John Hickner

Academic Physicians Use Placebos in Clinical Practice and Believe in the Mind–Body Connection

BackgroundThe placebo and the placebo effect are often investigated in the context of clinical trials. Little data exist on the use of placebos in the course of routine health care.ObjectiveThe aim of this study is to describe a group of academic physicians’ use of placebos and their knowledge, attitudes, and beliefs about placebos and the placebo effect.DesignA 16-question anonymous web-based survey of physicians from Internal Medicine departments of 3 Chicago-area medical schools was used.ResultsThere were 231/466 (50%) physicians who responded; of these, 45% reported they had used a placebo in clinical practice. The most common reasons for placebo use were to calm the patient and as supplemental treatment. Physicians did not widely agree on the definition of a placebo and had a variety of explanations for its mechanism of action. Ninety-six percent of the respondents believed that placebos can have therapeutic effects, and up to 40% of the physicians reported that placebos could benefit patients physiologically for certain health problems. Only 12% of the respondents said that placebo use in routine medical care should be categorically prohibited. Regarding “placebo-like” treatment, 48% of respondents reported giving at least 1 type of treatment in a situation where there was no evidence of clinical efficacy.ConclusionNearly half of the respondents use placebos in clinical practice and most believe in the mind–body connection. The results of this study, based on retrospective self-reported behavior, are subject to recall bias and may not be representative of American physicians.

A National Survey of Primary Care Practice-Based Research Networks

PURPOSE Increasing numbers of primary care practice-based research networks (PBRNs) are being developed in the United States to perform research relevant to everyday practice. To assess the current status and potential value of this resource, we surveyed US primary care PBRNs in operation from late 2003 to early 2004. METHODS We performed a Web-based survey and structured interviews with PBRN directors and administrative officers, assessing PBRNs’ history, size, location, organization, resources, operations, and productivity (funding obtained, studies performed, and articles published). RESULTS Of 111 primary care PBRNs identified, 89 (80%) responded to the survey. The 86 (77%) meeting the criteria for primary care PBRNs contained 1,871 practices, 12,957 physicians (mean 152 per PBRN, median 100), and 14.7 million patients (mean 229,880 per PBRN, median 105,000). Minority and underinsured patients were overrepresented. The average PBRN was young (4.4 ± 5.7 years): one-half had performed 3 or fewer studies. Three-quarters were affiliated with universities. Common research foci included prevention, diabetes, cardiovascular risk factors, and mental health. Respondent PBRNs had published more than 600 articles in peer-reviewed journals. PBRNs studying questions posed by outside researchers had more federal funding (84% vs 27%, P=.006). PBRNs citing funding as a weakness relied more on local resources to fund research projects (70% vs 40%, P=.036). CONCLUSIONS American primary care PBRNs are mainly young, diverse, and pursuing a variety of research foci. Most have university links and provide a dynamic town-gown relationship that could be a vital national resource for improving primary care, translating research into practice, and meeting the National Institutes of Health Roadmap goals. PBRNs merit further attention from both private and public funding agencies and researchers interested in studying the delivery of primary care.

A Comparison of Frequent and Infrequent Visitors to an Urban Emergency Department

Frequent visitors account for a high proportion of Emergency Department (ED) visits and costs. Some of these visits could be handled effectively in less expensive primary care settings. Effective interventions to redirect these patients to primary care depend on an in-depth understanding of frequent visitors and the reasons they seek care in the ED. The objective of this study was to explore the differences between frequent visitors and infrequent visitors who seek medical care in one urban ED, as a first step toward developing effective interventions to direct patients to effective sources of care. In structured interviews, we asked 69 frequent visitors and 99 infrequent visitors to an inner-city, adult ED about medical diagnoses, general health, depression, alcohol abuse, physical functioning, self-perceived social support, primary care and ED service use, payment method, satisfaction with their primary care physician, and demographic characteristics. Differences in responses between groups were compared using t-tests for continuous variables and chi-square for categorical variables. Frequent visitors were more likely than infrequent visitors to be insured by Medicaid (53% vs. 39%, respectively) and less likely to be uninsured (13% vs. 24%, respectively) or have private insurance (6% vs. 15%, respectively). They reported higher levels of stress, lower levels of social support, and worse general health status. They were much more likely to screen positive for depression (47% vs. 27%, respectively, p = 0.017). Frequent visitors were more likely to have a primary care physician (75% vs. 66%, respectively), and 45% of the frequent visitors had a primary care physician at the ED hospital compared to 23% of the infrequent visitors. These findings suggest the need to improve access to frequent visitors primary care physicians, screen them for depression, and offer psychological and social services more aggressively. These findings may apply to other inner city EDs.

