John Hickner, MD, MSc

Shoulder pain is a very common presenting complaint in family physicians’ offices. Typically, a patient will have had minor trauma, such as a fall, or overuse from work or a recreational activity. Most of these patients have rotator cuff injuries, so we refer them to physical therapy or we prescribe a self-directed home exercise program and the problem gradually resolves. If the patient does not improve, however, should s(he) be referred for arthroscopic surgery? This answer, of course, is “it depends.”

Certain conditions involving shoulder, knee, and back pain should prompt us to advise against surgery.

In this issue of JFP, Onks et al provide an excellent review of conservative vs surgical management of rotator cuff tears. For complete or near complete tears in young people—especially athletes—arthroscopic surgery is the preferred approach. For partial tears, chronic tears, and for older folks like me, nonoperative management is the preferred approach. Surgery is reserved for those who do not improve with prolonged conservative management.

But what approach is best for the majority of people in whom shoulder pain is due to impingement syndrome, with or without a small rotator cuff tear? This question has been studied extensively and summarized in a recent Cochrane meta-analysis.¹

The meta-analysis included 8 trials, with a total of 1062 participants with rotator cuff disease, all with subacromial impingement. “Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence).”¹

A recently published guideline developed by doctors and patients for the treatment of shoulder pain gives a strong recommendation to avoid surgery for chronic shoulder pain due to impingement syndrome.²

Interestingly, research has shown that arthroscopic surgery for knee osteoarthritis and chronic meniscus tears is no better that conservative therapy.^3,4 Similarly, surgery for chronic back pain due to degenerative disease (in the absence of spondylolisthesis) provides minimal, if any, improvement in pain and function.⁵ I see a pattern here.

When we talk to our patients who are contemplating these surgical procedures for these indications (except complete rotator cuff tears), we should advise them to have limited expectations or to avoid surgery altogether.

Shoulder pain is a very common presenting complaint in family physicians’ offices. Typically, a patient will have had minor trauma, such as a fall, or overuse from work or a recreational activity. Most of these patients have rotator cuff injuries, so we refer them to physical therapy or we prescribe a self-directed home exercise program and the problem gradually resolves. If the patient does not improve, however, should s(he) be referred for arthroscopic surgery? This answer, of course, is “it depends.”

Certain conditions involving shoulder, knee, and back pain should prompt us to advise against surgery.

In this issue of JFP, Onks et al provide an excellent review of conservative vs surgical management of rotator cuff tears. For complete or near complete tears in young people—especially athletes—arthroscopic surgery is the preferred approach. For partial tears, chronic tears, and for older folks like me, nonoperative management is the preferred approach. Surgery is reserved for those who do not improve with prolonged conservative management.

But what approach is best for the majority of people in whom shoulder pain is due to impingement syndrome, with or without a small rotator cuff tear? This question has been studied extensively and summarized in a recent Cochrane meta-analysis.¹

The meta-analysis included 8 trials, with a total of 1062 participants with rotator cuff disease, all with subacromial impingement. “Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence).”¹

A recently published guideline developed by doctors and patients for the treatment of shoulder pain gives a strong recommendation to avoid surgery for chronic shoulder pain due to impingement syndrome.²

Interestingly, research has shown that arthroscopic surgery for knee osteoarthritis and chronic meniscus tears is no better that conservative therapy.^3,4 Similarly, surgery for chronic back pain due to degenerative disease (in the absence of spondylolisthesis) provides minimal, if any, improvement in pain and function.⁵ I see a pattern here.

When we talk to our patients who are contemplating these surgical procedures for these indications (except complete rotator cuff tears), we should advise them to have limited expectations or to avoid surgery altogether.

Shoulder pain is a very common presenting complaint in family physicians’ offices. Typically, a patient will have had minor trauma, such as a fall, or overuse from work or a recreational activity. Most of these patients have rotator cuff injuries, so we refer them to physical therapy or we prescribe a self-directed home exercise program and the problem gradually resolves. If the patient does not improve, however, should s(he) be referred for arthroscopic surgery? This answer, of course, is “it depends.”

Certain conditions involving shoulder, knee, and back pain should prompt us to advise against surgery.

