Audiometry Interpretation for Hearing Loss in Adults.

Hearing loss is a prevalent, chronic condition in the United States; it is often gradual and progressive and is underreported by patients and undertreated by physicians. The impaired ability to effectively hear and communicate may result in negative emotional, cognitive, economic, and social consequences for individuals and may pose a safety risk. Questionnaires and smartphone apps are available to help identify and evaluate self-perceived hearing loss. Physicians should assess for objective hearing impairment when the patient or family member raises a concern or if cognitive or mood symptoms are present that could be influenced by hearing loss. Three types of hearing loss exist: conductive, sensorineural, and mixed. Pure-tone audiometry uses an audiometer and is reported on an audiogram; it is the most accurate method for hearing loss detection. It can be used for screening or comprehensive testing when combined with tympanometry, speech-reception thresholds, and word-recognition testing. Audiograms that show a unilateral or asymmetrical sensorineural hearing loss can be signs of retrocochlear pathology and warrant additional evaluation by an audiologist and otolaryngologist as well as imaging studies. Medicare Parts A and B do not pay for hearing aids, although some Medicare Advantage (Part C) or supplemental plans may provide insurance coverage for hearing aids. Less expensive, over-the-counter hearing aids may help mild to moderate hearing loss. Family physicians should counsel patients on the importance of protecting their hearing.

Mobility Assistive Device Use in Older Adults.

Many individuals need a mobility assistive device as they age. These devices include canes, crutches, walkers, and wheelchairs. Clinicians should understand how to select the appropriate device and size for individual patients (or work with a physical therapist) and prescribe the device using the patient's health insurance plan. Canes can improve standing tolerance and gait by off-loading a weak or painful limb; however, they are the least stable of all assistive devices, and patients must have sufficient balance, upper body strength, and dexterity to use them safely. Older adults rarely use crutches because of the amount of upper body strength that is needed. Walkers provide a large base of support for patients who have poor balance or who have bilateral lower limb weakness and thus cannot always bear full weight on their legs. A two-wheel rolling walker is more functional and easier to maneuver than a standard walker with no wheels. A four-wheel rolling walker (rollator) can be used by higher-functioning individuals who do not need to fully off-load a lower limb and who need rest breaks for cardiopulmonary endurance reasons, but this is the least stable type of walker. Wheelchairs should be considered for patients who lack the lower body strength, balance, or endurance for ambulation. Proper sizing and patient education are essential to avoid skin breakdown. To use manual wheelchairs, patients must have sufficient upper body strength and coordination. Power chairs may be considered for patients who cannot operate a manual wheelchair or if they need the features of a power wheelchair.

Diagnosis and Management of Adnexal Masses.

Adnexal masses can have gynecologic or nongynecologic etiologies, ranging from normal luteal cysts to ovarian cancer to bowel abscesses. Women who report abdominal or pelvic pain, increased abdominal size or bloating, difficulty eating, or rapid satiety that occurs more than 12 times per month in less than a year should be evaluated for ovarian cancer. Pelvic examination has low sensitivity for detecting an adnexal mass; negative pelvic examination findings in a symptomatic woman should not deter further workup. Ectopic pregnancy must be ruled out in women of reproductive age. A cancer antigen 125 (CA 125) test may assist in the evaluation of an adnexal mass in appropriate patients. CA 125 levels are elevated in conditions other than ovarian cancer. Because substantial overlap in CA 125 levels between pre- and postmenopausal women may occur, this level alone is not recommended for differentiating between a benign and a malignant adnexal mass. Transvaginal ultrasonography is the first choice for imaging of an adnexal mass. Large mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer. If disease is suspected outside of the ovary, computed tomography may be indicated; magnetic resonance imaging may better show malignant characteristics in the ovary. Serial ultrasonography and periodic measurement of CA 125 levels may help in differentiating between benign or potentially malignant adnexal masses. If an adnexal mass larger than 6 cm is found on ultrasonography, or if findings persist longer than 12 weeks, referral to a gynecologist or gynecologic oncologist is indicated.

Institution-Specific Factors Associated With Family Medicine Residency Match Rates.

