Abstract
This issue of the JABFM features research on a broad array of clinical topics. The topics of 5 articles involve controlled substances, including a sobering article on the risks of amphetamines in older adults. An excellent quick reference guide for managing common COVID-19 symptoms is presented. Two other articles consider hypertension treatment in primary care, demonstrating that treating blood pressure is anything but straightforward. Several additional clinical topics include mononucleosis, influenza, and the impact of home life on childhood weight and eating habits. A study from Virginia underscores that primary care, as a system, is distressed. A review of the existing literature on “slow medicine” comes to important conclusions. Some health systems are partnering with local resources to practically address such social determinants as food insecurity. Not surprisingly, family physicians are filling gaps in emergency care around the country.
Research on Clinical Topics
Controlled Substances—Problems and Problem Prevention
Four articles in this issue report on clinical issues related to controlled substances. Some clinicians prescribe amphetamines in older adults, expecting that a small dose is not related to adverse events. Dr. Latronica and coauthors1 analyzed evidence related to the safety of the quickly increasing use of amphetamines for attention deficit disorder in a database of more than 13,000 patients older than 65 years of age—about 5000 of whom were prescribed amphetamines. The results show dramatic increases in cardiovascular events.
Family physicians have heeded the dangers of opioid therapy for chronic noncancer pain and are altering their narcotic prescribing approach for these patients. This change is challenging for both clinicians and patients. Suen et al2 explored the patient's perspective on these shifting norms in opioid therapy for chronic noncancer pain. A report from Russell et al3 demonstrates that even with training, many challenges remain to significantly increasing the numbers of family physicians prescribing buprenorphine.
One tool that can address these challenges is the benchmark tracking assessment Sussman et al4 developed to guide clinicians through the process of implementing buprenorphine therapy. Family physicians need other tools to address the ongoing, and apparently growing, substance use epidemic. Would clinicians be open to using a clinical support tool to manage opioid use disorder, and what would it need to be like to assist primary care clinicians to manage opioid use disorder? Further, would clinicians use it? Solberg et al report on their findings.5
COVID-19
The Journal is pleased to publish a quick-reference guide for management of post-COVID symptoms for primary care clinicians created by a multidisciplinary group from the University of Michigan.6 Most practices went through dramatic increases in telemedicine during the early phases of the COVID-19 pandemic. A report of how telemedicine changed in the pandemic highlights some of the challenges and solutions found by 36 community health center centers across New York state, 1 of the hardest-hit regions.7
Hypertension
Hypertension guidelines have undergone considerable changes over the last several years. A thought- provoking report by Rogers et al8 explores potential unintended consequences of guidelines that result in clinicians prescribing multiple antihypertensive medications for patients. This report is a good reminder that all clinical decisions have consequences, not all which are immediately obvious. Hypertension control has deteriorated, and Solberg et al9 investigated what could be improved. By considering the disparate reasons noted by patients who were dissatisfied with their care, the authors identified 4 major types of issues, each requiring a different clinician approach. This suggests the need to both inquire, then listen carefully to patients to mutually find an acceptable path to improved adherence and blood pressure control.
Other Clinical Topics
Ebell et al10 evaluated a range of clinical prediction rules for diagnosing influenza. Importantly, their findings suggest that such a rule could play an important role diagnosing this common infection without bringing sick people in for an examination. Cai et al11 present a thorough systematic review and meta-analysis of the accuracy of laboratory findings, as well as signs and symptoms, of infectious mononucleosis.
A hint for family physicians wondering about the adherence rate for chronic medications by their patients: look at how well they follow prevention screening recommendations.12
Methotrexate can be a very useful drug. However, when a dosing error is made, it can have very serious consequences. The type of most common errors suggest that patients need even-greater-than-usual assistance to avoid problems.13
Life with children can be chaotic at times, and some homes operate with a higher baseline level of chaos and stress than others. Does CHAOS correlate with health outcomes? A study of home environment profiles and childhood body mass index, among other outcomes, looks at this issue.14 The next challenge will be to determine how clinicians should counsel patients based on these study findings.
Health Systems Research
Slow medicine is not the norm in the US health care system. Yet many (perhaps most) family physicians have a gut feeling that it is often a better approach. Marx and Kahn15 report on a broad-ranging review of the topic and identified some tantalizing hints about that gut feeling. The authors make the case that slow medicine needs to be taken more seriously by researchers and policy makers.
Clinicians are increasingly attempting to address the social determinants of health. To address food insecurity, collaborations between community food sources and health systems are likely to be more common in the future. An analysis of 1 such collaboration involving the Mid-Ohio Farmacy found a mix of successes and barriers to the program.16
How many specialist referrals do family physicians, on average, make for patients? A report from a single academic institution shows surprisingly wide differences. The authors were able to identify some associations with variable referral rates but also evidence that there is room for improvement in family medicine training.17
Brooks et al18 offer a snapshot of the primary health care system in the Commonwealth of Virginia. They describe significant challenges existing for a system that functions as a safety net for many of the commonwealth's most vulnerable patients. The sobering aspect of the report is that the data were collected before 2 major stressors, Medicaid expansion and COVID-19, occurred. Clifton et al19 investigate burnout in team members across 41 family physician practices, and not just among the health care professionals. Notably, the family medicine residents were the most distressed.
Bennett et al20 provide yet more evidence of family medicine's large and diverse impact on the American health care system. This team studied the AMA's Physician Masterfile to create an estimate of the amount of emergency medicine conducted in the nation by family physicians. The results, especially in some underserved areas, are impressive.
Notes
Conflict of interest: The authors are editors of the JABFM.
To see this article online, please go to: http://jabfm.org/content/34/6/1071.full.
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