Editorials - April 1, 2000 - American Academy of Family Physicians

Editorials

50 Years of American Family Physician

JAY SIWEK, M.D.
Georgetown University Medical Center
Washington, D.C.
STANLEY J. SIWEK, M.D.
Harrison, New Jersey

See "AFP 50 Years Ago" in this issue.

Lately, everyone has been focusing on a major milestone--the new millennium. But here at American Family Physician, we're celebrating an anniversary closer to our hearts: AFP's 50th anniversary. Throughout the year, we're featuring glimpses of what it was like 50 years ago for the journal, family practice and medicine in America (see page 1951). And since AFP and I both recently turned the same age, it's made me do a lot of thinking about my own career path to becoming a family physician--which brings me to my dad.

See "Inside AFP" in this issue.

Dr. Siwek senior showed me what it meant to be a family doctor. When I went to medical school at Georgetown, my concept of being a doctor was pretty much to be like him. That's something I'm still trying to do. He's been a family physician longer than this journal or the Academy has been around--more than 55 years now. And he still works harder than me. He loves doctoring and he loves people. So, in planning for this anniversary piece, I thought it might be nice to see how family practice has changed, and how it hasn't, and look at it through his eyes.

Dad is a small town doctor in Harrison, New Jersey. He's in solo practice, and he's a general practitioner in the true sense of the term. Besides caring for children and adults, he has done deliveries--thousands of them. He's delivered the children of children he's delivered. He's delivered the only set of triplets in his county. He's attended weddings where he had delivered both the bride and the groom. And, speaking of solo practice, I remember him driving up from the Jersey shore during the middle of summer vacations to deliver a baby or admit a patient.

Back then, he tells me, OB patients stayed in the hospital for 10 days, for a total hospital charge of $90. They had nine days of complete bed rest, and then they were sent home on the 10th day. After all that bed rest, they were too weak to stand and had to be wheeled out. His total charge for prenatal care, the delivery and postpartum follow-up was $50. Once, he sent an indigent maternity patient home on the fourth day to save her some money, and was roundly criticized for the premature discharge. And to save another indigent woman the hospital fees, he labored with her at her cold-water-flat for 24 hours on Christmas day, finally delivering her of a 14-lb baby.

He did tonsillectomies, at a rate of two to four a week, for a charge of $35, back when everyone, including me, got their tonsils out. He did appendectomies, herniorrhaphies and set fractures. And, he made house calls--lots of them--for $3 each. (Office visits were $2.) My mother, a registered nurse, was his office nurse, receptionist and bookkeeper. They did it all, at a time when the paperwork was simpler, of course.

What else was different then? Infectious disease, for one. That was when whooping cough, measles, mumps, rubella, polio, diphtheria and smallpox were routine. (The family practice residents in our program have never seen any of these once commonplace conditions.) Besides immunizations, antibiotics were a major breakthrough. Penicillin was initially scarce, and dosing was much different from the megaunits of today: 15,000 to 30,000 units of penicillin were plenty in those days. But aqueous penicillin had to be given frequently, every two to three hours. For one house call, my mother and father took turns going to the house every three hours around the clock to give an injection, saving the patient a hospital admission. In addition to the cost of hospital stays, small as they seem today, people were afraid to go to the hospital. Mortality rates were high, and people preferred being cared for at home. Hospital wards were typically multibed units, with double or single rooms rare or nonexistent.

To prolong the effect of penicillin, and reduce dosing, for a time it was mixed in melted beeswax. This was injected in the buttock, and supposedly lasted for up to a day. My father remembers the mixture solidifying twice at an unheated home. Fortunately, procaine and benzathine penicillin came along. But, the technology of the day seems rudimentary by today's standards. Injections were given using glass syringes with reusable steel needles. While I was growing up, living above my father's office, I remember seeing the glistening metal sterilizer container that all those shiny instruments soaked in. When the needles got dull, they were sharpened. In the hospital, rubber tubing was washed, sterilized and reused, and so were surgical gloves. And blood transfusions went directly from one person, through a stopcock, into another. It sure brought the sense of "giving life" closer to home.

In addition to his office work, my father had a busy hospital practice. At age 82, he still does. When I asked him recently how his work was going, he admitted that the hospital practice was "slowing down." How many patients was he typically following? Only about eight or 10 at a time. (When our family practice inpatient service hits double digits, the three residents who staff it feel like things are getting busy). And if you want to get a good night's sleep, don't visit Dad. He can get hospital calls all night long.

To round things out, my father's been team doctor for the high school football team for 50 years, watching the games from the sidelines. He's also town doctor for the police and fire department.

