Research to Improve Clinical Care in Family Medicine: Big Data, Telehealth, Artificial Intelligence, and More.

This issue highlights changes in medical care delivery since the start of the COVID-19 pandemic and features research to advance the delivery of primary care. Several articles report on the effectiveness of telehealth, including its use for hospital follow-up, medication abortion, management of diabetes, and as a potential tool for reducing health disparities. Other articles detail innovations in clinical practice, from the use of artificial intelligence and machine learning to a validated simple risk score that can support outpatient triage decisions for patients with COVID-19. Notably one article reports the impact of a voluntary program using scribes in a large health system on physician documentation behaviors and performance. One article addresses the wage gap between early-career female and male family physicians. Several articles report on inappropriate testing for common health problems; are you following recommendations for ordering Pulmonary Function Tests, mt-sDNA for colon cancer screening, and HIV testing?

Screening for cardiac amyloidosis in patients with tenosynovial red flags: A collaboration between family medicine and cardiology.

BACKGROUND: Amyloid deposition in tenosynovial structures precedes cardiac involvement up to 20 years. Therefore, a cardiological screening in patients with a history of tenosynovial manifestations of cardiac amyloidosis (CA) could lead to an increased number of early diagnoses. METHODS: Patients with tenosynovial manifestations of CA (carpal tunnel syndrome, atraumatic biceps tendon rupture, lumbar spinal stenosis) have been identified by general practitioners and evaluated in a Referral Center for CA. Patients with a high suspicion of CA underwent the CA diagnostic pathway. RESULTS: Among 50 General Practitioners (GP) contacted, 10 (20%) agreed to participate in the study for a total of 5615 patients ≥60 years. One hundred forty-five patients met the inclusion criteria, 2 of them already had a diagnosis of CA, and 57 agreed to undergo a cardiological evaluation (electrocardiography, echocardiography, NTproBNP assay). The median age was 73 [67-80] years and 31 (54%) were women. Eight patients were suggested to start the CA diagnostic pathway, five of them underwent a complete diagnostic evaluation for CA, three refused to complete the diagnostic exams and no new diagnoses were made. CONCLUSION: A screening program for CA in patients with tenosynovial manifestations identified by general practitioners is feasible, but may not yield a high rate of new diagnosis. In this study, we identified two patients who already had a diagnosis of CA, and among patients at high risk for CA, 37% refused to complete the diagnostic pathway. Increased awareness of CA among patients might increase participation and diagnostic yield in screening studies. Further validation of this protocol is needed to evaluate its diagnostic performance.

Family Medicine Team Perspectives on Screening for Health-Related Social Needs.

INTRODUCTION: Social drivers of health (SDH) strongly influence health outcomes and disparities. Although systemic level change is vital to address the disparities driven by SDH, it is also crucial that health care organizations develop the ability to care for patients in a manner that accounts for social factors and their influence on patient health. Although primary care is a natural fit for health-related social needs (HRSN) screening and intervention, significant barriers can impede primary care's effectiveness in this area. METHODS: We conducted 3 focus groups with family medicine clinicians, clinical staff, and social care workers in an academic medical center using a semistructured discussion guide to explore current practices, perceived benefits, barriers, and potential opportunities and approaches for integrating routine HRSN screening in primary care. RESULTS: 3 primary themes emerged from the focus groups. They included 1) the barriers to routine screening in primary care, including time, workload, emotional burden, patient factors, and team members' fear of inadequacy of resources or their own ability; 2) the importance and benefit of HRSN screening, including the opportunity to improve patient care through increased care team awareness of the patient's context, interventions to address HRSN, and improved relationships between the care team and the patient; and 3) recommendations for implementing routine screening in primary care, including opportunities to optimize workflow and technology, the importance of an electronic medical record (EMR)-integrated resource database, and the centrality of teamwork. DISCUSSION: Family medicine health care teams embrace the importance of HRSN screening and the potential for positive impact. However, there are vital barriers and considerations to address for HRSN screening to be effectively integrated into primary care visits.

