News Release 

May/June 2020 Annals of Family Medicine tip sheet

American Academy of Family Physicians

What We Can Learn From Singapore's COVID-19 Containment Response in Primary Care

Singapore, a global hub for international travel and business, was among the first countries affected by the COVID-19 pandemic. With its first confirmed COVID-19 case on January 23, 2020, the country mounted aggressive public health and containment measures. The country's network of primary care clinics were at the front lines of these measures. In this new report, those physicians share their triage, containment and infection control measures--including protocols they put in place to ensure the safety of health care workers. At the time of writing the report, zero health care workers within their primary care network were infected with COVID-19. The authors describe the framework for how their primary care clinics responded to this pandemic in the hope others may find solutions to their unique needs."

COVID-19: Notes From the Front Line, Singapore's Primary Health Care Perspective
Wei Han Lim, MBBS, et al
Raffles Medical Group, Department of Primary Care, Singapore

Opportunities for Human Connectedness in "Physically Distant" Care

Relationships between patients and clinicians matter, even in telehealth visits. A new article explores how clinicians can invest in relationships during a variety of visit types, from short-term telehealth, urgent care, and emergency department visits to ongoing visits for well care and chronic disease management. In a telehealth visit, for example, clinicians can invest in the relationship by giving "full attention to [the] patient via the screen, or allowing no visual if that's what the patient wants." In a more in-depth chronic disease management visit, clinicians can consider the illness context and the patient's life story in order to help the patient identify personal and community resources for managing their condition.

As patients are more often treated by health care teams, and with the emergence of telemedicine, virtual visits are becoming more common--often with health care providers who do not know the patient or their health history. Investing in relationships in all types of visits can personalize the experience for both patients and providers and may also result in more efficient, less costly care.

The authors conclude, "what we need in a pandemic is not social distancing, but physical distancing with social connectedness."

Physical Distancing With Social Connectedness
Kurt C. Stange, MD, PhD, et al
School of Medicine, Case Western Reserve University, Cleveland, Ohio

Lung Cancer Screenings Study Shows Low Complication Rates With the Support of a Coordinated Multidisciplinary Care Team

The benefits of routine lung cancer screenings have been hotly debated in the medical community. After reviewing a national trial published in 2011, the US Preventive Services Task Force introduced a recommendation for systematic low-dose CT lung cancer screenings for people at high risk. At the time, some leaders in the primary care community were not convinced that there was strong enough evidence in the initial trial to support routine screening. A new lung cancer screening cohort study conducted at a large integrated health system suggests that lung cancer screening in primary care is feasible. The study demonstrated low adverse event rates, and 70 percent of diagnosed lung cancer cases were detected at early stages in their development.

"Screening can be highly beneficial but can also create an illusion of benefits even when causing a net harm," notes Mayo Clinic clinical epidemiologist Chyke A. Doubeni and colleagues, in an editorial response to the Handy et al study. The "window of net benefit" depends on a number of factors in the screening and treatment process, including "quality of CT images and quality of interpretation, disease prevalence in the population, patient health status, and the timeliness, safety, and effectiveness of treatment for abnormal screening results."

Still, the authors write, "Family medicine is critical for increasing the reach of lung cancer screenings," and primary care is an "ideal setting to improve access to screenings, particularly for underserved populations." Therefore, family physicians should be engaged and equipped with guidance on best practices in lung cancer screenings and referrals.

Results of Lung Cancer Screening in the Community
John R. Handy, Jr, MD, HonD, et al
Providence Cancer Institute, Portland, Oregon

Lung Cancer Screening Guidelines Implementation in Primary Care: A Call to Action
Chyke A. Doubeni, MD, MPH, et al
Mayo Clinic College of Medicine and Science, Rochester, Minnesota

A Hidden History of Artificial Intelligence in Primary Care

Artificial intelligence methods are being utilized in radiology, cardiology and other medical specialty fields to quickly and accurately process large quantities of health data to improve the diagnostic and treatment power of health care teams. Compared to other medical specialty fields, primary care physicians deal with a very broad spectrum of illnesses, taking a person-centric approach to care, with fewer diagnostic instruments or tests available. The nature of primary care may pose unique challenges to the meaningful application of AI.

A comprehensive review of 405 studies led by researchers at Western University in Ontario shows that work on AI for primary care is at an early stage of maturity. The scoping review summarizes major trends in primary care AI.

"For the field to mature," the authors note, "value must be placed both on developing rigorous [AI] and on identifying potential impacts...on care delivery and longer-term health outcomes."