Turning 50 recently, I took a week off work and my wife and I visited old friends. I also did something I've wanted to do for a while--visit my dad in his office, this time as a family physician myself, and accompany him on hospital rounds, as I did when I was little boy. We made the rounds from patient to patient, and nurses' station to nurses' station, where they all had to tell me what a great doctor he was. One nurse told the story of how this "Miracle Man" abated her runny eyes--a side effect of cancer chemotherapy that doctors at Sloan Kettering couldn't resolve. Several nurses said that if I could be half as good a doctor as my father, I'd be doing okay.

I think my dad thinks I am doing okay--at least I hope so, which brings me back to this journal's 50th anniversary. I've been editor or associate editor of AFP for nearly 20 years now. I have my dad to thank for helping me become a family physician and for showing me how to be one. It's partly with him in mind, and all the GPs of the past and the FPs of today, that my fellow editors and I strive to put together a publication worthy of them and the noble work they do. In many ways, this journal reminds me of Dad, a great American Family Physician.

Jay Siwek, M.D., is professor and chair of the Department of Family Medicine at Georgetown University Medical Center, Washington, D.C., and editor of American Family Physician. Stanley J. Siwek, M.D., is a family physician in private solo practice, Harrison, N.J.

Address correspondence to Jay Siwek, M.D., Georgetown University Medical Center, Dept. of Family Medicine, 212 Kober-Cogan Hall, 3800 Reservoir Rd., NW, Washington, DC 20007.

Evidence-Based Preventive Care: A Timely Matter

DOUGLAS B. KAMEROW, M.D., M.P.H.
Agency for Healthcare Research and Quality
Rockville, Maryland

See "Putting Prevention into Practice" in this issue.

Time is at the heart of most clinical encounters. The patient presents to the office with complaints; the time required to address those complaints often overrides the delivery of routine preventive care. Other competing priorities and barriers that jeopardize the effective delivery of clinical preventive services include uncertainty about conflicting recommendations and lack of training in prevention.¹ Again, time is the villain; there is precious little time available for physicians to become completely familiar with the evidence for or against the routine delivery of specific clinical preventive services.

This lack of time results in preventive care not being adequately provided by primary care physicians in the United States.² Yet, the evidence base for the effectiveness of many preventive services does exist, and it is continually being expanded and updated. Without a working knowledge of this evidence, physicians are subject to the whims of patient demand for preventive services (often fueled by Internet information, media reports and direct-to-consumer advertising), even when that demand runs counter to the evidence for effectiveness. Furthermore, because the provision of preventive care always costs patients something--whether money, time, or physical or emotional comfort--physicians and their patients need to know that the chosen preventive service is worth the costs.

The new series of evidence-based case studies in preventive care that begins in this issue of American Family Physician³ is an effort by the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), to help family physicians become more knowledgeable about ways to incorporate evidence-based preventive care into every encounter with their patients. We aim to do this by presenting physicians with timely, interesting, case-based clinical prevention scenarios that, in a minimal amount of time, will provide the supporting evidence and practical information needed to implement these interventions in the office.

This monthly series of case studies is based on evidence amassed by the U.S. Preventive Services Task Force (USPSTF) and on the "Clinician's Handbook of Preventive Services, 2nd ed.,"⁴ part of AHRQ's Put Prevention Into Practice (PPIP) program (the handbook and other PPIP materials are available online at http://www.ahrq.gov/ppip). The USPSTF is a government-appointed panel of independent experts that was first established in 1984 to systematically review the evidence of effectiveness of a wide range of clinical preventive services, including common screening tests, counseling interventions, immunizations, and chemoprophylactic agents such as aspirin and hormone therapy. The first USPSTF "Guide to Clinical Preventive Services" was published in 1989. The second edition of the guide,⁵ published in 1996, evaluated more than 200 preventive interventions for 70 conditions. The second edition is available online at http://text.nlm.nih.gov and at http://odphp.osophs.dhhs.gov/pubs/guidecps.

This year, a newly appointed USPSTF (convened by AHRQ in November 1998) will begin the process of releasing new assessments and updates of previously issued recommendations as they are completed. Individual task force assessments will be available online through the AHRQ Web site (http://www. ahrq.gov) and in print. AHRQ's PPIP program will disseminate the USPSTF recommendations to clinicians, policymakers and patients. As part of its work, the task force is identifying areas in which to refine its methodology for assessing preventive services, including the following: developing more specific information on the benefits and risks of preventive services to assist shared decision making; expanding consideration of costs and cost-effectiveness; and focusing more attention on specific screening issues such as when to start, when to stop and intervals at which screening is beneficial.⁶

In addition to supporting the USPSTF and implementing PPIP, AHRQ--in partnership with the American Medical Association and the American Association of Health Plans--has established the World Wide Web-based National Guideline Clearinghouse (NGC) to provide one-stopshopping for best practices in clinical care, including clinical preventive services. The NGC is available free of charge at http://www.guideline.gov. This site provides rapid, easy access to key recommendations of more than 700 clinical practice guidelines, with more being added every week. For the family physician, it offers the opportunity to review and evaluate comprehensive sources of information to assist with clinical decision-making and patient counseling in the clinical practice setting.

