Family Physicians Can/Should Do: What? Where? And How?

Improving Patient Care

Multiple articles in this issue have valuable information to improve patient care. For example, the new Tennessee Functional Status Questionnaire is straightforward, easy to complete by a patient, and more informative than other instruments.¹

Diabetes drugs are often expensive. Patients with diabetes often have comorbid conditions, requiring additional medications. Even with good “prescription drug coverage” by insurance, the costs often add up to substantial amounts. Chiang et al² explore cost-related nonadherence and less adequate diabetes control in those with comorbidities.

Karra et al³ argue that an additional booster is unnecessary if adult patients do not achieve seroconversion after 2 doses of the measles–mumps–rubella vaccine. Definitely worth reading!

Dermoscopy is a fairly new tool that is increasingly used in primary care practice. That means standards are not yet well established. A group of family physicians and dermatologists⁴ used a modified Delphi method to develop foundational and intermediate proficiency standards for family physicians using dermoscopy. They also present a helpful list of dermoscopic diagnoses and associated features.

A meta-analysis of studies comparing denosumab to bisphosphonate effects on osteoporotic fracture rates has what may be considered to be a surprising outcome, with the lower-cost drug looking like a better option than the more expensive alternative.⁵

This title says it all—“Antidepressant Tapering Is Not Routine but Could Be.”⁶ Some argue that long-acting antidepressants do not need to be tapered, but some patients have difficulty with discontinuation of antidepressants past the time of medical need. Even if not physiologically necessary, tapering could help some patients discontinue their medication. The authors provide evidence from 1 health system.

Screening for prostate cancer is common but has been increasingly recognized as of low value in men older than 70 without other specific indications. Gillette et al⁷ provide updated data on the rate of such screening and quantify other tests ordered concurrently with prostate-specific antigen testing.

In addition, can you diagnose angioedema of the small intestine—or know why it happened—as reported by Niyibizi et al?⁸ Rounding out the direct clinical care articles in this issue is a quick-read update on hair loss in people wearing a hijab.⁹

Social Determinants of Health

Berge et al¹⁰ advance this science, identifying a specific factor that could be a substantive intervention point to prevent obesity in school-aged children. Suresh et al¹¹ report potentially modifiable factors—over and beyond the usual—related to obesity interventions in primary care practices.

Screening for social determinants of health is becoming more widespread and is presumed to be positive. Some insurers (such as some Medicaid insurers) essentially require such screening. But does this screening help patients? Brown et al¹² completed a systematic scoping review to identify the specific perspective of patients and caregivers. Only 16 articles that included 2 or more social domains were found, a telling fact in and of itself, as having multiple authors and articles is often important to identify many viewpoints. This study’s outcomes showed mixed results and are worth considering.

Health Implications Related to Practice and Provider Characteristics

Not surprisingly, rural family medicine is associated with a wider scope of practice, probably as a result of physician shortages and a lack of alternate resources. We admire the dedication and impact of rural family physicians. Killeen et al¹³ provide additional observations of practice scope by location, leading to a conclusion that policy makers should encourage payment/accountability models that incentivize broader practice scope, an important factor in a variety of positive outcomes. Another article¹⁴ reports that female primary care providers are more likely to share their patients with an interprofessional team. Aul et al¹⁵ compared the perceptions of various types of clinicians who care only for infants or mothers versus those who care for both the mother and infant, specifically investigating their views on vitamin D supplementation for newborns. There were clear differences in recommendation practices, with unclear long-term implications, such as on adherence and infant outcomes. This is an area ripe for additional research.

Policy

The straightforward data from this issue’s policy brief: Female family physicians are more racially diverse than their male counterparts in federal sites, but not at nonfederal sites.¹⁶ The questions: What are the hidden learnings behind these facts? What drives this—the female physicians’ type of minority status, mission-driven orientation, finances, or other factors? Read more discussion in the associated commentary.

The Accreditation Council for Graduate Medical Education’s new paid family and medical leave policy is the next step forward—by adding the requirement that the maternity/paternity leave be paid!¹⁷ What a thought!

COVID Persists for Patients and Clinicians

In a study of 1.5 million patients diagnosed with mild COVID-19 in Mexico, daily telephonic contact was associated with a lower death rate than for those who were not in the regular telephonic contact group.¹⁸ This is a reminder that telephonic contact can facilitate critical follow-up in the face of clinical uncertainty or when return visits prove difficult.

As a group, family physicians are dedicated to patient care. In this follow-up to an earlier study, Cunningham et al¹⁹ find the impact of the COVID-19 pandemic continued to be significant, and primary care team members perceive the reactions of their organizations to be inadequate.

When asked, patients in Northeast Ohio reported that financial incentives decreased their likelihood of COVID-19 vaccination.²⁰ In this fascinating report, not only the highly publicized, high-dollar ($1 million) Ohio lottery but also other types of financial incentives do not ensure higher COVID-19 vaccination rates. More influential for acceptance of COVID-19 vaccination is personal motivation and, hopefully, clinician–patient relationships.

Practice Management and Characteristics

Lai et al²¹ provide an overview of how to create work and an environment that attracts and retains medical assistants. In addition to making medical assistants’ work efforts and workplaces more pleasant and professionally attractive as suggested, we would add a note that helping medical assistants take courses to become RNs (or other types of health care workers) can also advance their careers.

Medical practices have large computer databases that host medical records. Theoretically, we should be able to search and find that we need to maximize individual patients’ health. Petrik et al²² show just how bad electronic medical records are at identifying the correct patients for colorectal cancer screening. Is your record system any better? And, if not—which is likely the case—how does your office ensure adequate, appropriate screening? Another study finds continuity with a clinician/team did not vary much by payment model.²³ It is pertinent that this study was completed in the setting of Canadian universal health insurance.