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How Do Clinical Practice Guidelines Go Awry? - AFP Journal Club
ABSTRACT: Family physicians commonly find themselves in difficult clinical encounters. These encounters often leave the physician feeling frustrated. The patient may also be dissatisfied with these encounters because of unmet needs, unfulfilled expectations, and unresolved medical issues. Difficult encounters may be attributable to factors associated with the physician, patient, situation, or a combination. Common physician factors include negative bias toward specific health conditions, poor communication skills, and situational stressors. Patient factors may include personality disorders, multiple and poorly defined symptoms, nonadherence to medical advice, and self-destructive behaviors. Situational factors include time pressures during visits, patient and staff conflicts, or complex social issues. To better manage difficult clinical encounters, the physician needs to identify all contributing factors, starting with his or her personal frame of reference for the situation. During the encounter, the physician should use empathetic listening skills and a nonjudgmental, caring attitude; evaluate the challenging patient for underlying psychological and medical disorders and previous or current physical or mental abuse; set boundaries; and use patient-centered communication to reach a mutually agreed upon plan. The timing and duration of visits, as well as expected conduct, may need to be specifically negotiated. Understanding and managing the factors contributing to a difficult encounter will lead to a more effective and satisfactory experience for the physician and the patient.
When to Order Contrast-Enhanced CT - Article
ABSTRACT: Family physicians often must determine the most appropriate diagnostic tests to order for their patients. It is essential to know the types of contrast agents, their risks, contraindications, and common clinical scenarios in which contrast-enhanced computed tomography is appropriate. Many types of contrast agents can be used in computed tomography: oral, intravenous, rectal, and intrathecal. The choice of contrast agent depends on route of administration, desired tissue differentiation, and suspected diagnosis. Possible contraindications for using intravenous contrast agents during computed tomography include a history of reactions to contrast agents, pregnancy, radioactive iodine treatment for thyroid disease, metformin use, and chronic or acutely worsening renal disease. The American College of Radiology Appropriateness Criteria is a useful online resource. Clear communication between the physician and radiologist is essential for obtaining the most appropriate study at the lowest cost and risk to the patient.
Historic Growth Rates Vary Widely Across the Primary Care Physician Disciplines - Graham Center Policy One-Pagers
Dermoscopy for the Family Physician - Article
ABSTRACT: Noninvasive in vivo imaging techniques have become an important diagnostic aid for skin cancer detection. Dermoscopy, also known as dermatoscopy, epiluminescence microscopy, incident light microscopy, or skin surface microscopy, has been shown to increase the clinician’s diagnostic accuracy when evaluating cutaneous neoplasms. A handheld instrument called a dermatoscope or dermoscope, which has a transilluminating light source and standard magnifying optics, is used to perform dermoscopy. The dermatoscope facilitates the visualization of subsurface skin structures that are not visible to the unaided eye. The main purpose for using dermoscopy is to help correctly identify lesions that have a high likelihood of being malignant (i.e., melanoma or basal cell carcinoma) and to assist in differentiating them from benign lesions clinically mimicking these cancers. Colors and structures visible with dermoscopy are required for generating a correct diagnosis. Routinely using dermoscopy and recognizing the presence of atypical pigment network, blue-white color, and dermoscopic asymmetry will likely improve the observer’s sensitivity for detecting pigmented basal cell carcinoma and melanoma. A two-step algorithm based on a seven-level criterion ladder is the foundation for dermoscopic evaluation of skin lesions. The first step of the algorithm is intended to help physicians differentiate melanocytic lesions from the following nonmelanocytic lesions: dermatofibroma, basal cell carcinoma, seborrheic keratosis, and hemangioma. The second step is intended to help physicians differentiate nevi from melanoma using one of several scoring systems. From a management perspective, the two-step algorithm is intended to guide the decision-making process on whether to perform a biopsy, or to refer or reassure the patient.
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