The importance of providing appropriate clinical preventive services routinely is well documented. The evidence base supporting the use of these services is continually being expanded and refined to resolve remaining areas of controversy and address new issues. The challenge for physicians is to take the time to translate the evidence into routine clinical practice. We sincerely hope that this new series will help family physicians meet that challenge.

Douglas B. Kamerow, M.D., M.P.H., is assistant surgeon general, U.S. Public Health Service, and director, Center for Practice and Technology Assessment at the Agency for Healthcare Research and Quality, Rockville, Md.

Address correspondence to Douglas B. Kamerow, M.D., M.P.H., Ste. 300, 6010 Executive Blvd., Rockville, MD 20815.

REFERENCES

McVea K, Crabtree BF, Medder JD, Susman JL, Lukas L, McIlvain HE, et al. An ounce of prevention? Evaluation of the Put Prevention Into Practice program. J Fam Pract 1996;43:361-9.

Ewing GB, Selassie AW, Lopez CH, McCutcheon EP. Self-report of delivery of clinical preventive services by U.S. physicians: comparing specialty, gender, age, setting of practice, and area of practice. Am J Prev Med 1999;17:62-72.

Adult immunization--pneumococcal vaccine. Am Fam Physician 2000;61:2239-40.

Office of Disease Prevention and Health Promotion. Clinician's handbook of preventive services, 2d ed. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1998; AHCPR publication no. APPIP 98-0025.

U.S. Preventive Services Task Force. Guide to clinical preventive services, 2d ed. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996; AHCPR publication no. OM97-0001.

Atkins D. Preventive services task force reactivated. SGIM Forum April 1999;22:2,6,9.

Tympanocentesis: To Tap or Not to Tap

LARRY CULPEPPER, M.D., M.P.H.
Boston University Medical Center
Boston, Massachusetts

See article in this issue.

Is tympanocentesis safe and does it improve outcomes following episodes of acute otitis media? Undoubtedly, we need to improve diagnostic strategies for acute otitis media. Several strategies recommended by Pichichero in an article in this issue of American Family Physician¹ are valuable, such as assuring adequate illumination by replacing old otoscope bulbs, removing cerumen and adding a soft rubber sleeve (e.g., Welch Allyn SoftSpec) to aid in conducting pneumatic otoscopy. For many children, the examination reveals the presence of a bulging red or cloudy eardrum with impaired movement and, in 5 to 10 percent of these children, the examination yields a perforated tympanic membrane with draining pus.² In such examinations, the physician can be confident of the diagnosis and proceed with the preferred treatment strategy.³ However, this leaves a group of children in whom the diagnosis remains uncertain.

In our international study of acute otitis media,² family physicians were uncertain of their diagnosis in 42 percent of children less than one year of age, in 34 percent of children 13 to 30 months of age, and in 27 percent of children older than 30 months. Pichichero¹ recommends increasingly aggressive strategies to deal with these children: tympanometry or acoustic reflectometry and, if the physician is still uncertain of the diagnosis, tympanocentesis.

However, in considering these options, we must keep in mind a basic principle of medicine--first do no harm, a mandate that has been extended by the concept of Patient Oriented Evidence That Matters (POEMs).^4,5 The concept of POEMs suggests two important principles. First, treat the patient, not the chart (or the petri dish!)--be sure that the outcome of interest is important to the patient. Second, rather than opinion, seek evidence as a basis for evaluating alternatives before changing practice. In the child with a painful ear and possible acute otitis media, the outcomes of interest include short-term symptomatic improvement, avoidance of complications and prevention of recurrence.

In addition to tympanocentesis, the family physician has another important diagnostic strategy available: time! Simply maintaining contact with the family and treating the child for pain (with acetaminophen or ibuprofen) will lead to marked improvement in 65 to 80 percent of children within 24 to 48 hours and help clarify the diagnosis in others.^6,7 A watchful waiting approach is safe and will help avoid development of antibiotic resistance in those who improve on their own.^8,9 Pneumococcal infections are the infections least likely to remit without the use of antibiotics; therefore, if the new pneumococcal vaccine proves as useful as early data suggest, we may see a shift in the microbial spectrum with a concomitant increase in rates of early resolution of acute otitis media without the use of antibiotics.

