physicians, family

Objective: To provide family physicians and general otolaryngologists with a practical, evidence-based, and comprehensive approach to the management of patients presenting with suspected referred otalgia.

Sources of information: The approach described is a review based on the authors' clinical practices along with research and clinical review articles published between 2000 and 2020. MEDLINE and PubMed were searched using the terms otalgia, referred otalgia, and secondary otalgia. Current guidelines for the management of referred otalgia were also reviewed.

Main message: Otalgia is defined as pain localized to the ear. It is one of the most common head and neck presentations in primary care, otolaryngology, and emergency medicine. Secondary otalgia arises from nonotologic pathology and represents nearly 50% of otalgia cases. Otalgia in the absence of other otologic symptoms is highly indicative of a secondary cause. A thorough assessment of patients presenting with referred otalgia requires an understanding of the possible causes of this condition, including dental and oral mucosal pathologies, temporomandibular joint disorders, cervical spine pathology, sinusitis, upper airway infection, and reflux, as well as head and neck malignancy. This paper aims to highlight the most common causes of referred otalgia, their presentations, and initial options for assessment and management.

Conclusion: The prevalence of referred otalgia makes this an important condition for family physicians to be able to assess, manage, and triage based on patient presentation and examination. Understanding the common causes of referred otalgia will help reduce wait times for specialist assessment and allow ease and speed of access to management options for patients in community clinics.

Author/s:

Fatemeh Ramazani, Charmaine Szalay-Anderson, Arthur Volpato Batista, Phillip Park, Euna Hwang, Justin Chau, Justin Lui

Evaluation of a Dragons' Den-inspired symposium to spread primary health care innovations in Quebec, Canada: a mixed-methods study using quality-improvement e-surveys

Saige Blanchard — Tue, 29 Mar 2022 05:00:00 +0000

Date Added:

March 29, 2022

Journal/Publication:

CMAJ Open

Publisher:

CMA Impact Inc.

Publication Date:

March 22, 2022

Issue:

Volume:

Pages:

E247-E254

URL:

Evaluation of a Dragons' Den-inspired symposium to spread primary health care innovations in Quebec, Canada: a mixed-methods study using quality-improvement e-surveys

Type:

Best Local Practices

Format:

Article

DOI (1):

https://doi.org/10.9778/cmajo.20200251

Keywords

PMID (1):

35318248

MeSH

An apparently effective way to spread innovation in primary care. James W. Mold, MD, MPH

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Background: On May 24, 2017, the Quebec College of Family Physicians held an innovation symposium inspired by the television show Dragons' Den, at which innovators pitched their innovations to Dragon-Facilitators (i.e., decision-makers) and academic family medicine clinical leads. We evaluated the effects of the symposium on the spread of primary health care innovations.

Methods: We conducted a mixed-methods evaluation of the symposium. We collected data related to Rogers' innovation-decision process using 3 quality-improvement e-surveys (distributed between May 2017 and February 2018). The first survey evaluated spread outputs (innovation discovery, intention to spread, improvements) and was sent to all participants immediately after the symposium. The second evaluated short-term spread outcomes (follow-ups, successes, barriers) and was sent to innovators 3 months after the symposium. The third evaluated medium-term spread outcomes (spread, perceived impact) and was sent to innovators and clinical leads 9 months after the symposium. We analyzed the data using descriptive statistics, content analysis and joint display.

Results: Fifty-one innovators, 66 clinical leads (representing 42 clinics) and 37 Dragon-Facilitators attended the symposium. The response rates for the surveys were 61% (82/134) for the immediate post-symposium survey of all participants; 68% (21/31) for the 3-month survey of innovators; and 49% (48/97) for the 9-month survey of clinical leads and innovators. Immediately after the symposium, clinical leads and Dragon-Facilitators reported a high likelihood of adopting an innovation (mean ± standard deviation 8.02 ± 1.63 on a 10-point Likert scale) and 87% (53/61) agreed that they had discovered innovations at the symposium. Nearly all innovators (95%, 20/21) intended to follow up with potential adopters. After 3 months, 62% (13/21) of innovators had followed up in some way. After 9 months, 72% of clinical leads (18/25) had implemented at least 1 innovation, and 52% of innovators (12/23) had spread or were in the process of spreading innovations.

Interpretation: The innovation symposium supported participants in achieving the early stages of spreading primary health care innovations. Replicating such symposia may help spread other health care innovations.

Author/s:

Smithman, M. A., Dumas-Pilon, M., Campbell, M. J., Breton, M.

Axillary and inguinal erythrasma

Bethie Seay — Tue, 05 Oct 2021 05:00:00 +0000

Date Added:

October 5, 2021

Journal/Publication:

CMAJ

Publication Date:

October 4, 2021

Issue:

Volume:

193

Pages:

E1535

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.1503/cmaj.210310

A concise review of erythrasma.

