This Issue: International Issues, Infectious Diseases, Medical Liability, and Medical Home Ideas

International Health Perspectives

Of our featured articles related to international health, the first is a rich resource for evaluating and managing US children who become ill after traveling abroad.¹ These problems are more common with the increase of international travel. On a personal level, more than once, my (MAB) children were febrile after international travel, and I was very impressed with our family physician's knowledge of malaria and clinical experiences with similar situations. In another article, Gonzalez et al² report on immigrant experience with US care, finding lower satisfaction and perceived quality of care for Latino newcomers to the US when the language of the office visit was not concordant with their own.

In another telling article, Wallace and Brinister³ completed in-depth interviews with family physicians in Moldova, part of the former Soviet Union. Although the country is poor and residency-trained family physicians are relatively new, the themes voiced by the study participants were startlingly similar to those of many US physicians; ie, family medicine as a career choice offers great diversity and satisfaction, there is too little time and too much paperwork, and many patients have problems that are above and beyond what traditional medicine can cure. By way of comparison, the article from Deshpande et al⁹ about primary care physician satisfaction in the United States found that these physicians want more time with patients, more pay, and fewer malpractice suits. Other than the malpractice difference, there are substantial similarities between the two studies. Overall, Deshpande et al⁹ was unable to determine the majority of the factors related to satisfaction of primary care physicians. One interesting finding was that owning one's own practice was associated with lower satisfaction for general internists and pediatricians, but not family physicians—we suspect the emphasis on practice management in family medicine residencies (and journals) has been helpful.

Medical Liability Issues

Speaking of malpractice, consider the greatest liability risks for family physicians; sadly, more than 11% of medical liability claims in the United States involved family physicians, with almost a third resulting in payment averaging more than $160,000.¹⁰ Diagnostic error was the major cause of the claims, with myocardial infarction and breast cancer comprising the top two, followed by appendicitis, lung cancer, and colon cancer. Care is always a good watchword, but extra caution when dealing with these potential diagnoses is warranted. An interesting finding from this article, and the one that plays into physicians’ fears about malpractice,⁹ is that the second most common type of claim—with the lowest rate of payout—was one in which no medical misadventure was claimed.

Medical liability claims related to breast cancer are particularly problematic. Mammograms are widely believed to prevent breast cancer and to reduce strongly its subsequent mortality. However, evidenced-based findings do not support the strength of these beliefs,⁶ yet these same beliefs probably lead to a number of malpractice suits, and possibly even to some unwarranted payouts. Keen⁶ provides data to put into perspective the utility of screening mammography as a diagnostic tool to prevent breast cancer death, and he argues that the decision of some women to avoid mammograms should be respected.

The Patient-Centered Medical Home: How Do We Get There?

Moving on to the “how to get there category” to meet the goals of the patient-centered medical home, we have a useful article describing the experience of partnering a patient navigator with a few small family physician practices.¹¹ In a situation crying out for the advantages of a patient-centered medical home, we currently have many veterans returning home and reintegrating with their families, which can be a time of great stress. Hinojosa et al⁷ wishes to raise our awareness of care for both the veterans and their families outside of the Veterans Administration, a situation more common than not. Seehusen,⁸ one of our editorial board members and a military physician, provides a thoughtful commentary.

Infectious Diseases

Vaughn et al¹² describe the experiences of a practice-based research network that provided specimens for the Centers for Disease Control and Prevention in an effort to help identify the cause of Southern tick-associated rash illness. This type of research by a family medicine research network has been not yet reported, but it could be highly valuable to health care in the United States, and it represents excellent teamwork between family physicians and basic science researchers. For another infectious illness, see Frei et al's¹³ retrospective cohort study about the treatment of community-associated, methicillin-resistant Staphylococcus aureus infection: should it be trimethoprim-sulfamethoxazole or clindamycin? The major conclusion is that incision and drainage is very important but the antibiotic choice is less so.

Adolescent males have some advice for family physicians on how to help them with sensitive and confidential issues related to sexual practices and sexually transmitted diseases: make it personal.¹⁴

Case Reports

Lastly, be sure to review the unusual but important case provided by Patterson⁴: cannabinoid hyperemesis with compulsive bathing. Many physicians’ practices probably see at least one patient who experiences recurrent vomiting and dehydration, often probably without a certain diagnosis. Here is another question to consider: How often is the patient bathing? And, Is he or she using marijuana?

In the next issue look for articles about sleep apnea, obesity, the complexity of family medicine encounters compared with other specialties, novel over-the-counter treatment of onychomycosis, and much more!