Original Research

The goal for glycemic control in current guidelines on type 2 diabetes is a glycosylated hemoglobin (HbA_1c) value of <7.0%.¹ If this target is not achieved or maintained with sulfonylurea and metformin at maximally tolerated dosages, insulin therapy is recommended as the next step for patients without advanced diabetes complications and with a reasonably long life expectancy.²

There is little doubt that exogenous insulin aids in glycemic control at this stage of disease. It is still debated, though, whether insulin should be used as monotherapy or be added to a regimen of 1 or 2 oral agents (combination therapy).^{3, 4}

Guidelines on type 2 diabetes conflict with one another about indications for treatment and preferred regimens, and most recommendations are based on less-than-sufficient evidence.¹ For example, it is unclear in the case of combination therapy whether sulfonylurea or metformin or both should be continued. Moreover, the Dutch guideline on type 2 diabetes recommends that in combination therapy, the dose of isophane (neutral protamine Hagedorn or NPH) insulin be taken to a maximum of 40 IU, after which one should switch to a regimen of twice-daily insulin only. This recommendation is not based on published evidence.⁵

A number of randomized controlled trials have investigated the efficacy of different insulin regimens in patients whose diabetes was not controlled with oral agents. Few studies, though, have included patients using both sulfonylurea and metformin.⁶ In addition, studies that have measured treatment satisfaction, general wellbeing, fear of injections, and hypoglycemic complaints are sparse. Although we know from observational studies that insulin therapy is usually well accepted,^7,8 little is known as to what extent patient satisfaction and quality of life are influenced by either treatment schemes.

The purpose of this study was to compare insulin monotherapy with insulin combination therapy in patients whose diabetes was inadequately controlled (HbA_1c ≥7.0%) despite maximally tolerated dosages of sulfonylurea and metformin. Endpoints included glycemic control, insulin dosage, body weight, number of treatment failures, number of hypoglycemic events and symptoms, treatment satisfaction, general well-being, and fear of injections and self testing.

Methods

Design

This was an open-label, parallel group trial of 12 months duration. Patients were randomly assigned to receive NPH insulin at bedtime (Insulatard; Novo Nordisk, Copenhagen, Denmark) in addition to current treatment with sulfonylurea and metformin (insulin combination [IC] group) or to receive a mixture of 30% soluble and 70% NPH insulin (Mixtard 30/70; Novo Nordisk, Copenhagen, Denmark), twice daily before breakfast and dinner (insulin monotherapy [IM] group). Randomization was performed by a telephone call to an independent trial center that used a computer-generated random assignment.

The medical ethics committee of the University Medical Centre of Utrecht approved the study. All patients gave written informed consent.

Patients

Patients were recruited from family practices in and around the city of Utrecht, the Netherlands. Patients were asked to participate if they were younger than 76 years, had HbA_1c ≥7.0% despite treatment with both sulfonylurea and metformin in maximally tolerated dosages, were willing to start insulin therapy, and were deemed by their family physician to be candidates for more tight glycemic control.

Exclusion criteria were severe comorbidity (ie, an illness that surpasses the impact of diabetes or was associated with a short life expectancy) and insufficient understanding of spoken Dutch to follow instructions. The final study population was 64 patients.

Study protocol

After randomization, patients were referred to the diabetes nurse of their family practice to receive usual education for patients starting on insulin therapy. This included information on diabetes (eg, symptoms of hypoglycemia) and dietary counseling as well as instructions on how to inject insulin and how to monitor blood glucose levels before breakfast, after meals, and before bedtime twice weekly.

Patients were also instructed to register any symptomatic hypoglycemic event, along with accompanying measurement of the blood glucose value if possible, and to report whether assistance from a third party was required. Blood glucose values and hypoglycemic events were to be recorded in a personal diabetes diary.

Insulin therapy was initiated with 8 IU before bedtime in the IC group, and with 12 and 6 IU before breakfast and dinner in the IM group, respectively. Insulin dosages were adjusted twice weekly by telephone contact with the diabetes nurse (adjusting phase), aiming for a target fasting blood glucose of 4.0–7.0 mmol/L and a target postprandial glucose of 4.0–10.0 mmol/L. When these targets were achieved and had proved stable, the insulin dose was fixed and telephone contacts were decreased to once monthly (stable phase).

Treatment failure was declared for patients in the IC group if glucose targets were not reached with a maximum daily dose of 40 IU NPH insulin. In the IM group, no ceiling was set for the insulin dose, but treatment was declared a failure when patients were switched to other treatment regimens due to unsatisfactory diurnal blood glucose profiles. Practice visits with the diabetes nurse or the family physician (according to local policy) were scheduled for 3, 6, 9, and 12 months after start of treatment.

Outcome measures

HbA_1c —measured by turbidimetric inhibition immunoassay (Hitachi 917; Roche Diagnostics, Basel, Switzerland; normal range 4%–6%)—and body weight were documented at randomization and at 3, 6, 9, and 12 months.

Frequency and severity of hypoglycemic events were monitored during telephone contacts and by checking patients’ diaries. At 3 and 12 months, patients completed a hypoglycemic symptoms checklist—including 18 autonomic, neuroglycopenic, and malaise symptoms—the severity of which was scored on a 7-point scale, ranging from 0 (not at all) to 6 (very intense), providing a potential range of 0 to 108.

Treatment satisfaction was measured at baseline and at 3 and 12 months, using the Dutch version of the Diabetes Treatment Satisfaction Questionnaire (DTSQ).⁹ The DTSQ is a validated self-report questionnaire; it consists of 8 questions, 6 of which refer to satisfaction with treatment. The answers were scored on a 0-to-6 Likert scale and added to produce a measure of satisfaction with diabetes treatment, providing a potential range of 0 (very dissatisfied) to 36 (very satisfied).

Well-being was measured at baseline and at 3 and 12 months with the Dutch version of the 12-item Well-Being Questionnaire (WBQ-12).¹⁰ The WBQ-12 consists of 12 assertions about the patients’ feelings, and is divided into 3 subscales from which a General Well-Being score is calculated, providing a potential range of 0 (low) to 36 (high).

Fear of self-injecting with insulin (FSI) and fear of self-testing for blood glucose levels (FST) was assessed at 3 and 12 months by the short version of the Diabetes Fear of Injecting and Self-Testing Questionnaire (D-FISQ), which has proved useful for research in insulin-treated diabetes patients.¹¹ This self-report questionnaire consists of a 6-item subscale for FSI, and a 9-item subscale for FST. The items were scored on a 4-point Likert scale, ranging from 0 (almost never) to 3 (almost always), referring to the past month.

Statistical methods

The primary outcome of the study was the difference in HbA_1c between the interventions. To detect a difference of at least 0.8%, 32 patients were needed in each group (standard deviation [SD]=1.1, α=0.05, power=80%). Data were expressed as means ± SD unless indicated otherwise. Analyses were based on intention to treat, and missing data were fitted by the last-observation-carried-forward principle. Last available measurements were used for patients reaching a study end point before 12 months of follow-up. Outcome measurements were compared between the 2 intervention groups by either analyses of covariance (ANCOVA) adjusting for baseline values,¹² unpaired t tests, or Mann-Whitney U test. The probability of treatment success was analyzed using Kaplan-Meier plots with the log-rank test. P<.05 was considered statistically significant. Data analyses were performed with SPSS release 11 (SPSS Inc, Chicago, Ill, USA).

Results

In total, 69 patients were randomized, 5 of whom did not initiate the intervention. Baseline characteristics of included patients are summarized in Table 1. Except for weight and body mass index, no significant differences were found between the groups.

TABLE 1
Characteristics at baseline (n=64)

Glycemic control and insulin dosage

In both groups, HbA_1c improved, mainly during the first months (Figure 1). In the IC group, mean decrease was 0.8 ± 1.3%, vs 1.2 ± 1.2 in the IM group. Adjusted for baseline values, HbA_1c for IM fell by 0.14% more than for IC (95% confidential interval [CI], –0.72 to 0.44; P=NS). In the IC group, 36% of the patients reached HbA_1c levels <7.0%, compared with 42% in the IM group (P = NS).

When treatment failures (see below) were omitted, mean decrease of Hb A_1c for IC was 1.0 ± 1.2% (Figure 2). Mean daily insulin dosages at endpoint were 25.8 ± 12.2 IU for IC vs 68.3 ± 27.5 for IM. Mean daily dosages adjusted for body weight were 0.27 ± 0.13 IU/kg for IC vs 0.86 ± 0.37 for IM.

FIGURE 1
Course of HbA_1c values (SD)

FIGURE 2
Combination vs monotherapy

Treatment failures

In the IC group, 8 patients (24%) experienced a treatment failure because glucose targets were not reached with a daily dose of 40 IU NPH insulin. The mean time for reaching this study endpoint was 4.6 months (range, 1–10). HbA_1c deteriorated in this period from 8.5 ± 1.3 % to 8.6 ± 1.5%.

Age, sex, duration of diabetes, and baseline values for HbA_1c, body mass index, treatment satisfaction, and general well-being of these patients did not significantly differ from those who completed the study on IC therapy (data not shown). Mean daily insulin dosages at endpoint, adjusted for body weight, were 0.41 ± 0.13 IU/kg for treatment failures vs 0.23 ± 0.11 for non-treatment failures (95 % CI, 0.10 to 0.28; P<.001). In the IM group, 2 patients (6%) were switched to another insulin regimen due to unsatisfactory diurnal glucose profiles. Figure 2 shows the Kaplan-Meier curves of probability of treatment success. Log-rank test showed a borderline significant difference between the groups (P=.09).

Weight gain

In the IC group, body weight increased with 1.3 ± 3.9 kg, compared with 4.2 ± 4.3 kg in the IM group. Adjusted for baseline values, body weight in the IM group increased by 3.0 kg more than in the IC group (95% CI, 0.68 to 5.25; P=.01).

Hypoglycemic events and symptoms

The average number of hypoglycemic events per patient was 2.7 ± 5.2 in the IC group, and 4.3 ± 4.3 for the IM group (P=.02). For events accompanied by documented blood glucose values <4.0 mmol/L, the results were 2.4 ± 5.2 and 2.7 ± 3.5, respectively (P=.1). All events were mild, expect for 1 patient in the IM group who experienced 2 severe events (unconsciousness and support needed from a third party). At 3 and 12 months, hypoglycemic symptoms scores were 17.2 ± 13.3 and 16.3 ± 16.0 for IC, vs 19.1 ± 15.6 and 22.4 ± 15.7 for IM (P=NS).

Diabetes treatment satisfaction and general well-being

Satisfaction with treatment improved in the IC group from 28.0 ± 8.2 to 30.9 ± 5.1, and in the IM group from 26.1 ± 8.1 to 28.4 ± 7.4. Adjusted for baseline values, the difference between the mean change scores was not significant (95% CI, –5.0 to 1.0; P=NS). Well-being scores increased from 21.7 ± 8.1 to 25.1 ± 6.8 in the IC group, vs 22.7 ± 6.9 to 22.8 ± 7.6 in the IM group. Adjusted for baseline scores, wellbeing for IC improved by 3.0 points more than for IM (95 % CI, 0.02 to 5.8; P=.05).

Fear of self-injecting and self-testing

At 3 and 12 months, FSI scores were 0.6 ± 1.3 and 0.5 ± 1.1 in the IC group, vs 2.1 ± 4.1 and 1.0 ± 2.1 in the IM group. For FST, these scores were 0.6 ± 1.9 and 2.3 ± 4.8 in the IC group, and 2.5 ± 4.4 and 1.7 ± 3.6 in the IM group. At neither 3 nor 12 months were statistical differences found between the groups. Approximately 70% of the patients in both groups had scores of 0 (no fear at all) on both subscales.

Discussion

In this practice-based study of insulin-naïve patients, HbA_1c improved ~1 percentage point with both insulin combination therapy and insulin monotherapy. However, with both strategies, around 40% of patients reached HbA_1c levels <7%, which forces us to be realistic regarding the glycemic target that can be achieved in the current family practice setting. Despite systematic titration of the insulin dosage, 24% of the patients in the IC group did not reach the titration targets. In addition, HbA_1c levels for those patients did not change from baseline, in contrast with patients in the IC group who did reach the targets (Figure 1). So it is doubtful if lower HbA_1c levels could have been achieved if the study design had allowed for increasing the daily insulin dose over 40 IU.

Treatment failure rate in this study was considerably lower compared with 66% failures reported in another trial in which insulin NPH or glargine was added to oral therapy.¹³ However, this difference could probably be explained by a difference in target for fasting blood glucose: ≤5.6 mmol/L vs ≤7.0 in our study. So it might be relevant in future research to seek factors that could predict failure on oral agent/insulin combinations.¹⁴

With insulin monotherapy, body weight increased significantly, and patients experienced more hypoglycemic events. Treatment satisfaction did not differ, whereas general well-being improved more with combination therapy. For most patients, the injection- and test-activities appeared to be well tolerated, with no differences between treatment groups.

Though several trials have been conducted to compare insulin combination therapies with insulin monotherapy in insulin-naïve patients,^6,15-17 studies with follow-up >6 months, and including patients taking maximum dosages of two oral agents, are sparse. Moreover, no studies have been conducted in a primary care setting. Chow et al compared a regimen of bedtime NPH insulin and 1 or 2 oral agents with a regimen of premixed insulin 30/70 in 53 mostly lean patients during 6 months.¹⁸ The effects on HbA_1c, body weight, and number of hypoglycemic events were comparable to our results, and a similar treatment failure rate in the combination group was found.

Yki-Järvinen et al studied the effects of 4 insulin regimens including the addition of bedtime NPH insulin to either morning NPH, glyburide, metformin, or glyburide plus metformin in patients previously treated with maximal dosage sulfonylurea.¹⁹ The greatest decrease in HbA_1c accompanied by the lowest number of hypoglycemic events was observed in the insulin/metformin group.

However, the impact of these results might be limited, since current guidelines recommend treatment with maximum doses of both sulfonylurea and metformin before introducing insulin therapy.^2,8 Nevertheless, the results underline the favorable influence on relevant outcomes of insulin combination therapy compared with insulin monotherapy, provided that at least metformin is used.

Patients in our study were recruited during regular appointments with their own care provider, and insulin treatment was established under “usual care” conditions. So it is likely that this study group represents the type 2 diabetes patients in primary care that, sooner or later, should start insulin therapy, and that the results of this study are highly applicable to them.

Our results suggest that an evening injection with NPH insulin in addition to an existing maximal therapy with sulfonylurea and metformin can be recommended as an effective, simple, and well-tolerated first-choice approach with patients who are willing to continue oral medication. Since both family physicians and patients are inclined to delay starting insulin,²⁰ such a strategy might encourage the timely use of insulin.¹⁴

Acknowledgments

We thank Rianne Maillé for her expert contribution concerning the questionnaires. In particular we would like to thank the patients, diabetes nurses, and family physicians for their participation.

Corresponding author
Alex N. Goudswaard, Koperslagersgilde 5, 3994 CH Houten, Netherlands. E-mail: [email protected].

