Editorials - July 1999 - American Academy of Family Physicians

Editorials

Family Practice as a Career Choice

JAY SIWEK, M.D.
Georgetown University Medical Center
Washington, D.C.

As a specialty choice, family practice has come of age. It is the second most popular choice of residency among medical students, second only to internal medicine. Surprising as it may seem, as a career choice family practice is number one. More office-based physicians in the United States call themselves family physicians than any other type of practitioner.¹

See article in this issue.

Since most internists subspecialize, there are more family physicians than physicians in any of the subspecialties of internal medicine--more family physicians than cardiologists, gastroenterologists or general internists or, for that matter, pediatricians, general surgeons, psychiatrists or obstetricians/gynecologists.

Despite the large number of family physicians compared with subspecialists, family physicians have struggled at times with turf issues regarding hospital privileges and academic stature. Thanks to the resurgence of interest in primary care during the 1990s, these issues are largely in the past. Family physicians are strongly recruited to practice, enjoy parity with other specialties at academic medical centers and remain near the hearts of the millions of Americans for whom they provide care.

In years past, medical students understandably wondered about the nature of family practice and the role of family physicians in the health care system. To address these questions, Scherger and other leaders in family medicine published a now-classic article, "Responses to Questions Frequently Asked by Medical Students About Family Practice."² This article was subsequently expanded to serve as an authoritative reference about family practice as a career, still mainly for medical students but also for others with an interest in family medicine, including residents, other physicians, policy makers and the public.^3,4

In this issue, we are proud to present the fourth version of this special article, "Responses to Questions About the Specialty of Family Practice as a Career."⁵ Even experienced family physicians may benefit from reading this article, perhaps just to refresh their memory, but also to keep current with statistics and information about a career in family practice. In doing so, they will be well positioned to advise students, colleagues and policy makers about the only specialty that can claim, among medical students, health organizations and, most of all, our patients: "We're number one."

Dr. Siwek is chair of the Department of Family Medicine at Georgetown University Medical Center, Washington, D.C., and editor of American Family Physician.

Address correspondence to Jay Siwek, M.D., Department of Family Medicine, 212 Kober-Cogan Hall, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, D.C. 20007.

REFERENCES

Pasko T, Seidman B, eds. Physician characteristics and distribution in the U.S. Chicago: American Medical Association, 1999.

Scherger JE, Beasley JW, Brunton SA, Hudson TW, Mishkin GJ, Patric KW, et al. Responses to questions frequently asked by medical students about family practice. J Fam Pract 1983;17:1047-52.

Scherger JE, Beasley JW, Rodney WM, Tsou CV, Swee DE, Greaves LB Jr. Responses to questions by medical students about family practice. J Fam Pract 1988;26:169-76.

Scherger JE, Beasley JW, Gaebe GI, Swee DE, Kahn NB, Rodney WM. Responses to questions about family practice as a career. Am Fam Physician 1992;46:115-25.

Garner JG, Scherger JE, Beasley JW, Rodney WM, Swee DE, Garrett EA, Kahn NB. Responses to questions about the specialty of family practice as a career. Am Fam Physician 1999;60:167-74.

Pain, Depression and Survival

PETER S. STAATS, M.D.
Johns Hopkins University School of Medicine
Baltimore, Maryland

Adequate pain relief has an obvious positive effect on a patient's quality of life. However, recent data suggest that pain control also improves morbidity and mortality, that pain relief administered before surgery and during the postoperative period improves clinical outcomes, and that depression, anxiety and poor coping skills are independently associated with mortality and, therefore, are important factors to address.¹ Whether the correlation between improved analgesia and increased life expectancy is the result of biomedical or psychosocial factors is unclear. However, several recent studies support the contention that pain causes increased severity of disease and mortality. Therefore, providing pain relief is not only a humane gesture but also a medical necessity.²

For example, a prospective, randomized placebo-controlled study assessed the efficacy of pain relief in patients with unresectable pancreatic cancer.³ A total of 137 patients were randomized and blinded to receive either intraoperative chemical splanchnicectomy with alcohol block or placebo. This simple technique sections the splanchnic nerve innervation to the retroperitoneum. Patients receiving the alcohol block had a significantly reduced mean pain score after two, four and six months of follow-up. These patients also had a reduced need for postoperative opioids and an improvement in mood; they also had a lower incidence of pain at death. More surprisingly, however, patients who received the alcohol block actually lived longer.