UNLABELLED: Phenomenon: Existing research provides little specific evidence regarding the association between public and private medical school curricular settings and the proportion of medical students matching into family medicine careers. Institutional differences have been inadequately investigated, as students who match into family medicine are often consolidated into the umbrella of primary care along with those matching in internal medicine and pediatrics. However, understanding medical school contexts in relation to career choice is critical toward designing targeted strategies to address the projected shortage of family physicians. This study examines factors associated with family medicine residency match rates and the extent to which such factors differ across medical school settings. APPROACH: We combined data from a survey of 123 departments of family medicine with graduate placement rates reported to the American Academy of Family Physicians over a 2-year period. Chi-square/Fisher's Exact texts, t tests, and linear regression analyses were used to identify factors significantly associated with average match rate percentages. FINDINGS: The resulting data set included 85% of the U.S. medical schools with Departments of Family Medicine that reported 2011 and 2012 residency match rates in family medicine. Match rates in family medicine were higher among graduates of public than private medical schools-11% versus 7%, respectively, t(92) = 4.00, p < .001. Using a linear regression model and controlling for institutional type, the results indicated 2% higher match rates among schools with smaller annual clerkship enrollments (p  = .03), 3% higher match rates among schools with clerkships lasting more than 3 to 4 weeks (p  = .003), 3% higher match rates at schools with at least 1 family medicine faculty member in a senior leadership role (p  = .04), and 8% lower match rates at private medical schools offering community medicine electives (p < .001, R(2) = .48), F(6, 64) = 9.95, p < .001. Three additional factors were less strongly related and varied by institutional type-informal mentoring, ambulatory primary care learning experiences, and institutional research focus. Insights: Educational opportunities associated with higher match rates in family medicine differ across private and public medical schools. Future research is needed to identify the qualitative aspects of educational programming that contribute to differences in match rates across institutional contexts. Results of this study should prove useful in mitigating physician shortages, particularly in primary care fields such as family medicine.

Polypharmacy Prevalence and Perceptions of Deprescribing in Elderly Patients Among Community Primary Care Providers in Mid-Michigan Practices.

INTRODUCTION: Polypharmacy is common among the elderly and can predispose them to increased morbidity and higher healthcare expenditures. Deprescribing is an important aspect of preventative medicine to minimize polypharmacy-related adverse effects. Mid-Michigan has historically been considered a medically underserved area. We sought to describe polypharmacy prevalence and primary care provider (PCP) perceptions of deprescribing in the elderly at community practices in the region. METHODS: Medicare Part D claims data from 2018 to 2020 were queried to calculate the prevalence of polypharmacy, which is defined as Medicare beneficiaries who were concurrently prescribed at least five medications. PCPs from four community practices in adjacent counties in mid-Michigan, including two high- and two low-prescribing practices, were surveyed to assess their perceptions of deprescribing. RESULTS: The prevalence of polypharmacy in two adjacent mid-Michigan counties was 44.0% and 42.5%, which was similar to Michigan's overall prevalence of 40.7% (p = 0.720 and 0.844, respectively). Additionally, 27 survey responses were received from mid-Michigan PCPs (response rate, 30.7%). Most respondents expressed confidence in deprescribing in the elderly from a clinical standpoint (66.7%). Barriers to deprescribing included patient/family concerns (70.4%) and lack of time during office visits (37.0%). Facilitators to deprescribing included patient readiness (18.5%), collaboration with case managers/pharmacists (18.5%), and up-to-date medication lists (18.5%). An exploratory comparison of perceptions at high- and low-prescribing practices showed no significant differences. CONCLUSION: These findings demonstrate a high prevalence of polypharmacy in mid-Michigan and suggest that PCPs in the region are generally supportive of deprescribing. Potential targets to improve deprescribing in patients with polypharmacy include addressing visit length, patient/family concerns, increasing interdisciplinary collaboration, and medication reconciliation support.

Premenstrual syndrome and premenstrual dysphoric disorder.

Premenstrual syndrome is defined as recurrent moderate psychological and physical symptoms that occur during the luteal phase of menses and resolve with menstruation. It affects 20 to 32 percent of premenopausal women. Women with premenstrual dysphoric disorder experience affective or somatic symptoms that cause severe dysfunction in social or occupational realms. The disorder affects 3 to 8 percent of premenopausal women. Proposed etiologies include increased sensitivity to normal cycling levels of estrogen and progesterone, increased aldosterone and plasma renin activity, and neurotransmitter abnormalities, particularly serotonin. The Daily Record of Severity of Problems is one tool with which women may self-report the presence and severity of premenstrual symptoms that correlate with the criteria for premenstrual dysphoric disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Symptom relief is the goal for treatment of premenstrual syndrome and premenstrual dysphoric disorder. There is limited evidence to support the use of calcium, vitamin D, and vitamin B6 supplementation, and insufficient evidence to support cognitive behavior therapy. Serotonergic antidepressants (citalopram, escitalopram, fluoxetine, sertraline, venlafaxine) are first-line pharmacologic therapy.

Patients' Attitudes and Sources of Information on Coronavirus Disease 2019 in Rural Michigan.