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A 50-year-old man presented to the dermatology department with a 1-year history of itchy axillary and groin lesions. He had been treated with a topical antifungal preparation (cyclopyroxolamin), without improvement, by his family physician, who had suspected fungal intertrigo. On physical examination, we observed well-circumscribed, erythematous, brownish, scaly plaques affecting both armpits and the groin area bilaterally (Figure 1). To rule out superficial mycoses, we examined skin scrapings from the infected site under direct microscopy after potassium hydroxide preparation. We did not find any signs of fungal infection and did not isolate any dermatophytes in Sabouraud agar.

Author/s:

Riquelme, R. L., Moyano, E. G.

Can family physicians accurately screen for AAA with point-of-care ultrasound?

Bethie Seay — Thu, 23 Sep 2021 05:00:00 +0000

Date Added:

September 23, 2021

Journal/Publication:

The Journal of Family Practice

Issue:

Volume:

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.12788/jfp.0231

MeSH

point-of-care systems

physicians, family

Aortic Aneurysm, Abdominal

Primary care office ultrasound is as good as consultative ultrasound for identifying AAA.

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EVIDENCE-BASED ANSWER:
LIKELY YES. POINT-OF-CARE ULTRASOUND (POCUS) SCREENING FOR ABDOMINAL AORTIC ANEURYSM (AAA) BY NONRADIOLOGIST PHYSICIANS IS 98% SENSITIVE AND 99% SPECIFIC, COMPARED WITH IMAGING PERFORMED BY RADIOLOGISTS (STRENGTH OF RECOMMENDATION [SOR]: B, META-ANALYSIS OF DIAGNOSTIC ACCURACY STUDIES MOSTLY INVOLVING EMERGENCY MEDICINE PHYSICIANS). EUROPEAN FAMILY PHYSICIANS DEMONSTRATED 100% CONCORDANCE WITH RADIOLOGIST READINGS (SOR: C, VERY SMALL SUBSEQUENT DIAGNOSTIC ACCURACY STUDIES).

Author/s:

Cade, N., Granath, B., Nether, J. O., Safranek, S.

Unhealthy alcohol use in a 65-year-old man awaiting surgery

Bethie Seay — Tue, 17 Aug 2021 05:00:00 +0000

Date Added:

August 17, 2021

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.1503/cmaj.202128

MeSH

substance withdrawal syndrome

Not surprisingly, unhealthy levels of alcohol use is associated with surgical complications. Adressing it through screening and clinical management could improve outcomes.

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Three months before elective hip arthroplasty, a 65-yearold man with osteoarthritis presents to his family physician to discuss his alcohol consumption. His surgeon had expressed concern and advised him to speak to his family physician about decreasing his drinking before surgery. He reports drinking around 6 to 10 ounces of whiskey daily for the past 5 years. His alcohol intake increased gradually after retirement, and he now has cravings daily. He recently abstained from alcohol for 4 days while visiting family and developed irritability, tremor, nausea and headache. He has never had withdrawal seizures or delirium tremens, and he does not use any other substances. He is otherwise healthy, apart from hypertension that is controlled with perindopril. He is alarmed by his cravings, withdrawal symptoms and surgeon’s concerns, and is considering decreasing his alcohol use.

Author/s:

Brothers, T. D., Kaulbach, J., Tran, A.

Sudden Sensorineural Hearing Loss: A Diagnostic and Therapeutic Emergency

Devin Evans — Fri, 26 Feb 2021 06:00:00 +0000

Date Added:

February 26, 2021

Journal/Publication:

Journal of the American Board of Family Medicine

Publication Date:

January 31, 2021

Issue:

Volume:

Pages:

216-223

URL:

Sudden Sensorineural Hearing Loss: A Diagnostic and Therapeutic Emergency

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3122/jabfm.2021.01.200199

Keywords

Audiology

clinical decision-making

Conductive Hearing Loss

PMID (1):

33452100

MeSH

physicians, family

Hearing Loss, Sudden

Hearing Loss, Sensorineural

Otolaryngology

Medicine

primary health care

A summary for primary care clinicians of the recently updated ENT guidelines for evaluation and management of sudden acute hearing loss. James W. Mold, MD, MPH

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The family physician's role in recognizing and managing sudden sensorineural hearing loss (SSNHL) is crucial. A recently updated otolaryngologic clinical practice guideline has been released for this emergency syndrome, but dissemination is limited to a specialty journal. As a result, the guidelines may not be widely available in the primary care setting where patients often present. We provide this focused review to clarify and disseminate SSNHL guidelines for the frontline family physician.

