosamine and chondroitin. The findings? The group taking placebo actually had superior pain relief at 6 months!

What else works … and doesn’t? You may find that the following 4 “pearls,” taken from the literature, are also useful to know as you seek to manage patients’ musculoskeletal pain.

Studies remind us to harness the placebo effect, rather than dismiss it.

Pearl #1. Don’t use diazepam (valium) for acute low back pain. It doesn’t improve pain or function for this back pain. One hundred fourteen patients with acute low back pain were randomized to naproxen 500 mg bid as needed plus either placebo or diazepam 5 mg, 1 or 2 tablets, every 12 hours prn. At 7 days, 32% of the diazepam group reported moderate to severe pain and 22% of the placebo group did.²

Pearl #2. Use naproxen alone when treating acute low back pain. Three hundred twenty-three patients with acute low back pain were randomized to receive naproxen 500 mg bid plus placebo; naproxen plus oxycodone/acetaminophen; or naproxen plus cyclobenzaprine.³ At 7 days and 3 months, pain and function scores did not differ between groups.

Pearl #3. Don’t inject knees with corticosteroids. Enroll these patients in exercise and walking programs, which do provide benefit. One hundred forty patients with moderately severe knee OA were randomized to saline or triamcinolone 40 mg intra-articular injections every 3 months for 2 years.⁴ There was no difference in pain or function scores measured every 3 months and there was more cartilage degeneration in the triamcinolone group.

Continue to: Pearl #4

Pearl #4. Don’t dismiss the placebo effect. Eighty-three patients with chronic low back pain were randomized to either continue their current pain medications or to continue their current pain medication plus a placebo tablet twice daily for 3 weeks.⁵ They were told that placebos can have significant pain-relieving qualities. At 3 weeks, the patients taking placebo had less pain than those not taking placebo.

I’m not sure if we should start prescribing placebos, but this study is a strong reminder that we should harness the placebo effect, rather than dismiss it.

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

This month's article by Dr. Yuen and colleagues on cognitive biases and the diagnostic errors that can result is a humbling reminder of the limitations of our brains and the need for us to be ever vigilant about the accuracy of our clinical diagnoses.

According to the article, at least 8 different kinds of bias can unintentionally derail our efforts to make the correct diagnosis. In my editorial last month (J Fam Pract. 2018;67:268), I presented data showing that up to 30% of patients with a physician’s diagnosis of asthma do not, in fact, have asthma. These mistaken diagnoses are most likely due to the bias known as “diagnostic momentum,” which is the tendency of physicians to accept a diagnosis without questioning its validity.

We are also prone to anchoring. Because family physicians (FPs) are very busy and use type 1 reasoning (pattern recognition or intuitive reasoning) more frequently than type 2 reasoning (analytical thinking, which requires more time), I suspect we are most susceptible to the bias of premature closure of the diagnostic process, also called anchoring. At times we attach too much weight to preliminary findings and don’t dig deep enough into the history or physical findings to confirm or support our diagnoses.

A memorable example of my own cognitive bias was my treatment of a middle-aged woman with hyperlipidemia. I thought I was being a good doctor, treating her appropriately with a statin. Luckily for her, she saw one of my partners when I was on vacation. My partner walked into the room and immediately recognized her myxedematous face as a sign of hypothyroidism. Her thyroid stimulating hormone level was 124 mIU/L! She was cured with thyroid hormone replacement and did not need a statin at all. I had not taken the time to think through the case carefully. And I had not noticed her gradual weight gain or the changes to her face.

My partner saw the patient's myxedematous face and knew she had hypothyroidism—not hyperlipidemia.

Lulled by common diagnoses. Another difficulty for FPs and other primary care practitioners is that most of the patients we see have a common illness that is easy to diagnose. Recognizing shingles, eczema, acute appendicitis, and viral respiratory infections and managing chronic illnesses such as hypertension, diabetes, and chronic obstructive pulmonary disease (COPD) is second nature to us. But we must constantly be on the lookout for uncommon and potentially serious conditions. A classic example is not considering alpha-1 antitrypsin deficiency in a patient with COPD who does not smoke.

The bottom line: Take an extra minute or 2 to think through every diagnosis carefully—especially when one or more of the puzzle pieces do not fit together properly.