"Changing primary care is difficult when only one out of every seven of these papers includes a primary care author," says Winston Liaw, MD MPH and Ioannis A. Kakadiaris, PhD, in an accompanying editorial. "Without input from primary care, these teams may fail to grasp the context of primary care data collection, its role within the health system, and the forces shaping its evolution." Liaw and Kakadiaris lay out seven challenges that primary care AI teams must address in order to move AI forward.

Artificial Intelligence and Primary Care Research: A Scoping Review
Jacqueline K. Kueper, MSc, et al
Western University, Schulich School of Medicine & Dentistry, London, Ontario, Canada

Primary Care Artificial Intelligence: A Branch Hiding in Plain Sight
Winston Liaw, MD, MPH, et al
University of Houston College of Medicine, Department of Health Systems and Population Health Sciences, Houston, Texas

#ThisIsOurLane: How Physicians Can Take Action to Reduce Gun Violence

As strategies to curb gun violence at the federal level have stalled, leaders in primary care and health policy have identified the role doctors can play in national gun safety efforts and the prevention of firearm suicide. In this pair of recommendation papers, clinicians place themselves at the front lines of this public health issue and offer a call to action for the medical community. Both papers lay out a grassroots course of action to help physicians engage with their patients and policy makers.

Thomas M. Wickizer and colleagues at the Ohio State University focus on the issue of firearm suicide and how improvements in primary care health screening could enhance physicians' ability to identify patients most at risk. Adding firearm safety questions to mental health screening could make firearm safety a more routine part of primary care. The authors also call on collective advocacy for policy change, recognizing the role that physician organizations have historically played in bringing about state-level drunk driving laws and regulation of tobacco advertising. In the wake of gun violence tragedies, physicians have mobilized on social media, using #ThisIsOurLane. The authors believe the medical community can harness the momentum of their online conversations to collectively influence the political discourse on firearms.

Amy Lynn McGuire and colleagues at the Baylor College of Medicine and the Center for Medical Ethics and Health Policy, identify barriers that doctors face in addressing the issue of gun safety and violence with patients. State-level legislation has attempted to prohibit physicians from inquiring about a patient's firearm ownership, resulting in long lasting fears of a "gag order" heightening physicians' concerns over potential liability. Additionally, physicians may be concerned that discussing firearm safety could break the trust they establish in the doctor-patient relationship. The authors advocate that discussions about gun safety and violence become a standard component of routine clinical care to step up the effort to protect public safety and improve public health.

The Firearm Suicide Crisis: Physicians Can Make a Difference
Thomas M. Wickizer, PhD, MPH, et al
The Ohio State University, College of Public Health, Columbus, Ohio

Physician Involvement in Promoting Gun Safety
Amy Lynn McGuire, JD, PhD, et al
Baylor College of Medicine, Center for Medical Ethics and Health Policy, Houston, Texas

Trouble Getting a Doctor's Appointment May Drive Medicaid Enrollees to Opt for the ER

The expansion of Medi-Cal, California's Medicaid program, gave millions of low-income Californians access to health insurance, but this study conducted in Northern California found that new patients may have to wait up up to a month for an appointment with a participating primary care provider, depending on their county of residence. It is not uncommon for Medi-Cal enrollees to visit emergency rooms if they require more immediate care.

This study looks at the variation between contiguous counties in the availability of new patient primary care appointments for Medi-Cal enrollees and at the correlation between primary care access and rates of Medi-Cal patients' emergency room usage. Researchers found that counties where it was more difficult to schedule new patient primary care appointments had higher rates of emergency room usage by Medi-Cal patients. This places a greater strain on already overburdened emergency departments and drives up health care costs overall.

How California's challenges compare with those faced by other states that have expanded Medicaid eligibility under the Affordable Care Act is unclear, though the data suggest that "adequate access to primary care will begin to improve health outcomes and control costs among beneficiaries of Medicaid expansion."

Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study
Joy Melnikow, MD, MPH, et al
University of California, Davis, Center for Healthcare for Policy and Research, Sacramento, California

Arthritis Clinical Trial Shows Support for Dextrose Injection to Alleviate Knee Pain

A randomized controlled trial conducted by a research team at a primary care clinic at the Chinese University of Hong Kong indicates that intra-articular-only injection therapy with hypertonic dextrose is safe and effective for alleviating symptoms of knee osteoarthritis.

