Public Release: 

January/February 2018 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Patients Who Receive Prescription Opioids are More Satisfied With Care Than Other Patients

Patients with musculoskeletal conditions who receive prescription opioids are more satisfied with their care than comparable patients who do not receive opioids. In a study of nationally representative data, 13 percent (2,564) of more than 19,000 patients with musculoskeletal conditions used prescription opioids. Among those who used opioids over time, moderate and heavy use was associated with greater likelihood (55 percent and 43 percent, respectively) of being most satisfied, compared to single or no use of opioids. Although opioids may be expected to offer patients with musculoskeletal conditions improved pain control, patients taking opioids in this study had more pain and worse health and disability than those taking limited or no opioids, suggesting a more complex picture. As clinician compensation is increasingly linked to patient satisfaction, and as the United States struggles with an epidemic in opioid use, the authors suggest it is imperative to determine whether improved satisfaction with care is associated with demonstrable health benefits.

Prescription Opioid Use and Satisfaction With Care Among Adults With Musculoskeletal Conditions
Brian D. Sites MD, MS, et al
Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
http://www.annfammed.org/content/16/1/6

Physicians Use Complex Process in Addressing Non-Patient Requests

When confronted with a medical request from family or friends (non-patients), physicians follow a complex process in deciding how to respond. According to a focus group study of 33 family medicine residents and 16 senior physicians, physicians first orient themselves to the situation: who is this person; what is he or she asking of me, and where are we? They also consider the nature and strength of the relationship with the non-patient, their level of trust in their own knowledge and skills, potential consequences of making mistakes, the importance of work-life balance, and the risk of disturbing the individual's relationship with her/his physician. Senior physicians apply more nuanced considerations when deciding whether or not to respond; residents experience more difficulties in dealing with these requests, are less inclined to respond, and are more concerned about disturbing the existing patient-physician relationship. Although non-patient requests of physicians are common, they are rarely formally discussed. The authors suggest developing facilitated group discussions to help residents gain an understanding of and confidence in addressing such issues.

Family Physicians Managing Medical Requests From Family and Friends
Esther Giroldi, PhD, et al
Maastricht University, Maastricht, The Netherlands
http://www.annfammed.org/content/16/1/45.full

Strengths and Challenges in Interactions With Newly Diagnosed Diabetes Patients

When patients are diagnosed with diabetes, primary care clinicians display high levels of technical knowledge and communication skill, but initial consultations are often driven by biomedical explanations out of context from patient experience. A qualitative study of 32 patients newly diagnosed with type 2 diabetes found strengths in primary care interactions including high levels of communication skills, coordination of services, and significant allocation of time with patients. Challenges to optimal care remain, however. Despite high levels of generic communication expertise by clinicians, many patients found the style and content of health promotion and lifestyle advice not applicable to their lives. Similarly, although sufficient time was allocated, it was not well coordinated between health professionals. Other concerns included overuse of a checklist approach and a need for more effective methods of sharing patient information. The findings highlight the important role that communication plays in diabetes management and the commitment of primary care teams to engage with patient care. The authors recommend that clinicians employ a biopsychosocial framework for communications with newly diagnosed diabetes patients and coordinate allocation of time when patients see multiple clinicians.

A Longitudinal Study of the Interactions Between Health Professionals and People Newly Diagnosed With Diabetes
Anthony Dowell, MBChB, et al
University of Otago, Wellington, New Zealand
http://www.annfammed.org/content/16/1/37

Four Practice Characteristics Facilitate Integration of Community Health Workers

Four practice characteristics facilitate the integration of community health workers into medical home care teams: leaders who champion community health workers, a culture of innovation, recognition of patients' non-medical needs, and a positive perception of the financial sustainability of community health workers. Researchers from the University of Minnesota conducted 51 semi-structured, key informant interviews of personnel at nine Minnesota practices certified as medical homes. They found that in practices without community health workers, leaders lacked awareness of the value of community health workers' wide-ranging roles including outreach, health education and coaching, community resource linkage, system navigation, and facilitating communication between clinicians and patients. The authors contend that work remains to raise awareness of community health workers, in spite of growing evidence of their effectiveness.