This month's article by Dr. Yuen and colleagues on cognitive biases and the diagnostic errors that can result is a humbling reminder of the limitations of our brains and the need for us to be ever vigilant about the accuracy of our clinical diagnoses.

According to the article, at least 8 different kinds of bias can unintentionally derail our efforts to make the correct diagnosis. In my editorial last month (J Fam Pract. 2018;67:268), I presented data showing that up to 30% of patients with a physician’s diagnosis of asthma do not, in fact, have asthma. These mistaken diagnoses are most likely due to the bias known as “diagnostic momentum,” which is the tendency of physicians to accept a diagnosis without questioning its validity.

We are also prone to anchoring. Because family physicians (FPs) are very busy and use type 1 reasoning (pattern recognition or intuitive reasoning) more frequently than type 2 reasoning (analytical thinking, which requires more time), I suspect we are most susceptible to the bias of premature closure of the diagnostic process, also called anchoring. At times we attach too much weight to preliminary findings and don’t dig deep enough into the history or physical findings to confirm or support our diagnoses.

A memorable example of my own cognitive bias was my treatment of a middle-aged woman with hyperlipidemia. I thought I was being a good doctor, treating her appropriately with a statin. Luckily for her, she saw one of my partners when I was on vacation. My partner walked into the room and immediately recognized her myxedematous face as a sign of hypothyroidism. Her thyroid stimulating hormone level was 124 mIU/L! She was cured with thyroid hormone replacement and did not need a statin at all. I had not taken the time to think through the case carefully. And I had not noticed her gradual weight gain or the changes to her face.

My partner saw the patient's myxedematous face and knew she had hypothyroidism—not hyperlipidemia.

Lulled by common diagnoses. Another difficulty for FPs and other primary care practitioners is that most of the patients we see have a common illness that is easy to diagnose. Recognizing shingles, eczema, acute appendicitis, and viral respiratory infections and managing chronic illnesses such as hypertension, diabetes, and chronic obstructive pulmonary disease (COPD) is second nature to us. But we must constantly be on the lookout for uncommon and potentially serious conditions. A classic example is not considering alpha-1 antitrypsin deficiency in a patient with COPD who does not smoke.

The bottom line: Take an extra minute or 2 to think through every diagnosis carefully—especially when one or more of the puzzle pieces do not fit together properly.

This month's article by Dr. Yuen and colleagues on cognitive biases and the diagnostic errors that can result is a humbling reminder of the limitations of our brains and the need for us to be ever vigilant about the accuracy of our clinical diagnoses.

According to the article, at least 8 different kinds of bias can unintentionally derail our efforts to make the correct diagnosis. In my editorial last month (J Fam Pract. 2018;67:268), I presented data showing that up to 30% of patients with a physician’s diagnosis of asthma do not, in fact, have asthma. These mistaken diagnoses are most likely due to the bias known as “diagnostic momentum,” which is the tendency of physicians to accept a diagnosis without questioning its validity.

We are also prone to anchoring. Because family physicians (FPs) are very busy and use type 1 reasoning (pattern recognition or intuitive reasoning) more frequently than type 2 reasoning (analytical thinking, which requires more time), I suspect we are most susceptible to the bias of premature closure of the diagnostic process, also called anchoring. At times we attach too much weight to preliminary findings and don’t dig deep enough into the history or physical findings to confirm or support our diagnoses.

A memorable example of my own cognitive bias was my treatment of a middle-aged woman with hyperlipidemia. I thought I was being a good doctor, treating her appropriately with a statin. Luckily for her, she saw one of my partners when I was on vacation. My partner walked into the room and immediately recognized her myxedematous face as a sign of hypothyroidism. Her thyroid stimulating hormone level was 124 mIU/L! She was cured with thyroid hormone replacement and did not need a statin at all. I had not taken the time to think through the case carefully. And I had not noticed her gradual weight gain or the changes to her face.

My partner saw the patient's myxedematous face and knew she had hypothyroidism—not hyperlipidemia.