A subsequent analysis of these patients explored the association between pain intensity, mood state and survival.¹ Patients with more negative mood states had more preoperative and postoperative pain and a greater limitation of activity because of pain than those with less negative mood states as measured on a simple visual analog scale. It is not known whether the patients' mood states were more negative because of pain and immobility, or if a decrease in mood caused an increase in pain. However, it is clear that the removal of the nociceptive stimulus with a celiac plexus block resulted in decreased opiate use, improvement in mood and an increased life expectancy.

Another study examined the psychologic factors that can predict reported pain and survival.⁴ A total of 358 patients with leukemia and lymphoma who were about to undergo bone marrow transplantation were evaluated for physical functioning and biomedical, psychologic and social parameters. Following the transplantation procedure, patients completed a visual analog scale measuring oral pain daily for 25 days. In addition, opioid use during this time was documented. Once a week, observable transplant-related oral mucositis, reflecting nociception, was documented in a standardized fashion (using a mucositis index). Tissue injury (i.e., biomedical factors) was the factor that most strongly correlated with pain.

However, the strongest psychologic predictor of future post-transplant pain in this study was distress and worry about the upcoming bone marrow transplantation treatment, confirming that mood and pain are inextricably linked.^4,5 Analysis of psychologic factors, controlled for biomedical factors, found that relative risk of mortality was increased by more than 100 percent in patients who had somatic symptoms of depression, 94 percent in patients whose coping style did not include seeking support, and 78 percent in patients with severe symptoms of distress before treatment. These data indicate that psychosocial problems are associated with pain and mortality and should be addressed to improve outcome and survival.

Another study, conducted in animals, explored the hypothesis that painful experiences such as surgery can cause a neuroendocrine response that suppresses the immune system and promotes tumor growth.^5,6 The study tested the effect of a pre- and postoperative dose of morphine on tumor metastasis in rats. The study compared laparotomy with anesthesia versus anesthesia alone, and morphine versus placebo for pain relief. Five hours after surgery, a mammary adenocarcinoma (MADB106) cell line, which colonizes the lungs, was introduced intravenously.

In the animals undergoing surgery without morphine, retention and colonization of MADB106 cells in the lung were two- to fourfold higher than in rats receiving morphine.^5,6 In the anesthesia-only group, morphine had no effect on the metastatic outcomes. These results were replicated seven times, demonstrating convincingly that analgesia reversed the adverse effects of pain on the immune system.

These preliminary studies further support the importance of adequate pain control and of addressing the psychosocial needs of seriously ill patients. Further research is needed to validate the intriguing concept that, compared with postoperative pain control, pre- and intraoperative analgesia may actually lead to reduced morbidity and mortality.

Dr. Staats is the chief of the Division of Pain Medicine in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins Hospital, Baltimore, where he is also the director of the Anesthesia Pain Medicine Clinic. He holds associate professorships in the Department of Anesthesiology and Critical Care and the Department of Oncology at Johns Hopkins University School of Medicine.

Address correspondence to Peter Staats, M.D., Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 550 N. Broadway, Ste. 301, Baltimore, M.D. 21205.

REFERENCES

Staats PS, Hekmat H, Sauter P, Lillemoe K. The effects of alcohol, negative mood, and postoperative painon life expectancy in patients with pancreatic cancer. Presented at the American Pain Society Annual Meeting, October 1997.

Staats PS. The pain-mortality link. In: Payne R, Patt R, Hill CS, eds. Assessment and treatment of cancer pain. Seattle: IASP Press, 1998:145-56.

Lillemoe KD, Cameron JL, Kaufman HS, Yeo CJ, Pitt HA, Sauter PK. Chemical splanchnicectomy in patients with unresectable pancreatic cancer: a prospective randomized trail. Ann Surg 1993; 217:447-55.

Syrjala KL, Chapko ME. Evidence for a biopsychosocial model of cancer treatment-related pain. Pain 1995;61:69-79.

Page GG, Ben-Eliyahu S, Liebeskind JC. The role of LGL/NK cells in surgery-induced promotion of metastasis and its attenuation by morphine. Brain Behav Immun 1994;8:241-50.

Page GG, Ben-Eliyahu S, Yirmiya R, Liebeskind JC. Morphine attenuates surgery-induced enhancement of metastatic colonization in rats. Pain 1993;54:21-8.

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