May/June 2009 Annals of Family Medicine Tip Sheet

Media Contact: 
Angela Sharma
Annals of Family Medicine
(913) 269-2269
asharma@aafp.org

A Generalist Solution to Fixing the Fragmented World of Modern Healthcare
The second in a seven-part series of commentaries
With healthcare reform high on President Obama’s agenda, and Congress and the country on the verge of a national debate over how it will take shape, Annals of Family Medicine editor Kurt Stange, M.D., Ph.D., is authoring a seven-part series of commentaries designed to help make sense of the problems and opportunities we face for understanding and improving healthcare and health. The May/June issue of the Annals features the series’ second installment, which articulates the generalist approach and its value for patients, clinicians, healthcare systems and communities. Stange illustrates the importance of comprehensive, personalized primary care – an approach that is devalued and often overlooked in the fragmented world of modern healthcare. He cautions readers that quick-fix, no-pain solutions do not exist for the system’s complex problems and calls for a renewed commitment to primary care.
The Generalist Approach
By Kurt C. Stange, M.D., Ph.D.
Editor, Annals of Family Medicine

High Incidence of False-Positive Results in Multimodal Cancer Screening
As the number of recommended cancer screening tests increases with advances in technology and the proliferation of guidelines, Croswell and colleagues look at the costs – in resource and human terms – of the increasing numbers of false-positive test results. Analyzing data from a large multimodal cancer trial that screened for cancers of the prostate, lung, colon and ovary among 68,436 adults aged 55 to 74 years, researchers find that the risk of an individual obtaining a false-positive result increases with the number of screening tests. Specifically, by the fourth test, the risk of having at least one false-positive is about 37 percent for men and 26 percent for women. By the 14th test, the risk is approximately 60 percent for men and 49 percent for women. Moreover, the risk of undergoing any false-positive-prompted invasive diagnostic procedure is about 17 percent for men and 12 percent for women after four tests and 29 percent for men and 22 percent for women after 14 screening tests. The authors conclude that given the rate at which false-positive rates can accumulate in multimodal screening programs, and the potential physical, psychological and economic burdens these regimens can generate in healthy individuals, physicians should educate patients about the likelihood of false positives and resulting diagnostic interventions .
Cumulative Incidence of False-Positive Results in Repeated, Multimodal Cancer Screening
By Jennifer Miller Croswell, M.D., et al
National Institutes of Health, Rockville, Md.

The Realities of Practice Redesign: Early Lessons from AAFP’s National Demonstration Project
Transforming a primary care practice to a patient-centered medical home is possible, but more difficult than generally appreciated. This is according to the first report of the independent evaluation team of the National Demonstration Project, a two-year pilot project undertaken by TransforMED, LLC and supported by the American Academy of Family Physicians. As the PCMH model emerges as a potential catalyst for multiple health care reform efforts, this report describes the realities practices face when they assume large-scale change efforts, and provides recommendations for those assisting or engaging in the process. These findings have the potential to inform the many state and regional demonstration projects currently underway in the United States.
Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home
By Paul A. Nutting, M.D., M.S.P.H., et al
University of Colorado Health Sciences Center, Denver, Colo.


Four Personal Reflections by Noted Family Physician Explore the Value of Relationship-Centered Care
This issue of the Annals features four essays by noted family physician and author David Loxterkamp, M.D. The essays bring to life the value of relationships in the care of patients – something valued by both patients and doctors alike.

In the first of four articles, Loxterkamp explores the importance of “ownership” at a time when most primary care physicians are employed by large corporations and hospital networks. Ownership, he contends, is critical to the practice of medicine. It begets a sense of commitment and empowerment, is a reflection of our values and integrity, and solidifies who we are and what matters in our lives. In the second article, Loxterkamp discusses the daunting task of caring for patients who are aged, advocating the practice of “slow medicine,” care that diverges from modern, episodic care and takes its time to negotiate the proper course of treatment. He concludes that a large part of the answer lies in self-support, conversation and friendship, accepting our physical decay and finding the inner gift of ourselves that never grows old. The third essay examines the primary care physician’s role as an agent of change for patients and communities, being ready to facilitate change within the context of a trusting relationship. He concludes that it is through working with patients that physicians learn of both their patients’ and their own capacity for change. In the last of the four essays, Loxterkamp reflects on how his long career as a family physician – once seen as his true vocation – is simply a “means to an end.” Through an encounter with a patient, he realizes that the evolving nature of his profession is not a threat to his identify; rather, his work is a cherished opportunity to fulfill his calling – to connect with others and discover how they, like him, are learning to “come alive.”

As Marnocha explains in an accompanying editorial, these essays are as valuable and relevant to the science and policy of primary care as are research and empirical results. In fact, he concludes these narratives, written by one of family medicine’s most careful observers who is at the forefront of the initiative to recreate a medical home for primary care, may help discern the best future for family medicine.

The Dream of Home Ownership
The Old Duffers’ Club
A Change Will Do You Good
Doctors’ Work: Eulogy for My Vocation
By David Loxterkamp, M.D.
Seaport Family Practice, Belfast, Me.