The goal for glycemic control in current guidelines on type 2 diabetes is a glycosylated hemoglobin (HbA_1c) value of <7.0%.¹ If this target is not achieved or maintained with sulfonylurea and metformin at maximally tolerated dosages, insulin therapy is recommended as the next step for patients without advanced diabetes complications and with a reasonably long life expectancy.²

There is little doubt that exogenous insulin aids in glycemic control at this stage of disease. It is still debated, though, whether insulin should be used as monotherapy or be added to a regimen of 1 or 2 oral agents (combination therapy).^{3, 4}

Guidelines on type 2 diabetes conflict with one another about indications for treatment and preferred regimens, and most recommendations are based on less-than-sufficient evidence.¹ For example, it is unclear in the case of combination therapy whether sulfonylurea or metformin or both should be continued. Moreover, the Dutch guideline on type 2 diabetes recommends that in combination therapy, the dose of isophane (neutral protamine Hagedorn or NPH) insulin be taken to a maximum of 40 IU, after which one should switch to a regimen of twice-daily insulin only. This recommendation is not based on published evidence.⁵

A number of randomized controlled trials have investigated the efficacy of different insulin regimens in patients whose diabetes was not controlled with oral agents. Few studies, though, have included patients using both sulfonylurea and metformin.⁶ In addition, studies that have measured treatment satisfaction, general wellbeing, fear of injections, and hypoglycemic complaints are sparse. Although we know from observational studies that insulin therapy is usually well accepted,^7,8 little is known as to what extent patient satisfaction and quality of life are influenced by either treatment schemes.

The purpose of this study was to compare insulin monotherapy with insulin combination therapy in patients whose diabetes was inadequately controlled (HbA_1c ≥7.0%) despite maximally tolerated dosages of sulfonylurea and metformin. Endpoints included glycemic control, insulin dosage, body weight, number of treatment failures, number of hypoglycemic events and symptoms, treatment satisfaction, general well-being, and fear of injections and self testing.

Methods

Design

This was an open-label, parallel group trial of 12 months duration. Patients were randomly assigned to receive NPH insulin at bedtime (Insulatard; Novo Nordisk, Copenhagen, Denmark) in addition to current treatment with sulfonylurea and metformin (insulin combination [IC] group) or to receive a mixture of 30% soluble and 70% NPH insulin (Mixtard 30/70; Novo Nordisk, Copenhagen, Denmark), twice daily before breakfast and dinner (insulin monotherapy [IM] group). Randomization was performed by a telephone call to an independent trial center that used a computer-generated random assignment.

The medical ethics committee of the University Medical Centre of Utrecht approved the study. All patients gave written informed consent.

Patients

Patients were recruited from family practices in and around the city of Utrecht, the Netherlands. Patients were asked to participate if they were younger than 76 years, had HbA_1c ≥7.0% despite treatment with both sulfonylurea and metformin in maximally tolerated dosages, were willing to start insulin therapy, and were deemed by their family physician to be candidates for more tight glycemic control.

Exclusion criteria were severe comorbidity (ie, an illness that surpasses the impact of diabetes or was associated with a short life expectancy) and insufficient understanding of spoken Dutch to follow instructions. The final study population was 64 patients.

Study protocol

After randomization, patients were referred to the diabetes nurse of their family practice to receive usual education for patients starting on insulin therapy. This included information on diabetes (eg, symptoms of hypoglycemia) and dietary counseling as well as instructions on how to inject insulin and how to monitor blood glucose levels before breakfast, after meals, and before bedtime twice weekly.

Patients were also instructed to register any symptomatic hypoglycemic event, along with accompanying measurement of the blood glucose value if possible, and to report whether assistance from a third party was required. Blood glucose values and hypoglycemic events were to be recorded in a personal diabetes diary.

Insulin therapy was initiated with 8 IU before bedtime in the IC group, and with 12 and 6 IU before breakfast and dinner in the IM group, respectively. Insulin dosages were adjusted twice weekly by telephone contact with the diabetes nurse (adjusting phase), aiming for a target fasting blood glucose of 4.0–7.0 mmol/L and a target postprandial glucose of 4.0–10.0 mmol/L. When these targets were achieved and had proved stable, the insulin dose was fixed and telephone contacts were decreased to once monthly (stable phase).

Treatment failure was declared for patients in the IC group if glucose targets were not reached with a maximum daily dose of 40 IU NPH insulin. In the IM group, no ceiling was set for the insulin dose, but treatment was declared a failure when patients were switched to other treatment regimens due to unsatisfactory diurnal blood glucose profiles. Practice visits with the diabetes nurse or the family physician (according to local policy) were scheduled for 3, 6, 9, and 12 months after start of treatment.

Outcome measures

HbA_1c —measured by turbidimetric inhibition immunoassay (Hitachi 917; Roche Diagnostics, Basel, Switzerland; normal range 4%–6%)—and body weight were documented at randomization and at 3, 6, 9, and 12 months.

Frequency and severity of hypoglycemic events were monitored during telephone contacts and by checking patients’ diaries. At 3 and 12 months, patients completed a hypoglycemic symptoms checklist—including 18 autonomic, neuroglycopenic, and malaise symptoms—the severity of which was scored on a 7-point scale, ranging from 0 (not at all) to 6 (very intense), providing a potential range of 0 to 108.

Treatment satisfaction was measured at baseline and at 3 and 12 months, using the Dutch version of the Diabetes Treatment Satisfaction Questionnaire (DTSQ).⁹ The DTSQ is a validated self-report questionnaire; it consists of 8 questions, 6 of which refer to satisfaction with treatment. The answers were scored on a 0-to-6 Likert scale and added to produce a measure of satisfaction with diabetes treatment, providing a potential range of 0 (very dissatisfied) to 36 (very satisfied).

Well-being was measured at baseline and at 3 and 12 months with the Dutch version of the 12-item Well-Being Questionnaire (WBQ-12).¹⁰ The WBQ-12 consists of 12 assertions about the patients’ feelings, and is divided into 3 subscales from which a General Well-Being score is calculated, providing a potential range of 0 (low) to 36 (high).

Fear of self-injecting with insulin (FSI) and fear of self-testing for blood glucose levels (FST) was assessed at 3 and 12 months by the short version of the Diabetes Fear of Injecting and Self-Testing Questionnaire (D-FISQ), which has proved useful for research in insulin-treated diabetes patients.¹¹ This self-report questionnaire consists of a 6-item subscale for FSI, and a 9-item subscale for FST. The items were scored on a 4-point Likert scale, ranging from 0 (almost never) to 3 (almost always), referring to the past month.

Statistical methods

The primary outcome of the study was the difference in HbA_1c between the interventions. To detect a difference of at least 0.8%, 32 patients were needed in each group (standard deviation [SD]=1.1, α=0.05, power=80%). Data were expressed as means ± SD unless indicated otherwise. Analyses were based on intention to treat, and missing data were fitted by the last-observation-carried-forward principle. Last available measurements were used for patients reaching a study end point before 12 months of follow-up. Outcome measurements were compared between the 2 intervention groups by either analyses of covariance (ANCOVA) adjusting for baseline values,¹² unpaired t tests, or Mann-Whitney U test. The probability of treatment success was analyzed using Kaplan-Meier plots with the log-rank test. P<.05 was considered statistically significant. Data analyses were performed with SPSS release 11 (SPSS Inc, Chicago, Ill, USA).

Results

In total, 69 patients were randomized, 5 of whom did not initiate the intervention. Baseline characteristics of included patients are summarized in Table 1. Except for weight and body mass index, no significant differences were found between the groups.

TABLE 1
Characteristics at baseline (n=64)

Glycemic control and insulin dosage

In both groups, HbA_1c improved, mainly during the first months (Figure 1). In the IC group, mean decrease was 0.8 ± 1.3%, vs 1.2 ± 1.2 in the IM group. Adjusted for baseline values, HbA_1c for IM fell by 0.14% more than for IC (95% confidential interval [CI], –0.72 to 0.44; P=NS). In the IC group, 36% of the patients reached HbA_1c levels <7.0%, compared with 42% in the IM group (P = NS).

When treatment failures (see below) were omitted, mean decrease of Hb A_1c for IC was 1.0 ± 1.2% (Figure 2). Mean daily insulin dosages at endpoint were 25.8 ± 12.2 IU for IC vs 68.3 ± 27.5 for IM. Mean daily dosages adjusted for body weight were 0.27 ± 0.13 IU/kg for IC vs 0.86 ± 0.37 for IM.

FIGURE 1
Course of HbA_1c values (SD)

FIGURE 2
Combination vs monotherapy

Treatment failures

In the IC group, 8 patients (24%) experienced a treatment failure because glucose targets were not reached with a daily dose of 40 IU NPH insulin. The mean time for reaching this study endpoint was 4.6 months (range, 1–10). HbA_1c deteriorated in this period from 8.5 ± 1.3 % to 8.6 ± 1.5%.

Age, sex, duration of diabetes, and baseline values for HbA_1c, body mass index, treatment satisfaction, and general well-being of these patients did not significantly differ from those who completed the study on IC therapy (data not shown). Mean daily insulin dosages at endpoint, adjusted for body weight, were 0.41 ± 0.13 IU/kg for treatment failures vs 0.23 ± 0.11 for non-treatment failures (95 % CI, 0.10 to 0.28; P<.001). In the IM group, 2 patients (6%) were switched to another insulin regimen due to unsatisfactory diurnal glucose profiles. Figure 2 shows the Kaplan-Meier curves of probability of treatment success. Log-rank test showed a borderline significant difference between the groups (P=.09).

Weight gain

In the IC group, body weight increased with 1.3 ± 3.9 kg, compared with 4.2 ± 4.3 kg in the IM group. Adjusted for baseline values, body weight in the IM group increased by 3.0 kg more than in the IC group (95% CI, 0.68 to 5.25; P=.01).

Hypoglycemic events and symptoms

The average number of hypoglycemic events per patient was 2.7 ± 5.2 in the IC group, and 4.3 ± 4.3 for the IM group (P=.02). For events accompanied by documented blood glucose values <4.0 mmol/L, the results were 2.4 ± 5.2 and 2.7 ± 3.5, respectively (P=.1). All events were mild, expect for 1 patient in the IM group who experienced 2 severe events (unconsciousness and support needed from a third party). At 3 and 12 months, hypoglycemic symptoms scores were 17.2 ± 13.3 and 16.3 ± 16.0 for IC, vs 19.1 ± 15.6 and 22.4 ± 15.7 for IM (P=NS).

Diabetes treatment satisfaction and general well-being

Satisfaction with treatment improved in the IC group from 28.0 ± 8.2 to 30.9 ± 5.1, and in the IM group from 26.1 ± 8.1 to 28.4 ± 7.4. Adjusted for baseline values, the difference between the mean change scores was not significant (95% CI, –5.0 to 1.0; P=NS). Well-being scores increased from 21.7 ± 8.1 to 25.1 ± 6.8 in the IC group, vs 22.7 ± 6.9 to 22.8 ± 7.6 in the IM group. Adjusted for baseline scores, wellbeing for IC improved by 3.0 points more than for IM (95 % CI, 0.02 to 5.8; P=.05).

Fear of self-injecting and self-testing

At 3 and 12 months, FSI scores were 0.6 ± 1.3 and 0.5 ± 1.1 in the IC group, vs 2.1 ± 4.1 and 1.0 ± 2.1 in the IM group. For FST, these scores were 0.6 ± 1.9 and 2.3 ± 4.8 in the IC group, and 2.5 ± 4.4 and 1.7 ± 3.6 in the IM group. At neither 3 nor 12 months were statistical differences found between the groups. Approximately 70% of the patients in both groups had scores of 0 (no fear at all) on both subscales.

Discussion

In this practice-based study of insulin-naïve patients, HbA_1c improved ~1 percentage point with both insulin combination therapy and insulin monotherapy. However, with both strategies, around 40% of patients reached HbA_1c levels <7%, which forces us to be realistic regarding the glycemic target that can be achieved in the current family practice setting. Despite systematic titration of the insulin dosage, 24% of the patients in the IC group did not reach the titration targets. In addition, HbA_1c levels for those patients did not change from baseline, in contrast with patients in the IC group who did reach the targets (Figure 1). So it is doubtful if lower HbA_1c levels could have been achieved if the study design had allowed for increasing the daily insulin dose over 40 IU.

Treatment failure rate in this study was considerably lower compared with 66% failures reported in another trial in which insulin NPH or glargine was added to oral therapy.¹³ However, this difference could probably be explained by a difference in target for fasting blood glucose: ≤5.6 mmol/L vs ≤7.0 in our study. So it might be relevant in future research to seek factors that could predict failure on oral agent/insulin combinations.¹⁴

With insulin monotherapy, body weight increased significantly, and patients experienced more hypoglycemic events. Treatment satisfaction did not differ, whereas general well-being improved more with combination therapy. For most patients, the injection- and test-activities appeared to be well tolerated, with no differences between treatment groups.

Though several trials have been conducted to compare insulin combination therapies with insulin monotherapy in insulin-naïve patients,^6,15-17 studies with follow-up >6 months, and including patients taking maximum dosages of two oral agents, are sparse. Moreover, no studies have been conducted in a primary care setting. Chow et al compared a regimen of bedtime NPH insulin and 1 or 2 oral agents with a regimen of premixed insulin 30/70 in 53 mostly lean patients during 6 months.¹⁸ The effects on HbA_1c, body weight, and number of hypoglycemic events were comparable to our results, and a similar treatment failure rate in the combination group was found.

Yki-Järvinen et al studied the effects of 4 insulin regimens including the addition of bedtime NPH insulin to either morning NPH, glyburide, metformin, or glyburide plus metformin in patients previously treated with maximal dosage sulfonylurea.¹⁹ The greatest decrease in HbA_1c accompanied by the lowest number of hypoglycemic events was observed in the insulin/metformin group.

However, the impact of these results might be limited, since current guidelines recommend treatment with maximum doses of both sulfonylurea and metformin before introducing insulin therapy.^2,8 Nevertheless, the results underline the favorable influence on relevant outcomes of insulin combination therapy compared with insulin monotherapy, provided that at least metformin is used.

Patients in our study were recruited during regular appointments with their own care provider, and insulin treatment was established under “usual care” conditions. So it is likely that this study group represents the type 2 diabetes patients in primary care that, sooner or later, should start insulin therapy, and that the results of this study are highly applicable to them.

Our results suggest that an evening injection with NPH insulin in addition to an existing maximal therapy with sulfonylurea and metformin can be recommended as an effective, simple, and well-tolerated first-choice approach with patients who are willing to continue oral medication. Since both family physicians and patients are inclined to delay starting insulin,²⁰ such a strategy might encourage the timely use of insulin.¹⁴

Acknowledgments

We thank Rianne Maillé for her expert contribution concerning the questionnaires. In particular we would like to thank the patients, diabetes nurses, and family physicians for their participation.

Corresponding author
Alex N. Goudswaard, Koperslagersgilde 5, 3994 CH Houten, Netherlands. E-mail: [email protected].

The goal for glycemic control in current guidelines on type 2 diabetes is a glycosylated hemoglobin (HbA_1c) value of <7.0%.¹ If this target is not achieved or maintained with sulfonylurea and metformin at maximally tolerated dosages, insulin therapy is recommended as the next step for patients without advanced diabetes complications and with a reasonably long life expectancy.²

There is little doubt that exogenous insulin aids in glycemic control at this stage of disease. It is still debated, though, whether insulin should be used as monotherapy or be added to a regimen of 1 or 2 oral agents (combination therapy).^{3, 4}

Guidelines on type 2 diabetes conflict with one another about indications for treatment and preferred regimens, and most recommendations are based on less-than-sufficient evidence.¹ For example, it is unclear in the case of combination therapy whether sulfonylurea or metformin or both should be continued. Moreover, the Dutch guideline on type 2 diabetes recommends that in combination therapy, the dose of isophane (neutral protamine Hagedorn or NPH) insulin be taken to a maximum of 40 IU, after which one should switch to a regimen of twice-daily insulin only. This recommendation is not based on published evidence.⁵

A number of randomized controlled trials have investigated the efficacy of different insulin regimens in patients whose diabetes was not controlled with oral agents. Few studies, though, have included patients using both sulfonylurea and metformin.⁶ In addition, studies that have measured treatment satisfaction, general wellbeing, fear of injections, and hypoglycemic complaints are sparse. Although we know from observational studies that insulin therapy is usually well accepted,^7,8 little is known as to what extent patient satisfaction and quality of life are influenced by either treatment schemes.