Background This study investigated patients' attitudes about severe acute respiratory syndrome coronavirus 2 in rural Michigan. Despite increasing cases in rural communities across America, surveys have revealed that residents may feel less threatened by the virus compared to their urban counterparts. This difference in attitude and information appraisal can negatively affect rural health by discouraging coronavirus disease (COVID-19) preventative behaviors. Understanding social influences that contribute to the formation of opinions about the pandemic can help public health officials and clinicians better address rural health. Methodology This cross-sectional study surveyed 299 participants from three primary care clinics in Shiawassee County of Michigan during a seven-week interval. Statistical analysis, primarily through SAS version 9.4 (SAS Institute Inc., Cary, NC, USA), included descriptive statistics, multiple linear regression models, paired t-tests, and correlation coefficients. A p-value less than or equal to 0.05 was considered significant. Results Patients believed the risk COVID-19 posed to their family was significantly higher than the risk it posed to themselves (p < 0.001). Patients who reported that they would follow their provider's advice for treatment of a non-COVID-19 medical illness were found to be more likely to follow a provider's advice on COVID-19 (p < 0.001). However, patients overall were more agreeable with following provider advice for non-COVID-19 medical illnesses than they were for COVID-19 (p < 0.001). Conclusions As patients were more agreeable with following medical advice on chronic conditions than COVID-19, there may be extrinsic factors influencing patient views of COVID-19. Polarization of COVID-19 in the media has heavily influenced attitudes toward the virus in America. Initiatives to provide reliable patient education is key to encouraging constructive discussions and a healthy rural community. In a strong patient-provider relationship, primary care providers can share and encourage appropriate healthy behaviors regarding COVID-19, which have a direct impact on community health.

Limited evidence guides empiric Tx of female chronic pelvic pain.

This article reviews the limited evidence for treating chronic pelvic pain and offers recommendations for the primary care physician on providing symptomatic relief in the absence of diagnosed pathology.

State patterns in medical school expansion, 2000-2010: variation, discord, and policy priorities.

In 2006, the Association of American Medical Colleges recommended a 30% increase over 2002 enrollment in U.S. medical schools by the year 2016, particularly in areas with rapid population growth during the past 25 years or where the population was projected to grow rapidly in future years. Both MD-granting and DO-granting schools subsequently expanded enrollment. To examine the relationship between ongoing medical school expansion and state-level measures of population need and workforce capacity, the authors used established national health workforce and training site datasets to compare total medical school enrollment (2000-2010) with change in population, medical student retention in state (those returning to practice in the state where they graduated), and primary care supply.From 2000 to 2010, U.S. population increased 10% (median state population growth 7.4%). Median state total MD and DO medical school enrollment growth was 14.7%, with nine states increasing enrollment by more than 50%. Medical student retention rates varied from 9.8% to 67%. A wide variation in concordance and discordance between medical school enrollment to population growth and to medical student retention rates existed across states. States also demonstrated concordance or discordance between medical school enrollment and supply of primary care physicians.The authors recommend strategies for expansion that may help meet the population's need for primary care physicians and improved geographic distribution of specialties. Expansion of graduate medical education must also be aligned with population need, necessitating coordination of workforce planning.

Entry of US medical school graduates into family medicine residencies: 2012--2013.

BACKGROUND: Analyzing the US medical school origin of family medicine residents highlights schools, states, or regions that have higher entrance rates into family medicine. METHODS: The American Academy of Family Physicians (AAFP) 2013 Residency Census has a 100% response rate and lists information for family medicine residents who entered training July 2012. MD graduates are verified through medical school registrars or the American Medical Association's Physicians Masterfile data. The American Association of Colleges of Osteopathic Medicine provides data on DO graduates. Three-year rolling averages of graduates entering family medicine are calculated for Liaison Committee of Medical Education (LCME)-accredited medical schools. RESULTS: In July 2012, 3,523 first-year residents entered Accreditation Council for Graduation Medical Education (ACGME)-accredited family medicine residencies. Medical students from LCME-accredited schools account for less than half of the family medicine residents (46%). Public MD-granting medical schools graduate almost threefold more students into family medicine residencies than do private schools (1,101 versus 380). The Mountain, West North Central, and Pacific regions of the United States have the highest percentage of MD graduates (13.5%, 12.3%, and 11.4%, respectively) entering family medicine. Forty-five percent of MD medical students enter a family medicine residency in the state in which they attended medical school. CONCLUSIONS: LCME-accredited medical schools with lower percentages of graduates entering family medicine should examine the economic, environmental, and academic factors that may be causing low numbers of their students graduating and entering family medicine residencies.

