Health

Familiar faces speak as patients (AAFP annual scientific assembly)

■ Physicians and those they care for come together to explore state-of the-art science and the day-to-day reality of life affected by disease.

By Victoria Stagg Elliott — Posted Nov. 3, 2008

WITH THIS STORY:
» Patient education beyond the doctor's office
» Be on alert for novel and everyday viruses
» Research findings: Drug name confusion; meniscal tear detection; outpatient colonoscopy
» External links
» Related content

Nicole Johnson, MPH, would like physicians to be a little more positive. And as a former beauty queen and current diabetes activist, she hopes that telling doctors this will enhance the care she and other patients receive.

Johnson was diagnosed with type 1 diabetes in 1993, when she was a 19-year-old college sophomore. Her physician told her to drop out of school and stop entering beauty pageants. Those activities, he said, were now too stressful. She also should forget about bearing children.

"I was told my life was over ... and the worst part was that I believed it," she said, during a plenary session at the American Academy of Family Physicians' scientific assembly in San Diego, Sept. 17-21. After long-fought efforts to get her disease under control, she earned two master's degrees and won the 1999 Miss America Pageant. And she is a mother.

Johnson was one of several well-known people who detailed their experiences as part of the AAFP's new "Face of Disease" program. These lectures were paired with clinical insights by experts in the field.

"We wanted to try new types of learning, and this is one avenue we hadn't tried. We always hear from experts and family physicians. We never really get it from the patients," said Bradley P. Fox, MD, chair of the AAFP's subcommittee for scientific programming and a family physician in Erie, Pa.

The patients who spoke at the meeting generally praised the physicians in their lives, but also offered suggestions.

Johnson, for example, urged physicians and other health professionals to look at her face and see her as a human being, not just a list of blood glucose numbers. She also felt that outcomes would improve if efforts were made to get patients more engaged in the treatment processes.

"Healing can come to patients' hearts and minds when they are offered a chance to be a part of the circle of care -- when you're not just part of the problem, when you can help be part of the solution," said Johnson.

Such involvement was supported by Steven Edelman, MD, professor of medicine in the division of endocrinology, metabolism and diabetes at the University of California, San Diego. He was the expert who spoke after Johnson. Dr. Edelman, who also has type 1 diabetes, teaches patients to figure out their own insulin dosages. "It gets them motivated," he said.

The therapeutic value of listening

When she was in her late teens, actress Patty Duke began experiencing extreme mood swings -- steep lows followed by equally extreme highs, a cycle that continued until she was diagnosed as having bipolar disorder. She started taking lithium at age 35. Before taking this medication, there would be months when she couldn't get out of bed, followed by periods of extravagant spending and anonymous sexual experiences.

"I remember wishing the doctor would listen to me, even if what I had to say was gobbledygook," said Duke. She urged physicians to ask patients more often about suicidal tendencies. "There isn't anything you could ask a person like me that could make me worse."

Stanley Oakley Jr., MD, a bipolar disorder expert who spoke after Duke, said it was vital to distinguish this illness from unipolar depression, and suggested several signs that may differentiate the two. Bipolar disorder tends to have a stronger family history, and suicide attempts are more common, said Dr. Oakley, an associate professor of psychiatry at East Carolina University's Brody School of Medicine.

He also advocated checking metabolic factors, such as thyroid function, and reviewing medication side effects to hunt for a possible root cause. "We want to make sure we're not causing [bipolar symptoms]."

The family may be hurting, too

Duke and others implored physicians not to forget about patients' families when they are addressing specific health issues.

James "Butch" Rosser Jr., MD, chief of minimally invasive surgery at Beth Israel Medical Center in New York, had gastric bypass surgery eight years ago to treat his morbid obesity.

But his wife, Dana Rosser, for years withstood the collateral damage brought about by his weight problem. She curtailed her social life because her husband could not fit in the seats of many venues. She also held herself responsible for his weight.

"I stopped doing a lot of social things. That really hurt me," she said. "And I felt that the pressure was on me to cook meals that were delicious and nutritious. If I didn't make the meals correctly and he gained weight, it would be my fault."

Dr. Rosser spoke of the stigma and shame that can be attached to the outward manifestations of his condition.

"The victims of obesity have no place to hide," said Dr. Rosser, who weighed as much as 460 lbs. before his surgery. "I was so embarrassed. There was sadness in my heart."

Other speakers included actress Sally Field, who has osteoporosis, and Grace Anne Dorney Koppel, a lawyer and wife of journalist Ted Koppel, who spoke about chronic obstructive pulmonary disease.

ADDITIONAL INFORMATION

Patient education beyond the doctor's office

Physicians may be able to help patients make better decisions about complicated health issues if the discussions occur outside the exam room. "We are doing a lot of teaching in the worst situation for teaching -- when the patient is naked," said Joseph Hildner, MD, medical director of the Family Doctors of Belleview in Belleview, Fla.