In this issue of JFP, Onks et al provide an excellent review of conservative vs surgical management of rotator cuff tears. For complete or near complete tears in young people—especially athletes—arthroscopic surgery is the preferred approach. For partial tears, chronic tears, and for older folks like me, nonoperative management is the preferred approach. Surgery is reserved for those who do not improve with prolonged conservative management.

But what approach is best for the majority of people in whom shoulder pain is due to impingement syndrome, with or without a small rotator cuff tear? This question has been studied extensively and summarized in a recent Cochrane meta-analysis.¹

The meta-analysis included 8 trials, with a total of 1062 participants with rotator cuff disease, all with subacromial impingement. “Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence).”¹

A recently published guideline developed by doctors and patients for the treatment of shoulder pain gives a strong recommendation to avoid surgery for chronic shoulder pain due to impingement syndrome.²

Interestingly, research has shown that arthroscopic surgery for knee osteoarthritis and chronic meniscus tears is no better that conservative therapy.^3,4 Similarly, surgery for chronic back pain due to degenerative disease (in the absence of spondylolisthesis) provides minimal, if any, improvement in pain and function.⁵ I see a pattern here.

When we talk to our patients who are contemplating these surgical procedures for these indications (except complete rotator cuff tears), we should advise them to have limited expectations or to avoid surgery altogether.

Family physicians try to base treatment decisions on the very best available evidence from randomized trials and other high-quality studies. Very often, however, the evidence is not conclusive. Family physicians are confronted with questions about a wide variety of treatments that may or may not be effective. The classic example for me is the use of chondroitin sulfate/glucosamine for knee osteoarthritis. The preponderance of evidence tells us it is not effective, but one long-term clinical trial did find some benefit.¹ And some patients swear by it!

In this issue of JFP, we have 2 articles that fall into this category: 1 by Hahn about the treatment of asthma with macrolides and the other by Sorsby et al about use of positive airway pressure (PAP) for obstructive sleep apnea (OSA).

The article by Hahn is an extensive literature review regarding the effectiveness of macrolides for asthma. Despite 2 meta-analyses and many clinical trials, the results are not conclusive; but they are highly suggestive that macrolides may benefit patients with new-onset asthma and severe asthma that does not respond completely to mainstream treatments. Why don't we have conclusive evidence? Because the right studies have not been done. Most studies of macrolides for asthma have not focused on these 2 groups, so any treatment effect may have been diluted by including patients not likely to respond.

Why don't we have conclusive evidence? Because the right studies have not been done.

The issue with PAP, also known as CPAP (or continuous positive airway pressure), for the treatment of OSA is different. In this case, the question is: What conditions and outcomes are improved by use of PAP? Studies strongly support that PAP is effective in reducing daytime sleepiness and motor vehicle accidents associated with OSA. Most of us had high hopes that PAP also would reduce the adverse cardiovascular outcomes associated with OSA. But the results of large randomized trials have not found a protective effective.

Enthusiasts argue that the studies have not been of sufficient duration and that the participants did not use their PAP devices long enough each night. Some follow-up studies have suggested a protective effective when the device is used for many years, but those studies have the major flaw of volunteer bias, meaning those who adhere to any treatment have better health outcomes than those who do not adhere.

What should you do when there is uncertainty regarding effectiveness? Use shared decision making: What does the patient want to do after you have explained the possible benefits and harms?

Family physicians try to base treatment decisions on the very best available evidence from randomized trials and other high-quality studies. Very often, however, the evidence is not conclusive. Family physicians are confronted with questions about a wide variety of treatments that may or may not be effective. The classic example for me is the use of chondroitin sulfate/glucosamine for knee osteoarthritis. The preponderance of evidence tells us it is not effective, but one long-term clinical trial did find some benefit.¹ And some patients swear by it!

In this issue of JFP, we have 2 articles that fall into this category: 1 by Hahn about the treatment of asthma with macrolides and the other by Sorsby et al about use of positive airway pressure (PAP) for obstructive sleep apnea (OSA).

The article by Hahn is an extensive literature review regarding the effectiveness of macrolides for asthma. Despite 2 meta-analyses and many clinical trials, the results are not conclusive; but they are highly suggestive that macrolides may benefit patients with new-onset asthma and severe asthma that does not respond completely to mainstream treatments. Why don't we have conclusive evidence? Because the right studies have not been done. Most studies of macrolides for asthma have not focused on these 2 groups, so any treatment effect may have been diluted by including patients not likely to respond.