Lulled by common diagnoses. Another difficulty for FPs and other primary care practitioners is that most of the patients we see have a common illness that is easy to diagnose. Recognizing shingles, eczema, acute appendicitis, and viral respiratory infections and managing chronic illnesses such as hypertension, diabetes, and chronic obstructive pulmonary disease (COPD) is second nature to us. But we must constantly be on the lookout for uncommon and potentially serious conditions. A classic example is not considering alpha-1 antitrypsin deficiency in a patient with COPD who does not smoke.

The bottom line: Take an extra minute or 2 to think through every diagnosis carefully—especially when one or more of the puzzle pieces do not fit together properly.

In this issue of JFP, Dr. Mendoza reminds us that “Parkinson’s disease can be a tough diagnosis to navigate.”¹ Classically, Parkinson’s disease (PD) is associated with a resting tremor, but bradykinesia is actually the hallmark of the disease. PD can also present with subtle movement disorders, as well as depression and early dementia. It is, indeed, a difficult clinical diagnosis, and consultation with an expert to confirm or deny its presence can be quite helpful.

Other conundrums. PD, however, is not the only illness whose signs and symptoms can present a challenge. Chronic and intermittent shortness of breath, for example, can be very difficult to sort out. Is the shortness of breath due to congestive heart failure, chronic obstructive pulmonary disease, asthma, or a neurologic condition such as myasthenia gravis? Or is it the result of several causes?

When asthma isn’t asthma. Because it is a common illness, physicians often diagnose asthma in patients with shortness of breath or wheezing. But a recent study suggests that as many as 30% of primary care patients with a current diagnosis of asthma do not have asthma at all.²

In the study, Canadian researchers recruited 701 adults with physician-diagnosed asthma, all of whom were taking asthma medications regularly. The researchers did baseline pulmonary function testing (including methacholine challenge testing, if needed) and monitored symptoms frequently. Then they gradually withdrew asthma medications from those who did not appear to have a definitive diagnosis of asthma. They followed these patients for one year. One-third (203 of 613) of the patients with complete follow-up data were no longer taking asthma medications one year later and had no symptoms of asthma. Twelve patients had serious alternative diagnoses such as coronary artery disease and bronchiectasis.

Reevaluate your asthma patients to be sure they have the correct Dx, and keep Parkinson's in the differential for patients with atypical symptoms.

Closer to home. In my practice, I found 2 patients with long-standing diagnoses of asthma who didn’t, in fact, have the condition at all. In both cases, my suspicion was raised by lung examination. In one case, fine bibasilar rales suggested pulmonary fibrosis, which was the correct diagnosis, and the patient is now on the lung transplant list. In the other case, a loud venous hum suggested an arteriovenous malformation. Surgery corrected the patient’s “asthma.”

I urge you to reevaluate your asthma patients to be sure they have the correct diagnosis and to keep PD in your differential for patients who present with atypical symptoms. Primary care clinicians must be expert diagnosticians, willing to question prior diagnoses.

In this issue of JFP, Dr. Mendoza reminds us that “Parkinson’s disease can be a tough diagnosis to navigate.”¹ Classically, Parkinson’s disease (PD) is associated with a resting tremor, but bradykinesia is actually the hallmark of the disease. PD can also present with subtle movement disorders, as well as depression and early dementia. It is, indeed, a difficult clinical diagnosis, and consultation with an expert to confirm or deny its presence can be quite helpful.

Other conundrums. PD, however, is not the only illness whose signs and symptoms can present a challenge. Chronic and intermittent shortness of breath, for example, can be very difficult to sort out. Is the shortness of breath due to congestive heart failure, chronic obstructive pulmonary disease, asthma, or a neurologic condition such as myasthenia gravis? Or is it the result of several causes?

When asthma isn’t asthma. Because it is a common illness, physicians often diagnose asthma in patients with shortness of breath or wheezing. But a recent study suggests that as many as 30% of primary care patients with a current diagnosis of asthma do not have asthma at all.²

In the study, Canadian researchers recruited 701 adults with physician-diagnosed asthma, all of whom were taking asthma medications regularly. The researchers did baseline pulmonary function testing (including methacholine challenge testing, if needed) and monitored symptoms frequently. Then they gradually withdrew asthma medications from those who did not appear to have a definitive diagnosis of asthma. They followed these patients for one year. One-third (203 of 613) of the patients with complete follow-up data were no longer taking asthma medications one year later and had no symptoms of asthma. Twelve patients had serious alternative diagnoses such as coronary artery disease and bronchiectasis.

