Letters

EBM in AFP

To the Editor:

We read "Making Evidence-Based Medicine Doable in Everyday Practice" [February 2004, page 51] with great interest. For more than five years, we have taught such a model to residents and colleagues and have presented data on our work in regional and national forums. We are proponents of the use of secondary resources of publication as a tool for physicians to do "just-in-time" knowledge management in daily practice. We are disappointed to see American Family Physician (AFP) listed as such a resource.

Although AFP is the premier publication of the AAFP, it fails the standard of a resource of secondary publication. Articles do not consistently cite levels of evidence or provide such critical data as number needed to treat, odds ratios or likelihood ratios. At times, the content of articles may conflict with the best available evidence. In addition to the uneven consistency of AFP from an evidentiary point of view, its online search engine lacks the sophistication and efficiency to permit efficient searches while seeing patients.

Recent examples of the above are a patient handout in the Feb. 1, 2004, issue, which supported routine self-exam to screen for testicular cancer. This recommendation runs counter to the U.S. Preventive Services Task Force (USPSTF) finding that there is no evidence to support routine screening for testicular cancer by physicians or self-examination by patients. The Dec. 15, 2003, issue had a feature article on strategies for primary prevention of stroke. The article included a table on the effectiveness of various stroke prevention strategies that cited relative risk reductions (RRR), rather than the much more clinically meaningful absolute risk reductions (ARR) or numbers needed to treat (NNT) for the respective interventions.

While AFP remains an important review journal and CME resource for family physicians, it does not yet possess the rigor and utility of an adequate resource of secondary publication for using evidence at the point of care. It is our hope that one day AFP will achieve that status. At that time we will wholeheartedly incorporate it into our teaching and presentations.

Eamon Armstrong, MD
Brian Stello, MD
Allentown, Pa.

Editor's response:

It's true that AFP is not a purely evidence-based, just-in-time resource. It was included in the article because of its evidence-based components, which anyone can access free of charge at http://www.aafp.org/afp, and because of its efforts to include evidence-grading scales for key clinical recommendations and offer more evidence-based clinical review articles. For more information about these efforts, read "AFP: Doing More to Help You Get the Best Evidence" in the Feb. 1, 2004, issue of AFP .

Given the nature of the comments by Dr. Armstrong and Dr. Stello, we asked the editors of AFP to respond as well.

AFP's response:

At AFP, we are strongly committed to the transition from an authority-based review journal to an evidence-based review journal. This commitment is exemplified by the following:

• Development of new evidence-based features, such as Clinical Evidence Concise, Cochrane for Clinicians, POEMs (Patient-Oriented Evidence That Matters), Point-of-Care Guides, and Recommendations and Rationale from the USPSTF;

• Leadership in the development of the Strength of Recommendations Taxonomy (SORT) for rating evidence;

• Consistent use of the SORT in all upcoming review articles;

• Naming a Deputy Editor for Evidence-Based Medicine and new medical editors such as Allen Shaughnessy, PharmD, and Henry Barry, MD, MS, who have national reputations as experts in evidence-based medicine.

Obviously, any effort to change the editorial direction of a journal that publishes more than 2,000 pages per year takes time. We appreciate the patience and support of our readers as we make this transition. And we would welcome good, succinct, practical, evidence-based reviews from physicians such as Drs. Armstrong and Stello.

Mark H. Ebell, MS, MD
Deputy Editor for Evidence-Based Medicine

Jay Siwek, MD
Editor

Proceduralism would boost interest in the specialty

To the Editor:

I was very interested in "Family Medicine Takes Center Stage" [November/December 2003, page 43], particularly in how "medical students ... put income at the top of the list of drawbacks for going into family medicine today." This is certainly reasonable and partially why I initially chose anesthesiology as a specialty. I have since fallen in love with family medicine and would like to suggest how to boost student and professional interest in the specialty: emphasize procedures. The money is in procedures.

