New Tools and Approaches for Family Physicians

Office Procedures

Many family physicians are interested in expanding the number of procedures they perform. Three articles address procedures that some family physicians are currently adding to their skill set. Battlefield acupuncture refers to a type of acupuncture named after its use by the military for acute injuries in the field. It is relatively easy to learn, puts the needles or tacks only in the outer ear, and has a very low rate of complications. In the article by Moss and Crawford,¹ family physicians were trained to use this type of acupuncture for acute sore throat. Great idea—and nice success, with a considerable decrease in pain and ibuprofen use; however, time away from work was not statistically significant. Having another tool to provide relief that is fast, easy, and potentially reimbursable is a nice outcome. Maybe it should be considered for other acute painful conditions in the office as well.

The office use of ultrasound is quickly becoming commonplace, but it takes more training than some more common office procedures. The amount and type of training that leads to excellent accuracy by family physician operators is unclear. A small study by Bornemann et al² looks at the family physician training for and outcomes using a pocket-sized ultrasound as a screening tool for left ventricular hypertrophy. This study, and its results, give the reader a peek at the exciting future possibilities of this technology.

Colonoscopy is increasingly used for colorectal cancer screening. Inadequate numbers of endoscopists to handle the growing need could be resolved by more family physicians being trained to perform colonoscopies. Several quality indicator outcomes, recommended by the American Society for Gastrointestinal Endoscopy, among 1155 colonoscopies completed by family physicians were reviewed by McClellan et al.³ The results of several quality indicators recommended by the ASC were generally positive.

Alternative Models of Care

A topic of much current interest—at least certainly when estimated from the large number of participants attending the national conferences on the topic—direct primary care is increasing rapidly in the United States. The current forces that are changing family physicians' clinical workload, administrative burden, and career satisfaction are leading to a number of newer models. One could argue that these models are actually variations of past models from years ago, but nevertheless, they are not the recent norm. Eskew and Klink⁴ provide a wonderful service by filling in some data gaps on this type of practice and clarifying definitions with reference to enabling language in the Affordable Care Act.

Two articles relate to how to enhance the emergency department (ED) and primary care partnership. Wexler et al⁵ studied a set of interventions designed to decrease the rate of inappropriate use of the ED by Medicaid beneficiaries. Although their interventions did not have the desired effect, at least in the 1-year time span they studied, the results shed light on the reasons why this group of patients is so notoriously difficult to keep within the primary care arena and out of the ED. Simply eliminating the barrier of access was not enough to overcome numerous other issues. van Gils-van Rooij et al⁶ report on a collaborative model in the Netherlands that attempts to address the chronic problem of patients seeking care in the ED after hours for nonemergent issues. This model uses a shared entrance to the ED and to primary care to direct patients, via a triage system, to the most appropriate care setting. The model is different from the urgent care centers attached to many EDs in the United States and has the potential to both reduce cost and increase continuity.

In other research on care models, White VanGompel et al⁷ evaluated whether patient access to practices with primary care attributes (PCAs) such as enhanced access and patient-centeredness is associated with increased rates of the receipt of preventive services such as colorectal cancer screening and mammography completion. Ongoing evaluation of PCA outcomes is central to optimizing the patient-centered medical home model. The authors' findings are generally reassuring that PCAs are largely associated with improved receipt of preventive services. However, the most important findings of this study may be the few negative associations that were identified.

Using Technology to Enhance Care

The Primary Care Information Project (PCIP) used health information technology to improve patient care. The impact of the PCIP on medication adherence is reported for members of a large union health plan in New York and their diffuse primary care physician population.⁸ The authors must be commended for the large effort necessary to implement the data exchange as well as the education and support for the physicians in this multi-effort project. Yes, getting helpful information can make a difference and improve patient care. A strong and recurrent lament in family medicine is that these types of supports and patient-specific information can be so difficult to obtain and are not always readily available in our current health care system.

Delayed subaponeurotic fluid collection is an uncommon and self-limited condition among infants. Worthen et al⁹ describe the innovative use of a disease-specific blog to understand this condition and its impact on families. Both affected families and their physicians made use of the information provided by other affected families, a finding unlikely to be limited to this one uncommon disease.

A wide array of methods, new and old, are available to family physicians for communicating with patients. LaRocque et al¹⁰ explored the comfort levels of patients with various computer methods for sending/receiving test results. The findings are somewhat predictable, yet mixed in are some surprises. Importantly, the nature of the clinical test had an impact on patient comfort levels.

Specific Medical Topics

Here's something new: Treat diabetic education like a game! Make learning about lifestyle interventions fun! An impressive study by Crawford and Wiltz¹¹ reports the results of a board game–like diabetic educational strategy. Patients participating in this game-like educational program showed improvement in their HbA_1c, low-density lipoprotein, and blood pressure compared with a sex- and age-matched comparison group. An intervention that produces results, and that patients might actually find enjoyable, is truly a noteworthy tool. These impressive results need to be repeated prospectively but are certainly a reason for excitement.

Female veterans are a rapidly growing, and relatively understudied, patient population. Iverson et al¹² report on their findings of intimate partner violence among female veterans in the Veteran's Health Administration. Screening positive for intimate partner violence within the past year was strongly associated with screening positive for common mental health conditions.

Clark et al¹³ report on a study with implications for physician–patient communication: the influence of older sisters' human papillomavirus (HPV) vaccine status on younger sibling's HPV vaccine status. The authors found an association between having an older sister who was not vaccinated against HPV and a negative vaccine status of younger siblings. Clark et al suggest ways in which this knowledge could inform discussions with families about HPV vaccination.

When it comes to treating type 2 diabetes, metformin is an important mainstay, yet a survey by Goldberg et al¹⁴ uncovers significant variation in the prescribing attitudes of medical providers. The authors argue that the divergent opinions they found suggest the need for national guidelines on the use of metformin.

Han and Tran¹⁵ provide a comprehensive review of current guidelines for managing chronic hepatitis B. Giménez-García et al¹⁶ teach us about chronically draining sinus tracts of the face with dental origins. Patients with this condition could easily present first to a family physician. Readers should also take the time to read an excellent Reflections in Family Medicine article. Ventres¹⁷ reflects on what he refers to as 3 distinct “spaces” that have given meaning to his career in family medicine.

Other Topical Information

The idea of patient-reported outcome measures has gained significant popularity in recent years. In this issue, Solberg et al¹⁸ address the question of which patient-reported outcome measures are important to patients and compare them with patient satisfaction. Not surprisingly, not all outcomes that can be reported by patients are actually important to them. Focusing on those outcomes that are both reported by and important to patients, and their satisfaction, represents a logical progression in how outcomes should be chosen.

Lambing et al¹⁹ report the outcomes of an online, American Board of Family Medicine–approved, Maintenance of Certification (MOC) Part IV activity focused on osteoporosis diagnosis and treatment. It is encouraging to see evidence that MOC activities can have a positive impact on provider performance. This is an important link in a chain that will hopefully one day show that MOC activities have a positive impact on patient outcomes.

In a special communication, Mainous et al²⁰ explore the current quandary over how to classify e-cigarettes and how they should be taxed. The answers to these questions should follow the health outcomes associated with e-cigarettes, but these effects are not currently fully known. This thoughtful essay presents and analyzes many potential approaches that could be taken.