Integrating Community Health Workers Into Medical Homes
Elizabeth A. Rogers, MD, MAS, et al
University of Minnesota Medical School, Minneapolis, Miinnesota
http://www.annfammed.org/content/16/1/14

Public Health-Primary Care Testing Has High Uptake but Does Not Identify Hidden Hepatitis C

A strategy to test the general population for hepatitis B and C viruses in areas of high prevalence had high test uptake but did not detect hidden chronic hepatitis C infections. The study, a public health-primary care collaboration, sought to test individuals between 40 and 70 years of age (n=6,743) in two Dutch hepatitis hotspots. All family physicians in the hotspots invited their patients to be tested, with implementation and follow-up by the regional public health service. Test uptake was higher than expected at 51 percent (n=3,434), however no active/chronic hepatitis C infections were detected. This strategy, the authors surmise, could be effective in countries with higher rates of hepatitis or other infectious diseases, but is not recommended for low prevalence countries.

Detecting Hepatitis B and C by Combined Public Health and Primary Care Birth Cohort Testing
Jeanne Heil, MSc, et al
Public Health Service and Maastricht University Medical Centre, The Netherlands
http://www.annfammed.org/content/16/1/21

State Administrative Data Can Help Identify Children's Adverse Experiences

Identifying children with adverse childhood experiences is crucial but challenging. A new study finds that state administrative data can be used to identify children's social complexity risk factors. Researchers linked administrative data for more than 500,000 children receiving Washington State Medicaid insurance coverage with parent data to identify social complexity risk factors (individual, family, or community characteristics that can affect health outcomes), such as poverty and parent mental illness. They found that social complexity risk factors frequently co-occurred, with approximately half the study population having two or more risk factors. Of 11 identifiable risk factors, nine were associated with a higher rate of emergency department utilization. The magnitude of the association with the rate of emergency department utilization was small for individual risk factors, but the rate increased as the number of risk factors increased independent of medical complexity. Providing primary care physicians with a social complexity flag or score, the authors suggest, could facilitate targeted screening of families who are likely to have social risk. This, in turn, would help make best use of limited time and resources in primary care.

Using State Administrative Data to Identify Social Complexity Risk Factors for Children
Kimberly C. Arthur, MPH, et al
Seattle Children's Research Institute, Seattle, Washington
http://www.annfammed.org/content/16/1/62.full

"I was one of the lucky ones." A Physician Recounts His Experience With Cardiac Arrest

When a physician experienced chest pain, he denied he could be having a heart attack. When he lost consciousness driving to work, an extraordinary group of people was close by--"the right people with the right equipment in the right place at the right time"--and saved his life. Now, thankful for a second chance, he is determined to make a difference as a clinician and educator.

The Day I Died
Julie M. Stausmire MSN, RN, ACNS-BC, et al
Mercy Health St. Vincent Medical Center, Toledo, Ohio
http://www.annfammed.org/content/16/1/77.full

Precision Medicine Must Recognize Patients as People

The practice of precision medicine must not only focus on a patient's genetic and biological individuality. To truly personalize care, clinicians must get to know the patient as a person. An editorial by Roy C. Ziegelstein, MD, MACP, states that precision medicine, which aims to tailor treatment and prevention based on genes, environment, and lifestyle, can be most effective and best meet patients' needs by understanding them in a range of real-life contexts. He calls on educators to teach physicians and trainees effective and reliable techniques for understanding the psychological, social, cultural, behavioral and economic factors that shape our experiences of health and illness.

Knowing the Patient as a Person in the Precision Medicine Era


Roy C. Ziegelstein, MD, MACP
Johns Hopkins University School of Medicine, Baltimore, Maryland
http://www.annfammed.org/content/16/1/4

Family Physicians in South Africa Strengthen District Hospital Care, not Community Health Center Care

In South Africa, district (generalist) hospitals with family physicians have better clinical processes and health system performance, while community health centers with family physicians have lower scores in those domains. In a study across seven South African provinces, district hospitals with family physicians had higher availability of essential services, such as pediatric and emergency care, and better child and neonatal health. In contrast, community health centers with family physicians generally had lower scores for health system performance and clinical care and were associated with significantly lower scores for continuity and coordination of care. These findings differ from a large body of literature which finds that family physicians enhance continuity and coordination. The authors hypothesize that the differences might be due to the areas in which family physicians were deployed (areas of greatest need and workload, which were predisposed to perform more poorly) and/or to differing levels of physician influence (hospital teams were led by doctors, community health center teams were led by nurses). As South Africa moves toward a system of universal health coverage, the authors call for training programs that have sufficient focus on community health settings and further exploration of family physicians' roles in community health centers.