Reevaluate your asthma patients to be sure they have the correct Dx, and keep Parkinson's in the differential for patients with atypical symptoms.

Closer to home. In my practice, I found 2 patients with long-standing diagnoses of asthma who didn’t, in fact, have the condition at all. In both cases, my suspicion was raised by lung examination. In one case, fine bibasilar rales suggested pulmonary fibrosis, which was the correct diagnosis, and the patient is now on the lung transplant list. In the other case, a loud venous hum suggested an arteriovenous malformation. Surgery corrected the patient’s “asthma.”

I urge you to reevaluate your asthma patients to be sure they have the correct diagnosis and to keep PD in your differential for patients who present with atypical symptoms. Primary care clinicians must be expert diagnosticians, willing to question prior diagnoses.

In this issue of JFP, Dr. Mendoza reminds us that “Parkinson’s disease can be a tough diagnosis to navigate.”¹ Classically, Parkinson’s disease (PD) is associated with a resting tremor, but bradykinesia is actually the hallmark of the disease. PD can also present with subtle movement disorders, as well as depression and early dementia. It is, indeed, a difficult clinical diagnosis, and consultation with an expert to confirm or deny its presence can be quite helpful.

Other conundrums. PD, however, is not the only illness whose signs and symptoms can present a challenge. Chronic and intermittent shortness of breath, for example, can be very difficult to sort out. Is the shortness of breath due to congestive heart failure, chronic obstructive pulmonary disease, asthma, or a neurologic condition such as myasthenia gravis? Or is it the result of several causes?

When asthma isn’t asthma. Because it is a common illness, physicians often diagnose asthma in patients with shortness of breath or wheezing. But a recent study suggests that as many as 30% of primary care patients with a current diagnosis of asthma do not have asthma at all.²

In the study, Canadian researchers recruited 701 adults with physician-diagnosed asthma, all of whom were taking asthma medications regularly. The researchers did baseline pulmonary function testing (including methacholine challenge testing, if needed) and monitored symptoms frequently. Then they gradually withdrew asthma medications from those who did not appear to have a definitive diagnosis of asthma. They followed these patients for one year. One-third (203 of 613) of the patients with complete follow-up data were no longer taking asthma medications one year later and had no symptoms of asthma. Twelve patients had serious alternative diagnoses such as coronary artery disease and bronchiectasis.

Reevaluate your asthma patients to be sure they have the correct Dx, and keep Parkinson's in the differential for patients with atypical symptoms.

Closer to home. In my practice, I found 2 patients with long-standing diagnoses of asthma who didn’t, in fact, have the condition at all. In both cases, my suspicion was raised by lung examination. In one case, fine bibasilar rales suggested pulmonary fibrosis, which was the correct diagnosis, and the patient is now on the lung transplant list. In the other case, a loud venous hum suggested an arteriovenous malformation. Surgery corrected the patient’s “asthma.”

I urge you to reevaluate your asthma patients to be sure they have the correct diagnosis and to keep PD in your differential for patients who present with atypical symptoms. Primary care clinicians must be expert diagnosticians, willing to question prior diagnoses.

In an interesting bit of timing, just one month before the tragic shooting at the Marjory Stoneman Douglas High School in Parkland, Florida, the AMA Journal of Ethics devoted its entire January issue to the role of physicians in preventing violence. Part of the discussion centered on the idea of treating gun violence as an infectious disease epidemic.¹

Dr. Gary Slutkin, an infectious disease specialist and former Centers for Disease Control and Prevention epidemiologist, is a proponent of this approach. His research has demonstrated that epidemic disease control measures are effective in reducing violence and violence-related deaths.^2-5

Just look at incidence. Violent deaths in the United States are at an epidemic proportion, just like deaths due to narcotic overdoses. In 2015, there were approximately 33,091 deaths due to narcotic overdoses and 36,252 deaths due to gun violence.^6,7

Imagine it—a day when violence goes the way of polio.

Geographic and social factors. Like infectious disease epidemics, violence tends to cluster in certain geographic areas and social networks. The cause of violence is multifactorial, just like other infectious disease epidemics, such as tuberculosis. Poverty, poor education, and inadequate family structure act as modulating factors that increase the rate of violence in those exposed to it.