Why don't we have conclusive evidence? Because the right studies have not been done.

The issue with PAP, also known as CPAP (or continuous positive airway pressure), for the treatment of OSA is different. In this case, the question is: What conditions and outcomes are improved by use of PAP? Studies strongly support that PAP is effective in reducing daytime sleepiness and motor vehicle accidents associated with OSA. Most of us had high hopes that PAP also would reduce the adverse cardiovascular outcomes associated with OSA. But the results of large randomized trials have not found a protective effective.

Enthusiasts argue that the studies have not been of sufficient duration and that the participants did not use their PAP devices long enough each night. Some follow-up studies have suggested a protective effective when the device is used for many years, but those studies have the major flaw of volunteer bias, meaning those who adhere to any treatment have better health outcomes than those who do not adhere.

What should you do when there is uncertainty regarding effectiveness? Use shared decision making: What does the patient want to do after you have explained the possible benefits and harms?

Family physicians try to base treatment decisions on the very best available evidence from randomized trials and other high-quality studies. Very often, however, the evidence is not conclusive. Family physicians are confronted with questions about a wide variety of treatments that may or may not be effective. The classic example for me is the use of chondroitin sulfate/glucosamine for knee osteoarthritis. The preponderance of evidence tells us it is not effective, but one long-term clinical trial did find some benefit.¹ And some patients swear by it!

In this issue of JFP, we have 2 articles that fall into this category: 1 by Hahn about the treatment of asthma with macrolides and the other by Sorsby et al about use of positive airway pressure (PAP) for obstructive sleep apnea (OSA).

The article by Hahn is an extensive literature review regarding the effectiveness of macrolides for asthma. Despite 2 meta-analyses and many clinical trials, the results are not conclusive; but they are highly suggestive that macrolides may benefit patients with new-onset asthma and severe asthma that does not respond completely to mainstream treatments. Why don't we have conclusive evidence? Because the right studies have not been done. Most studies of macrolides for asthma have not focused on these 2 groups, so any treatment effect may have been diluted by including patients not likely to respond.

Why don't we have conclusive evidence? Because the right studies have not been done.

The issue with PAP, also known as CPAP (or continuous positive airway pressure), for the treatment of OSA is different. In this case, the question is: What conditions and outcomes are improved by use of PAP? Studies strongly support that PAP is effective in reducing daytime sleepiness and motor vehicle accidents associated with OSA. Most of us had high hopes that PAP also would reduce the adverse cardiovascular outcomes associated with OSA. But the results of large randomized trials have not found a protective effective.

Enthusiasts argue that the studies have not been of sufficient duration and that the participants did not use their PAP devices long enough each night. Some follow-up studies have suggested a protective effective when the device is used for many years, but those studies have the major flaw of volunteer bias, meaning those who adhere to any treatment have better health outcomes than those who do not adhere.

What should you do when there is uncertainty regarding effectiveness? Use shared decision making: What does the patient want to do after you have explained the possible benefits and harms?

This month’s cover story on artificial intelligence (AI) and machine learning provides a glimpse into the future of medical care. The article’s title, “An FP’s guide to AI-enabled clinical decision support” points to the fact that practical and useful applications of AI and machine learning are making inroads into medicine. However, other industries are far ahead of medicine when it comes to AI.

For example, I met with a financial advisor last week, and our discussion included a display of the likelihood that my wife and I would have sufficient funds in our retirement account based on a Monte Carlo simulation using 500 trials! In other words, our advisor used a huge database of financial information, analyzed that data with a sophisticated statistical technique, and applied the results to our personal situation. (No, we won’t run out of money—with 99% certainty.)

So as physicians, how can we further increase our certainty in the diagnoses we make and the guidance we offer our patients?

Artificial intelligence will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making.

Halamka and Cerrato provide some insights. They discuss 2 clinical applications of AI and machine learning that are ready to use in primary care: screening for diabetic retinopathy and risk assessment for colon cancer. The first is an example of using AI for diagnosis and the second for risk assessment; both are core functions of primary care clinicians. These tools were developed with very sophisticated computer programs, but they are not unlike a plethora of clinical decision aids already widely used in primary care for diagnosis and risk assessment, such as the Ottawa Ankle Rules, the Gail Model for breast cancer risk, the FRAX tool for osteoporosis-related fracture risk, the ASCVD Risk Calculator for cardiovascular risk, and the CHA₂DS₂-VASC score for prediction of thrombosis and bleeding risk from anticoagulation therapy.