Issues and Initiatives in the Testing Process in Primary Care Physician Offices

BACKGROUNDnErrors occur frequently in management of the testing process in primary care physicians offices. These errors may result in significant harm to patients and lead to inefficient practice. Important issues are summarized for primary care clinicians and their offices toconsider in improving the management of the testing processes.nnnMETHODSnTo identify published efforts to improve management of the testing process, a literature search was performed and the references from the identified articles were checked for additional studies. Descriptive studies, expert opinion pieces, and controlled trials were all included. Unpublished results of ongoing studies in laboratory testing errors in primary care practice are presented.nnnRESULTSnA conceptual model of the testing process was developed, with identified general and specific errors that occur in the testing process. On the basis largely of descriptive studies, ways are described to reduce testing process errors and the harm resulting from these errors.nnnCONCLUSIONSnStandardization of processes, computerized test tracking systems (especially those embedded in electronic medical records), and attention to human factors issues are likely to reduce errors and harm. These ideas need confirmation in well-designed randomized trials and quality improvement initiatives.

Data Collection Outcomes Comparing Paper Forms With PDA Forms in an Office-Based Patient Survey

PURPOSE We compared the completeness of data collection using paper forms and using electronic forms loaded on handheld computers in an office-based patient interview survey conducted within the American Academy of Family Physicians National Research Network. METHODS We asked 19 medical assistants and nurses in family practices to administer a survey about pneumococcal immunizations to 60 older adults each, 30 using paper forms and 30 using electronic forms on handheld computers. By random assignment, the interviewers used either the paper or electronic form first. Using multilevel analyses adjusted for patient characteristics and clustering of forms by practice, we analyzed the completeness of the data. RESULTS A total of 1,003 of the expected 1,140 forms were returned to the data center. The overall return rate was better for paper forms (537 of 570, 94%) than for electronic forms (466 of 570, 82%) because of technical difficulties experienced with electronic data collection and stolen or lost handheld computers. Errors of omission on the returned forms, however, were more common using paper forms. Of the returned forms, only 3% of those gathered electronically had errors of omission, compared with 35% of those gathered on paper. Similarly, only 0.04% of total survey items were missing on the electronic forms, compared with 3.5% of the survey items using paper forms. CONCLUSIONS Although handheld computers produced more complete data than the paper method for the returned forms, they were not superior because of the large amount of missing data due to technical difficulties with the hand-held computers or loss or theft. Other hardware solutions, such as tablet computers or cell phones linked via a wireless network directly to a Web site, may be better electronic solutions for the future.

Clinicians' management of children and adolescents with acute pharyngitis

OBJECTIVE. Sore throat is a common complaint in children and adolescents. With increasing antimicrobial resistance because of antimicrobial overuse, accurate diagnosis is imperative. Appropriate management of acute pharyngitis depends on proper use and interpretation of clinical findings, rapid antigen-detection tests, and throat cultures. We surveyed pediatricians and family physicians to evaluate their management strategies for children and adolescents with acute pharyngitis and to assess the availability and use of diagnostic tests in office practice. METHODS. In 2004, surveys were mailed to a random sample of 1000 pediatrician members of the American Academy of Pediatrics and 1000 family physician members of the American Academy of Family Physicians. We assessed factors associated with physicians using an appropriate management strategy for treating acute pharyngitis. RESULTS. Of 948 eligible responses, 42% of physicians would start antimicrobials before knowing diagnostic test results and continue them despite negative results, with 27% doing this often or always. When presented with clinical scenarios of patients with acute pharyngitis, ≤23% chose an empirical approach, 32% used an inappropriate strategy for a child with pharyngitis suggestive of group A Streptococcus, and 81% used an inappropriate strategy for a child with findings consistent with viral pharyngitis. Plating cultures in the office was associated with an appropriate management strategy, although not statistically significant. Solo/2-person practice and rural location were both independent factors predicting inappropriate strategies. CONCLUSIONS. here is much room for improvement in the management of acute pharyngitis in children and adolescents. Most physicians use appropriate management strategies; however, a substantial number uses inappropriate ones, particularly for children with likely viral pharyngitis. Efforts to help physicians improve practices will need to be multifaceted and should include health policy and educational approaches.