Author/s:

Prince, Andrew D.P., Stucken, Emily Z.

New HHS/ONC Tool Helps Consumers Access Health Records

Brian Desmarais — Thu, 29 Oct 2020 15:12:48 +0000

Date Added:

October 29, 2020

Publisher:

AAFP

Publication Date:

April 13, 2019

URL:

New HHS/ONC Tool Helps Consumers Access Health Records

Type:

Notifications and Opportunities

Format:

Web Page

MeSH

Patient Portals

physicians, family

Health Records, Personal

Records

tablets

Emergency Medical Services

Appointments and Schedules

The 21st Century Cures Act requires that patients be allowed to see their medical records including visit notes beginning November 2. To facilitate that process, the Medicare program has developed this online decision support tool. James W. Mold, MD, MPH

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Not available.

Testosterone Treatment in Adult Men With Age-Related Low Testosterone: A Clinical Guideline From the American College of Physicians

John Bayhi — Tue, 07 Jan 2020 19:22:41 +0000

Date Added:

January 7, 2020

Journal/Publication:

Annals of Internal Medicine

Publisher:

American College of Physicians

Publication Date:

January 7, 2020

URL:

Testosterone Treatment in Adult Men With Age-Related Low Testosterone: A Clinical Guideline From the American College of Physicians

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M19-0882

Keywords

testosterone

guidelines

age-related testosterone deficiency

PMID (1):

31905405

MeSH

depressive disorder, major

Sexual Dysfunction

Physiological

Cognition

cardiovascular diseases

It appears that testosterone replacement in men with documented age-related testosterone deficiency may have small benefits in terms of sexual function and quality of life with no effect on physical function and no increase in significant adverse events. James W. Mold, MD, MPH

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DESCRIPTION:

The American College of Physicians (ACP) developed this guideline to provide clinical recommendations based on the current evidence of the benefits and harms of testosterone treatment in adult men with age-related low testosterone. This guideline is endorsed by the American Academy of Family Physicians.

METHODS:

The ACP Clinical Guidelines Committee based these recommendations on a systematic review on the efficacy and safety of testosterone treatment in adult men with age-related low testosterone. Clinical outcomes were evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system and included sexual function, physical function, quality of life, energy and vitality, depression, cognition, serious adverse events, major adverse cardiovascular events, and other adverse events.

TARGET AUDIENCE AND PATIENT POPULATION:

The target audience includes all clinicians, and the target patient population includes adult men with age-related low testosterone.

RECOMMENDATION 1A:

ACP suggests that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function (conditional recommendation; low-certainty evidence). The discussion should include the potential benefits, harms, costs, and patient's preferences.

RECOMMENDATION 1B:

ACP suggests that clinicians should reevaluate symptoms within 12 months and periodically thereafter. Clinicians should discontinue testosterone treatment in men with age-related low testosterone with sexual dysfunction in whom there is no improvement in sexual function (conditional recommendation; low-certainty evidence).

RECOMMENDATION 1C:

ACP suggests that clinicians consider intramuscular rather than transdermal formulations when initiating testosterone treatment to improve sexual function in men with age-related low testosterone, as costs are considerably lower for the intramuscular formulation and clinical effectiveness and harms are similar.

RECOMMENDATION 2:

ACP suggests that clinicians not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition (conditional recommendation; low-certainty evidence).

Author/s:

Qaseem, A., Horwitch, CA, Vijan, S, Etxeandia-Ikobaltzeta, I, Kansagara, D, Clinical Guidelines Committee of the American College of Physicians

The 2020 Medicare Documentation, Coding, and Payment Update

Brian Desmarais — Fri, 03 Jan 2020 19:58:25 +0000

Date Added:

January 3, 2020

Journal/Publication:

Mayo

Publisher:

American Academy of Family Physicians

Publication Date:

December 12, 2019

URL:

The 2020 Medicare Documentation, Coding, and Payment Update

Type:

Practice Management Reviews and Guidelines

Format:

Article

Keywords

coding

MeSH

Centers for Medicare and Medicaid Services, U.S.

referral and consultation

abdominal pain

Records

Major changes in coding will occur in 2021, but this 2020 update is also important. James W. Mold, MD, MPH

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As usual, the new year brings changes in how doctors bill and get paid for the services they provide to Medicare patients. The reforms that will most affect family physicians’ pay aren’t coming until 2021, when several changes in evaluation and management (E/M) coding and payment are projected to result in a 12% increase for family medicine.1 But there are still a host of things family physicians should know for 2020, including new codes to help you get paid for interacting with patients via the internet and new codes that should help make chronic care management (CCM) more financially rewarding. The Centers for Medicare & Medicaid Services (CMS) is also continuing its quest to streamline documentation requirements and develop new payment models intended to reward quality instead of volume. This article summarizes the 2020 changes most relevant to family medicine. As always, private payers’ policies may differ, so consult with your billing staff to understand any important differences.