Enlisting the community. This contagious disease prevention approach uses community health workers to map areas of high transmission, reach out to those exposed, and intervene to reduce risk factors. For example, gang-related deaths are often due to retaliation. A thorough investigation of a patient who arrives in the emergency department (ED) with a gunshot wound can reveal the next likely perpetrators and victims. Then community violence prevention workers can go directly to these people and others in their social networks, such as parents and friends, to attempt to prevent the next shooting. This approach, dubbed “Cure Violence” (CureViolence.org), has resulted in up to a 70% decrease in violence in some areas of Chicago.² Some neighborhoods of Baltimore and New York have seen similar reductions.^3-5

What can family practitioners do? Dr. Slutkin believes his approach could be expanded from EDs to other health care settings, like primary care, where we can identify people at risk and refer them to community violence prevention resources. Imagine it—a day when violence goes the way of polio.

In an interesting bit of timing, just one month before the tragic shooting at the Marjory Stoneman Douglas High School in Parkland, Florida, the AMA Journal of Ethics devoted its entire January issue to the role of physicians in preventing violence. Part of the discussion centered on the idea of treating gun violence as an infectious disease epidemic.¹

Dr. Gary Slutkin, an infectious disease specialist and former Centers for Disease Control and Prevention epidemiologist, is a proponent of this approach. His research has demonstrated that epidemic disease control measures are effective in reducing violence and violence-related deaths.^2-5

Just look at incidence. Violent deaths in the United States are at an epidemic proportion, just like deaths due to narcotic overdoses. In 2015, there were approximately 33,091 deaths due to narcotic overdoses and 36,252 deaths due to gun violence.^6,7

Imagine it—a day when violence goes the way of polio.

Geographic and social factors. Like infectious disease epidemics, violence tends to cluster in certain geographic areas and social networks. The cause of violence is multifactorial, just like other infectious disease epidemics, such as tuberculosis. Poverty, poor education, and inadequate family structure act as modulating factors that increase the rate of violence in those exposed to it.

Enlisting the community. This contagious disease prevention approach uses community health workers to map areas of high transmission, reach out to those exposed, and intervene to reduce risk factors. For example, gang-related deaths are often due to retaliation. A thorough investigation of a patient who arrives in the emergency department (ED) with a gunshot wound can reveal the next likely perpetrators and victims. Then community violence prevention workers can go directly to these people and others in their social networks, such as parents and friends, to attempt to prevent the next shooting. This approach, dubbed “Cure Violence” (CureViolence.org), has resulted in up to a 70% decrease in violence in some areas of Chicago.² Some neighborhoods of Baltimore and New York have seen similar reductions.^3-5

What can family practitioners do? Dr. Slutkin believes his approach could be expanded from EDs to other health care settings, like primary care, where we can identify people at risk and refer them to community violence prevention resources. Imagine it—a day when violence goes the way of polio.

In an interesting bit of timing, just one month before the tragic shooting at the Marjory Stoneman Douglas High School in Parkland, Florida, the AMA Journal of Ethics devoted its entire January issue to the role of physicians in preventing violence. Part of the discussion centered on the idea of treating gun violence as an infectious disease epidemic.¹

Dr. Gary Slutkin, an infectious disease specialist and former Centers for Disease Control and Prevention epidemiologist, is a proponent of this approach. His research has demonstrated that epidemic disease control measures are effective in reducing violence and violence-related deaths.^2-5

Just look at incidence. Violent deaths in the United States are at an epidemic proportion, just like deaths due to narcotic overdoses. In 2015, there were approximately 33,091 deaths due to narcotic overdoses and 36,252 deaths due to gun violence.^6,7

Imagine it—a day when violence goes the way of polio.

Geographic and social factors. Like infectious disease epidemics, violence tends to cluster in certain geographic areas and social networks. The cause of violence is multifactorial, just like other infectious disease epidemics, such as tuberculosis. Poverty, poor education, and inadequate family structure act as modulating factors that increase the rate of violence in those exposed to it.

