Unraveling the Mysteries of Patient Complaints
The 2008 March/April issue of the Journal of the American Board of Family Medicine (JABFM) highlights new data about several common yet disturbing symptoms we see in family medicine for which medical care has not yet provided adequate solutions.
Night Sweats
We have a long way to go to understand both sleep disorders and night sweats. Reporting sweating at night is rarely related to fevers, as many of us learned in medical school, but people with night sweats have many sleep complaints and feel sleepier. Yet, as Mold1 reports, these sleep complaints are not associated with verifiable sleep disturbances by traditional measures in formal sleep studies. Something is happening for these people, and more effort should go toward truly measuring and understanding the meaning of their symptoms and to help them get relief. Is this depression talking? If so, what aspects of sleep studies could help verify this?
Sleep
A big problem. Sometimes simple answers. Often not. As Sorscher2 found, family physicians often do not include sleep questions on routine intake questionnaires. Do we fear the potential “yes” answer? The major apparent choices: 1) controlled, potentially addictive medicines which physicians are berated for using, and for which insurance companies make us fill out extra forms or make more phone calls; or 2) difficult life changes by patients. To make matters worse, “insomnia” is not always considered a reimbursable service for family physicians (apparently, it is considered a mental health diagnosis that some insurers say requires a mental health professional). Sometimes simple answers. Often not.
Chest Pain
We admit many patients with acute chest pain who are subsequently not found to have an acute cardiac event, and various attempts have been made to make this sorting process more accurate and rapid. Despite new laboratory studies plus more and more data on risk factors, occasionally patients are still sent home who later have an event and die. Crawford et al3 evaluated the utility of the American College of Cardiology/American Heart Association guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. Conducted in a military hospital with a low percentage of patients having positive troponins and high likelihood of follow-up the finding that a major clinical practice guideline did not perform better than routine clinical judgment suggests no significant benefit to requiring the specific validated guideline in their setting.
Chronic Pain Treated with Opioids
Fleming and coauthors4 provide data on an enigmatic population—patients with chronic pain that family physicians have decided to treat with long-term opioids. They report that low to medium dosing is associated with higher quality of life than high dosing. Finding the happy medium between improved pain control and side effects of the medicines is an important but not always simple task.
Counseling to Increase Exercise
Carroll5 reminds us of the need to be specific in our counseling for physical activity, yet it was uncommon for family physicians to include all 5 “A's”: Ask, Advise, Agree, Assist, and Arrange. The daunting challenge of helping patients incorporate routine exercise into their lives suggest that this more comprehensive approach would be useful.
Eating Behaviors Associated with Obesity
Greenwood et al6 suggest that we help patients with obesity by emphasizing a few simple known items about food behaviors that contribute to obesity. By providing a limited number of easily understood and actionable facts, the message may be clearer and more effective.
Antibiotics without a Prescription
As noted in our recent Global Theme Issue on Poverty and Human Development,7 patients unnecessarily taking antibiotics without a prescription may well contribute to worldwide antibiotic resistance.8 In a focus group study, Mainous et al9 found Latino adults, particularly those from countries with fewer restrictions on antibiotics, regularly took unprescribed antibiotics and were not aware of the potential problems. Patients often perceived it as easier to obtain antibiotics than go to the doctor especially when they believed the antibiotics would improve their symptoms.
This JABFM issue also provides interesting clinical discussions of a case of large and recurrent keloids,10 the lack of an apparent relationship between serum chromium levels and the development of diabetes during pregnancy,11 and brucellosis with sacroiliitis.12
The relevance of articles in this current issue seem particularly high—every single article can be related to at least one patient seen in the office on one routine day.
Top 20 JABFM Online Articles in 2007
Table 1 shows the 20 JABFM articles most frequently read in 2007. Rankings are based on hits received by articles archived on the JABFM website only. Remarkably, 12 of these 20 were also on the 2006 list of most frequently accessed articles.13 The 12 articles with impressive staying power (on both the 2006 and 2007 list of the top 20 most frequently read articles) were by Eberl et al14; Mork et al15; Ely et al16; another Ely et al17; Astin et al18; Oh19; Dominguez20; Pejic and Lee21; Ringdahl et al22; Douglass and Bope23; Rives and Douglass24; and Gjerdingen.25
The 20 Most Frequently Read* Articles in the JABFM during January 2007 through December 2007†
Lee Dresang had an evidence-based colposcopy update in the JABFM top 20 in 200626 and another article on molar pregnancy on the 2007 top 20 list (both were published in 2005).27
Three papers published in 2003 or 2004 and most read in 2007 were not on the 2006 most read list; some papers seem to regain interest, probably because of other events in medicine. They were: the Lijoi and Brady28 article on vasa previa diagnosis and management; the Geyman29 commentary on the corporate transformation of medicine and its impact on costs and access to care; and the Holland and Prodan30 study of peripheral neuropathy and “borderline” diabetes.
Several more recent articles attracted heavy readership in 2007. These included a review article by Kassab31 on transcranial dopplers. Clinical case reports with literatures reviews by family medicine authors continue to attract readers: Desai32 on addiction to dextromethorphan; Dresang27 on a molar pregnancy; Lijoi28 on vasa previa; and Lopez33 on choroid plexus cysts. Readers also enjoyed a brief report on maternal shoe size and infant birth weight (Stephens).34
Content Usage
Figure 1 illustrates online content usage for 2007. With an average of 117,000 requests for content per month, this is the first year the JABFM has reached the 1 million mark in total content access events. Even with the rise in content usage over the last year, the JABFM experienced a 32% decrease (since 2006) in homepage viewings, which suggests that users are accessing content by using different methods (ie, e-mail alerts of new issue table of contents, or via indexing services and search engines).
Data source: “Year-to-Date Usage Summary” for the JABFM, HighWire Press, produced January 8, 2008 (accessed January 14, 2008).
Notes
Conflict of interest: The authors are editors and staff of the JABFM.