Some express concern that sophisticated AI could eventually replace primary care clinicians, similar to how automation reduces the need for routine labor in manufacturing. I think this is highly unlikely, but I do think AI will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making. For example, the colon cancer risk calculator may actually help some patients decide NOT to be screened because their personal risk is so low.

It’s incumbent upon us, then, to familiarize ourselves with the potential that these AI tools offer. It’s time to get to know AI.

This month’s cover story on artificial intelligence (AI) and machine learning provides a glimpse into the future of medical care. The article’s title, “An FP’s guide to AI-enabled clinical decision support” points to the fact that practical and useful applications of AI and machine learning are making inroads into medicine. However, other industries are far ahead of medicine when it comes to AI.

For example, I met with a financial advisor last week, and our discussion included a display of the likelihood that my wife and I would have sufficient funds in our retirement account based on a Monte Carlo simulation using 500 trials! In other words, our advisor used a huge database of financial information, analyzed that data with a sophisticated statistical technique, and applied the results to our personal situation. (No, we won’t run out of money—with 99% certainty.)

So as physicians, how can we further increase our certainty in the diagnoses we make and the guidance we offer our patients?

Artificial intelligence will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making.

Halamka and Cerrato provide some insights. They discuss 2 clinical applications of AI and machine learning that are ready to use in primary care: screening for diabetic retinopathy and risk assessment for colon cancer. The first is an example of using AI for diagnosis and the second for risk assessment; both are core functions of primary care clinicians. These tools were developed with very sophisticated computer programs, but they are not unlike a plethora of clinical decision aids already widely used in primary care for diagnosis and risk assessment, such as the Ottawa Ankle Rules, the Gail Model for breast cancer risk, the FRAX tool for osteoporosis-related fracture risk, the ASCVD Risk Calculator for cardiovascular risk, and the CHA₂DS₂-VASC score for prediction of thrombosis and bleeding risk from anticoagulation therapy.

Some express concern that sophisticated AI could eventually replace primary care clinicians, similar to how automation reduces the need for routine labor in manufacturing. I think this is highly unlikely, but I do think AI will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making. For example, the colon cancer risk calculator may actually help some patients decide NOT to be screened because their personal risk is so low.

It’s incumbent upon us, then, to familiarize ourselves with the potential that these AI tools offer. It’s time to get to know AI.

This month’s cover story on artificial intelligence (AI) and machine learning provides a glimpse into the future of medical care. The article’s title, “An FP’s guide to AI-enabled clinical decision support” points to the fact that practical and useful applications of AI and machine learning are making inroads into medicine. However, other industries are far ahead of medicine when it comes to AI.

For example, I met with a financial advisor last week, and our discussion included a display of the likelihood that my wife and I would have sufficient funds in our retirement account based on a Monte Carlo simulation using 500 trials! In other words, our advisor used a huge database of financial information, analyzed that data with a sophisticated statistical technique, and applied the results to our personal situation. (No, we won’t run out of money—with 99% certainty.)

So as physicians, how can we further increase our certainty in the diagnoses we make and the guidance we offer our patients?

Artificial intelligence will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making.

Halamka and Cerrato provide some insights. They discuss 2 clinical applications of AI and machine learning that are ready to use in primary care: screening for diabetic retinopathy and risk assessment for colon cancer. The first is an example of using AI for diagnosis and the second for risk assessment; both are core functions of primary care clinicians. These tools were developed with very sophisticated computer programs, but they are not unlike a plethora of clinical decision aids already widely used in primary care for diagnosis and risk assessment, such as the Ottawa Ankle Rules, the Gail Model for breast cancer risk, the FRAX tool for osteoporosis-related fracture risk, the ASCVD Risk Calculator for cardiovascular risk, and the CHA₂DS₂-VASC score for prediction of thrombosis and bleeding risk from anticoagulation therapy.

Some express concern that sophisticated AI could eventually replace primary care clinicians, similar to how automation reduces the need for routine labor in manufacturing. I think this is highly unlikely, but I do think AI will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making. For example, the colon cancer risk calculator may actually help some patients decide NOT to be screened because their personal risk is so low.