The purpose of this study was to compare insulin monotherapy with insulin combination therapy in patients whose diabetes was inadequately controlled (HbA_1c ≥7.0%) despite maximally tolerated dosages of sulfonylurea and metformin. Endpoints included glycemic control, insulin dosage, body weight, number of treatment failures, number of hypoglycemic events and symptoms, treatment satisfaction, general well-being, and fear of injections and self testing.

Methods

Design

This was an open-label, parallel group trial of 12 months duration. Patients were randomly assigned to receive NPH insulin at bedtime (Insulatard; Novo Nordisk, Copenhagen, Denmark) in addition to current treatment with sulfonylurea and metformin (insulin combination [IC] group) or to receive a mixture of 30% soluble and 70% NPH insulin (Mixtard 30/70; Novo Nordisk, Copenhagen, Denmark), twice daily before breakfast and dinner (insulin monotherapy [IM] group). Randomization was performed by a telephone call to an independent trial center that used a computer-generated random assignment.

The medical ethics committee of the University Medical Centre of Utrecht approved the study. All patients gave written informed consent.

Patients

Patients were recruited from family practices in and around the city of Utrecht, the Netherlands. Patients were asked to participate if they were younger than 76 years, had HbA_1c ≥7.0% despite treatment with both sulfonylurea and metformin in maximally tolerated dosages, were willing to start insulin therapy, and were deemed by their family physician to be candidates for more tight glycemic control.

Exclusion criteria were severe comorbidity (ie, an illness that surpasses the impact of diabetes or was associated with a short life expectancy) and insufficient understanding of spoken Dutch to follow instructions. The final study population was 64 patients.

Study protocol

After randomization, patients were referred to the diabetes nurse of their family practice to receive usual education for patients starting on insulin therapy. This included information on diabetes (eg, symptoms of hypoglycemia) and dietary counseling as well as instructions on how to inject insulin and how to monitor blood glucose levels before breakfast, after meals, and before bedtime twice weekly.

Patients were also instructed to register any symptomatic hypoglycemic event, along with accompanying measurement of the blood glucose value if possible, and to report whether assistance from a third party was required. Blood glucose values and hypoglycemic events were to be recorded in a personal diabetes diary.

Insulin therapy was initiated with 8 IU before bedtime in the IC group, and with 12 and 6 IU before breakfast and dinner in the IM group, respectively. Insulin dosages were adjusted twice weekly by telephone contact with the diabetes nurse (adjusting phase), aiming for a target fasting blood glucose of 4.0–7.0 mmol/L and a target postprandial glucose of 4.0–10.0 mmol/L. When these targets were achieved and had proved stable, the insulin dose was fixed and telephone contacts were decreased to once monthly (stable phase).

Treatment failure was declared for patients in the IC group if glucose targets were not reached with a maximum daily dose of 40 IU NPH insulin. In the IM group, no ceiling was set for the insulin dose, but treatment was declared a failure when patients were switched to other treatment regimens due to unsatisfactory diurnal blood glucose profiles. Practice visits with the diabetes nurse or the family physician (according to local policy) were scheduled for 3, 6, 9, and 12 months after start of treatment.

Outcome measures

HbA_1c —measured by turbidimetric inhibition immunoassay (Hitachi 917; Roche Diagnostics, Basel, Switzerland; normal range 4%–6%)—and body weight were documented at randomization and at 3, 6, 9, and 12 months.

Frequency and severity of hypoglycemic events were monitored during telephone contacts and by checking patients’ diaries. At 3 and 12 months, patients completed a hypoglycemic symptoms checklist—including 18 autonomic, neuroglycopenic, and malaise symptoms—the severity of which was scored on a 7-point scale, ranging from 0 (not at all) to 6 (very intense), providing a potential range of 0 to 108.

Treatment satisfaction was measured at baseline and at 3 and 12 months, using the Dutch version of the Diabetes Treatment Satisfaction Questionnaire (DTSQ).⁹ The DTSQ is a validated self-report questionnaire; it consists of 8 questions, 6 of which refer to satisfaction with treatment. The answers were scored on a 0-to-6 Likert scale and added to produce a measure of satisfaction with diabetes treatment, providing a potential range of 0 (very dissatisfied) to 36 (very satisfied).

Well-being was measured at baseline and at 3 and 12 months with the Dutch version of the 12-item Well-Being Questionnaire (WBQ-12).¹⁰ The WBQ-12 consists of 12 assertions about the patients’ feelings, and is divided into 3 subscales from which a General Well-Being score is calculated, providing a potential range of 0 (low) to 36 (high).

Fear of self-injecting with insulin (FSI) and fear of self-testing for blood glucose levels (FST) was assessed at 3 and 12 months by the short version of the Diabetes Fear of Injecting and Self-Testing Questionnaire (D-FISQ), which has proved useful for research in insulin-treated diabetes patients.¹¹ This self-report questionnaire consists of a 6-item subscale for FSI, and a 9-item subscale for FST. The items were scored on a 4-point Likert scale, ranging from 0 (almost never) to 3 (almost always), referring to the past month.

Statistical methods

The primary outcome of the study was the difference in HbA_1c between the interventions. To detect a difference of at least 0.8%, 32 patients were needed in each group (standard deviation [SD]=1.1, α=0.05, power=80%). Data were expressed as means ± SD unless indicated otherwise. Analyses were based on intention to treat, and missing data were fitted by the last-observation-carried-forward principle. Last available measurements were used for patients reaching a study end point before 12 months of follow-up. Outcome measurements were compared between the 2 intervention groups by either analyses of covariance (ANCOVA) adjusting for baseline values,¹² unpaired t tests, or Mann-Whitney U test. The probability of treatment success was analyzed using Kaplan-Meier plots with the log-rank test. P<.05 was considered statistically significant. Data analyses were performed with SPSS release 11 (SPSS Inc, Chicago, Ill, USA).

Results

In total, 69 patients were randomized, 5 of whom did not initiate the intervention. Baseline characteristics of included patients are summarized in Table 1. Except for weight and body mass index, no significant differences were found between the groups.

TABLE 1
Characteristics at baseline (n=64)

Glycemic control and insulin dosage

In both groups, HbA_1c improved, mainly during the first months (Figure 1). In the IC group, mean decrease was 0.8 ± 1.3%, vs 1.2 ± 1.2 in the IM group. Adjusted for baseline values, HbA_1c for IM fell by 0.14% more than for IC (95% confidential interval [CI], –0.72 to 0.44; P=NS). In the IC group, 36% of the patients reached HbA_1c levels <7.0%, compared with 42% in the IM group (P = NS).

When treatment failures (see below) were omitted, mean decrease of Hb A_1c for IC was 1.0 ± 1.2% (Figure 2). Mean daily insulin dosages at endpoint were 25.8 ± 12.2 IU for IC vs 68.3 ± 27.5 for IM. Mean daily dosages adjusted for body weight were 0.27 ± 0.13 IU/kg for IC vs 0.86 ± 0.37 for IM.

FIGURE 1
Course of HbA_1c values (SD)

FIGURE 2
Combination vs monotherapy

Treatment failures

In the IC group, 8 patients (24%) experienced a treatment failure because glucose targets were not reached with a daily dose of 40 IU NPH insulin. The mean time for reaching this study endpoint was 4.6 months (range, 1–10). HbA_1c deteriorated in this period from 8.5 ± 1.3 % to 8.6 ± 1.5%.

Age, sex, duration of diabetes, and baseline values for HbA_1c, body mass index, treatment satisfaction, and general well-being of these patients did not significantly differ from those who completed the study on IC therapy (data not shown). Mean daily insulin dosages at endpoint, adjusted for body weight, were 0.41 ± 0.13 IU/kg for treatment failures vs 0.23 ± 0.11 for non-treatment failures (95 % CI, 0.10 to 0.28; P<.001). In the IM group, 2 patients (6%) were switched to another insulin regimen due to unsatisfactory diurnal glucose profiles. Figure 2 shows the Kaplan-Meier curves of probability of treatment success. Log-rank test showed a borderline significant difference between the groups (P=.09).

Weight gain

In the IC group, body weight increased with 1.3 ± 3.9 kg, compared with 4.2 ± 4.3 kg in the IM group. Adjusted for baseline values, body weight in the IM group increased by 3.0 kg more than in the IC group (95% CI, 0.68 to 5.25; P=.01).

Hypoglycemic events and symptoms

The average number of hypoglycemic events per patient was 2.7 ± 5.2 in the IC group, and 4.3 ± 4.3 for the IM group (P=.02). For events accompanied by documented blood glucose values <4.0 mmol/L, the results were 2.4 ± 5.2 and 2.7 ± 3.5, respectively (P=.1). All events were mild, expect for 1 patient in the IM group who experienced 2 severe events (unconsciousness and support needed from a third party). At 3 and 12 months, hypoglycemic symptoms scores were 17.2 ± 13.3 and 16.3 ± 16.0 for IC, vs 19.1 ± 15.6 and 22.4 ± 15.7 for IM (P=NS).

Diabetes treatment satisfaction and general well-being

Satisfaction with treatment improved in the IC group from 28.0 ± 8.2 to 30.9 ± 5.1, and in the IM group from 26.1 ± 8.1 to 28.4 ± 7.4. Adjusted for baseline values, the difference between the mean change scores was not significant (95% CI, –5.0 to 1.0; P=NS). Well-being scores increased from 21.7 ± 8.1 to 25.1 ± 6.8 in the IC group, vs 22.7 ± 6.9 to 22.8 ± 7.6 in the IM group. Adjusted for baseline scores, wellbeing for IC improved by 3.0 points more than for IM (95 % CI, 0.02 to 5.8; P=.05).

Fear of self-injecting and self-testing

At 3 and 12 months, FSI scores were 0.6 ± 1.3 and 0.5 ± 1.1 in the IC group, vs 2.1 ± 4.1 and 1.0 ± 2.1 in the IM group. For FST, these scores were 0.6 ± 1.9 and 2.3 ± 4.8 in the IC group, and 2.5 ± 4.4 and 1.7 ± 3.6 in the IM group. At neither 3 nor 12 months were statistical differences found between the groups. Approximately 70% of the patients in both groups had scores of 0 (no fear at all) on both subscales.

Discussion

In this practice-based study of insulin-naïve patients, HbA_1c improved ~1 percentage point with both insulin combination therapy and insulin monotherapy. However, with both strategies, around 40% of patients reached HbA_1c levels <7%, which forces us to be realistic regarding the glycemic target that can be achieved in the current family practice setting. Despite systematic titration of the insulin dosage, 24% of the patients in the IC group did not reach the titration targets. In addition, HbA_1c levels for those patients did not change from baseline, in contrast with patients in the IC group who did reach the targets (Figure 1). So it is doubtful if lower HbA_1c levels could have been achieved if the study design had allowed for increasing the daily insulin dose over 40 IU.

Treatment failure rate in this study was considerably lower compared with 66% failures reported in another trial in which insulin NPH or glargine was added to oral therapy.¹³ However, this difference could probably be explained by a difference in target for fasting blood glucose: ≤5.6 mmol/L vs ≤7.0 in our study. So it might be relevant in future research to seek factors that could predict failure on oral agent/insulin combinations.¹⁴

With insulin monotherapy, body weight increased significantly, and patients experienced more hypoglycemic events. Treatment satisfaction did not differ, whereas general well-being improved more with combination therapy. For most patients, the injection- and test-activities appeared to be well tolerated, with no differences between treatment groups.

Though several trials have been conducted to compare insulin combination therapies with insulin monotherapy in insulin-naïve patients,^6,15-17 studies with follow-up >6 months, and including patients taking maximum dosages of two oral agents, are sparse. Moreover, no studies have been conducted in a primary care setting. Chow et al compared a regimen of bedtime NPH insulin and 1 or 2 oral agents with a regimen of premixed insulin 30/70 in 53 mostly lean patients during 6 months.¹⁸ The effects on HbA_1c, body weight, and number of hypoglycemic events were comparable to our results, and a similar treatment failure rate in the combination group was found.

Yki-Järvinen et al studied the effects of 4 insulin regimens including the addition of bedtime NPH insulin to either morning NPH, glyburide, metformin, or glyburide plus metformin in patients previously treated with maximal dosage sulfonylurea.¹⁹ The greatest decrease in HbA_1c accompanied by the lowest number of hypoglycemic events was observed in the insulin/metformin group.

However, the impact of these results might be limited, since current guidelines recommend treatment with maximum doses of both sulfonylurea and metformin before introducing insulin therapy.^2,8 Nevertheless, the results underline the favorable influence on relevant outcomes of insulin combination therapy compared with insulin monotherapy, provided that at least metformin is used.

Patients in our study were recruited during regular appointments with their own care provider, and insulin treatment was established under “usual care” conditions. So it is likely that this study group represents the type 2 diabetes patients in primary care that, sooner or later, should start insulin therapy, and that the results of this study are highly applicable to them.

Our results suggest that an evening injection with NPH insulin in addition to an existing maximal therapy with sulfonylurea and metformin can be recommended as an effective, simple, and well-tolerated first-choice approach with patients who are willing to continue oral medication. Since both family physicians and patients are inclined to delay starting insulin,²⁰ such a strategy might encourage the timely use of insulin.¹⁴

Acknowledgments

We thank Rianne Maillé for her expert contribution concerning the questionnaires. In particular we would like to thank the patients, diabetes nurses, and family physicians for their participation.

Corresponding author
Alex N. Goudswaard, Koperslagersgilde 5, 3994 CH Houten, Netherlands. E-mail: [email protected].

The physician who doctors himself has a fool for a patient.
—Sir William Osler

The consistent message in the medical literature, beginning with Osler, has been that physicians should not doctor themselves.^1-9 Despite this belief, a number of cross-sectional studies suggest that at best only 50% of physicians even have a personal physician^1,8-13 and that between 42% and 82% of physicians doctor themselves in some fashion.^1,6,8,12

Becoming a competent physician does not automatically make one a competent patient.^14,15 In fact, physicians are allegedly the “very worst patients.”¹⁵ Physicians are expected to understand and empathize with the patient’s perspective, yet most authors have maintained that physicians tend to avoid, deny, or reject patient-hood,^{2,3,5,11,13,14,16-22} and even the susceptibility to illness.²³

Given the high prevalence of self-doctoring behavior among physician-patients, we sought to further explore seriously ill physicians’ experiences with self-doctoring. Specifically, we wanted to know if they doctored themselves and, if so, when, why, and with what outcome.

Methods

Design

For this qualitative study, approved by the Johns Hopkins Institutional Review Board, we used semistructured in-depth interviews.

Study population and sampling

A convenience sample of physicians who had been treated for cancer during or after their medical training was identified by clinicians in the divisions of oncology and radiation oncology at our institution. Of 38 physicians contacted, 25 agreed to participate; however, 2 subjects died before their interview could be arranged. Enrollment continued until no new concepts were identified, also called the point of theoretical saturation.²⁴

Data collection

We based the interview questions on themes extracted from a literature search that identified 5 books, 26 articles, and 3 videotapes. (These references are available online as Table W1.) Interviews lasted approximately 1.5 hours. The interviewer (E.F.) started by asking subjects to tell the story of how they learned of their cancer and progressed to more focused questions about whether they acted as their own doctor and why. All interviews were taped and transcribed, and their accuracy was verified by listening to the audiotape.

Analysis. Two coders (E.F. and R.H.) independently coded all 23 transcripts. In case of disagreement, the coders achieved consensus through discussion and used this information to refine the boundaries of each theme.