Results of the 2013 National Resident Matching Program: family medicine.

BACKGROUND: The percentage of US seniors who chose primary care careers remains well below the nation's future workforce needs. Entrants into family medicine residency programs, along with their colleagues entering other primary care-designated residencies, will compose the primary care workforce of the future. METHODS: Data in this article are collected from the 2013 National Resident Matching Program (NRMP) Main Residency Match and the 2013 American Academy of Family Physicians (AAFP) Medical Education Residency Census. The information provided includes the number of applicants to graduate medical education programs for the 2013--2014 academic year, specialty choice, and trends in specialty selection. RESULTS: Family medicine residency programs experienced a modest increase in both the overall fill rate as well as the number of positions filled with US seniors through the NRMP in 2013 in comparison to 2012. Other primary care fields, primary care internal medicine positions, pediatrics-primary care, and internal medicine-pediatrics programs also experienced modest increases in 2013. The 2013 NRMP results show a small increase in medical students choosing primary care careers for the fourth year in a row. CONCLUSIONS: Changes in the NRMP Match process in 2013 make a comparison to prior years' Match results difficult. Medical school admission changes, loan repayment, and improved primary care reimbursement may help increase the number of students pursuing family medicine.

Residency program solutions: making a difference in quality residency education.

BACKGROUND: Residency Program Solutions (RPS) consultants assist family medicine residency programs in solving issues perceived as limiting quality resident education. Residencies ask RPS to assist in preparing for accreditation site visits by the Residency Review Committee-Family Medicine (RC-FM). The RPS Criteria for Excellence in Family Medicine Education (RPS Criteria) may have influenced the accreditation standards of the RC-FM. RPS consultations also may affect accreditation visit cycle length and number of RC-FM citations. METHODS: The authors reviewed the RC-FM Program Requirements for Family Medicine Residency Education and the RPS Criteria from 1978 to 2007, comparing statements between the two documents for "nearly verbatim" and equivalent "must" or "should" requirements. The average number of citations and cycle length for programs seeking a Comprehensive Accreditation Program (CAP) Consultation from 2004--2010 were compared to cohort programs evaluated at the same RC-FM meeting using an independent samples t test. RESULTS: The strongest relationship between the RC-FM requirements and the RPS criteria occurred in 1983--1984. Nine "nearly verbatim" statements, 15 "must-should" or "must-must" statements, and 11 "should-should" statements existed. Over time, additional concurrences between organizational statements occurred. Residency programs with CAP consultations benefited significantly by both a decrease in number of citations and an increase in the length of accreditation cycle. CONCLUSIONS: The RPS Criteria have positively impacted iterations of RC-FM requirements. Family medicine residency programs concerned about successful accreditation by the RC-FM will likely benefit from RPS CAP consultations by increased length of accreditation cycle and/or a decreased number of citations.

Results of the 2012 National Resident Matching Program: family medicine.

BACKGROUND: The percentage of US seniors choosing primary care careers remains well below the nation's future workforce needs. Data in this article are collected from the 2012 National Resident Matching Program (NRMP) Main Residency Match and the 2012 American Academy of Family Physicians (AAFP) Medical Education Residency Census, which had a response rate of 100%. The census verified residents who entered training July 2012 from all medical schools. The information provided includes the number of applicants to graduate medical education programs for the 2012--2013 academic year, specialty choice, and trends in specialty selection. Compared with the 2011 Match, family medicine residency programs filled 35 more positions (with 18 more US seniors) through the NRMP in 2012. In other primary care fields, 31 more primary care internal medicine positions (20 more US seniors), two fewer positions in pediatrics-primary care (one less US senior), and 18 fewer positions in internal medicine-pediatrics programs (33 fewer US seniors) filled. The 2012 NRMP results indicate a small increase in medical students choosing primary care careers for the third year in a row; however, students continue to show an overall preference for subspecialty careers.

Entry of US medical school graduates into family medicine residencies: 2011--2012.

BACKGROUND: This study reports on the number of graduates entering family medicine residencies in 2011 from allopathic, osteopathic, and international medical schools. Allopathic graduate data come from medical school registrars or the American Medical Association Masterfile. The 2012 family medicine residency program director census, with a response rate of 100%, verified residents who entered training July 2011 from all medical schools. Approximately 8.4% allopathic medical school's graduates of the 17,478 graduates (July 2010 to June 2011) were first-year family medicine residents in 2011, compared with 8.0% in 2010 and 7.5% in 2009. The percent of medical school graduates entering family medicine from each of the allopathic schools was calculated and averaged over 3 years to diminish 1-year fluctuations. Allopathic medical schools' 3-year average percentage of graduates who entered family medicine residency programs in 2011 ranged from 0.6% to 21.4%. Compared to 2010, osteopathic graduates in Accreditation Council for Graduate Medical Education-accredited family medicine residencies (21.5%) increased 2.8% from 2010, whereas international medical graduates (32.1%) decreased 3.4%. An increasing trend is seen in the number of allopathic graduates entering family medicine residencies. Osteopathic and international graduates' entry to residency appears inversely related. As medical schools emphasize social accountability to improve the health of communities, higher family medicine graduation rates may occur. Initiatives in medical school admissions may increase the number of medical students more likely to select family medicine careers.