The Influence of Family Physicians Within the South African District Health System
Klaus B. von Pressentin, MMed, FCFP, PhD, et al
Stellenbosch University, Cape Town, South Africa
http://www.annfammed.org/content/16/1/28

Students Who View Medicine as a Calling Are More Likely to Pursue Primary Care

Medical students who strongly believe that medicine is a calling are more likely than their counterparts to select a primary care residency. A survey of a random sample of 1,000 fourth-year allopathic and osteopathic medical students found that while most respondents saw the practice of medicine as a calling, those who strongly agreed had significantly greater odds of selecting a primary care-related residency. Fostering, or at least not undermining, a sense of calling among future physicians could be a strategy to help address the looming primary care physician shortage.

Medical Students' Views of Medicine as a Calling and Selection of a Primary Care-Related Residency
Audiey C. Kao, MD, PhD, et al
American Medical Association, Chicago, Illinois
http://www.annfammed.org/content/16/1/59.full

Dirt-Like Skin Condition is Described

Terra firma-forme dermatosis is a hyperpigmented skin disease with a dirt-like appearance. Swabbing the lesions with alcohol serves to both diagnose and treat it. Although not well known, the condition might be more common than expected. In a retrospective study of the medical records of 79 patients, the dermatoses were found on the trunks of 28 percent of patients, on extremities of 27 percent of patients, in fold zones of 9 percent of patients, and on the heads of 3 percent of patients. Thirty-four percent of patients had more than one lesion. Recognizing terra firma-forme dermatosis can help avoid unnecessary diagnostic testing and treatment.

Features of Terra Firma-Forme Dermatosis
Nursad Çifci Aslan, MD, et al
Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey
http://www.annfammed.org/content/16/1/52

Language Access Plans are Key as US Demographics Change

United States' medical professionals who work with patients with limited English proficiency should rely on trained medical interpreters to give them the best comprehension of what a patient is saying. According to a new report from medical, legal, and education professionals, federal law requires health programs and clinicians receiving federal funds (e.g., federal grants, Medicaid, or Medicare Part A) to take reasonable steps to provide meaningful access to individuals with limited English proficiency, including interpreter services. In some cases, Medicaid or other federally funded medical insurance will cover the cost of an interpreter. The authors suggest that a language access plan involving professional medical interpreters will provide better health outcomes, ethical patient care, improved patient satisfaction, and reduce costly repeat visits by patients with limited understanding of their clinicians.

Medical Interpreters in Outpatient Practice


Barry D. Weiss, MD, et al
University of Arizona College of Medicine, Tucson, Arizona
http://www.annfammed.org/content/16/1/70.full

More Than Five Percent of Family Physicians Did Not Attempt Recertification

Of 51,678 family physicians who received board certification between 1980 and 2000, 5.6 percent did not attempt to recertify, with a slight increase in the most recent cohort. The percentage not attempting recertification increased with each additional failed initial certification attempt, rising to 24 percent for diplomates who failed three or more times. International medical graduates, men, and older diplomates were more likely to not attempt recertification. According to the authors, attrition from board certification may be a transitional step between burnout and leaving the primary care workforce. Medical boards' shift to maintenance of certification programs has also provoked fears of attrition. The authors recommend following these trends, uncovering underlying motivations, and identifying new interventions to minimize attrition.

Predictors of Attrition From Family Medicine Board Certification
Winston Liaw, MD, MPH, et al
Robert Graham Center, Washington, DC
http://www.annfammed.org/content/16/1/55.full

Family Physician Urges a New Generation to Be There for Patients, Communities

Family physician David Loxterkamp reflects on the differences between his generation, in which physicians spent long hours in practices they owned, and a new generation in which physicians are more likely to be employees striving for work-life balance. While he notes their generational differences, Loxterkamp is more struck by what they have in common: a sense of purpose and a desire to connect. In the end, he suggests that his younger colleagues have both an opportunity and a challenge: "to be there for your patients, on their terms and yours, in communities you both will call home."

Where We Belong: An Open Letter to My Colleagues in Training
David Loxterkamp, MD, MA
Seaport Community Health Center, Belfast, Maine
http://www.annfammed.org/content/16/1/80.full

Innovations in Primary Care: Behavioral Approach to Treating Opioid Use Disorder

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:

*Interdisciplinary Management of Opioid Use Disorder in Primary Care - A multidisciplinary team implemented a behavioral health-focused model for medication assisted treatment of opioid use disorder. They report it has streamlined care, improved access to care, reduced clinician barriers, and increased patients' sense of support.
http://www.annfammed.org/content/16/1/83.full

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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

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