I am not convinced that the data presented in Pichichero's article¹ indicate that routine tympanocentesis for infants and children in whom the diagnosis is uncertain would lead to better patient outcomes. First, as therapy, tympanocentesis provides no improvement either alone or in combination with an antibiotic in the treatment of acute otitis media.⁷ Second, I am concerned that even a low rate of adverse consequences--damage to the bony structure of the middle ear, laceration of the ear canal, persistent perforation, cholesteatoma--may outweigh the modest anticipated benefit or early symptom improvement from confirming the diagnosis and starting treatment (one to two days earlier in 10 to 20 percent of children).^6,7

The data on which Pichichero¹ bases his assessment of the safety of tympanocentesis were obtained from one physician who conducts 30 to 100 procedures a year, a rate unlikely to be generalized to most family physicians. The squirming, crying infant or toddler, in whom I most often have difficulty making a diagnosis with certainty, is also the one for whom I would be most concerned with performing tympanocentesis.

We also need to consider the consequences of a failed tympanocentesis attempt. It has been suggested that the next step would be an attempt following mild sedation.¹ In my practice setting, the time and effort required to obtain consent, educate the parent regarding care of the sedated child, administer and wait for the sedation to take effect, and help parents manage the occasional side effects of sedation all suggest that this would be a practice unsuitable for routine adoption, even if it were to lead to improved patient outcome. This leads to the last option: referral to an otolaryngologist. However, such referral usually requires a delay, and activates by default the watchful waiting approach, or, given the heightened parental concern invoked by the failed tympanocentesis, the presumptive use of an antibiotic.

We also have no evidence that the Improving Outcomes in Acute Otitis Media workshop (mentioned in the Pichichero article),¹ at which middle ear mannequins are used to teach the procedure, will result in the skills required for family physicians to perform tympanocentesis with the support available in most offices. Nor is there evidence that these skills learned at the procedures workshop would be maintained, given the few times a year most family physicians would use them.

Until more convincing data regarding the benefits and adverse effects of diagnostic tympanocentesis are available, it is prudent to use alternative diagnostic strategies, including those recommended by Pichichero.¹ Tympanocentesis is best reserved for the child with persistent acute otitis media unresponsive to multiple courses of antibiotics or for the child with a complex history, anatomic or immunologic abnormality, or other complication. In such situations, referral to an otolaryngologist might be the best option.

For the child with a painful ear or abnormal otoscopic findings, an uncertain diagnosis is best managed by treating symptoms. Seventy to 90 percent of painful ear episodes develop during a viral upper respiratory infection.¹⁰ A bulging or full tympanic membrane is a marker of an obstructed eustachian tube. Children whose tubes are not obstructed or intermittently obstructed from the upper respiratory infection often have normal position or retracted eardrums (see Table 2 in the Pichichero article¹). Depending on other findings, these patients might have acute otitis media 30 to 90 percent of the time,³ and are the patients in whom we have the most diagnostic uncertainty, even though they are also the ones whose symptoms might clear most quickly. Therefore, in children whose ear findings leave the physician uncertain, treatment of symptoms and reevaluation if symptoms persist are, in my opinion, the best options. An invasive procedure, even if usually benign, is unjustified when more than 80 percent of patients will improve rapidly without intervention,⁷ and the remainder are not placed at increased risk by delaying antibiotics.

Larry Culpepper, M.D., M.P.H., is chair of family medicine at Boston University Medical Center. Dr. Culpepper is a member of the American Academy of Family Physician's Task Force to Enhance Research and of the Institute of Medicine. He has directed International Primary Care Research Network Studies of otitis media.

Address correspondence to Larry Culpepper, M.D., M.P.H., Family Medicine, Boston University, One Boston Medical Center Place, Boston, MA 02118-2393.

REFERENCES

1. Pichichero ME. Acute otitis media. Part I. Improving diagnostic accuracy. Am Fam Physician 2000;61: 2051-6.

2. Froom J, Culpepper L, Grob P, et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ 1990;300:582-6.

3. Pelton SI. Otoscopy for the diagnosis of otitis media. Pediatr Infec Dis J 1998;17:540-3.

4. Ebell MH, Barry HC, Slawson DC, Shaughnessy AF. Finding POEMs in the medical literature. J Fam Pract 1999;48:350-5.

5. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract 1994; 39:489-99.

6. Culpepper L, Froom J. Routine antimicrobial treatment of acute otitis media: is it necessary? JAMA 1997;278:1643-5.

7. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: meta-analysis of 5400 children from thrity-three randomized trials. J Pediatrics 1994;124:355-67.

8. Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ 1997;315:98-102.

9. van Buchem FL, Peeters MF, van't Hof MA. Acute otitis media: a new treatment strategy. BMJ 1985; 290:1033-7.

10. Koivunen P, Konitiokari T, Niemela M, Pokka T, Uhari M. Time to development of acute otitis media during an upper respiratory tract infection in children. Pediatr Infect Dis J 1999;18:303-5.

Copyright © 2000 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

April 1, 2000 Contents | AFP Home Page | AAFP Home | Search