Abordaje contextual en la práctica del médico de familia / Contextual approach in the practice of the family physician

El contexto representa un conjunto de circunstancias que rodean una situación y, sin las cuales, esta no puede comprenderse en forma correcta. La relación médico paciente está enmarcada en un vínculo contextual. En la práctica cotidiana del médico de familia la atención del paciente se realiza de manera integral, sin disociar el cuerpo del contexto. En este artículo los autores desarrollan el abordaje contextual como herramienta diagnóstica y se describen con detalle dos instrumentos útiles para ponerla en práctica: la evaluación contextual y la entrevista de FOCO (Familia, Orientación y Contexto). (AU)

The context represents a set of circumstances that surround a situation without which it can not be properly understood.The patient-physician relationship is framed in a contextual link. In the daily practice of the family physician, patient careis carried out in an integral manner, without dissociating the body from the context. In this article the authors develop the contextual approach as a diagnostic tool and describe in detail two useful instruments to put it into practice: the contextual assessment and the FOCO interview (Family, Orientation and Context). (AU)

Guarding against nonmelanoma skin cancer in solid organ transplant recipients.

Periodic skin examination and ongoing counseling are central in your posttransplantation care of these patients at high risk of skin malignancy.

37-year-old man • cough • increasing shortness of breath • pleuritic chest pain • Dx?

► Cough ► Increasing shortness of breath ► Pleuritic chest pain.

A Thoughtful Rebirth of Health Care: Lessons From the Pandemic.

In 16 years of practice, I had never seen a patient light a cigarette or pour a glass of wine in front of me. Yet, that occurred at the very onset of the COVID-19 era, a time that has shattered any preconceived notions of what I might experience during a clinical visit. The COVID-19 pandemic has forced many physicians to approach patient care in completely different ways. While many have been providing care in hospitals, many more of us have had to stop seeing patients in person, shift to telemedicine, and consider other ways to improve the health of our patients. The rapid changes we have had to make in the last year have demonstrated the resiliency of our profession. This is a critical time to refocus and make sure that health care is person-centered, encompasses all modifiable health determinants, and helps individuals achieve health rather than primarily manage disease.

Historia de la Medicina Familiar en Colón / History of Family Medicine in Colón

RESUMEN La formación de un médico de nuevo modelo en Cuba surge de forma experimental por la necesidad que tenía la población de recibir una atención médica integral. Como siempre nuestro comandante con sus ideas revolucionarias plantea la necesidad de su creación para que cada familia cubana contara con un médico y una enfermera que les brindara apoyo y cuidado desde el punto de vista clínico, epidemiológico y social. El municipio de Colón fue el primero en implementar este novedoso programa en la provincia de Matanzas. Con el objetivo de dar a conocer el surgimiento y desarrollo del mismo en esta ciudad es que se realiza el siguiente trabajo (AU).

SUMMARY The training of a new model doctor in Cuba arises experimentally because of the need of the population to receive comprehensive medical care. As always, our commander with his revolutionary ideas raised the need for its creation so that each Cuban family would have a doctor and a nurse who could provide support and care from a clinical, epidemiological and social point of view. The municipality of Colón was the first to implement this novel program in the province of Matanzas. With the aim of publicizing its emergence and development in our city, the authors wrote the following article (AU).

Dysphagia: Evaluation and Collaborative Management.

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.

Degenerative Cervical Myelopathy: Recognition and Management.

Degenerative cervical myelopathy encompasses a collection of pathologic conditions that result in progressive spinal cord dysfunction secondary to cord compression. Patients are typically male (3: 1 male-to-female ratio), and the average age of presentation is 64 years. The exact incidence is unclear because of differences in terminology and because radiographic findings can be present in asymptomatic individuals. Common examination findings include neck pain or stiffness, a wide-based ataxic gait, ascending paresthesia in the upper or lower extremities, lower extremity weakness, decreased hand dexterity, hyperreflexia, clonus, Babinski sign, and bowel or bladder dysfunction in severe disease. Definitive diagnosis requires correlation of physical examination findings with imaging findings. Magnetic resonance imaging of the cervical spine with and without contrast media is the preferred imaging modality. Cervical spine computed tomography, computed tomography myelography, and plain radiography are helpful in certain situations. Treatment depends on the presence and severity of symptoms. Surgery is recommended for patients with moderate to severe symptoms or rapidly progressive disease. Conservative treatments with monitoring for progression may be considered in patients with mild to moderate disease. The evidence for the effectiveness of conservative treatments is scarce and of low quality, and outcomes can vary with individual patients. Primary care physicians play a vital role in recognizing the typical presentation of degenerative cervical myelopathy, coordinating treatment as indicated, and managing comorbidities.

