Letters to the Editor
Family Physicians Capable of Administering Immunotherapy
Original Article: The Role of Allergens in Asthma
Issue Date: September 1, 2007
Available at: http://www.aafp.org/afp/20070901/675.html
TO THE EDITOR: I was disappointed that the article, "The Role of Allergens in Asthma," had such a strong recommendation regarding referral for immunotherapy. The four family physicians in our group, many family physicians throughout the Kansas City, Mo., area, and many general internists perform immunotherapy. The four of us are all Advanced Cardiac Life Support (ACLS) certified. As the director of several hospital-based ACLS courses, I have yet to have an allergist attend for the purpose of responding to a life-threatening reaction to immunotherapy injections. The rationale for this recommendation seems to have been turf protection, rather than legitimate patient care considerations.
Author disclosure: Nothing to disclose.
in reply: We apologize for implying that family physicians should not or could not carry out allergen immunotherapy. Clearly, many physicians including Dr. Saxer and his colleagues in Kansas City, Mo., have taken the time to learn the technique and the necessary safety precautions. However, we understand that family physicians and general internists have limited time to spend on physician and patient education regarding immunotherapy. The new National Asthma Education and Prevention Program guidelines stress the importance of education for both allergen avoidance and immunotherapy.1 Many articles about severe reactions, as well as practice parameters for immunotherapy, have been published in the allergy literature.2,3 Courses on immunotherapy and the management of anaphylaxis are a well-attended feature of our meetings. We remain convinced that for the majority of busy family physicians, initiation of allergen specific immunotherapy is a legitimate reason for referral to a specialist.
Author disclosure: Dr. Platts-Mills and Dr. Leung have no conflict of interest. Dr. Schatz has received research supports from GlaxoSmithKline, Sanofi-Aventis, and Merck & Co., Inc., and has consulted with GlaxoSmithKline regarding a non-branded asthma campaign.
REFERENCES
1. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(5 suppl):S94-138. http://www.nhlbi.nih.gov/guidelines/asthma. Accessed January 15, 2008.
2. Bernstein DI, Wanner M, Borish L, Liss GM; for the Immunotherapy Committee, American Academy of Allergy, Asthma and Immunology. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol. 2004;113(6):1129-1136.
3. Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. Allergen immunotherapy: a practice parameter second update. J Allergy Clin Immunol. 2007;120(3 suppl):S25-85.
editor's note: Although the recommendation to refer asthma patients to an allergy subspecialist for immunotherapy received a SORT evidence rating of "A" in the AFP article, this recommendation from the National Asthma Education and Prevention Program1 is actually based on expert consensus, or an evidence rating of "C". A Cochrane review has concluded that immunotherapy benefits selected patients with asthma, not that it works better when administered by an allergist or primary care clinician.2 A third option would be to request that an allergist perform initial allergy testing and determine the dose, composition, and schedule for immunotherapy, with the family physician taking subsequent responsibility for the administration of injections and office monitoring. This co-management strategy leverages specialist expertise while maintaining continuity of care, and it may be a practical middle ground for family physicians caring for patients with allergen-triggered asthma.
REFERENCES
1. Williams SG, Schmidt DK, Redd SC, Storms W; for the National Asthma Education and Prevention Program. Key clinical activities for quality asthma care. Recommendations of the National Asthma Education and Prevention Program. MMWR Recomm Rep. 2003;52(RR-6):1-8.
2. Abramson MJ, Puy RM, Weiner JM. Allergen immunotherapy for asthma. Cochrane Database Syst Rev. 2003;(4):CD001186.
Scope of Practice Differences in Urban and Rural Settings
Original Article: Responses to Medical Students' Frequently Asked Questions About Family Medicine
Issue Date: July 1, 2007
Available at: http://www.aafp.org/afp/20070701/99.html
TO THE EDITOR: The article "Responses to Medical Students' Frequently Asked Questions About Family Medicine," provides valuable and important information; however, the answer to the question "What is the scope of practice for family physicians?" is incomplete. The authors give a good general idea of the scope of family medicine but do not differentiate sufficiently according to the practice location, specifically urban versus rural settings.