Relationship-Centered Care
By Mark Marnocha, Ph.D.
University of Wisconsin School of Medicine and Public Health, Appleton




Other Studies in this Issue:

Elucidating the Experience of Surrogate Decision Makers: Making Decisions vs. Reporting Preferences
An ethics analysis provides new insights into the role of surrogate decision makers when they are called on to speak on behalf of patients who can no longer make decisions about their medical care. The authors distinguish between making genuine decisions for the patient (and the associated heavy psychosocial burdens) and simply reporting on the patient’s preferences (and the associated lighter psychosocial burdens). They conclude that clinicians can relieve some of the burden of surrogacy by making this distinction clear.
Reconceptualizing the Experience of Surrogate Decision Making: Reports vs Genuine Decisions
By Ursula K. Braun, M.D., M.P.H., et al
Houston Center for Quality of Care and Utilization Studies, Texas

Study is the First to Identify and Classify Patient Errors
With the current research into medical errors in health care focused almost exclusively on system and clinician error, Buetow and colleagues attempt to account for patients’ role in errors. This study presents the first taxonomy of patient errors, a three-level system that includes action errors and mental errors. They identify 70 potential types of patient error in eight categories, including: attendance errors, assertion errors and adherence errors. They call for future research to go beyond seeing patient, system and clinician errors as separate categories of error and attempt to explain how patients, clinicians and systems can interact to co-create and reduce errors.
Patient Error: A Preliminary Taxonomy
By Stephen Buetow, Ph.D., et al
University of Auckland, New Zealand

Paper-and-Pencil Mail Surveys Still Have a Place in Medical Research Despite Explosion of Web-based Survey Tools
Despite the proliferation of Internet-based survey designs, traditional paper-based surveys may still be required to get an adequate response rate. Analyzing the response rate of a survey implemented both electronically (with 5 rounds of solicitation) and subsequently by mail (with 2 rounds of solicitation) in three different practice-based research networks, researchers found that 24 percent of the responses received were in the paper mode despite the intense promotion of the survey in the initial electronic phase. The findings suggest that using a mixed-mode research method that includes both hard copy and electronic surveys may yield a greater response rate than electronic alone.
Combining Web-based and Mail Surveys Improves Response Rates: A PBRN Study From PRIME Net
By Philip J. Kroth, M.D., M.S., et al
University of New Mexico Health Sciences Center, Albuquerque

Limited Health Literacy Contributes to Disparities in Self-Rated Health Status and Use of Preventive Services
Bennett and colleagues shed light on the under-researched relationship between health literacy, health disparities and preventive services. Studying a nationally representative sample of 2,668 older adults, they find that health-related print literacy contributes to racial/ethnic and education-related disparities in self-rated health status and receipt of influenza vaccination. Education-related disparities were also associated with receipt of mammography and dental care. The researchers conclude that efforts to improve the health-related print literacy of adults and reduce the reading level of print materials targeting older adults might help to reduce literary-related obstacles to health care.
The Contribution of Health Literacy to Disparities in Self-Rated Health Status and Preventive Health Behaviors in Older Adults
By Ian M. Bennett, M.D., Ph.D., et al
University of Pennsylvania School of Medicine, Philadelphia

Adding a Help Question to a Lifestyle and Mood Assessment Tool Is Valuable
The CHAT is a short, self-administered assessment tool for lifestyle and mental health assessment in primary care that looks at inactivity, tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety, stress, abuse and anger problems. In this study, researchers found the tool can be made more valuable by adding a “help” question to determine whether patients would like help with an issue either during the consultation or at a later date. Researchers analyzed 775 completed CHAT forms and found that the help question increases the specificity of the test and its predictive value. The help question also helps reduce the number of false-positive findings and easily identifies issues about which patients indicate their readiness to change.
Asking for Help is Helpful: Validation of a Brief Lifestyle and Mood Assessment Tool in Primary Care
By Felicity Goodyear-Smith, M.B., Ch.B., M.G.P., F.R.N.Z.C.G.P., et al
The University of Auckland, New Zealand

Brief Questionnaire Effective at Identifying Patients with Medically Unexplained Symptoms
The PHQ-15, a short, self-administered diagnostic tool developed for the detection of medically unexplained symptoms (known as somatoform disorders) is valid and moderately reliable. Evaluating the questionnaire’s performance in 906 adult patients from a high-risk primary care population in The Netherlands, researchers found that the PHQ-15 had sensitivity of 78 percent, a specificity of 71 percent and a negative predictive value of 97 percent. The test-retest reliability was 0.60. They conclude the PHQ-15 might bring clinicians the closest they can get to objectively identifying patients at high risk for somatoform disorders.
Detecting Somatoform Disorders in Primary Care With the PHQ-15
By Hiske van Ravesteijn, M.D., et al
Radboud University, Nijmegen, The Netherlands 


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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s Web site, www.annfammed.org.