Peripheral Neuropathy: Evaluation and Differential Diagnosis.

Peripheral neuropathy, a common neurologic problem encountered by family physicians, can be classified clinically by the anatomic pattern of presenting symptoms and, if indicated, by results of electrodiagnostic studies for axonal and demyelinating disease. The prevalence of peripheral neuropathy in the general population ranges from 1% to 7%, with higher rates among those older than 50 years. Common identifiable causes include diabetes mellitus, nerve compression or injury, alcohol use, toxin exposure, hereditary diseases, and nutritional deficiencies. Peripheral neuropathy is idiopathic in 25% to 46% of cases. Diagnosis requires a comprehensive history, physical examination, and judicious laboratory testing. Early peripheral neuropathy may present as sensory alterations that are often progressive, including sensory loss, numbness, pain, or burning sensations in a "stocking and glove" distribution of the extremities. Later stages may involve proximal numbness, distal weakness, or atrophy. Physical examination should include a comprehensive neurologic and musculoskeletal evaluation. If the peripheral nervous system is identified as the likely source of the patient's symptoms, evaluation for potential underlying etiologies should initially focus on treatable causes. Initial laboratory evaluation includes a complete blood count; a comprehensive metabolic profile; fasting blood glucose, vitamin B12, and thyroid-stimulating hormone levels; and serum protein electrophoresis with immunofixation. If the initial evaluation is inconclusive, referral to a neurologist for additional testing (e.g., electrodiagnostic studies, specific antibody assays, nerve biopsy) should be considered. Treatment of peripheral neuropathy focuses on managing the underlying etiology. Several classes of medications, including gabapentinoids and antidepressants, can help alleviate neuropathic pain.

Parkinson Disease.

Parkinson disease is a progressive neurodegenerative disorder with significant morbidity and mortality. Most patients consult with their primary care physician about Parkinson disease symptoms before seeking care from a specialist. The diagnosis of Parkinson disease is clinical, and key disease features are bradykinesia, rigidity, and tremor. The main diagnostic signs of Parkinson disease are motor symptoms; however, Parkinson disease is also associated with nonmotor symptoms, including autonomic dysfunction, depression, and hallucinations, which can make the initial diagnosis of Parkinson disease difficult. Disease progression is variable and clinical signs cannot be used to predict progression accurately. Therapies, including levodopa, have not demonstrated the ability to slow disease progression. Motor symptoms are managed with carbidopa/levodopa, monoamine oxidase-B inhibitors, and nonergot dopamine agonists. Prolonged use and higher doses of levodopa result in dyskinesias and motor symptom fluctuations over time. Deep brain stimulation surgery is performed for patients who do not achieve adequate control with levodopa therapy. Deep brain stimulation is most effective for significant motor fluctuations, dyskinesias, and tremors. Nonmotor symptom therapies target patient-specific conditions during the disease course. Interdisciplinary team care can alleviate multiple symptoms of Parkinson disease.

Effect of an intelligent family physician-optimised coordination model program on hypertension management in a Beijing community.

The prevalence of hypertension in China is increasing. To control chronic diseases, the Beijing Municipal Government implemented an intelligent family physician-optimised collaborative model (IFOCM). The present retrospective study assessed the effectiveness of the IFOCM in the management of hypertensive patients at the Fangzhuang Community Health Service Centre, Beijing. Using deidentified data from hypertensive patients, blood pressure (BP), BP control rate, 10-year risks of ASCVD, lifestyle changes and blood lipid levels were compared before and after implementation of the IFOCM. In all, 7332 patients with hypertension were included in the study. Systolic BP decreased from 144.59 to 142.96mmHg after program implementation (P<0.001), and the overall BP control rate increased from 41.43% to 46.49% (P<0.001). The proportion of patients predicted to be at a high 10-year risk of developing atherosclerotic cardiovascular disease decreased from 77.27% to 64.61% (P<0.001). After program implementation, body mass index decreased (from 24.87 to 24.36kg/m2; P<0.001), exercise frequency and intensity increased and salt intake, cigarette smoking, total cholesterol and low-density lipoprotein cholesterol all decreased significantly (P<0.001). The IFOCM program is effective in managing hypertension and providing timely patient care.

