GERD management. Strategies recommended for primary care practice.

Primary care physicians are on the front lines in the treatment of gastroesophageal reflux disease. Therefore, they need the most current information available regarding how to achieve the best outcomes possible. Much clinical evidence indicates that when prescribed for initial and maintenance therapy, the proton pump inhibitors are effective for symptom relief and cost-effective in maintaining remission. In this article, Drs Kuritzky and Rodney discuss several step management strategies that could well be "just what the doctor ordered."

Basal and squamous cell carcinoma.

Nonmelanotic skin cancer, primarily basal and squamous cell carcinoma, represents a major health concern in both the United States and the world. Primary care physicians must be able to recognize these cancers and perform the appropriate diagnostic tests to confirm their clinical suspicion. Several biopsy techniques are available for the physician to use in their office, and once diagnosis is confirmed, a variety of treatment modalities exist that provide excellent cure rates. Nevertheless, primary prevention with the use of sunscreen, protective clothing, and wide-brimmed hats is necessary to reduce the incidence of this costly disease.

Responses to questions about the specialty of family practice as a career.

This article provides answers to many of the questions medical students ask about the specialty of family practice. It is the fourth update of a previous article and was developed in response to feedback from medical students at the 1997 National Congress of Student Members held by the American Academy of Family Physicians. Students at the 1998 Congress also identified areas of interest and concern. This article discusses the hours and income of the family physician, the scope of medical practice in the specialty, required continuing medical education and board certification, family practice residency training and combined-specialty training.

Enhancing the family medicine curriculum in deliveries and emergency medicine as a way of developing a rural teaching site.

BACKGROUND: The urban family practice residencies of Memphis were not providing sufficient training or encouragement to young physicians for practice in rural communities. METHODS: In 1990, the Department of Family Medicine, in partnership with the State of Tennessee Health Access Act and the Baptist Health Care System, developed a teaching practice in a rural county of western Tennessee. The family practice curriculum included special skills in advanced women's health care and emergency medicine so that uniformly trained physicians could provide around-the-clock coverage in the hospital, including the delivery of babies and first-hour emergency care. RESULTS: After 7 years, the group now includes six full-time board-certified, OB-capable family physicians. In addition, faculty members from the department's urban program in Memphis are required to contribute a "mini locum tenens" of 2-3 days of rural coverage per month. Since 1992, the practice has provided care for more than 54,000 continuity office visits, 81,000 emergency department visits, more than 3,500 hospital admissions, and 621 obstetrical deliveries. Since 1994, residents have been assigned to the site full time, with growth to 12 (4-4-4) residents assigned to this location as of 1997. Several graduates from the initial group of residents have remained in the community after graduation, and three others have established practices in rural areas. Most recently, control of the practice is being transferred from the family medicine department to the university's corporate group practice. This may result in fundamental changes in the practice's operation. CONCLUSIONS: The approach described in this report may be useful for the expansion of urban departments of family medicine into rural and underserved communities.

Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice.

This paper describes the background, experience, training, and preceptorship of a rural family physician that culminated in provision of diagnostic and therapeutic colonoscopy to his patients. Initial training took place in a two-day continuing medical education course. Subsequent training consisted of one-on-one training in 11 colonoscopies and five polypectomies, correspondence, recommended readings, a one-on-one preceptorship, and telephone consultation. Training was provided by University of Tennessee faculty who were experts in the area of colonoscopy and polypectomy procedures. The outcomes of 250 consecutive colonoscopies performed by the rural family physician are documented here. Training requirements vary widely by professional organization and subspecialty. Some subspecialists have recommended as many as 100 supervised colonoscopies and 25 polypectomies as a minimum training requirement for hospital privileges. It is our contention that unnecessarily high training requirements add to educational costs and may restrict qualified rural physicians from providing these services.

The dilemma of required curriculum for emerging technologies in primary care.

BACKGROUND AND OBJECTIVES: A core curriculum for procedural training in family practice is desirable. However, opinions differ as to which of many emerging technologies should be taught. This lack of agreement is due in part to the political and financial burdens of securing hospital privileges, the scheduling burdens of expanding an overcrowded curriculum, and a generational barrier between physicians who feel that technology enhances the biopsychosocial model versus those who feel otherwise. Nevertheless, as emerging technologies are shown to have established value in primary care, the core procedural curriculum will continue to evolve.

Colonoscopy by a family physician: a 9-year experience of 1048 procedures.

BACKGROUND: In the last 15 years, family physicians and general internists have adopted flexible fiberoptic endoscopy as a procedure to screen patients at risk of premature death from colorectal cancer. There has been controversy regarding the ability of non-fellowship-trained primary care physicians to extend this experience to full colonoscopy. METHODS: The results of 1048 consecutive colonoscopy examinations performed by a family physician over a 9-year period were tabulated. Outcomes measured included the reach-the-cecum rate (RCR), use of medication, complication rate, and diagnostic yield. In a convenience sample of 110 cases, the effectiveness of the non-narcotic analgesic ketorolac was assessed by the RCR. Outcomes of cases in which ketorolac was used were compared with cases in which traditional sedation and analgesia were used. RESULT: A high diagnostic yield without significant complications was noted. The RCR for nonmedicated patients was 36%. Among all medicated cases, the RCR was 93%. In patients who were given the non-narcotic analgesic ketorolac, the RCR was 96%, compared with 95% in patients not given ketorolac. CONCLUSIONS: A family physician in rural practice was able to attain and sustain a state-of-the-art, reach-the-cecum rate over a 9-year period. This service resulted in a high diagnostic yield, high degree of safety, and satisfactory results for the community. Ketorolac is an effective alternative for patients who may be hypersensitive to narcotic analgesia/sedation.

False-negative endoscopic biopsy of colonic adenocarcinoma in a young man.

A 26-year-old man presented with intermittent bright red blood per rectum. His physical examination was unremarkable; however, because microcytic anemia was noted, the patient underwent colonoscopy. A large ascending colonic lesion was noted, a biopsy of which was negative for cancer. Nevertheless, the patient underwent a radical hemicolectomy. Adenocarcinoma of the cecum was found. This case report is an example of a false-negative endoscopic-directed biopsy. A review of recorded video-endoscopy assisted the family physician in appropriate management.