Enlisting the community. This contagious disease prevention approach uses community health workers to map areas of high transmission, reach out to those exposed, and intervene to reduce risk factors. For example, gang-related deaths are often due to retaliation. A thorough investigation of a patient who arrives in the emergency department (ED) with a gunshot wound can reveal the next likely perpetrators and victims. Then community violence prevention workers can go directly to these people and others in their social networks, such as parents and friends, to attempt to prevent the next shooting. This approach, dubbed “Cure Violence” (CureViolence.org), has resulted in up to a 70% decrease in violence in some areas of Chicago.² Some neighborhoods of Baltimore and New York have seen similar reductions.^3-5

What can family practitioners do? Dr. Slutkin believes his approach could be expanded from EDs to other health care settings, like primary care, where we can identify people at risk and refer them to community violence prevention resources. Imagine it—a day when violence goes the way of polio.

“Good morning, Mr. Harris. What can I do for you today?”

“Dr. Hickner, I need an MRI of my right knee. I hurt it last week, and I need to find out if I tore something.”

We all know that too many patients request—and often get—costly (and unnecessary) magnetic resonance imaging (MRI) and computed tomography (CT) scans of their joints and backs. That’s why such imaging is targeted in the Choosing Wisely campaign, which aims to eliminate needless testing.¹

But how can we confidently tell Mr. Harris that he doesn’t need an MRI or CT scan? One approach is to explain that imaging is generally reserved for those considering surgery, as it serves to inform the surgeon of the exact procedure needed. Another approach is to be skilled in physical exam techniques that increase our confidence in the clinical diagnosis.

Applying this to acute knee injuries. In this issue of JFP, Koster and colleagues explain that the Lachman test (and possibly the newer lever sign test) are maneuvers that have a high probability of ruling out complete anterior cruciate ligament (ACL) tears when performed properly. The Lachman test, for example, has a 96% sensitivity for complete ACL ruptures.² (The anterior drawer test has too low a sensitivity to rule out ACL injuries, and the pivot shift test is a bit too challenging to be performed reliably.)

A thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

This is important information because early surgery for ACL tears leads to better outcomes for athletes, and a reliable physical exam to rule out an ACL tear reduces the need for imaging. Moreover, other than fractures near the knee, no other knee injuries require early surgery. So a thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

The same is true for back and shoulder injuries, where acute imaging with MRI or CT is rarely called for. A thorough and accurate physical examination is usually sufficient, supplemented with plain X-rays on a selective basis.

Going one step further, consider taking a look at the JAMA series called, “The Rational Clinical Examination,” which has been compiled into a single publication by the same name.³ It is an excellent guide to the sensitivity, specificity, and positive and negative likelihood ratios of a host of clinical findings and tests. It can help to greatly improve clinical skills and reduce unnecessary testing.

“Good morning, Mr. Harris. What can I do for you today?”

“Dr. Hickner, I need an MRI of my right knee. I hurt it last week, and I need to find out if I tore something.”

We all know that too many patients request—and often get—costly (and unnecessary) magnetic resonance imaging (MRI) and computed tomography (CT) scans of their joints and backs. That’s why such imaging is targeted in the Choosing Wisely campaign, which aims to eliminate needless testing.¹

But how can we confidently tell Mr. Harris that he doesn’t need an MRI or CT scan? One approach is to explain that imaging is generally reserved for those considering surgery, as it serves to inform the surgeon of the exact procedure needed. Another approach is to be skilled in physical exam techniques that increase our confidence in the clinical diagnosis.

Applying this to acute knee injuries. In this issue of JFP, Koster and colleagues explain that the Lachman test (and possibly the newer lever sign test) are maneuvers that have a high probability of ruling out complete anterior cruciate ligament (ACL) tears when performed properly. The Lachman test, for example, has a 96% sensitivity for complete ACL ruptures.² (The anterior drawer test has too low a sensitivity to rule out ACL injuries, and the pivot shift test is a bit too challenging to be performed reliably.)

A thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

This is important information because early surgery for ACL tears leads to better outcomes for athletes, and a reliable physical exam to rule out an ACL tear reduces the need for imaging. Moreover, other than fractures near the knee, no other knee injuries require early surgery. So a thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

The same is true for back and shoulder injuries, where acute imaging with MRI or CT is rarely called for. A thorough and accurate physical examination is usually sufficient, supplemented with plain X-rays on a selective basis.