Results of the 2011 National Resident Matching Program: family medicine.

The results of the 2011 National Resident Matching Program (NRMP) reflect another small but promising increased level of student interest in family medicine residency training in the United States. Compared with the 2010 Match, family medicine residency programs filled 172 more positions (with 133 more US seniors) through the NRMP in 2011. In other primary care fields, 26 more primary care internal medicine positions filled (10 more US seniors), one more position in pediatrics-primary care (two fewer US seniors), and seven more positions in internal medicine-pediatrics programs (10 more US seniors). The 2011 NRMP results suggest a small increase in choosing primary care careers for the second year in a row; however, students continue to show an overall preference for subspecialty careers. Multiple forces continue to influence medical student career choices. Despite matching the highest number of US seniors into family medicine residencies since 2002, the production of family physicians remains insufficient to meet the current and anticipated need to support the nation's primary care infrastructure.

Entry of US medical school graduates into family medicine residencies: 2010-2011 and 3-year summary.

This is the 30th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family medicine residency programs. This retrospective analysis based on data reported to the AAFP from medical schools and family medicine residency programs shows approximately 8.0% of the 17,081 graduates of US medical schools between July 2009 and June 2010 were first-year family medicine residents in 2010, compared to 7.5% in 2009 and 8.2% in 2008. Medical school graduates from publicly funded medical schools were more likely to be first-year family medicine residents in October 2010 than were residents from privately funded schools (9.6% versus 5.4%). The Mountain and West North Central regions reported the highest percentage of medical school graduates who were first-year residents in family medicine programs in October 2010 (14.3% and 11.3%, respectively); the New England and Middle Atlantic regions reported the lowest percentages (5.6% and 5.3%, respectively). Approximately four in 10 of the medical school graduates (40.3%) entering a family medicine residency program as first-year residents entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the 3-year average percentage from each medical school of graduates entering family medicine residencies and the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Council for Graduate Medical Education-accredited family medicine residency programs in 2010.

Common gynecologic infections.

Many women seek care for vulvar, vaginal, or pelvic complaints. Primary care providers should possess a solid understanding of the differential diagnosis and treatment of gynecologic infections. Many infections in the reproductive tract are sexually transmitted, whereas other common infections are attributable to an overgrowth of the normally present bacteria or yeast in the vagina. Presenting symptoms and signs are helpful in determining the source of infection, but often a battery of tests must be performed to make a definitive diagnosis.

Evaluation and treatment of constipation in infants and children.

Constipation in children usually is functional and the result of stool retention. However, family physicians must be alert for red flags that may indicate the presence of an uncommon but serious organic cause of constipation, such as Hirschsprung's disease (congenital aganglionic megacolon), pseudo-obstruction, spinal cord abnormality, hypothyroidism, diabetes insipidus, cystic fibrosis, gluten enteropathy, or congenital anorectal malformation. Treatment of functional constipation involves disimpaction using oral or rectal medication. Polyethylene glycol is effective and well tolerated, but a number of alternatives are available. After disimpaction, a maintenance program may be required for months to years because relapse of functional constipation is common. Maintenance medications include mineral oil, lactulose, milk of magnesia, polyethylene glycol powder, and sorbitol. Education of the family and, when possible, the child is instrumental in improving functional constipation. Behavioral education improves response to treatment; biofeedback training does not. Because cow's milk may promote constipation in some children, a trial of withholding milk may be considered. Adding fiber to the diet may improve constipation. Despite treatment, only 50 to 70 percent of children with functional constipation demonstrate long-term improvement.

Diagnosis and management of positional head deformity.

In children with positional head deformity (posterior plagiocephaly), the occiput is flattened with corresponding facial asymmetry. The incidence of positional head deformity increased dramatically between 1992 and 1999, and now occurs in one of every 60 live births. One proposed cause of the increased incidence of positional head deformity is the initiative to place infants on their backs during sleep to prevent sudden infant death syndrome. With early detection and intervention, most positional head deformities can be treated conservatively with physical therapy or a head orthosis ("helmet").