Optimism: A Good Theme for Family Medicine

“What seems to us as bitter trials are often blessings in disguise.”—Oscar Wilde (Irish poet, novelist, dramatist, and critic, 1854–1900)

Dr. Pugno's commentary¹ provides a good case for continuing to believe in the specialty of family medicine—optimism can spread optimism. Katerndahl et al's² article about perceived complexity of care, autonomy, and career satisfaction is consistent with Dr. Pugno's thesis. First, most primary care physicians in the study were satisfied with their primary care careers. Most felt they could make autonomous medical decisions, and this was important to their satisfaction. However, the practice environment was more important than physician perception of complexity or autonomy. The availability of health care support services such as physical therapy, home health, and mental health services were associated with higher satisfaction, probably because being able to get patients the care they need makes physicians feel better, too. Group practice physicians were more satisfied than solo physicians. Physicians who felt the complexity was higher than desirable were less satisfied across the 3 specialties of family medicine, internal medicine, and pediatrics. Note that this was a perception of complexity, not measured complexity. We know that physicians can be trained to deal with multiple concurrent problems, thereby potentially enhancing their ability to deal with complexity and the sense of whether or not it felt like “too much.” Still, only approximately 12% of the variance in satisfaction was explained through all the variables. Perhaps thinking more positively could help the 20% of physicians who were dissatisfied.

“Pessimism leads to weakness, optimism to power.”—William James (American philosopher and psychologist, leader of the philosophical movement of Pragmatism, 1842–1910)

Some of the perceived complexity noted by Katerndahl et al² is related to patients that physicians report as “difficult.” As reported by Elder et al³ in a previous issue of the Journal of the American Board of Family Medicine (JABFM), “studies examining physician characteristics have found that physicians with lower job satisfaction, less experience, and poorer psychosocial attitudes describe more difficult patient encounters.” This same article went on to note that family physicians described patient behaviors (stay sick and demanding) and medical problems (multiple, chronic pain, drug seeking, psychiatric) that they found frustrating. Their management strategies for success in dealing with these were to incorporate collaboration and the appropriate use of power and empathy. Training physicians in doctor–patient interactions and empathy can decrease both the number of and perceived complexity of “difficult” patients, thereby enhancing satisfaction.

The September/October 2008 issue of JABFM emphasized medical homes^4–7 and the November/December issue focused on diabetes,^8–12 cardiovascular disease,^13–16 and obesity.^17–20 This issue includes many clinical topics. From Israel, we have a trial that suggests the effectiveness of vitamin B₁₂ for recurrent aphthous stomatitis; this treatment is safe, and could be tried without significant risk.²¹ We have 3 articles about back pain. Just as vitamin B₁₂ was used in Volkov et al's²¹ study about aphthous stomatitis, Schwalfenberg²² provide a case series of using vitamin D for chronic back pain. This apparently successful case series on chronic low back pain suggests another circumstance in which to check vitamin D levels. I (MAB) have been testing vitamin D serum levels of more patients with chronic muscle pain or multiple sclerosis and finding many patients need supplementation. Furthermore, Freedman et al²³ suggests that when there is excess ongoing pain related to a vertebral compression fracture, consider avascular necrosis of the vertebral body (Kimmel disease). In the third article on back pain, with yet another truism, Deyo et al²⁴ makes a reasoned argument for decreasing our treatment of chronic back pain; more and more is being done (imaging, injections, narcotics, and surgery), yet disability does not lessen.

Ferris et al²⁵ reported that one-third of men are interested in the human papilloma virus vaccine, with an even larger group undecided. It is heartening that those with risky health behaviors were more, not less, interested in getting the vaccine. On the face of it, human papilloma virus should be an equal opportunity vaccine for both men and women. Shah et al²⁶ present important new findings about portable entertainment use and hearing acuity.

Afonso²⁷ reviews the latest information on diagnosing and treating women at high risk for breast cancer. Our diagnostic methods have expanded and our knowledge of the genetics increased, and this review provides clear direction on how to proceed. Most women have a family history of breast cancer that does not much increase risk, so specific patterns of breast cancer in the family should be determined. The article also reviews the important aspects of personal history, mammographic findings, as well as the risk calculators that are available to determine individual risk. Current recommendations on when to order a breast magnetic resonance image for diagnostic testing, sometimes in addition to mammograms, are based on a combination of risk factors. The information about chemoprevention and breast cancer is also very helpful.

Given all the many recent papers and advancing knowledge, Terpening's²⁸ review of the use of clopidogrel and aspirin for cardiovascular disease provides clarity and is a useful reference.

We also have case report articles about unusual problems. Lu et al²⁹ describe 3 sore throat patients (all younger than 30 years old), each with Lemierre Syndrome (fusobacteria associated jugular venous thrombosis and septic emboli) from one university family medicine practice within 1 year. Retropharyngeal calcific tendonitis, an entity of which many will not be aware, is described in 2 patients from another academic family medicine center.³⁰ Hatch et al³¹ also describes a case of bullous lesions on a skin graft site.

Shvartzman et al³² describe the 30-year growth in biomedical publishing among Israeli family physicians. Both the similarities and differences of what is known about US family physician authors are interesting. In a 2007 article, Pathman et al³³ also described the growth in published research among US family medicine authors. These 2 articles are among a small group of studies demonstrating how the academic and scholarly endeavors in the family medicine specialty are growing despite considerable challenges, such as a great disparity in funding by the National Institutes of Health compared with that received by sub-specialities.³⁴

Overall, this is a clinically relevant issue that clarifies burgeoning literature about topics important to family medicine, including the use of vitamins for common clinical problems, recognizing unusual causes of common complaints, and diagnosing and treating women at high risk for breast cancer. Once again, family physicians have much to teach other family physicians from their own practice experiences. No wonder we are generally satisfied with our medical practices and should remain optimistic.

“Optimist: Person who travels on nothing from nowhere to happiness.”—Mark Twain (American humorist, writer, and lecturer, 1835–1910)