A different approach would be to provide patients with access to useful information in advance, thereby making the one-on-one experience a more productive encounter, he said at a seminar at the American Academy of Family Physicians' annual scientific assembly.

Dr. Hildner suggested assessing the practice population to determine the best form for health information. He discovered that most of his patients, particularly the older ones, had e-mail and Internet access. So he recommends specific Web sites for them to read. He also suggested that physicians create their own educational materials to deal with often-discussed subjects. "Hopefully, [patients] can start the educational process in a more effective environment," he said.

Improving this interaction is crucial, because patients are, for the most part, in full control of their care, he added. Most also prefer having a role in the decision-making process, and studies have shown that when patients and physicians reach conclusions together on treatment strategies, compliance is more likely.

"I don't treat diabetes," Dr. Hildner said. "I don't treat congestive heart failure. I don't treat lipids. My patients do, and I help them."

Be on alert for novel and everyday viruses

The woman was ill when she returned to Texas after visiting her family in Singapore. She first saw her primary care physician, who referred her to an emergency department. There, because relatives had similar symptoms, her illness was believed to be infectious. But it was not until her physician checked the Web site for the Singapore's Ministry of Health, which detailed a dengue fever outbreak, that she was screened for and diagnosed with that sickness.

"This was an interesting case, but it's not such a rare disease. Travel history is important," said Michael Hellemn, MD, who presented the case study at the September American Academy of Family Physicians scientific assembly. Dr. Hellman is a third-year resident at Baylor Family Medicine Residency in Garland, Texas.

According to the Centers for Disease Control and Prevention, 50 million to 100 million cases of dengue fever occur around the world annually, with a couple hundred in the U.S. The illness is one of several caused by emergent viruses and bacteria experts say family physicians could see.

According to a seminar on emerging infections, family physicians need to be vigilant to the possibility that dengue, as well as extensively drug-resistant tuberculosis, may surface in their practices. They also need to maintain strong links with the local public health department. Such ties would be particularly important if a pandemic influenza event -- the threat which continues to generate serious concern -- were to occur.

"All the flu experts around the world are expecting another pandemic," said Doug Campos-Outcalt, MD, session leader and associate chair of the Dept. of Family and Community Medicine at the University of Arizona College of Medicine. "Public health and physician collaboration in a situation like this is going to be very important."

But another study found that many physicians may not be ready. Researchers interviewed 30 clinicians participating in four practice-based research networks. Most did not have a formal plan to handle a surge of patients, although findings suggested that Internet and telephone triage systems could be helpful.

"Most planning has focused on hospitals," said Lauren DeAlleaume, MD, lead author and assistant professor of family medicine at the University of Colorado Health Sciences Center. "The majority of practices have no formal plan."

A moderate to severe pandemic is expected to generate 45 million outpatient visits.

In such a situation, Dr. Campos-Outcalt anticipates that much of the distribution of vaccines and antivirals would fall on primary care physicians. These doctors also may need to educate patients about how a pandemic changes the rules.

"There will be a lot of pressure to prescribe outside of recommendations," he said. "There may be a need for isolation and restriction of activities. Physicians will need to inform patients of their responsibilities to the community."

He also advocated infection control policies. "The uncovered cough should be as unpopular as smoking in a doctor's office."

Research findings: Drug name confusion; meniscal tear detection; outpatient colonoscopy

Noise levels and drug familiarity determine if a doctor will identify accurately a medicine's name when it is spoken, according to a study presented at the American Academy of Family Physicians' scientific assembly.

Researchers from the University of Illinois, Chicago, recruited 74 family physicians at the 2005 AAFP meeting. The physicians were asked to identify 197 drug names they heard through a set of headphones. As background noise increased, physicians' abilities to identify drug names decreased. Drugs with similar names were more likely to be confused, and more commonly prescribed drugs were identified more accurately than those used less frequently. Physicians also were better able to identify generic rather than brand names.

Another paper suggested a low-tech movement test can detect meniscal tears. Researchers from the Dwight D. Eisenhower Army Medical Center in Fort Gordon, Ga., performed the Thessaly clinical test on 116 consecutive patients referred for knee arthroscopy to treat possible meniscal problems. Thessaly requires a patient to stand on flat feet with knees flexed at 20 degrees. Supported by the physician, the patient rotates three times. Most patients who have meniscal tears experience joint-line discomfort during this exercise. The authors concluded the test may have better accuracy than usual assessment methods.

"This may reduce the need for imaging," said Bradley K. Harrison, MD, lead author and a staff physician in the Dept. of Family and Community Medicine at Dwight David Eisenhower Army Medical Center in Fort Gordon, Ga.

Another study concluded that family physicians trained in colonoscopy can perform this procedure safely. Researchers in Fort Wayne, Ind., reviewed the charts of 2,585 patients who received colonoscopy performed by a family physician between January 1999 to June 2007 in an endoscopy suite at a suburban hospital. Nearly 31% had an adenoma detected. More than 35% of these would not have been found through sigmoidoscopy. The complication rate was 0.1%.