Going one step further, consider taking a look at the JAMA series called, “The Rational Clinical Examination,” which has been compiled into a single publication by the same name.³ It is an excellent guide to the sensitivity, specificity, and positive and negative likelihood ratios of a host of clinical findings and tests. It can help to greatly improve clinical skills and reduce unnecessary testing.

“Good morning, Mr. Harris. What can I do for you today?”

“Dr. Hickner, I need an MRI of my right knee. I hurt it last week, and I need to find out if I tore something.”

We all know that too many patients request—and often get—costly (and unnecessary) magnetic resonance imaging (MRI) and computed tomography (CT) scans of their joints and backs. That’s why such imaging is targeted in the Choosing Wisely campaign, which aims to eliminate needless testing.¹

But how can we confidently tell Mr. Harris that he doesn’t need an MRI or CT scan? One approach is to explain that imaging is generally reserved for those considering surgery, as it serves to inform the surgeon of the exact procedure needed. Another approach is to be skilled in physical exam techniques that increase our confidence in the clinical diagnosis.

Applying this to acute knee injuries. In this issue of JFP, Koster and colleagues explain that the Lachman test (and possibly the newer lever sign test) are maneuvers that have a high probability of ruling out complete anterior cruciate ligament (ACL) tears when performed properly. The Lachman test, for example, has a 96% sensitivity for complete ACL ruptures.² (The anterior drawer test has too low a sensitivity to rule out ACL injuries, and the pivot shift test is a bit too challenging to be performed reliably.)

A thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

This is important information because early surgery for ACL tears leads to better outcomes for athletes, and a reliable physical exam to rule out an ACL tear reduces the need for imaging. Moreover, other than fractures near the knee, no other knee injuries require early surgery. So a thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

The same is true for back and shoulder injuries, where acute imaging with MRI or CT is rarely called for. A thorough and accurate physical examination is usually sufficient, supplemented with plain X-rays on a selective basis.

Going one step further, consider taking a look at the JAMA series called, “The Rational Clinical Examination,” which has been compiled into a single publication by the same name.³ It is an excellent guide to the sensitivity, specificity, and positive and negative likelihood ratios of a host of clinical findings and tests. It can help to greatly improve clinical skills and reduce unnecessary testing.

Two weeks ago, I saw a man with a swollen left leg in the office. It took me 2 days to get a Doppler study completed in my busy health care system. Point-of-care ultrasound (POCUS) would have been invaluable for this gentleman. As we know, though, POCUS has been “slow to grow” in primary care. However, as this month’s cover story suggests, things are changing.

Since the 1970s, ultrasound has been a standard diagnostic tool for many conditions. Initially considered the domain of radiologists and cardiologists with extensive training, technologic advances now allow accurate interpretation of ultrasound images by generalist physicians with a modest amount of training.

Hopefully point-of-care ultrasound will become a standard part of family medicine training and practice sooner, rather than later.

One of the first references to POCUS in general practice in the United States was published in 1988.¹ Use of ultrasound in family medicine has developed slowly over the past 30 years, due to the high cost of equipment, a lack of training as a formal component of family medicine residency curricula, and a lack of evidence of its effectiveness in office practice. Only 6% of practicing family physicians (FPs) reported using non-obstetric POCUS in their practices in 2016, and only 2% of family medicine residency programs had established POCUS curricula in 2015.^2,3

Ready for prime time. Although I had considered POCUS to be a relatively new and untested technology for primary care settings, my reading of the POCUS article has convinced me that POCUS is now ready for widespread deployment in family medicine office practice. Bornemann and colleagues review the evidence for the use of POCUS in 4 areas: the heart, the lung, screening for abdominal aortic aneurysm (AAA), and the diagnosis of deep vein thrombosis. They provide more than 30 references that support the accuracy and effectiveness of the use of POCUS by FPs for these areas. The equipment is affordable, there is ample evidence of accuracy and effectiveness, and, as they note, a curriculum for FP training has been published.

I certainly hope that POCUS continues to make its way into FPs’ offices. It would certainly help patients like the one I saw 2 weeks ago, and it would help us to screen for AAA in older male smokers, as recommended by the US Preventive Services Task Force.

I am delighted to see FP pioneers working to advance the use of POCUS in family medicine. Hopefully, it will become a standard part of family medicine training and practice sooner, rather than later.

