Re: Are a Speculum Examination and Wet Mount Always Necessary for Patients with Vaginal Symptoms? A Pilot Randomized Controlled Trial
In this study of care for women with vaginitis, Anderson et al1 compare the detailed evaluation of the “classical approach” to an empirical, symptom-based approach to diagnosis and treatment. In day-to-day clinical practice, every problem cannot be worked up definitively, and the empirical arm of this study is close to what we do in everyday primary care practice. As the study authors point out, most patients with vaginal complaints are at low risk of having a life-threatening illness. If appropriately screened, most patients with vaginal symptoms have benign and self-limited problems; besides vaginal infections, psychosocial issues can bring the patient to the doctor with this kind of complaint. The study suffers from a small sample size, but it does help reinforce and lend weight to what already happens in clinical practice every day: “treating patients based on symptoms and reserving a more in-depth (classical approach) work up for those who fail the initial treatment.” Prescribing antifungals for patients with typical yeast symptoms is common practice. However, I am more comfortable prescribing metronidazole when I have a positive wet preparation, so probably clinical judgment will always be an important part of the medical decision, in addition to evidence such as that presented by Anderson et al.
Re: Prevalence of Depression Symptoms in Outpatients with a Complaint of Headache
I liked this study! Marlow et al2 add some epidemiologic bite to the differential diagnosis triggered in the minds of experienced clinicians. This is a useful study based in our kind of setting, ie, outpatient family medicine offices. We see this type of patient almost every day in our practices, but how far behind we are in the clinic or how late it is in the day often determines if we open that black box and ask about depression. Just as knowing that the patient in room 2 with shortness of breath had a recent joint replacement tips one off that she may have a pulmonary embolism, a headache is a tip-off for underlying depression. When we fail to recognize this, patients will probably not improve and we may select treatments that make them worse.
Re: Increased Osteoporosis Screening Rates Associated with the Provision of a Preventive Health Examination
I rarely have a patient come in to see me for a “physical” or “general medical examination” who does not have some complaint or problem to discuss. Because billing for “physical exams” is often difficult, I appreciated this study's3 promotion of the need for a General Medical Examination. Besides billing issues, the take home message is that primary care offices must have a prevention and screening agenda for their patients. If not, we are unlikely to hit current recommended guidelines for prevention. I may bill for diabetes, hypertension, or a headache, but if the visit is designated for an annual checkup then it is time to sit down and review all health matters of importance, especially preventive ones. My office makes special plans for prevention visits and has protocols that the nurses must follow. I was a little taken aback by the study's finding that male physicians were less likely to offer screening than female physicians, possibly revealing a disease-specific gender bias. Offices need to have a way of evaluating their performance. This study makes a good argument to have a registry or an electronic medical record that allows us to audit our work. At the Mayo Clinic, Grover et al3 had such a registry; however, we audit our osteoporosis patients’ charts using electronic billing reports that are easily queried and with the paper record; this shows it can be done without an electronic registry.
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