Working together, we created a comprehensive coding scheme by arranging data into logical categories of themes using the strategies of textual analysis and codebook development described by Crabtree and Miller.²⁵ The work by Crabtree and Miller addressed the theme “health care-seeking behaviors and strategies” and its associated codes developed using an “editing-style analysis” consistent with the constant comparative method in the Grounded Theory tradition.²⁶

Trustworthiness. To ensure trustworthiness, we mailed an 11-item summary of the main points to the 21 surviving participants as the analysis neared completion. We asked them to review the main points of our study, indicate whether they agreed or disagreed (with no response indicating agreement), and add any clarifying comments they felt appropriate. This information was used to clarify and further develop themes.

RESULTS

Our sample was predominately Caucasian and represented a diversity of gender, specialty, and participant characteristics (Table 1).

TABLE 1
Participant characteristics (N=23)

The nature of self-doctoring What is self-doctoring and when does it occur?

The participants did not identify a discrete activity or group of activities that constituted self-doctoring (Table 2). Some activities were obvious because they required privileges restricted to medical personnel—for example, ordering one’s own abdominal computed tomography scan. Other activities were less obvious because they could be performed by any patient—such as treating oneself for a minor illness like low back pain.

Should you doctor yourself? Whereas only 1 participant recommended self-doctoring, the rest were more or less strongly opposed to the practice. Despite this stance, most participants were able to identify instances during which they did doctor themselves. Sometimes they doctored themselves without acknowledging this activity as doctoring.

EF: Do you ever feel like you do anything where you doctor yourself?

PARTICIPANT: No I don’t think so . . . I’ve never had a primary care physician, which is probably a mistake because I tell all my patients they should have one.

EF: How did you get your PSAs [prostate-specific antigen]?

PARTICIPANT: I would just go down and get my blood done myself.

EF: So would you say that is an example of being your own doctor?

PARTICIPANT: Yeah, I suppose it is to some degree!

Reframing the question: from self-doctoring to health care-seeking strategies. Although our questions were about self-doctoring, participants spoke less about self-doctoring and more about their strategy for obtaining health care. This concept of health care-seeking strategies accounted for all of the various methods that participants used to obtain health care, of which self-doctoring was one.

TABLE 2
Subtle ways in which participants doctored themselves

The continuum of health care-seeking strategies

The following examples illustrate 3 health care-seeking strategies. When viewed together, these strategies create a continuum ranging between the roles of physician and patient. The following categories are not intended to be mutually exclusive, but to indicate an individual participant’s emphasized role. We referred to strategies that emphasized the physician role as PHYSICIAN-patient, here exemplified by this internist who had more than 40 years of experience in clinical practice.

One evening I felt a mass in my right lower quadrant. I figured I had a little hematoma—I couldn’t see anything, but I was pretty asymptomatic and by chance felt [the mass]. I watched it for maybe a week or so and it didn’t seem to change. I did a couple of routine blood tests and my CBC and Chem-20 profile were okay. But then when [the mass] didn’t go down, I asked one of my partners to feel it. He said “yes, I can feel a mass—you’d better look into it.” I didn’t see a doctor—just a curbside-type thing. So then I set up a CT scan, I got a CE antigen, and I just did this on my own, and the CT scan showed a mass in the appendiceal area and the CE antigen was up a little bit. I guess I went right to my surgeon!

At the other end of the continuum, this middleaged pediatric subspecialist represents those physicians whose health care-seeking strategies were based on their roles as patients. We labeled this strategy physician-PATIENT, emphasizing the patient role.

You know, I think that a physician diagnosed with cancer is like any person diagnosed with cancer. Their first concern has nothing to do with their careers. I think the hardest thing about being a physician-patient is that you hate to bother your doctors. Or you want to sort of “call your doctor with the answer” instead of just asking questions. I think you sort of feel like sometimes that you should be able to somehow know whether [your] symptom is related to metastatic disease without having to ask, “Should I be worried about this or not?” Physicians have the same fears and difficulties as anyone else does and need to give themselves permission to act like a normal patient.

This next physician, a medical subspecialist who had recently undergone bilateral mastectomy for stage I breast cancer, falls somewhere in the middle of this continuum. We labeled this approach Physician-Patient, signifying the incorporation of both roles into her health care-seeking strategy.

This breast mass was discovered by my gynecologist but he told me, don’t worry—it’s a fibroadenoma. It was small, not really moveable, so I didn’t listen to him. I went to a surgeon. I wouldn’t say I doctored myself just because I didn’t necessarily listen to my physician. It didn’t make sense from my medical training, so I did what made sense—I can listen to those doctors’ advice, but I use my own judgment.

Advantages of being a physician-patient: convenience and control. Physicians recognized definite advantages afforded by their status, mostly related to added convenience in navigating through the system and scheduling appointments, and being able to control many aspects of their care. This specialist in infectious disease with metastatic cancer illustrates the importance of convenience and control in explaining why she often relied on self-doctoring.

I think idealistically you should never be your own doctor, but realistically I think I can accomplish more faster without interrupting the doctor’s schedule. A couple of weeks ago I started spiking fevers but I had no symptoms of any kind…. After the third day I thought, “I bet this is tumor fever!” So I went out and bought Naprosyn and I was afebrile the next morning…. Now I guess there is a small chance I have an abscess somewhere, but I think I can obviate a lot of workup that my physician is more obligated to do than I am, medico-legally … I am sure there are control issues because we all like control and I am sure I like the control and the convenience.

Disadvantages of being a physician-patient: denying yourself the opportunity to receive support; lack of objectivity; delaying care. In talking about the disadvantages of their strategies, physicians invariably referred to a previous negative experience. This young pediatrician with a large retroperitoneal mass described how she learned of her computed tomography scan results.

More insidious is the potential loss of objectivity that can occur when one’s own health is at stake. For example, a pediatric subspecialist with lymphoma described how she rationalized not bringing the enlarged lymph nodes in her neck to medical attention by telling herself that she “knew what cancer felt like.”

Advantages of being a physician-patient: trusting one’s care to others; relinquishing control; benefiting from the expertise and support of other physicians. Physicians who relied more on their physicians and less on self-doctoring approached control from the perspective of “letting go.” This emergency medicine specialist explains why he would rather trust his physician’s expertise than his own.

Find doctors you trust and listen to them because they’re the experts. The same way you’re the expert to your patients, the patients you care for. In some real sense, relinquish control. Give control to somebody else and even for nonphysician patients it’s very difficult but for physician-patients I think it’s one of the most difficult things but you have to do this. You have to trust yourself to someone else.

Disadvantages of being a physician-patient: being too trusting. This physician-patient describes adopting a more passive stance toward his health care in order to “be a good patient.” The result was that his Hodgkin’s disease was not diagnosed until 18 months after his initial biopsy.

By adopting that stance, I might have done myself a disservice. Our lives would have been very different had I questioned more aggressively the use of a needle biopsy because the pathologist here said, “You know, that’s an absolutely foolish inept way to look for lymphoma.” So in some ways the strategy backfired a bit.… But I really trusted their judgment.

Discussion

The attitudes and experiences of the study participants paralleled the medical literature: all but 1 recommended against self-doctoring, yet almost all were able to identify situations in which they did doctor themselves. Our findings show that participants’ health care-seeking strategies can be identified along a continuum ranging between the roles of physician and patient ( Figure 1 ). Whereas previous literature on physician-patients has characterized their situation as “role-reversal,”^16,19,27 our findings suggest that physicians assume both roles depending on circumstances, influenced by their desire for control and degree of trust.

Trusting health care may be particularly difficult for physician-patients.^2,3,27 In our study, participants at the “physician” end of the continuum were reluctant to “let go” of control over care, especially care they did not trust. They valued the convenience and time saved when they did things themselves and felt less need for support from their professional caregivers. These physicians did not consciously set out to doctor themselves. Instead, they simply used the expertise and status of their physician role to take care of themselves in the same way they might take care of a patient.

At the “patient” end of the health care-seeking continuum, participants approached their own health care as they thought a patient should. They tended not to be as involved with the details of their care, felt less pressure to be an expert in their own illness, and wanted their doctor to play an active role in medical decisions. They frequently emphasized the importance of being able to trust their care to another person and letting go of the need to be in control of their care. They valued the relationships with their physicians and appreciated the support these relationships provided.

Negative experiences invariably changed participants’ attitudes and where they were identified on the continuum. Both roles included unanticipated pitfalls, particularly for participants who adhered rigidly to either end of the continuum.

This study had important limitations. We recruited only physician-patients with cancer from a single institution and our sample was skewed toward survivors and presumably toward individuals who were comfortable talking about their experiences. Moreover, we replied on a convenience sample of patient-physicians identified by their specialists. Thus, the transferability of out findings ma be limited. Finally, our data captured the perspective of only the “physician-patient”—we did not interview their physicians. Nonetheless, we believe this provides robust new insights into physicians self-doctoring behaviors in the face of a serious, life-threatening illness.

Our findings make sense of the apparent mismatch between expert recommendations and physicians’ stated beliefs on one side, and physicians’ reported activities on the other. Rather than warning physicians not to doctor themselves, we advocate trying to focus on what is important: obtaining and providing good care ( Table 3 ). These questions are derived from 1 or more participating physician-patients’ experiences. In this way, we hope that readers might benefit from our participants’ experiences.

TABLE 3
Questions for physicians to ask themselves when seeking health care

FIGURE 1
Physician-patient continuum

Acknowledgments

Dr Carrese was a Robert Wood Johnson Generalist Physician Faculty Scholar when this work was conducted. This work was largely completed while Drs Fromme and Hebert were fellows in the Division of General Internal Medicine, The Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center. It was presented in abstract form at the 24th Annual Meeting of the Society of General Internal Medicine, San Diego, California in May 2001 and was funded by a grant from the Kenneth B. Schwartz Center, Boston, Mass.

Corresponding author
Erik K. Fromme, MD, Division of General Medicine and Geriatrics, L475, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098. E-mail: [email protected].

The physician who doctors himself has a fool for a patient.
—Sir William Osler

The consistent message in the medical literature, beginning with Osler, has been that physicians should not doctor themselves.^1-9 Despite this belief, a number of cross-sectional studies suggest that at best only 50% of physicians even have a personal physician^1,8-13 and that between 42% and 82% of physicians doctor themselves in some fashion.^1,6,8,12

Becoming a competent physician does not automatically make one a competent patient.^14,15 In fact, physicians are allegedly the “very worst patients.”¹⁵ Physicians are expected to understand and empathize with the patient’s perspective, yet most authors have maintained that physicians tend to avoid, deny, or reject patient-hood,^{2,3,5,11,13,14,16-22} and even the susceptibility to illness.²³

Given the high prevalence of self-doctoring behavior among physician-patients, we sought to further explore seriously ill physicians’ experiences with self-doctoring. Specifically, we wanted to know if they doctored themselves and, if so, when, why, and with what outcome.

Methods

Design

For this qualitative study, approved by the Johns Hopkins Institutional Review Board, we used semistructured in-depth interviews.

Study population and sampling

A convenience sample of physicians who had been treated for cancer during or after their medical training was identified by clinicians in the divisions of oncology and radiation oncology at our institution. Of 38 physicians contacted, 25 agreed to participate; however, 2 subjects died before their interview could be arranged. Enrollment continued until no new concepts were identified, also called the point of theoretical saturation.²⁴

Data collection

We based the interview questions on themes extracted from a literature search that identified 5 books, 26 articles, and 3 videotapes. (These references are available online as Table W1.) Interviews lasted approximately 1.5 hours. The interviewer (E.F.) started by asking subjects to tell the story of how they learned of their cancer and progressed to more focused questions about whether they acted as their own doctor and why. All interviews were taped and transcribed, and their accuracy was verified by listening to the audiotape.

Analysis. Two coders (E.F. and R.H.) independently coded all 23 transcripts. In case of disagreement, the coders achieved consensus through discussion and used this information to refine the boundaries of each theme.

Working together, we created a comprehensive coding scheme by arranging data into logical categories of themes using the strategies of textual analysis and codebook development described by Crabtree and Miller.²⁵ The work by Crabtree and Miller addressed the theme “health care-seeking behaviors and strategies” and its associated codes developed using an “editing-style analysis” consistent with the constant comparative method in the Grounded Theory tradition.²⁶

Trustworthiness. To ensure trustworthiness, we mailed an 11-item summary of the main points to the 21 surviving participants as the analysis neared completion. We asked them to review the main points of our study, indicate whether they agreed or disagreed (with no response indicating agreement), and add any clarifying comments they felt appropriate. This information was used to clarify and further develop themes.

RESULTS

Our sample was predominately Caucasian and represented a diversity of gender, specialty, and participant characteristics (Table 1).

TABLE 1
Participant characteristics (N=23)

The nature of self-doctoring What is self-doctoring and when does it occur?

The participants did not identify a discrete activity or group of activities that constituted self-doctoring (Table 2). Some activities were obvious because they required privileges restricted to medical personnel—for example, ordering one’s own abdominal computed tomography scan. Other activities were less obvious because they could be performed by any patient—such as treating oneself for a minor illness like low back pain.

Should you doctor yourself? Whereas only 1 participant recommended self-doctoring, the rest were more or less strongly opposed to the practice. Despite this stance, most participants were able to identify instances during which they did doctor themselves. Sometimes they doctored themselves without acknowledging this activity as doctoring.

EF: Do you ever feel like you do anything where you doctor yourself?

PARTICIPANT: No I don’t think so . . . I’ve never had a primary care physician, which is probably a mistake because I tell all my patients they should have one.

EF: How did you get your PSAs [prostate-specific antigen]?

PARTICIPANT: I would just go down and get my blood done myself.

EF: So would you say that is an example of being your own doctor?

PARTICIPANT: Yeah, I suppose it is to some degree!

Reframing the question: from self-doctoring to health care-seeking strategies. Although our questions were about self-doctoring, participants spoke less about self-doctoring and more about their strategy for obtaining health care. This concept of health care-seeking strategies accounted for all of the various methods that participants used to obtain health care, of which self-doctoring was one.

TABLE 2
Subtle ways in which participants doctored themselves

The continuum of health care-seeking strategies

The following examples illustrate 3 health care-seeking strategies. When viewed together, these strategies create a continuum ranging between the roles of physician and patient. The following categories are not intended to be mutually exclusive, but to indicate an individual participant’s emphasized role. We referred to strategies that emphasized the physician role as PHYSICIAN-patient, here exemplified by this internist who had more than 40 years of experience in clinical practice.

One evening I felt a mass in my right lower quadrant. I figured I had a little hematoma—I couldn’t see anything, but I was pretty asymptomatic and by chance felt [the mass]. I watched it for maybe a week or so and it didn’t seem to change. I did a couple of routine blood tests and my CBC and Chem-20 profile were okay. But then when [the mass] didn’t go down, I asked one of my partners to feel it. He said “yes, I can feel a mass—you’d better look into it.” I didn’t see a doctor—just a curbside-type thing. So then I set up a CT scan, I got a CE antigen, and I just did this on my own, and the CT scan showed a mass in the appendiceal area and the CE antigen was up a little bit. I guess I went right to my surgeon!

At the other end of the continuum, this middleaged pediatric subspecialist represents those physicians whose health care-seeking strategies were based on their roles as patients. We labeled this strategy physician-PATIENT, emphasizing the patient role.

You know, I think that a physician diagnosed with cancer is like any person diagnosed with cancer. Their first concern has nothing to do with their careers. I think the hardest thing about being a physician-patient is that you hate to bother your doctors. Or you want to sort of “call your doctor with the answer” instead of just asking questions. I think you sort of feel like sometimes that you should be able to somehow know whether [your] symptom is related to metastatic disease without having to ask, “Should I be worried about this or not?” Physicians have the same fears and difficulties as anyone else does and need to give themselves permission to act like a normal patient.