Two weeks ago, I saw a man with a swollen left leg in the office. It took me 2 days to get a Doppler study completed in my busy health care system. Point-of-care ultrasound (POCUS) would have been invaluable for this gentleman. As we know, though, POCUS has been “slow to grow” in primary care. However, as this month’s cover story suggests, things are changing.

Since the 1970s, ultrasound has been a standard diagnostic tool for many conditions. Initially considered the domain of radiologists and cardiologists with extensive training, technologic advances now allow accurate interpretation of ultrasound images by generalist physicians with a modest amount of training.

Hopefully point-of-care ultrasound will become a standard part of family medicine training and practice sooner, rather than later.

One of the first references to POCUS in general practice in the United States was published in 1988.¹ Use of ultrasound in family medicine has developed slowly over the past 30 years, due to the high cost of equipment, a lack of training as a formal component of family medicine residency curricula, and a lack of evidence of its effectiveness in office practice. Only 6% of practicing family physicians (FPs) reported using non-obstetric POCUS in their practices in 2016, and only 2% of family medicine residency programs had established POCUS curricula in 2015.^2,3

Ready for prime time. Although I had considered POCUS to be a relatively new and untested technology for primary care settings, my reading of the POCUS article has convinced me that POCUS is now ready for widespread deployment in family medicine office practice. Bornemann and colleagues review the evidence for the use of POCUS in 4 areas: the heart, the lung, screening for abdominal aortic aneurysm (AAA), and the diagnosis of deep vein thrombosis. They provide more than 30 references that support the accuracy and effectiveness of the use of POCUS by FPs for these areas. The equipment is affordable, there is ample evidence of accuracy and effectiveness, and, as they note, a curriculum for FP training has been published.

I certainly hope that POCUS continues to make its way into FPs’ offices. It would certainly help patients like the one I saw 2 weeks ago, and it would help us to screen for AAA in older male smokers, as recommended by the US Preventive Services Task Force.

I am delighted to see FP pioneers working to advance the use of POCUS in family medicine. Hopefully, it will become a standard part of family medicine training and practice sooner, rather than later.

Two weeks ago, I saw a man with a swollen left leg in the office. It took me 2 days to get a Doppler study completed in my busy health care system. Point-of-care ultrasound (POCUS) would have been invaluable for this gentleman. As we know, though, POCUS has been “slow to grow” in primary care. However, as this month’s cover story suggests, things are changing.

Since the 1970s, ultrasound has been a standard diagnostic tool for many conditions. Initially considered the domain of radiologists and cardiologists with extensive training, technologic advances now allow accurate interpretation of ultrasound images by generalist physicians with a modest amount of training.

Hopefully point-of-care ultrasound will become a standard part of family medicine training and practice sooner, rather than later.

One of the first references to POCUS in general practice in the United States was published in 1988.¹ Use of ultrasound in family medicine has developed slowly over the past 30 years, due to the high cost of equipment, a lack of training as a formal component of family medicine residency curricula, and a lack of evidence of its effectiveness in office practice. Only 6% of practicing family physicians (FPs) reported using non-obstetric POCUS in their practices in 2016, and only 2% of family medicine residency programs had established POCUS curricula in 2015.^2,3

Ready for prime time. Although I had considered POCUS to be a relatively new and untested technology for primary care settings, my reading of the POCUS article has convinced me that POCUS is now ready for widespread deployment in family medicine office practice. Bornemann and colleagues review the evidence for the use of POCUS in 4 areas: the heart, the lung, screening for abdominal aortic aneurysm (AAA), and the diagnosis of deep vein thrombosis. They provide more than 30 references that support the accuracy and effectiveness of the use of POCUS by FPs for these areas. The equipment is affordable, there is ample evidence of accuracy and effectiveness, and, as they note, a curriculum for FP training has been published.

I certainly hope that POCUS continues to make its way into FPs’ offices. It would certainly help patients like the one I saw 2 weeks ago, and it would help us to screen for AAA in older male smokers, as recommended by the US Preventive Services Task Force.

I am delighted to see FP pioneers working to advance the use of POCUS in family medicine. Hopefully, it will become a standard part of family medicine training and practice sooner, rather than later.