Author/s:

Moore, K., Mullins, A., Solis, E.

Electronic Nicotine Delivery Systems (ENDS)

Brian Desmarais — Sat, 18 May 2019 05:00:00 +0000

Date Added:

May 18, 2019

Publisher:

AAFP

Publication Date:

April 1, 2019

URL:

Electronic Nicotine Delivery Systems (ENDS)

Type:

Public Health Announcements

Format:

Web Page

Keywords

MeSH

electronic nicotine delivery systems

Antineoplastic Combined Chemotherapy Protocols

AAFP statement regarding e-cigarettes.

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Electronic nicotine delivery systems (ENDS), also called electronic cigarettes, e-cigarettes, vaping devices, or vape pens, are battery-powered devices used to smoke or “vape” a flavored solution which usually contains nicotine. The American Academy of Family Physicians (AAFP) recognizes the alarmingly increased use of ENDS, especially among youth and young adults, as well as its use by those attempting to quit smoking tobacco.

The AAFP calls for further research to assess ENDS’ safety, quality, and efficacy as a potential cessation device. The AAFP also recommends that the marketing and advertising of ENDS to children and youth cease immediately. The AAFP encourages members to screen for ENDS use starting with school-age children, to discuss the potential harms of ENDS, and to recommend cessation interventions with e-cigarette users. The AAFP encourages members to inform patients who use ENDS, especially children, that the majority of these products contain nicotine and are addictive. (2014 COD) (April 2019 BOD)

Terminating a Patient: Is It Time to Part Ways?

Jeffrey Wilson — Thu, 04 Apr 2019 17:58:17 +0000

Date Added:

April 4, 2019

Journal/Publication:

Family Practice Medicine

Publisher:

American Association of Family Practitioners

Publication Date:

September 1, 2005

Issue:

Volume:

Pages:

34-38

URL:

Terminating a Patient: Is It Time to Part Ways?

Type:

Practice Management Reviews and Guidelines

Format:

Article

Keywords

family practice

patients

PMID (1):

16218291

MeSH

physicians, family

family practice

Guidance from Family Practice Management on when and how to dismiss a patient from your practice. James W. Mold, MD, MPH

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Many family physicians chose the specialty of family medicine because of the value placed on the therapeutic relationship between the patient and the physician. When that relationship is significantly or repeatedly challenged, family physicians feel it deeply, and it’s not always clear how best to address the problem.

We have found that, when emotions are high, having a standardized process for dealing with these challenges makes it easier to take appropriate action. Our process provides patients with plenty of opportunities to reconsider their behavior and re-engage in the relationship, when appropriate, and it provides the physician and staff the assurance that comes with following a reasoned, consistent approach when difficult circumstances arise. If it becomes necessary to terminate the relationship, our approach describes how to do it without running afoul of payers’ guidelines.

While our system is not perfect, it has significantly improved our ability to set expectations and draw boundaries in an environment where some payers have very narrowly defined the circumstances under which termination is acceptable. The flow charts in this article are based on ones we have used with success in our health system. You can download them below and adapt them for use in your practice.

Author/s:

Willis, Deanna R., Zerr, Ann

Guide to Enhancing Referrals and Consultations Between Physicians

Tracy Ashby — Fri, 01 Feb 2019 06:00:00 +0000

Date Added:

February 1, 2019

Publisher:

The College of Family Physicians of Canada

Publication Date:

October 1, 2009

Type:

Practice Management Reviews and Guidelines

Format:

Article

Keywords

referral and consultation

patient care

physicians

MeSH

physicians, family

referral and consultation

patient care

This is a summary of consultation and referral best practices from the College of Family Physicians of Canada.

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Access to care is a challenge for many of our patients. The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (Royal College) recognize that every possible measure must be taken to help ensure access to timely and quality medical and other health care service.
As part of ongoing efforts, the CFPC and the Royal College released a conjoint paper in 2006, to address the issue of intra-professional relationships between physiciansi. This paper identifies a number of issues and recommendations to improve patient care and professional satisfaction. The referral-consultation process is chief among the areas addressed in follow up to this conjoint paper.
There is growing knowledge and many new approaches developing in various regions of the country to improve the referral-consultation processes of care between referring and consulting physicians.
This guide on enhancing referrals and consultations between physicians is not intended to replace instruments already in place. It is complementary and may also help fill gaps where there are few or no tools in place to support good referrals and consultations, both within as well as between community and hospital settings. It is hoped that physicians will find this reference to be a valuable addition to practice.