This next physician, a medical subspecialist who had recently undergone bilateral mastectomy for stage I breast cancer, falls somewhere in the middle of this continuum. We labeled this approach Physician-Patient, signifying the incorporation of both roles into her health care-seeking strategy.

This breast mass was discovered by my gynecologist but he told me, don’t worry—it’s a fibroadenoma. It was small, not really moveable, so I didn’t listen to him. I went to a surgeon. I wouldn’t say I doctored myself just because I didn’t necessarily listen to my physician. It didn’t make sense from my medical training, so I did what made sense—I can listen to those doctors’ advice, but I use my own judgment.

Advantages of being a physician-patient: convenience and control. Physicians recognized definite advantages afforded by their status, mostly related to added convenience in navigating through the system and scheduling appointments, and being able to control many aspects of their care. This specialist in infectious disease with metastatic cancer illustrates the importance of convenience and control in explaining why she often relied on self-doctoring.

I think idealistically you should never be your own doctor, but realistically I think I can accomplish more faster without interrupting the doctor’s schedule. A couple of weeks ago I started spiking fevers but I had no symptoms of any kind…. After the third day I thought, “I bet this is tumor fever!” So I went out and bought Naprosyn and I was afebrile the next morning…. Now I guess there is a small chance I have an abscess somewhere, but I think I can obviate a lot of workup that my physician is more obligated to do than I am, medico-legally … I am sure there are control issues because we all like control and I am sure I like the control and the convenience.

Disadvantages of being a physician-patient: denying yourself the opportunity to receive support; lack of objectivity; delaying care. In talking about the disadvantages of their strategies, physicians invariably referred to a previous negative experience. This young pediatrician with a large retroperitoneal mass described how she learned of her computed tomography scan results.

More insidious is the potential loss of objectivity that can occur when one’s own health is at stake. For example, a pediatric subspecialist with lymphoma described how she rationalized not bringing the enlarged lymph nodes in her neck to medical attention by telling herself that she “knew what cancer felt like.”

Advantages of being a physician-patient: trusting one’s care to others; relinquishing control; benefiting from the expertise and support of other physicians. Physicians who relied more on their physicians and less on self-doctoring approached control from the perspective of “letting go.” This emergency medicine specialist explains why he would rather trust his physician’s expertise than his own.

Find doctors you trust and listen to them because they’re the experts. The same way you’re the expert to your patients, the patients you care for. In some real sense, relinquish control. Give control to somebody else and even for nonphysician patients it’s very difficult but for physician-patients I think it’s one of the most difficult things but you have to do this. You have to trust yourself to someone else.

Disadvantages of being a physician-patient: being too trusting. This physician-patient describes adopting a more passive stance toward his health care in order to “be a good patient.” The result was that his Hodgkin’s disease was not diagnosed until 18 months after his initial biopsy.

By adopting that stance, I might have done myself a disservice. Our lives would have been very different had I questioned more aggressively the use of a needle biopsy because the pathologist here said, “You know, that’s an absolutely foolish inept way to look for lymphoma.” So in some ways the strategy backfired a bit.… But I really trusted their judgment.

Discussion

The attitudes and experiences of the study participants paralleled the medical literature: all but 1 recommended against self-doctoring, yet almost all were able to identify situations in which they did doctor themselves. Our findings show that participants’ health care-seeking strategies can be identified along a continuum ranging between the roles of physician and patient ( Figure 1 ). Whereas previous literature on physician-patients has characterized their situation as “role-reversal,”^16,19,27 our findings suggest that physicians assume both roles depending on circumstances, influenced by their desire for control and degree of trust.

Trusting health care may be particularly difficult for physician-patients.^2,3,27 In our study, participants at the “physician” end of the continuum were reluctant to “let go” of control over care, especially care they did not trust. They valued the convenience and time saved when they did things themselves and felt less need for support from their professional caregivers. These physicians did not consciously set out to doctor themselves. Instead, they simply used the expertise and status of their physician role to take care of themselves in the same way they might take care of a patient.

At the “patient” end of the health care-seeking continuum, participants approached their own health care as they thought a patient should. They tended not to be as involved with the details of their care, felt less pressure to be an expert in their own illness, and wanted their doctor to play an active role in medical decisions. They frequently emphasized the importance of being able to trust their care to another person and letting go of the need to be in control of their care. They valued the relationships with their physicians and appreciated the support these relationships provided.

Negative experiences invariably changed participants’ attitudes and where they were identified on the continuum. Both roles included unanticipated pitfalls, particularly for participants who adhered rigidly to either end of the continuum.

This study had important limitations. We recruited only physician-patients with cancer from a single institution and our sample was skewed toward survivors and presumably toward individuals who were comfortable talking about their experiences. Moreover, we replied on a convenience sample of patient-physicians identified by their specialists. Thus, the transferability of out findings ma be limited. Finally, our data captured the perspective of only the “physician-patient”—we did not interview their physicians. Nonetheless, we believe this provides robust new insights into physicians self-doctoring behaviors in the face of a serious, life-threatening illness.

Our findings make sense of the apparent mismatch between expert recommendations and physicians’ stated beliefs on one side, and physicians’ reported activities on the other. Rather than warning physicians not to doctor themselves, we advocate trying to focus on what is important: obtaining and providing good care ( Table 3 ). These questions are derived from 1 or more participating physician-patients’ experiences. In this way, we hope that readers might benefit from our participants’ experiences.

TABLE 3
Questions for physicians to ask themselves when seeking health care

FIGURE 1
Physician-patient continuum

Acknowledgments

Dr Carrese was a Robert Wood Johnson Generalist Physician Faculty Scholar when this work was conducted. This work was largely completed while Drs Fromme and Hebert were fellows in the Division of General Internal Medicine, The Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center. It was presented in abstract form at the 24th Annual Meeting of the Society of General Internal Medicine, San Diego, California in May 2001 and was funded by a grant from the Kenneth B. Schwartz Center, Boston, Mass.

Corresponding author
Erik K. Fromme, MD, Division of General Medicine and Geriatrics, L475, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098. E-mail: [email protected].

The physician who doctors himself has a fool for a patient.
—Sir William Osler

The consistent message in the medical literature, beginning with Osler, has been that physicians should not doctor themselves.^1-9 Despite this belief, a number of cross-sectional studies suggest that at best only 50% of physicians even have a personal physician^1,8-13 and that between 42% and 82% of physicians doctor themselves in some fashion.^1,6,8,12

Becoming a competent physician does not automatically make one a competent patient.^14,15 In fact, physicians are allegedly the “very worst patients.”¹⁵ Physicians are expected to understand and empathize with the patient’s perspective, yet most authors have maintained that physicians tend to avoid, deny, or reject patient-hood,^{2,3,5,11,13,14,16-22} and even the susceptibility to illness.²³

Given the high prevalence of self-doctoring behavior among physician-patients, we sought to further explore seriously ill physicians’ experiences with self-doctoring. Specifically, we wanted to know if they doctored themselves and, if so, when, why, and with what outcome.

Methods

Design

For this qualitative study, approved by the Johns Hopkins Institutional Review Board, we used semistructured in-depth interviews.

Study population and sampling

A convenience sample of physicians who had been treated for cancer during or after their medical training was identified by clinicians in the divisions of oncology and radiation oncology at our institution. Of 38 physicians contacted, 25 agreed to participate; however, 2 subjects died before their interview could be arranged. Enrollment continued until no new concepts were identified, also called the point of theoretical saturation.²⁴

Data collection

We based the interview questions on themes extracted from a literature search that identified 5 books, 26 articles, and 3 videotapes. (These references are available online as Table W1.) Interviews lasted approximately 1.5 hours. The interviewer (E.F.) started by asking subjects to tell the story of how they learned of their cancer and progressed to more focused questions about whether they acted as their own doctor and why. All interviews were taped and transcribed, and their accuracy was verified by listening to the audiotape.

Analysis. Two coders (E.F. and R.H.) independently coded all 23 transcripts. In case of disagreement, the coders achieved consensus through discussion and used this information to refine the boundaries of each theme.

Working together, we created a comprehensive coding scheme by arranging data into logical categories of themes using the strategies of textual analysis and codebook development described by Crabtree and Miller.²⁵ The work by Crabtree and Miller addressed the theme “health care-seeking behaviors and strategies” and its associated codes developed using an “editing-style analysis” consistent with the constant comparative method in the Grounded Theory tradition.²⁶

Trustworthiness. To ensure trustworthiness, we mailed an 11-item summary of the main points to the 21 surviving participants as the analysis neared completion. We asked them to review the main points of our study, indicate whether they agreed or disagreed (with no response indicating agreement), and add any clarifying comments they felt appropriate. This information was used to clarify and further develop themes.

RESULTS

Our sample was predominately Caucasian and represented a diversity of gender, specialty, and participant characteristics (Table 1).

TABLE 1
Participant characteristics (N=23)

The nature of self-doctoring What is self-doctoring and when does it occur?

The participants did not identify a discrete activity or group of activities that constituted self-doctoring (Table 2). Some activities were obvious because they required privileges restricted to medical personnel—for example, ordering one’s own abdominal computed tomography scan. Other activities were less obvious because they could be performed by any patient—such as treating oneself for a minor illness like low back pain.

Should you doctor yourself? Whereas only 1 participant recommended self-doctoring, the rest were more or less strongly opposed to the practice. Despite this stance, most participants were able to identify instances during which they did doctor themselves. Sometimes they doctored themselves without acknowledging this activity as doctoring.

EF: Do you ever feel like you do anything where you doctor yourself?

PARTICIPANT: No I don’t think so . . . I’ve never had a primary care physician, which is probably a mistake because I tell all my patients they should have one.

EF: How did you get your PSAs [prostate-specific antigen]?

PARTICIPANT: I would just go down and get my blood done myself.

EF: So would you say that is an example of being your own doctor?

PARTICIPANT: Yeah, I suppose it is to some degree!

Reframing the question: from self-doctoring to health care-seeking strategies. Although our questions were about self-doctoring, participants spoke less about self-doctoring and more about their strategy for obtaining health care. This concept of health care-seeking strategies accounted for all of the various methods that participants used to obtain health care, of which self-doctoring was one.

TABLE 2
Subtle ways in which participants doctored themselves

The continuum of health care-seeking strategies

The following examples illustrate 3 health care-seeking strategies. When viewed together, these strategies create a continuum ranging between the roles of physician and patient. The following categories are not intended to be mutually exclusive, but to indicate an individual participant’s emphasized role. We referred to strategies that emphasized the physician role as PHYSICIAN-patient, here exemplified by this internist who had more than 40 years of experience in clinical practice.

One evening I felt a mass in my right lower quadrant. I figured I had a little hematoma—I couldn’t see anything, but I was pretty asymptomatic and by chance felt [the mass]. I watched it for maybe a week or so and it didn’t seem to change. I did a couple of routine blood tests and my CBC and Chem-20 profile were okay. But then when [the mass] didn’t go down, I asked one of my partners to feel it. He said “yes, I can feel a mass—you’d better look into it.” I didn’t see a doctor—just a curbside-type thing. So then I set up a CT scan, I got a CE antigen, and I just did this on my own, and the CT scan showed a mass in the appendiceal area and the CE antigen was up a little bit. I guess I went right to my surgeon!

At the other end of the continuum, this middleaged pediatric subspecialist represents those physicians whose health care-seeking strategies were based on their roles as patients. We labeled this strategy physician-PATIENT, emphasizing the patient role.

You know, I think that a physician diagnosed with cancer is like any person diagnosed with cancer. Their first concern has nothing to do with their careers. I think the hardest thing about being a physician-patient is that you hate to bother your doctors. Or you want to sort of “call your doctor with the answer” instead of just asking questions. I think you sort of feel like sometimes that you should be able to somehow know whether [your] symptom is related to metastatic disease without having to ask, “Should I be worried about this or not?” Physicians have the same fears and difficulties as anyone else does and need to give themselves permission to act like a normal patient.

This next physician, a medical subspecialist who had recently undergone bilateral mastectomy for stage I breast cancer, falls somewhere in the middle of this continuum. We labeled this approach Physician-Patient, signifying the incorporation of both roles into her health care-seeking strategy.

This breast mass was discovered by my gynecologist but he told me, don’t worry—it’s a fibroadenoma. It was small, not really moveable, so I didn’t listen to him. I went to a surgeon. I wouldn’t say I doctored myself just because I didn’t necessarily listen to my physician. It didn’t make sense from my medical training, so I did what made sense—I can listen to those doctors’ advice, but I use my own judgment.

Advantages of being a physician-patient: convenience and control. Physicians recognized definite advantages afforded by their status, mostly related to added convenience in navigating through the system and scheduling appointments, and being able to control many aspects of their care. This specialist in infectious disease with metastatic cancer illustrates the importance of convenience and control in explaining why she often relied on self-doctoring.

I think idealistically you should never be your own doctor, but realistically I think I can accomplish more faster without interrupting the doctor’s schedule. A couple of weeks ago I started spiking fevers but I had no symptoms of any kind…. After the third day I thought, “I bet this is tumor fever!” So I went out and bought Naprosyn and I was afebrile the next morning…. Now I guess there is a small chance I have an abscess somewhere, but I think I can obviate a lot of workup that my physician is more obligated to do than I am, medico-legally … I am sure there are control issues because we all like control and I am sure I like the control and the convenience.

Disadvantages of being a physician-patient: denying yourself the opportunity to receive support; lack of objectivity; delaying care. In talking about the disadvantages of their strategies, physicians invariably referred to a previous negative experience. This young pediatrician with a large retroperitoneal mass described how she learned of her computed tomography scan results.

More insidious is the potential loss of objectivity that can occur when one’s own health is at stake. For example, a pediatric subspecialist with lymphoma described how she rationalized not bringing the enlarged lymph nodes in her neck to medical attention by telling herself that she “knew what cancer felt like.”

Advantages of being a physician-patient: trusting one’s care to others; relinquishing control; benefiting from the expertise and support of other physicians. Physicians who relied more on their physicians and less on self-doctoring approached control from the perspective of “letting go.” This emergency medicine specialist explains why he would rather trust his physician’s expertise than his own.

Find doctors you trust and listen to them because they’re the experts. The same way you’re the expert to your patients, the patients you care for. In some real sense, relinquish control. Give control to somebody else and even for nonphysician patients it’s very difficult but for physician-patients I think it’s one of the most difficult things but you have to do this. You have to trust yourself to someone else.

Disadvantages of being a physician-patient: being too trusting. This physician-patient describes adopting a more passive stance toward his health care in order to “be a good patient.” The result was that his Hodgkin’s disease was not diagnosed until 18 months after his initial biopsy.

By adopting that stance, I might have done myself a disservice. Our lives would have been very different had I questioned more aggressively the use of a needle biopsy because the pathologist here said, “You know, that’s an absolutely foolish inept way to look for lymphoma.” So in some ways the strategy backfired a bit.… But I really trusted their judgment.

Discussion

The attitudes and experiences of the study participants paralleled the medical literature: all but 1 recommended against self-doctoring, yet almost all were able to identify situations in which they did doctor themselves. Our findings show that participants’ health care-seeking strategies can be identified along a continuum ranging between the roles of physician and patient ( Figure 1 ). Whereas previous literature on physician-patients has characterized their situation as “role-reversal,”^16,19,27 our findings suggest that physicians assume both roles depending on circumstances, influenced by their desire for control and degree of trust.