Over 52 weeks of treatment, the study followed 76 patients who were between 45 and 75 years old who had been diagnosed with knee osteoarthritis and who suffered moderate to severe chronic knee pain for at least three months. One group of 38 patients received the hypertonic dextrose injection therapy, while the other had the same therapy only using normal saline. While both groups reported some improvement, the hypertonic dextrose group reported more significant reductions in pain by the conclusion of the study. The researchers note that longer-term follow-up, direct comparison with other injection therapies, and cost-effective analysis are all needed.

Efficacy of Intra-Articular Hypertonic Dextrose (Prolotherapy) for Knee Osteoarthritis: A Randomized Controlled Trial
Regina Wing Shan Sit, MBBS, et al
The Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care, Hong Kong

After Cancer: The Role of Primary Care in Cancer Survivorship Care

Primary care physicians are treating an increasing number of cancer survivors, yet they have no clear guidance on how best to care for such patients. This study considers how primary care physicians perceive their role in delivering care to cancer survivors. The researchers conducted interviews with 38 primary care clinicians and collected data on the 14 practices in which they worked. While most felt cancer survivor care was within their purview, their approaches toward treating cancer survivors varied widely. More broadly, this study brings into question the role of primary care in addressing the complex needs of cancer survivors. Researchers recommend coordinating care between primary care physicians and oncologists as patients transition to long-term survivorship.

Cancer Survivorship Care Roles for Primary Care Physicians
Jenna Howard, PhD, et al
Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey

My Patient Wants to Kill Me

When trying to ease patients off of prescription opioids, primary care physicians may meet with resistance, anger--or worse--from those they seek to help. Dr David Bittleman shares his experience of dealing with a death threat from one such patient under his care at a Veterans Affairsclinic. The VA's existing protocols for responding to volatile situations could protect him while at work, but he felt vulnerable to a possible attack in the world outside the clinic. He ultimately sought a civil restraining order against his patient. While Dr Bittleman's experience did not result in any physical harm, he continues to feel concerned about the dangers that he and other medical practitioners face when treating patients who are prone to anger and violence. He feels that "violence is an important problem in health care, both underreported and understudied." One way to diffuse potential problems before they become dangerous, he suggests, is by allowing patients to express their feelings, including their grievances about their treatment plans, in honest, open conversations with their care teams.

My Patient Wants to Kill Me
David Bittleman, MD
Veterans Affairs San Diego Health Care System, San Diego, California

Primary Care Practice Transformation Introduces Different Staff Types

The Comprehensive Primary Care initiative was launched in 2012 by the CMS Innovation Center as a four-year multi-payer initiative designed to strengthen primary care. This study examines shifts in staffing patterns, from 2012 to 2016, at 461 primary care practices participating in the CPC transformation initiative with those at 358 non-CPC practices.

Over the four years of the study, CPC practices moved away from a traditional staffing model of physicians with medical assistants as they added a variety of new staff, most commonly care managers or coordinators and behavioral health staff, to support patients with comprehensive, team-based care. Non-CPC practices, by comparison, did not increase their team size or diversity as much as CPC practices did. For example, in 2016, 84% of CPC practices had care managers or care coordinators, but only 36% of comparison practices had them.

The authors suggest that future studies should examine the effect of team-based care and staff composition on health care cost, service utilization, patient experience and the overall sustainability of new staffing models. In addition, future work should also address how practices make decisions about augmenting staff in response to patients' medical and social needs.

Primary Care Practice Transformation Introduces Different Staff Types
Kaylyn E. Swankoski, MA, et al
Mathematica Policy Research, Princeton, New Jersey

Primary Care Case Management Among Frequent Users With Chronic Conditions

Case management is an effective, collaborative, and cost-effective way to help frequent users of health care services integrate all aspects of their care. The research team behind this study developed a program theory to investigate how, and in what circumstances, case management in primary care works to improve outcomes among frequent users who have chronic conditions.

The researchers note that their study only looks at case management in primary care for frequent users of health care, rather than case management use more generally. They also note that further research is still required to examine if the care setting or the professional role of case managers, such as nurses and social workers, may have an influence on the development of the patient-case manager relationship.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis
Catherine Hudon MD, PhD, et al
University of Sherbrooke, Department of Family and Emergency Medicine, Sherbrooke, Quebec, Canada

Innovations in Primary Care

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

  • Electronic Medical Record-Based Referrals to Community Nutritional Assistance for Food-Insecure Patients - More than 2,500 food-insecure households from two outpatient clinics were successfully referred to community food resources using the combination of a brief, standardized screening tool and an integrated referral mechanism in the Hennepin County Medical Center's electronic medical record system.


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,

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