My experience of going from a small community program to an urban practice was surprising. I observed significant differences between the two settings, and recent research supports my findings. Rural family physicians are more likely to be in private or solo practice, spend more time on call, perform a broader range of procedures, and provide obstetric care.1,2 Rural physicians perform more suturing, musculoskeletal injection and aspirations, casting and splinting, lumbar punctures, and nursing home and palliative care.3 Visits for acute injury and pain are more common in rural practices, whereas urban practices have more visits for general medical examinations and preventive services. Urban physicians have more access to medical resources compared with rural physicians.2 Patient populations in rural areas are more racially homogeneous than urban patient populations, and rural physicians provide more care to children than do urban physicians.4
It is crucial to describe the distinction between rural and urban practices so that medical students can make an educated, informed decision when choosing family medicine as a specialty. These differences will also help them in selecting the appropriate training program based on their future goals.
Author disclosure: Nothing to disclose.
REFERENCES
1. Baldwin LM, Hart LG, West PA, Norris TE, Gore E, Schneeweiss R. Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations. J Rural Health. 1995;11(1):60-72.
2. Rabinowitz HK, Paynter NP. MSJAMA. The rural vs urban practice decision. JAMA. 2002;287(1):113.
3. Hutten-Czapski P, Pitblado R, Slade S. Short report: scope of family practice in rural and urban settings. Can Fam Physician. 2004;50:1548-1550.
4. Probst JC, Moore CG, Baxley EG, Lammie JJ. Rural-urban differences in visits to primary care physicians. Fam Med. 2002;34(8):609-615.
in reply: We agree with Dr. Marfatia's points about the many differences between rural and urban family medicine practices. Individual practices may vary based on types of procedures offered, the community needs, and patient populations. Although variations in the scope of practice of rural and urban family physicians exist, both groups share a commitment to providing patient-centered medical care that is responsive to community needs. The authors recognize that the best way for medical students to learn more about the breadth of family medicine-including rural and urban practice-is to spend time with family physicians engaged in the type of practice they are considering. Information for students on planning a preceptorship is available through your local family medicine department or by contacting the American Academy of Family Physician's Division of Medical Education (Amy McGaha, MD, 913-906-6000, ext. 6710).
Author disclosure: Nothing to disclose.
Figure 2. (A) Normal right fundus and (B) a left fundus with retinal edema secondary to central retinal artery occlusion. The central macula is still being perfused because of the presence of a cilioretinal artery, which is found in 15 percent of the U.S. population.
The article "Diagnosis and Treatment of Chlamydia Trachomatis Infection," (April 15, 2006, page 1411) contained an error in the dosage of erythromycin for persistent urethritis recommended by the Centers for Disease Control and Prevention (CDC). In the first paragraph of the right hand column on page 1413. The dosage for erythromycin was listed as being 500 mg orally twice daily for seven days; it should have been 500 mg orally four times per day for seven days. The sentence should have read: "If symptoms suggest recurrent or persistent urethritis, the CDC recommends treatment with 2 g metronidazole (Flagyl) orally in a single dose plus 500 mg erythromycin base orally four times per day for seven days, or 800 mg erythromycin ethylsuccinate orally four times per day for seven days." The article has been corrected online.
The article "Ocular Emergencies" (September 15, 2007, page 829) contained an error in Figure 2B on page 833. The figure should have had two arrows pointing to areas of retinal edema. Instead, only one arrow appeared and pointed to the normal portion of the retina. The corrected version of the figure appears below and has been corrected online.
Send letters to Kenny Lin, MD, Assistant Editor, American Family Physician, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.
Please include your complete address, e-mail address, telephone number, and fax number. Letters should be fewer than 500 words and limited to six references (including citation of original article) and one table or figure.
Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
| Copyright © 2008 by the American
Academy of Family Physicians. |