Trusting health care may be particularly difficult for physician-patients.^2,3,27 In our study, participants at the “physician” end of the continuum were reluctant to “let go” of control over care, especially care they did not trust. They valued the convenience and time saved when they did things themselves and felt less need for support from their professional caregivers. These physicians did not consciously set out to doctor themselves. Instead, they simply used the expertise and status of their physician role to take care of themselves in the same way they might take care of a patient.

At the “patient” end of the health care-seeking continuum, participants approached their own health care as they thought a patient should. They tended not to be as involved with the details of their care, felt less pressure to be an expert in their own illness, and wanted their doctor to play an active role in medical decisions. They frequently emphasized the importance of being able to trust their care to another person and letting go of the need to be in control of their care. They valued the relationships with their physicians and appreciated the support these relationships provided.

Negative experiences invariably changed participants’ attitudes and where they were identified on the continuum. Both roles included unanticipated pitfalls, particularly for participants who adhered rigidly to either end of the continuum.

This study had important limitations. We recruited only physician-patients with cancer from a single institution and our sample was skewed toward survivors and presumably toward individuals who were comfortable talking about their experiences. Moreover, we replied on a convenience sample of patient-physicians identified by their specialists. Thus, the transferability of out findings ma be limited. Finally, our data captured the perspective of only the “physician-patient”—we did not interview their physicians. Nonetheless, we believe this provides robust new insights into physicians self-doctoring behaviors in the face of a serious, life-threatening illness.

Our findings make sense of the apparent mismatch between expert recommendations and physicians’ stated beliefs on one side, and physicians’ reported activities on the other. Rather than warning physicians not to doctor themselves, we advocate trying to focus on what is important: obtaining and providing good care ( Table 3 ). These questions are derived from 1 or more participating physician-patients’ experiences. In this way, we hope that readers might benefit from our participants’ experiences.

TABLE 3
Questions for physicians to ask themselves when seeking health care

FIGURE 1
Physician-patient continuum

Acknowledgments

Dr Carrese was a Robert Wood Johnson Generalist Physician Faculty Scholar when this work was conducted. This work was largely completed while Drs Fromme and Hebert were fellows in the Division of General Internal Medicine, The Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center. It was presented in abstract form at the 24th Annual Meeting of the Society of General Internal Medicine, San Diego, California in May 2001 and was funded by a grant from the Kenneth B. Schwartz Center, Boston, Mass.

Corresponding author
Erik K. Fromme, MD, Division of General Medicine and Geriatrics, L475, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098. E-mail: [email protected].

Laparoscopic cholecystectomy was first performed in France in 1987. In 1989, Reddick¹ popularized this procedure in the United States. Laparoscopic cholecystectomy was a natural outgrowth of laparoscopic surgery done by gynecologists in pelvic surgery and orthopedic surgeons doing endoscopic joint surgery for many decades before 1989. By late 1990 and early 1991, laparoscopic cholecystectomy had become widespread.

Large series of laparoscopic cholecystectomy were reported with few complications,^2-6 and most surgeons and patients prefer laparoscopic cholecystectomy to open cholecystectomy. Unfortunately, access to laparoscopic surgery and other procedures is limited in more rural areas. In this article, we report the first series of laparoscopic cholecystectomies performed by family physicians in a small rural community hospital.

Methods

From June 1992 to June 2001, the medical records of all patients with cholecystitis or cholelithiasis requiring surgical treatment at North Caddo Medical Center (NCMC), in Vivian, Louisiana, were reviewed. This group of patients was self-referred and consisted of consecutive individuals who presented to 2 family practitioners (1 primary surgeon and 1 partner) at the NCMC.

Patient selection for surgery was made preop-eratively on the basis of history, physical, and laboratory diagnostic evidence of gall bladder disease. No patients were referred to other facilities.

Surgical technique

Laparoscopic cholecystectomy was performed using the surgical technique advocated by Dr. Reddick¹ using 4 ports. All surgery was performed by the lead author after he completed the course taught by Dr Reddick. The first 9 operations were performed in a tertiary hospital (Willis-Knighton Hospital, Shreveport, La) for credentialing purposes. Case-by-case modifications of the technique were sometimes necessary for successful outcomes.

Results

This series involved 108 patients from ages 18 to 89 years (17 were 18–34 years, 46 were 35–64 years, and 45 were 65 years), all of whom presented to NCMC for cholecystectomy. Patients were about 60% white and 40% African American; about 75% were female. Patients lived in a 450-square-mile service area. Forty-one percent of patients possessed private insurance, 44% had Medicare, and 23% had Medicaid.

About 30% of patients had significant medical morbidity and about 30% had previous abdominal or pelvic surgery. Accordingly, the insertion point of the Veress needle was adjusted to avoid the risk of perforations or injury to the bowel. Occasionally, a cut down was performed to directly visualize the peritoneum and the contents underneath before the ports were introduced. Other ports were then introduced under direct visualization.

The average operating-room time was 130 minutes, and the length of postoperative hospital stay was approximately 14 hours. Each patient was diagnosed conclusively to have gall bladder disease, confirmed by histopathological diagnosis.

The outcomes of this series are reported in Table 1 . There were no deaths; 2 cases were converted to open cholecystectomy after failed laparoscopic technique. There were no common bile duct injuries or postoperative complications. Six patients had postoperative fever for a short duration. No evidence of systemic or local infection was seen.

TABLE 1

Comparison of major series in laparoscopic cholecystectomy

Discussion

The outcomes of this unique case series of laparo-scopic cholecystectomies performed by family physicians in a rural community hospital were equivalent to those in the surgical literature from tertiary care settings.^2-6

The low rate of morbidity and nosocomial infections may be due to the smaller facility, favorable staff-to-patient ratio, lower perceived stress, attention to aseptic technique, and environmental sanitation. Because surgeons and patients prefer laparoscopic cholecystectomy to open cholecystectomy, and because this procedure is cost-effective, cosmetically superior, and produces far less morbidity, access to laparoscopic cholecystectomy is important even in rural communities.

While the Society of American Gastrointestinal Endoscopic Surgeons (SAGES)¹⁰ has introduced proposals to implement dedicated endoscopic surgical training, including telesurgery and robotic techniques, access to such services in rural communities will likely remain limited.

Nonetheless, several limitations are worth noting. Successful performance of this procedure requires focused training, discipline, skills and technology, and ongoing maintenance of competency. More sophisticated technology may become available and transportation and physical barriers to access may ease. But we believe this series demonstrates that procedural training and ongoing practice assessment can provide timely, safe, and appropriate access to the latest surgical techniques.

Since we closed this study, we have performed another 30 cases with similar excellent results and a substantial decrease in procedure and post-operative recovery time (90 minutes and 7 hours, respectively). Our ongoing assessment of our practice and performance improvement are integral to procedural excellence.

Conclusion

The authors have successfully delivered this well-defined surgical service in their community without any compromise in quality of care. The resources are unique, including training, team selection, and collaboration within a rural community hospital setting.

This experience suggests that an alternative model of practice and surgical training in family medicine may be feasible and offer effective, and perhaps superior results in rural communities. The inclusion of procedural skills in the scope of family medicine should be considered as a viable solution to the healthcare access and quality concerns of rural Americans.

· Acknowledgements ·

The authors thankfully acknowledge the advice and help received from: David Driggers, MD, Providence Family Practice Center, Anchorage, Alaska; Frank Kurzwez, MD, formerly Chairman, Department of Surgery, Louisiana State University Health Science Center, Shreveport; Debi P. Mukherjee, Sc.D, Associate Professor, Department of Orthopedic Surgery and Coordinator of Bio-Engineering, Louisiana State University Health Science Center, Shreveport; W. Norwood, MD, Chief, Department of Surgery, WK Hospital Health System, Shreveport; James Elrod, President, Willis-Knighton Hospital Health System, Shreveport; John Harlan Haynes III, MD, FABFP, MScMM (UT SWHSC), Med Alliance Health Center, Fort Worth, Tex; Jishnu Guha; and Indranil Guha.

Laparoscopic cholecystectomy was first performed in France in 1987. In 1989, Reddick¹ popularized this procedure in the United States. Laparoscopic cholecystectomy was a natural outgrowth of laparoscopic surgery done by gynecologists in pelvic surgery and orthopedic surgeons doing endoscopic joint surgery for many decades before 1989. By late 1990 and early 1991, laparoscopic cholecystectomy had become widespread.

Large series of laparoscopic cholecystectomy were reported with few complications,^2-6 and most surgeons and patients prefer laparoscopic cholecystectomy to open cholecystectomy. Unfortunately, access to laparoscopic surgery and other procedures is limited in more rural areas. In this article, we report the first series of laparoscopic cholecystectomies performed by family physicians in a small rural community hospital.

Methods

From June 1992 to June 2001, the medical records of all patients with cholecystitis or cholelithiasis requiring surgical treatment at North Caddo Medical Center (NCMC), in Vivian, Louisiana, were reviewed. This group of patients was self-referred and consisted of consecutive individuals who presented to 2 family practitioners (1 primary surgeon and 1 partner) at the NCMC.

Patient selection for surgery was made preop-eratively on the basis of history, physical, and laboratory diagnostic evidence of gall bladder disease. No patients were referred to other facilities.

Surgical technique

Laparoscopic cholecystectomy was performed using the surgical technique advocated by Dr. Reddick¹ using 4 ports. All surgery was performed by the lead author after he completed the course taught by Dr Reddick. The first 9 operations were performed in a tertiary hospital (Willis-Knighton Hospital, Shreveport, La) for credentialing purposes. Case-by-case modifications of the technique were sometimes necessary for successful outcomes.

Results

This series involved 108 patients from ages 18 to 89 years (17 were 18–34 years, 46 were 35–64 years, and 45 were 65 years), all of whom presented to NCMC for cholecystectomy. Patients were about 60% white and 40% African American; about 75% were female. Patients lived in a 450-square-mile service area. Forty-one percent of patients possessed private insurance, 44% had Medicare, and 23% had Medicaid.

About 30% of patients had significant medical morbidity and about 30% had previous abdominal or pelvic surgery. Accordingly, the insertion point of the Veress needle was adjusted to avoid the risk of perforations or injury to the bowel. Occasionally, a cut down was performed to directly visualize the peritoneum and the contents underneath before the ports were introduced. Other ports were then introduced under direct visualization.

The average operating-room time was 130 minutes, and the length of postoperative hospital stay was approximately 14 hours. Each patient was diagnosed conclusively to have gall bladder disease, confirmed by histopathological diagnosis.

The outcomes of this series are reported in Table 1 . There were no deaths; 2 cases were converted to open cholecystectomy after failed laparoscopic technique. There were no common bile duct injuries or postoperative complications. Six patients had postoperative fever for a short duration. No evidence of systemic or local infection was seen.

TABLE 1

Comparison of major series in laparoscopic cholecystectomy

Discussion

The outcomes of this unique case series of laparo-scopic cholecystectomies performed by family physicians in a rural community hospital were equivalent to those in the surgical literature from tertiary care settings.^2-6

The low rate of morbidity and nosocomial infections may be due to the smaller facility, favorable staff-to-patient ratio, lower perceived stress, attention to aseptic technique, and environmental sanitation. Because surgeons and patients prefer laparoscopic cholecystectomy to open cholecystectomy, and because this procedure is cost-effective, cosmetically superior, and produces far less morbidity, access to laparoscopic cholecystectomy is important even in rural communities.

While the Society of American Gastrointestinal Endoscopic Surgeons (SAGES)¹⁰ has introduced proposals to implement dedicated endoscopic surgical training, including telesurgery and robotic techniques, access to such services in rural communities will likely remain limited.

Nonetheless, several limitations are worth noting. Successful performance of this procedure requires focused training, discipline, skills and technology, and ongoing maintenance of competency. More sophisticated technology may become available and transportation and physical barriers to access may ease. But we believe this series demonstrates that procedural training and ongoing practice assessment can provide timely, safe, and appropriate access to the latest surgical techniques.

Since we closed this study, we have performed another 30 cases with similar excellent results and a substantial decrease in procedure and post-operative recovery time (90 minutes and 7 hours, respectively). Our ongoing assessment of our practice and performance improvement are integral to procedural excellence.

Conclusion

The authors have successfully delivered this well-defined surgical service in their community without any compromise in quality of care. The resources are unique, including training, team selection, and collaboration within a rural community hospital setting.

This experience suggests that an alternative model of practice and surgical training in family medicine may be feasible and offer effective, and perhaps superior results in rural communities. The inclusion of procedural skills in the scope of family medicine should be considered as a viable solution to the healthcare access and quality concerns of rural Americans.

· Acknowledgements ·

The authors thankfully acknowledge the advice and help received from: David Driggers, MD, Providence Family Practice Center, Anchorage, Alaska; Frank Kurzwez, MD, formerly Chairman, Department of Surgery, Louisiana State University Health Science Center, Shreveport; Debi P. Mukherjee, Sc.D, Associate Professor, Department of Orthopedic Surgery and Coordinator of Bio-Engineering, Louisiana State University Health Science Center, Shreveport; W. Norwood, MD, Chief, Department of Surgery, WK Hospital Health System, Shreveport; James Elrod, President, Willis-Knighton Hospital Health System, Shreveport; John Harlan Haynes III, MD, FABFP, MScMM (UT SWHSC), Med Alliance Health Center, Fort Worth, Tex; Jishnu Guha; and Indranil Guha.

Laparoscopic cholecystectomy was first performed in France in 1987. In 1989, Reddick¹ popularized this procedure in the United States. Laparoscopic cholecystectomy was a natural outgrowth of laparoscopic surgery done by gynecologists in pelvic surgery and orthopedic surgeons doing endoscopic joint surgery for many decades before 1989. By late 1990 and early 1991, laparoscopic cholecystectomy had become widespread.

Large series of laparoscopic cholecystectomy were reported with few complications,^2-6 and most surgeons and patients prefer laparoscopic cholecystectomy to open cholecystectomy. Unfortunately, access to laparoscopic surgery and other procedures is limited in more rural areas. In this article, we report the first series of laparoscopic cholecystectomies performed by family physicians in a small rural community hospital.

Methods

From June 1992 to June 2001, the medical records of all patients with cholecystitis or cholelithiasis requiring surgical treatment at North Caddo Medical Center (NCMC), in Vivian, Louisiana, were reviewed. This group of patients was self-referred and consisted of consecutive individuals who presented to 2 family practitioners (1 primary surgeon and 1 partner) at the NCMC.

Patient selection for surgery was made preop-eratively on the basis of history, physical, and laboratory diagnostic evidence of gall bladder disease. No patients were referred to other facilities.

Surgical technique

Laparoscopic cholecystectomy was performed using the surgical technique advocated by Dr. Reddick¹ using 4 ports. All surgery was performed by the lead author after he completed the course taught by Dr Reddick. The first 9 operations were performed in a tertiary hospital (Willis-Knighton Hospital, Shreveport, La) for credentialing purposes. Case-by-case modifications of the technique were sometimes necessary for successful outcomes.

Results

This series involved 108 patients from ages 18 to 89 years (17 were 18–34 years, 46 were 35–64 years, and 45 were 65 years), all of whom presented to NCMC for cholecystectomy. Patients were about 60% white and 40% African American; about 75% were female. Patients lived in a 450-square-mile service area. Forty-one percent of patients possessed private insurance, 44% had Medicare, and 23% had Medicaid.

About 30% of patients had significant medical morbidity and about 30% had previous abdominal or pelvic surgery. Accordingly, the insertion point of the Veress needle was adjusted to avoid the risk of perforations or injury to the bowel. Occasionally, a cut down was performed to directly visualize the peritoneum and the contents underneath before the ports were introduced. Other ports were then introduced under direct visualization.

The average operating-room time was 130 minutes, and the length of postoperative hospital stay was approximately 14 hours. Each patient was diagnosed conclusively to have gall bladder disease, confirmed by histopathological diagnosis.