“Sticking to it—Diabetes Mellitus”: A Pilot Study of an Innovative Behavior Change Program for Women with Type 2 Diabetes

Abstract The goal of this project was to evaluate an innovative educational program for women with type 2 diabetes facilitated by trained lay health advisors from the local university extension service. The program focused on adherence to behaviors recommended to achieve optimal blood glucose control. We evaluated whether primary care physicians would refer to this program, whether the program would reach diabetic women in rural areas, and whether the program improved health behaviors and glycemic control. Women over 40 with type 2 diabetes were recruited through their primary care physicians offices. Eligible participants were randomly assigned to intervention (program) or control (usual care) groups. The six-session educational program focused on encouraging behavior change through instructor and group support, learning specific behavior change skills, and developing a confident attitude about self-management of diabetes. Physicians supported referral to the program, and the utilization of a lay health advisor for delivery of the program in rural areas was feasible. At 6-month follow-up the mean change in hemoglobin A1c and body mass index did not differ significantly between the intervention (n=67) and control (n=65) groups. However, participants felt better about their ability to control their diabetes and demonstrated an improvement in behaviors related to control.

First coitus for adolescents: Understanding why and when

Background: Correlates of initiation of coitus for teenagers were examined, and participants were asked their reasons for initiating or postponing the onset of coitus. Methods: Questionnaires were completed privately by 218 patients aged 13 to 18 years. Questions explored the reasons adolescents cite for their sexual decisions and the role of peer influence in these decisions. Results: Correlation was noted in young teenagers between perception of peer sexual behavior and participants initiation of coitus. Reasons stated for engaging in first intercourse reflect both active choices and loss of control. Reasons for refraining included fear of pregnancy and sexually transmitted diseases, lack of developmental readiness and opportunity, and social sanctions. Morality was cited infrequently as a reason for postponing sexual behavior. Conclusions: Results suggest that sexuality education should address the direct and curious questions of younger teenagers about sexuality, help youth define strategies that they can use to evaluate and resist peer pressure, and give more generalized attention to ways of helping youth feel competent. Physicians and other health educators might focus on helping older youth define how and when they know they are ready to have intercourse, consider ways of expressing sexuality that do not jeopardize health, and improve communication skills when talking with friends and potential partners about sexual issues.

Quality and Safety in Outpatient Laboratory Testing

Interactions between the laboratory and outpatient physician are critical to ensure the appropriateness, accuracy, and utility of laboratory results. A recent Institute of Medicine report suggested that the consequences of medical errors in the outpatient setting-and the opportunities to improve-may dwarf those in hospitals. This article focuses on the role of the physicians office in laboratory quality.

Antibiotic Prescribing for Acute Bronchitis: How Low Can We Go?

By the time I graduated from medical school in 1975, I had learned that most respiratory tract infections in otherwise healthy children and adults were caused by viruses, such as parainfiuenza, influenza, adenovirus, and respiratory syncytial virus. This learning was reinforced during my family practice residency training in Charleston, Se. I was taught that the challenge of primary care practice is to distinguish the many patients with benign, selflimited respiratory tract infections from those patients who are more seriously ill with bacterial pneumonia and who need an antibiotic to recover more quickly and more certainly. Anned with this scientific knowledge, I marched valiantly into practice, determined to base my prescribing on good science. It was only in rural practice that I clearly recall regularly confronting syndromes called acute bronchitis and sinusitis, for which patients seemed to expect an antibiotic and for which their previous physicians had prescribed one. I get this bronchitis every fall. Dr. Smith gives me a shot of penicillin and Im fine 2 days later. With modest success I was able to talk patients out of this approach, but I more frequently failed than succeeded, though many were willing to take my prescription for pills as an acceptable alternative to the shot in the buttock. A quarter-century later I am still fighting the good battle of appropriate antibiotic use for respiratory tract infections. After a 25-year cold war, however, the battle is heating up! The Centers for Disease Control and Prevention has entered the fray, urging us and our patients to use antibiotics sparingly and wisely for acute respiratory tract infections. 1 Family physicians have been named as a major contributor to the problem of bacterial resistance, and the reasons we participate in the problem have been thoroughly described. In the words