'Very brief advice' (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user's perspective.

BACKGROUND: Very Brief Advice on smoking (VBA) is an evidence-based intervention designed to increase quit attempts among patients who smoke. VBA has been widely disseminated in general practice settings in the United Kingdom, however its transferability to Southern European settings is not well established. This study sought to document the perspectives of Greek general practice patients in terms of the acceptability and satisfaction with receiving VBA from their general practitioner (GP) and its influence on patients' motivation to make a quit attempt. We also examine patient identified barriers and facilitators to acting on VBA. METHODS: Semi-structured interviews were conducted with 50 patients who reported current tobacco use recruited from five general practices in Crete, Greece. All patients received VBA from their GP and interviews were conducted immediately after the GP appointment. Thematic analysis was used to analyze data. RESULTS: The majority of patients were satisfied with the VBA intervention. Approximately one quarter of patients reported they were motivated to make an attempt to quit smoking after receiving VBA from their GP. Patients identified a clear preference for VBA to be delivered in a supportive manner, which communicated genuine concern versus fear-based approaches. Patients with an existing smoking-related illness were more likely to report plans to act on their GP's VBA. Patients not ready to quit smoking indicated they would be likely to seek the support of their GP for future quit attempts as a result of VBA. Many patients reported low self-efficacy with quitting and apprehension about available quit smoking supports. CONCLUSIONS: VBA was positively received by the majority of smokers interviewed. Participating patients confirmed the motivational role of advice when delivered in a supportive and caring manner. Personal health status, beliefs about quit smoking supports, and low self-efficacy appear to influence patient's motivation to make an aided quit attempt.

Cutaneous Cryosurgery for Common Skin Conditions.

Cryosurgery is the application of freezing temperatures to achieve the destruction of tissue. Cutaneous cryosurgery has become a commonly performed outpatient procedure because of the combination of its safety, effectiveness, low cost, ease of use, lack of need for injectable anesthetic, and good cosmetic results. Cryosurgery may be performed in the outpatient setting using dipstick, spray, or cryoprobe techniques to treat a variety of benign, premalignant, and malignant skin lesions with high cure rates. Benign lesions such as common and plantar warts, anogenital condylomas, molluscum contagiosum, and seborrheic keratoses can be treated with cryotherapy. Basal and squamous cell carcinomas with low-risk features may be treated with cryosurgery. Contraindications to cryosurgery include neoplasms with indefinite margins or when pathology is desired, basal cell or squamous cell carcinomas with high-risk features, and prior adverse local reaction or hypersensitivity to cryosurgery. Potential adverse effects include bleeding, blistering, edema, paresthesia, and pain and less commonly include tendon rupture, scarring, alopecia, atrophy, and hypopigmentation.

Frequent Headaches: Evaluation and Management.

Most frequent headaches are typically migraine or tension-type headaches and are often exacerbated by medication overuse. Repeated headaches can induce central sensitization and transformation to chronic headaches that are intractable, are difficult to treat, and cause significant morbidity and costs. A complete history is essential to identify the most likely headache type, indications of serious secondary headaches, and significant comorbidities. A headache diary can document headache frequency, symptoms, initiating and exacerbating conditions, and treatment response over time. Neurologic assessment and physical examination focused on the head and neck are indicated in all patients. Although rare, serious underlying conditions must be excluded by the patient history, screening tools such as SNNOOP10, neurologic and physical examinations, and targeted imaging and other assessments. Medication overuse headache should be suspected in patients with frequent headaches. Medication history should include nonprescription analgesics and substances, including opiates, that may be obtained from others. Patients who overuse opiates, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal. Patients who overuse other agents can usually withdraw more quickly. Evidence is mixed on the role of medications such as topiramate for patients with medication overuse headache. For the underlying headache, an individualized evidence-based management plan incorporating pharmacologic and nonpharmacologic strategies is necessary. Patients with frequent migraine, tension-type, and cluster headaches should be offered prophylactic therapy. A complete management plan includes addressing risk factors, headache triggers, and common comorbid conditions such as depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that can impair treatment effectiveness. Regular scheduled follow-up is important to monitor progress.