The outcomes of this series are reported in Table 1 . There were no deaths; 2 cases were converted to open cholecystectomy after failed laparoscopic technique. There were no common bile duct injuries or postoperative complications. Six patients had postoperative fever for a short duration. No evidence of systemic or local infection was seen.

TABLE 1

Comparison of major series in laparoscopic cholecystectomy

Discussion

The outcomes of this unique case series of laparo-scopic cholecystectomies performed by family physicians in a rural community hospital were equivalent to those in the surgical literature from tertiary care settings.^2-6

The low rate of morbidity and nosocomial infections may be due to the smaller facility, favorable staff-to-patient ratio, lower perceived stress, attention to aseptic technique, and environmental sanitation. Because surgeons and patients prefer laparoscopic cholecystectomy to open cholecystectomy, and because this procedure is cost-effective, cosmetically superior, and produces far less morbidity, access to laparoscopic cholecystectomy is important even in rural communities.

While the Society of American Gastrointestinal Endoscopic Surgeons (SAGES)¹⁰ has introduced proposals to implement dedicated endoscopic surgical training, including telesurgery and robotic techniques, access to such services in rural communities will likely remain limited.

Nonetheless, several limitations are worth noting. Successful performance of this procedure requires focused training, discipline, skills and technology, and ongoing maintenance of competency. More sophisticated technology may become available and transportation and physical barriers to access may ease. But we believe this series demonstrates that procedural training and ongoing practice assessment can provide timely, safe, and appropriate access to the latest surgical techniques.

Since we closed this study, we have performed another 30 cases with similar excellent results and a substantial decrease in procedure and post-operative recovery time (90 minutes and 7 hours, respectively). Our ongoing assessment of our practice and performance improvement are integral to procedural excellence.

Conclusion

The authors have successfully delivered this well-defined surgical service in their community without any compromise in quality of care. The resources are unique, including training, team selection, and collaboration within a rural community hospital setting.

This experience suggests that an alternative model of practice and surgical training in family medicine may be feasible and offer effective, and perhaps superior results in rural communities. The inclusion of procedural skills in the scope of family medicine should be considered as a viable solution to the healthcare access and quality concerns of rural Americans.

· Acknowledgements ·

The authors thankfully acknowledge the advice and help received from: David Driggers, MD, Providence Family Practice Center, Anchorage, Alaska; Frank Kurzwez, MD, formerly Chairman, Department of Surgery, Louisiana State University Health Science Center, Shreveport; Debi P. Mukherjee, Sc.D, Associate Professor, Department of Orthopedic Surgery and Coordinator of Bio-Engineering, Louisiana State University Health Science Center, Shreveport; W. Norwood, MD, Chief, Department of Surgery, WK Hospital Health System, Shreveport; James Elrod, President, Willis-Knighton Hospital Health System, Shreveport; John Harlan Haynes III, MD, FABFP, MScMM (UT SWHSC), Med Alliance Health Center, Fort Worth, Tex; Jishnu Guha; and Indranil Guha.

Most studies include a measure of the significance of treatment effects such as a P value or confidence interval (CI). CIs (Journal of family practice, December 2003, 53:970) are usually preferred to P values, which have notable limitations.

1. P values are easily misinterpreted

A P value is the probability of obtaining a result (usually a difference between treatments) as large or larger than that observed in a study if the null hypothesis (ie, no difference exists between treatments) is true. Differences in treatment effects can be expressed as absolute differences or as odds ratios. No difference, for example, corresponds to an absolute difference of zero or an odds ratio of 1.0.

Consider a recent primary care study from the UK comparing the effectiveness of different lipid-lowering drugs to simvastatin.¹ The odds ratio for achieving a cholesterol level ≤5 mmol/L with pravastatin compared with simvastatin was 0.58, with a P value of .003 (ie, simvastatin superior to pravastatin). This means that if there is no difference between pravastatin and simvastatin (ie, null hypothesis is true), the probability of getting an odds ratio of 0.58 or less is just .003 (0.3%).

A P<.05 (sometimes <.01) is usually considered to be sufficient evidence to reject the null hypothesis. This is not intuitively obvious and does not appear to provide useful information.

Many clinicians misinterpret the P value “backwards” as the probability of the null hypothesis assuming the results. In the example above, the misinterpretation would be that there is a 0.3% probability of there being no difference between simvastatin and pravastatin based on the results. Misinterpreting the P value in this way is serious, since the true probability of the null hypothesis based on the results is often much greater than the P value.

2. P values tell us nothing about the magnitude of a significant difference

In the example above, the odds ratio of 0.58, P=.003 has a 95% CI of 0.40​0.83. The confidence interval, unlike the P value, provides a measure of the precision of the odds ratio.

3. P values are very sensitive to sample size

A small difference between 2 treatments that is clinically insignificant (eg, 1-week difference in mean life expectancy between 2 lipid-lowering treatments) may have a statistically significant P value (ie, <.05) if the sample size is large enough. P values, therefore, can exaggerate the significance of results.

Correspondence
Goutham Rao, MD, 3518 Fifth Avenue, Pittsburgh, PA 15361. E-mail: [email protected].

Most studies include a measure of the significance of treatment effects such as a P value or confidence interval (CI). CIs (Journal of family practice, December 2003, 53:970) are usually preferred to P values, which have notable limitations.

1. P values are easily misinterpreted

A P value is the probability of obtaining a result (usually a difference between treatments) as large or larger than that observed in a study if the null hypothesis (ie, no difference exists between treatments) is true. Differences in treatment effects can be expressed as absolute differences or as odds ratios. No difference, for example, corresponds to an absolute difference of zero or an odds ratio of 1.0.

Consider a recent primary care study from the UK comparing the effectiveness of different lipid-lowering drugs to simvastatin.¹ The odds ratio for achieving a cholesterol level ≤5 mmol/L with pravastatin compared with simvastatin was 0.58, with a P value of .003 (ie, simvastatin superior to pravastatin). This means that if there is no difference between pravastatin and simvastatin (ie, null hypothesis is true), the probability of getting an odds ratio of 0.58 or less is just .003 (0.3%).

A P<.05 (sometimes <.01) is usually considered to be sufficient evidence to reject the null hypothesis. This is not intuitively obvious and does not appear to provide useful information.

Many clinicians misinterpret the P value “backwards” as the probability of the null hypothesis assuming the results. In the example above, the misinterpretation would be that there is a 0.3% probability of there being no difference between simvastatin and pravastatin based on the results. Misinterpreting the P value in this way is serious, since the true probability of the null hypothesis based on the results is often much greater than the P value.

2. P values tell us nothing about the magnitude of a significant difference

In the example above, the odds ratio of 0.58, P=.003 has a 95% CI of 0.40​0.83. The confidence interval, unlike the P value, provides a measure of the precision of the odds ratio.

3. P values are very sensitive to sample size

A small difference between 2 treatments that is clinically insignificant (eg, 1-week difference in mean life expectancy between 2 lipid-lowering treatments) may have a statistically significant P value (ie, <.05) if the sample size is large enough. P values, therefore, can exaggerate the significance of results.

Correspondence
Goutham Rao, MD, 3518 Fifth Avenue, Pittsburgh, PA 15361. E-mail: [email protected].

Most studies include a measure of the significance of treatment effects such as a P value or confidence interval (CI). CIs (Journal of family practice, December 2003, 53:970) are usually preferred to P values, which have notable limitations.

1. P values are easily misinterpreted

A P value is the probability of obtaining a result (usually a difference between treatments) as large or larger than that observed in a study if the null hypothesis (ie, no difference exists between treatments) is true. Differences in treatment effects can be expressed as absolute differences or as odds ratios. No difference, for example, corresponds to an absolute difference of zero or an odds ratio of 1.0.

Consider a recent primary care study from the UK comparing the effectiveness of different lipid-lowering drugs to simvastatin.¹ The odds ratio for achieving a cholesterol level ≤5 mmol/L with pravastatin compared with simvastatin was 0.58, with a P value of .003 (ie, simvastatin superior to pravastatin). This means that if there is no difference between pravastatin and simvastatin (ie, null hypothesis is true), the probability of getting an odds ratio of 0.58 or less is just .003 (0.3%).

A P<.05 (sometimes <.01) is usually considered to be sufficient evidence to reject the null hypothesis. This is not intuitively obvious and does not appear to provide useful information.

Many clinicians misinterpret the P value “backwards” as the probability of the null hypothesis assuming the results. In the example above, the misinterpretation would be that there is a 0.3% probability of there being no difference between simvastatin and pravastatin based on the results. Misinterpreting the P value in this way is serious, since the true probability of the null hypothesis based on the results is often much greater than the P value.

2. P values tell us nothing about the magnitude of a significant difference

In the example above, the odds ratio of 0.58, P=.003 has a 95% CI of 0.40​0.83. The confidence interval, unlike the P value, provides a measure of the precision of the odds ratio.

3. P values are very sensitive to sample size

A small difference between 2 treatments that is clinically insignificant (eg, 1-week difference in mean life expectancy between 2 lipid-lowering treatments) may have a statistically significant P value (ie, <.05) if the sample size is large enough. P values, therefore, can exaggerate the significance of results.

Correspondence
Goutham Rao, MD, 3518 Fifth Avenue, Pittsburgh, PA 15361. E-mail: [email protected].

► About: “Laparoscopic cholecystectomy in a rural family practice”

On the surface, the previous article by Haynes et al¹ appears to be a simple descriptive study of a well-established technology. So why publish something that is not new? Simply because the study is an incredible technical and political achievement in a JCAHO-accredited hospital by a family physician educator. All family physicians—whether they view themselves as “procedural” or not—should recognize it for its symbolic and political value.

High-touch and high-tech

If family physicians wish to provide more than “generic primary care,” they must provide clinical skills at the bedside, in addition to diagnostic and psychosocial expertise. No amount of the latter will compensate for the former at critical moments. For credibility in the community and in the life cycle of families, the provision of diagnostic and therapeutic procedures trumps prescription-writing every time.

By providing surgical or diagnostic procedures that improve access to health care in their communities, physicians such as Haynes are not regressing to a surgical mentality at the expense of psychosocial sensitivity and therapeutic listening. Our closest relations with patients and their families are established at the bedside while performing or assisting with a diagnostic or therapeutic procedure. Procedures frequently provide the ultimate “teachable moment.” As said at Keystone III: “You can pretend to know; you can pretend to care; but you can’t pretend to be there.”²

Also, procedures distinguish family physicians from the other “primary care providers” who are hired with the assumption that they will provide referrals. Patients will seek out those physicians who can simultaneously provide high-touch and high-tech.

1960s–1970s: The growth of high-tech

During the 1960s and 1970s, advances in technology were predominantly located in hospitals. The traditional office-based diagnostic and surgical skills of the general physician were gradually transferred to a more central place, namely the hospital. Many of these skills were then categorically assigned to more specialized physicians resulting in the withdrawal of the generalist physician in the participation of these skills.

Originally, family medicine educators thought the 3-year curriculum would be sufficient for procedural training, but they underestimated the political passion for control by opposing specialties with a need to maintain their training monopolies. Among 20 voting specialties, family medicine has only 1 vote. This is the democratic reality, which frames any potential turf struggle in a highly subspecialized environment. These environments include, but are not limited to, academic medical centers, most urban hospitals, and some rural hospitals.

The institutionalization of these interventions depersonalized the patient-doctor relationship, limited access, and escalated cost. Family practice as an emerging specialty willingly joined in this movement, resulting in the abandonment of many generalist-appropriate skills. During that time, studies of how tertiary-care technologies might transfer into the community were undertaken.^3,4

It became increasingly evident that many diagnostic and interventional procedures (eg, diagnostic ultrasound, gastrointestinal endoscopy, and colposcopy) had multiple-specialty applications and were clearly linked with important preventive activities. ^5,6 Some leaders suggested that technical skills combined with the unique biopsychosocial model of practice of family physicians was the right way to provide competent, personal care to patients. In other words, high-tech was most effective when blended with high-touch and vice-versa. ^7-9

1980s–1990s: The FP curriculum expands

In 1981, the first in a series of fourth-year fellowships emphasizing this expanded curriculum for family physicians was initiated.^10-12 Thereupon followed the development of CAQ experiences in Geriatric Medicine and Sports Medicine, which, while instructive, failed to create added market value to most rural and under-served communities. The American Academy of Family Physicians—through the Task Force on Obstetrics (1989–1993)¹³ and then the Task Force on Procedures (1993–1995)—ratified and distributed performance-based learning and competency-based testing programs. Moreover, the Advanced Life Support in Obstetrics (ALSO) program had a major impact nationally and internationally.¹⁴

By 1991, our discipline was focused on credentialing for lightning rod issues such as colonoscopy,¹⁵ esophagogastroduodenoscopy,¹⁶ colposcopy,¹⁷ obstetric ultrasound,¹⁸ and cesarean section.¹⁹ In Memphis, because of the political conflict associated with the teaching of diagnostic ultrasound, gastrointestinal endoscopy, and cesarean section, we chose not to “fan the flames” with development of office-based laparoscopy. But we were ready. We included laparoscopic tubal ligation in our FP/OB fellowship, but the resistance from specialties who felt family medicine was invading “their turf” was difficult and remains so.^20-24

By 1995, the Residency Review Committee for Family Medicine had codified the rural training tracks²⁵ and reaffirmed OB-capable faculty as part of the accreditation process. These advanced family practice curriculum needs were acknowledged, and various educational innovations with an emphasis on skills needed for success in rural or urban underserved communities began to emerge.^26,27

Nebraska,²⁸ Marshall University,²⁹ and the University of Tennessee–Memphis ³⁰ have summarized their experiences with the accelerated residency program and rural training tracks have done the same. These programs have recognized the need to train our future teachers and role models broadly, combating the “learned helplessness” that too often characterizes our training environments when we leave this teaching to subspecialists.

Meeting the needs of a rural practice

Some physicians with a more limited scope of practice appear threatened by proceduralists. While there is room for everyone in the big tent of family medicine, if our specialty is to survive and be credible, we must seek to meet the needs of our patients and our students. In most urban areas, family medicine has abandoned large parts of our patients’ care to the specialties of emergency medicine and obstetrics/gynecology.

From the rural perspective, it is impractical or fiscally impossible to recruit and maintain platoons of obstetricians and board-certified emergency medicine specialists to counties not located near a metropolitan area.^31,32 Family physicians, if properly trained, are the ideal physicians for nonmetropolitan practice.

Moreover, the current practice management curriculum in most family practice residencies is a do-it-yourself suicide kit where few physicians understand accountability measures for billing, collections, equipment, and human resources. They may have memorized the entire amino acid sequence for the human genome, but they don’t have the time to understand billing for Medicaid or the impact of providing a full range of services to their patients. What’s wrong with this picture?

FPs must adapt to serve their patients

The net result of the production of our graduates lacking technical skills is an overstocked urban job pool and a shortage of rural physicians. There are few 9-to-5 family practice jobs available in urban areas like Nashville and Memphis for limited generalists. On the other hand, there are jobs for every family physician willing to work after 5 P.M. This includes continuing care, urgent care, and middle-of-the-night hospital care. Procedural skills and hospital service predictably require “extra effort” and extra risk. Reimbursement policies continue to favor those physicians who assume these risks and provide these services.^33.34

Another result of following the path of least resistance (as reflected in nonprocedural family medicine is the decreasing student interest in family medicine.³⁵

Responsibility also rests with unskilled faculty who will not perform a broader scope of practice within the medical specialty of family medicine. There is personal risk for “being there” at the critical moment of procedural decisions. Students do not automatically shun this risk, but family medicine may be self-selecting for those who do.