As primary care physicians, we should be thoroughly trained in screening procedures (e.g., colonoscopy, colposcopy, stress testing, mammography). After all, who better to do screening procedures than primary care doctors? Though this is theoretically possible where I train, I realize that the glut of specialists, along with reimbursement and privileging issues, would make this difficult. Perhaps family medicine residency programs could emphasize just one or two types of procedures. Then they could graduate competent family physician-colonoscopists or family physician-preventive cardiologists, like some of the more rural residency programs do.

Natan Schleider, MD
Summit, N.J.

Physician couples and the Stark statute

To the Editor:

I am troubled by the example in Alice Gosfield's "The Stark Truth About the Stark Law: Part I" [November/December 2003, page 27] that describes the family physician whose husband is a pathologist. Even if her referrals do violate the law, is it likely they would be prosecuted? Let's say she is in the only family medicine group in town and her husband works at the only group that performs hospital laboratory services within a 100-mile radius. What about a family physician whose wife is a physician employee of the local hospital ED to which he sends patients? Does this violate the law?

It seems that with more and more physician couples, such situations must occur all the time. Who better to refer your patients to than the physician you married? In no other person will you have as much trust and confidence that the medical service you need carried out will be accomplished. A law this confusing benefits no one, least of all our patients who entrust us with their lives.

Ryan Crim, MD
Carlisle, Pa.

Author's response:

The issue of referrals between spouses for designated health services (DHS) under Stark is extremely problematic in this day of dual professional families. Because any referrals by a physician or immediate family member to an entity with which the physician or family member has a financial relationship could be implicated, the regulators have acknowledged the problems associated with these circumstances. The regulators explicitly believe that referrals to a spouse should be allowed if the Stark service is not the specific reason for the referral. For example, if the family physician refers a patient to his wife's cardiology practice for treatment of a heart condition and the cardiology group does an echocardiogram, that's a DHS but not a problem under the regulations. Additional comments may be made regarding this issue in the Phase II Stark regulations, which were expected last summer but have not yet been published.

Defending EBM

To the Editor:

Robert Edsall's editorial "The Evidence-Based Medicine Heresy" [February 2004, page 13] scared me. As a teacher and practitioner of EBM, I am fully aware that as long as the probability of an outcome is neither zero nor one, there will be the potential for harm using the most rational approach to patient care. Still, your report of Dr. Merenstein's experience with the lawyer's demonizing of EBM is worrisome.

But before we start ordering prostate specific antigen (PSA) tests on all males over the age of puberty, we might consider the following scenario. What might have happened if another 53-year-old patient of Dr. Merenstein had a recommended PSA that was elevated, underwent a biopsy that found no evidence of cancer and had a serious complication or died as a result of the procedure? An angry patient or family would probably find a lawyer. If that person were clever, he or she would find information and experts to show that EBM recommendations represented the highest quality of care and that a screening PSA was not a necessary test. I don't know whether such litigation has actually taken place, but it certainly would be possible.

So what do we do with EBM? Well, if we expect it or any other aid to medical practice to provide certainty, then we probably should be in a different field. It is not heretical to seek and use the best evidence available, as long as we temper it with our own experience, the patient's wishes and, apparently, the vagaries of our legal system.

Fredric J. Romm, MD, MPH
Milwaukee

Evaluating the efficiencies of technology

To the Editor:

We want to hear from you

Send your comments to fpmedit@aafp.org. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.

I have an engineering background and usually think that technology is terrific, but as "Rediscovering the Paper Planner" [March 2004, page 100] demonstrates, it has its limitations. I had a personal digital assistant (PDA) for a few years. It was a wonderful gadget - when it was working! I had to send it back for repairs twice and lost considerable data in the process. I have now gone back to a paper planner and am much more efficient. I am able to get to information much faster and enter it more quickly with the paper planner than with the PDA.

I believe that the same thing will occur with electronic medical records (EMRs). EMRs seem like the answer to everything, but we will all find out that they are actually costly and inefficient. As a solo physician in a rural area, I cannot afford to purchase and maintain an EMR system, and I cannot afford the extra time spent on record keeping. I would rather be caring for my patients. I believe that EMRs should not be mandated for everyone, but they should be a choice for those who have extra money and time. Technology is not always the best option for everyone.

Valerie Richey, MD, ND
Mount Orab, Ohio

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