Family physicians practicing in diverse geographic, social, and political environments will naturally adopt various diagnostic and therapeutic modalities in the service of their patients. It is not up to us to judge the appropriateness of those modalities except by the ultimate yardstick of the quality of the end result.

We are not advocating the addition of laparoscopic cholecystectomy to the “required” family medicine curriculum. However, we support the right of John Haynes to practice this skill and to teach it to others to the benefit of patients. The specialty that cannot provide training and credentials for its own members has been reproductively sterilized.^36,37 This is a unique market niche ideally suited for family medicine.^38,39

Procedurally trained family physicians represent the cutting edge of an emerging paradigm of care that includes ambulatory surgery, maternity care, cesarean section, and laparoscopy, particularly for patients in smaller communities and developing nations. We salute John Haynes and his co-authors for taking “the road less traveled.”

Corresponding author
Wm. MacMillan Rodney, MD, 6575 Black Thorne Cove, Memphis, TN 38119. E-mail: [email protected].

► About: “Laparoscopic cholecystectomy in a rural family practice”

On the surface, the previous article by Haynes et al¹ appears to be a simple descriptive study of a well-established technology. So why publish something that is not new? Simply because the study is an incredible technical and political achievement in a JCAHO-accredited hospital by a family physician educator. All family physicians—whether they view themselves as “procedural” or not—should recognize it for its symbolic and political value.

High-touch and high-tech

If family physicians wish to provide more than “generic primary care,” they must provide clinical skills at the bedside, in addition to diagnostic and psychosocial expertise. No amount of the latter will compensate for the former at critical moments. For credibility in the community and in the life cycle of families, the provision of diagnostic and therapeutic procedures trumps prescription-writing every time.

By providing surgical or diagnostic procedures that improve access to health care in their communities, physicians such as Haynes are not regressing to a surgical mentality at the expense of psychosocial sensitivity and therapeutic listening. Our closest relations with patients and their families are established at the bedside while performing or assisting with a diagnostic or therapeutic procedure. Procedures frequently provide the ultimate “teachable moment.” As said at Keystone III: “You can pretend to know; you can pretend to care; but you can’t pretend to be there.”²

Also, procedures distinguish family physicians from the other “primary care providers” who are hired with the assumption that they will provide referrals. Patients will seek out those physicians who can simultaneously provide high-touch and high-tech.

1960s–1970s: The growth of high-tech

During the 1960s and 1970s, advances in technology were predominantly located in hospitals. The traditional office-based diagnostic and surgical skills of the general physician were gradually transferred to a more central place, namely the hospital. Many of these skills were then categorically assigned to more specialized physicians resulting in the withdrawal of the generalist physician in the participation of these skills.

Originally, family medicine educators thought the 3-year curriculum would be sufficient for procedural training, but they underestimated the political passion for control by opposing specialties with a need to maintain their training monopolies. Among 20 voting specialties, family medicine has only 1 vote. This is the democratic reality, which frames any potential turf struggle in a highly subspecialized environment. These environments include, but are not limited to, academic medical centers, most urban hospitals, and some rural hospitals.

The institutionalization of these interventions depersonalized the patient-doctor relationship, limited access, and escalated cost. Family practice as an emerging specialty willingly joined in this movement, resulting in the abandonment of many generalist-appropriate skills. During that time, studies of how tertiary-care technologies might transfer into the community were undertaken.^3,4

It became increasingly evident that many diagnostic and interventional procedures (eg, diagnostic ultrasound, gastrointestinal endoscopy, and colposcopy) had multiple-specialty applications and were clearly linked with important preventive activities. ^5,6 Some leaders suggested that technical skills combined with the unique biopsychosocial model of practice of family physicians was the right way to provide competent, personal care to patients. In other words, high-tech was most effective when blended with high-touch and vice-versa. ^7-9

1980s–1990s: The FP curriculum expands

In 1981, the first in a series of fourth-year fellowships emphasizing this expanded curriculum for family physicians was initiated.^10-12 Thereupon followed the development of CAQ experiences in Geriatric Medicine and Sports Medicine, which, while instructive, failed to create added market value to most rural and under-served communities. The American Academy of Family Physicians—through the Task Force on Obstetrics (1989–1993)¹³ and then the Task Force on Procedures (1993–1995)—ratified and distributed performance-based learning and competency-based testing programs. Moreover, the Advanced Life Support in Obstetrics (ALSO) program had a major impact nationally and internationally.¹⁴

By 1991, our discipline was focused on credentialing for lightning rod issues such as colonoscopy,¹⁵ esophagogastroduodenoscopy,¹⁶ colposcopy,¹⁷ obstetric ultrasound,¹⁸ and cesarean section.¹⁹ In Memphis, because of the political conflict associated with the teaching of diagnostic ultrasound, gastrointestinal endoscopy, and cesarean section, we chose not to “fan the flames” with development of office-based laparoscopy. But we were ready. We included laparoscopic tubal ligation in our FP/OB fellowship, but the resistance from specialties who felt family medicine was invading “their turf” was difficult and remains so.^20-24

By 1995, the Residency Review Committee for Family Medicine had codified the rural training tracks²⁵ and reaffirmed OB-capable faculty as part of the accreditation process. These advanced family practice curriculum needs were acknowledged, and various educational innovations with an emphasis on skills needed for success in rural or urban underserved communities began to emerge.^26,27

Nebraska,²⁸ Marshall University,²⁹ and the University of Tennessee–Memphis ³⁰ have summarized their experiences with the accelerated residency program and rural training tracks have done the same. These programs have recognized the need to train our future teachers and role models broadly, combating the “learned helplessness” that too often characterizes our training environments when we leave this teaching to subspecialists.

Meeting the needs of a rural practice

Some physicians with a more limited scope of practice appear threatened by proceduralists. While there is room for everyone in the big tent of family medicine, if our specialty is to survive and be credible, we must seek to meet the needs of our patients and our students. In most urban areas, family medicine has abandoned large parts of our patients’ care to the specialties of emergency medicine and obstetrics/gynecology.

From the rural perspective, it is impractical or fiscally impossible to recruit and maintain platoons of obstetricians and board-certified emergency medicine specialists to counties not located near a metropolitan area.^31,32 Family physicians, if properly trained, are the ideal physicians for nonmetropolitan practice.

Moreover, the current practice management curriculum in most family practice residencies is a do-it-yourself suicide kit where few physicians understand accountability measures for billing, collections, equipment, and human resources. They may have memorized the entire amino acid sequence for the human genome, but they don’t have the time to understand billing for Medicaid or the impact of providing a full range of services to their patients. What’s wrong with this picture?

FPs must adapt to serve their patients

The net result of the production of our graduates lacking technical skills is an overstocked urban job pool and a shortage of rural physicians. There are few 9-to-5 family practice jobs available in urban areas like Nashville and Memphis for limited generalists. On the other hand, there are jobs for every family physician willing to work after 5 P.M. This includes continuing care, urgent care, and middle-of-the-night hospital care. Procedural skills and hospital service predictably require “extra effort” and extra risk. Reimbursement policies continue to favor those physicians who assume these risks and provide these services.^33.34

Another result of following the path of least resistance (as reflected in nonprocedural family medicine is the decreasing student interest in family medicine.³⁵

Responsibility also rests with unskilled faculty who will not perform a broader scope of practice within the medical specialty of family medicine. There is personal risk for “being there” at the critical moment of procedural decisions. Students do not automatically shun this risk, but family medicine may be self-selecting for those who do.

Family physicians practicing in diverse geographic, social, and political environments will naturally adopt various diagnostic and therapeutic modalities in the service of their patients. It is not up to us to judge the appropriateness of those modalities except by the ultimate yardstick of the quality of the end result.

We are not advocating the addition of laparoscopic cholecystectomy to the “required” family medicine curriculum. However, we support the right of John Haynes to practice this skill and to teach it to others to the benefit of patients. The specialty that cannot provide training and credentials for its own members has been reproductively sterilized.^36,37 This is a unique market niche ideally suited for family medicine.^38,39

Procedurally trained family physicians represent the cutting edge of an emerging paradigm of care that includes ambulatory surgery, maternity care, cesarean section, and laparoscopy, particularly for patients in smaller communities and developing nations. We salute John Haynes and his co-authors for taking “the road less traveled.”

Corresponding author
Wm. MacMillan Rodney, MD, 6575 Black Thorne Cove, Memphis, TN 38119. E-mail: [email protected].

► About: “Laparoscopic cholecystectomy in a rural family practice”

On the surface, the previous article by Haynes et al¹ appears to be a simple descriptive study of a well-established technology. So why publish something that is not new? Simply because the study is an incredible technical and political achievement in a JCAHO-accredited hospital by a family physician educator. All family physicians—whether they view themselves as “procedural” or not—should recognize it for its symbolic and political value.

High-touch and high-tech

If family physicians wish to provide more than “generic primary care,” they must provide clinical skills at the bedside, in addition to diagnostic and psychosocial expertise. No amount of the latter will compensate for the former at critical moments. For credibility in the community and in the life cycle of families, the provision of diagnostic and therapeutic procedures trumps prescription-writing every time.

By providing surgical or diagnostic procedures that improve access to health care in their communities, physicians such as Haynes are not regressing to a surgical mentality at the expense of psychosocial sensitivity and therapeutic listening. Our closest relations with patients and their families are established at the bedside while performing or assisting with a diagnostic or therapeutic procedure. Procedures frequently provide the ultimate “teachable moment.” As said at Keystone III: “You can pretend to know; you can pretend to care; but you can’t pretend to be there.”²

Also, procedures distinguish family physicians from the other “primary care providers” who are hired with the assumption that they will provide referrals. Patients will seek out those physicians who can simultaneously provide high-touch and high-tech.

1960s–1970s: The growth of high-tech

During the 1960s and 1970s, advances in technology were predominantly located in hospitals. The traditional office-based diagnostic and surgical skills of the general physician were gradually transferred to a more central place, namely the hospital. Many of these skills were then categorically assigned to more specialized physicians resulting in the withdrawal of the generalist physician in the participation of these skills.

Originally, family medicine educators thought the 3-year curriculum would be sufficient for procedural training, but they underestimated the political passion for control by opposing specialties with a need to maintain their training monopolies. Among 20 voting specialties, family medicine has only 1 vote. This is the democratic reality, which frames any potential turf struggle in a highly subspecialized environment. These environments include, but are not limited to, academic medical centers, most urban hospitals, and some rural hospitals.

The institutionalization of these interventions depersonalized the patient-doctor relationship, limited access, and escalated cost. Family practice as an emerging specialty willingly joined in this movement, resulting in the abandonment of many generalist-appropriate skills. During that time, studies of how tertiary-care technologies might transfer into the community were undertaken.^3,4

It became increasingly evident that many diagnostic and interventional procedures (eg, diagnostic ultrasound, gastrointestinal endoscopy, and colposcopy) had multiple-specialty applications and were clearly linked with important preventive activities. ^5,6 Some leaders suggested that technical skills combined with the unique biopsychosocial model of practice of family physicians was the right way to provide competent, personal care to patients. In other words, high-tech was most effective when blended with high-touch and vice-versa. ^7-9

1980s–1990s: The FP curriculum expands

In 1981, the first in a series of fourth-year fellowships emphasizing this expanded curriculum for family physicians was initiated.^10-12 Thereupon followed the development of CAQ experiences in Geriatric Medicine and Sports Medicine, which, while instructive, failed to create added market value to most rural and under-served communities. The American Academy of Family Physicians—through the Task Force on Obstetrics (1989–1993)¹³ and then the Task Force on Procedures (1993–1995)—ratified and distributed performance-based learning and competency-based testing programs. Moreover, the Advanced Life Support in Obstetrics (ALSO) program had a major impact nationally and internationally.¹⁴

By 1991, our discipline was focused on credentialing for lightning rod issues such as colonoscopy,¹⁵ esophagogastroduodenoscopy,¹⁶ colposcopy,¹⁷ obstetric ultrasound,¹⁸ and cesarean section.¹⁹ In Memphis, because of the political conflict associated with the teaching of diagnostic ultrasound, gastrointestinal endoscopy, and cesarean section, we chose not to “fan the flames” with development of office-based laparoscopy. But we were ready. We included laparoscopic tubal ligation in our FP/OB fellowship, but the resistance from specialties who felt family medicine was invading “their turf” was difficult and remains so.^20-24

By 1995, the Residency Review Committee for Family Medicine had codified the rural training tracks²⁵ and reaffirmed OB-capable faculty as part of the accreditation process. These advanced family practice curriculum needs were acknowledged, and various educational innovations with an emphasis on skills needed for success in rural or urban underserved communities began to emerge.^26,27

Nebraska,²⁸ Marshall University,²⁹ and the University of Tennessee–Memphis ³⁰ have summarized their experiences with the accelerated residency program and rural training tracks have done the same. These programs have recognized the need to train our future teachers and role models broadly, combating the “learned helplessness” that too often characterizes our training environments when we leave this teaching to subspecialists.

Meeting the needs of a rural practice

Some physicians with a more limited scope of practice appear threatened by proceduralists. While there is room for everyone in the big tent of family medicine, if our specialty is to survive and be credible, we must seek to meet the needs of our patients and our students. In most urban areas, family medicine has abandoned large parts of our patients’ care to the specialties of emergency medicine and obstetrics/gynecology.

From the rural perspective, it is impractical or fiscally impossible to recruit and maintain platoons of obstetricians and board-certified emergency medicine specialists to counties not located near a metropolitan area.^31,32 Family physicians, if properly trained, are the ideal physicians for nonmetropolitan practice.

Moreover, the current practice management curriculum in most family practice residencies is a do-it-yourself suicide kit where few physicians understand accountability measures for billing, collections, equipment, and human resources. They may have memorized the entire amino acid sequence for the human genome, but they don’t have the time to understand billing for Medicaid or the impact of providing a full range of services to their patients. What’s wrong with this picture?

FPs must adapt to serve their patients

The net result of the production of our graduates lacking technical skills is an overstocked urban job pool and a shortage of rural physicians. There are few 9-to-5 family practice jobs available in urban areas like Nashville and Memphis for limited generalists. On the other hand, there are jobs for every family physician willing to work after 5 P.M. This includes continuing care, urgent care, and middle-of-the-night hospital care. Procedural skills and hospital service predictably require “extra effort” and extra risk. Reimbursement policies continue to favor those physicians who assume these risks and provide these services.^33.34

Another result of following the path of least resistance (as reflected in nonprocedural family medicine is the decreasing student interest in family medicine.³⁵

Responsibility also rests with unskilled faculty who will not perform a broader scope of practice within the medical specialty of family medicine. There is personal risk for “being there” at the critical moment of procedural decisions. Students do not automatically shun this risk, but family medicine may be self-selecting for those who do.

Family physicians practicing in diverse geographic, social, and political environments will naturally adopt various diagnostic and therapeutic modalities in the service of their patients. It is not up to us to judge the appropriateness of those modalities except by the ultimate yardstick of the quality of the end result.

We are not advocating the addition of laparoscopic cholecystectomy to the “required” family medicine curriculum. However, we support the right of John Haynes to practice this skill and to teach it to others to the benefit of patients. The specialty that cannot provide training and credentials for its own members has been reproductively sterilized.^36,37 This is a unique market niche ideally suited for family medicine.^38,39

Procedurally trained family physicians represent the cutting edge of an emerging paradigm of care that includes ambulatory surgery, maternity care, cesarean section, and laparoscopy, particularly for patients in smaller communities and developing nations. We salute John Haynes and his co-authors for taking “the road less traveled.”

Corresponding author
Wm. MacMillan Rodney, MD, 6575 Black Thorne Cove, Memphis, TN 38119. E-mail: [email protected].