It’s incumbent upon us, then, to familiarize ourselves with the potential that these AI tools offer. It’s time to get to know AI.

This month’s cover story addresses a phenomenon familiar to all of us: burnout. Mohanty and colleagues provide an excellent, concise summary of what burnout is, the probable causes of it, and possible solutions.

What has puzzled me about burnout is why there was no discussion of it 30 years ago when physicians worked easily as many hours but did not complain of being “burned out.” We just described ourselves as being tired. One could argue that the disconnect is due to a change in physicians’ expectations, but that theory does not hold up because burnout is common in both older and younger physicians.

No amount of yoga, mindfulness, meditation, or exercise will be sufficient to combat physician burnout.

I think that Dr. Wendy Dean, a psychiatrist at the Henry M. Jackson Foundation for the Advancement of Military Medicine, and her colleagues are correct in identifying a different culprit. They contend that the real issue is that we are “increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients.”¹ To redefine the problem of burnout, Dr. Dean uses a different term to label this phenomenon of exhaustion, demoralization, and depersonalization. She calls it “moral injury.”

“Moral injury . . . describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.”¹

So what needs to change? No amount of yoga, mindfulness, meditation, or exercise will be sufficient, although these are great therapeutic activities. Office redesign, however, has already been shown to be highly effective in reducing physician burnout. For example, in an intensive practice redesign project in Colorado that included hiring more medical assistants, physician burnout declined from 56% to 25% in the first practice and from 40% to 0% in the second practice!²

One of the oldest examples of using team care to reduce physician burnout was implemented by Dr. Peter Anderson in 2003.³ Dr. Anderson was on the brink of throwing in the towel when he hired a second nurse and redistributed many tasks to the nurses. In a few years he had a thriving and satisfying practice for himself, his staff, and his patients.

These are only 2 examples of many successful redesign projects around the country. If you are getting burned out, change your practice, not yourself.

This month’s cover story addresses a phenomenon familiar to all of us: burnout. Mohanty and colleagues provide an excellent, concise summary of what burnout is, the probable causes of it, and possible solutions.

What has puzzled me about burnout is why there was no discussion of it 30 years ago when physicians worked easily as many hours but did not complain of being “burned out.” We just described ourselves as being tired. One could argue that the disconnect is due to a change in physicians’ expectations, but that theory does not hold up because burnout is common in both older and younger physicians.

No amount of yoga, mindfulness, meditation, or exercise will be sufficient to combat physician burnout.

I think that Dr. Wendy Dean, a psychiatrist at the Henry M. Jackson Foundation for the Advancement of Military Medicine, and her colleagues are correct in identifying a different culprit. They contend that the real issue is that we are “increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients.”¹ To redefine the problem of burnout, Dr. Dean uses a different term to label this phenomenon of exhaustion, demoralization, and depersonalization. She calls it “moral injury.”

“Moral injury . . . describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.”¹

So what needs to change? No amount of yoga, mindfulness, meditation, or exercise will be sufficient, although these are great therapeutic activities. Office redesign, however, has already been shown to be highly effective in reducing physician burnout. For example, in an intensive practice redesign project in Colorado that included hiring more medical assistants, physician burnout declined from 56% to 25% in the first practice and from 40% to 0% in the second practice!²

One of the oldest examples of using team care to reduce physician burnout was implemented by Dr. Peter Anderson in 2003.³ Dr. Anderson was on the brink of throwing in the towel when he hired a second nurse and redistributed many tasks to the nurses. In a few years he had a thriving and satisfying practice for himself, his staff, and his patients.

These are only 2 examples of many successful redesign projects around the country. If you are getting burned out, change your practice, not yourself.

This month’s cover story addresses a phenomenon familiar to all of us: burnout. Mohanty and colleagues provide an excellent, concise summary of what burnout is, the probable causes of it, and possible solutions.

What has puzzled me about burnout is why there was no discussion of it 30 years ago when physicians worked easily as many hours but did not complain of being “burned out.” We just described ourselves as being tired. One could argue that the disconnect is due to a change in physicians’ expectations, but that theory does not hold up because burnout is common in both older and younger physicians.

No amount of yoga, mindfulness, meditation, or exercise will be sufficient to combat physician burnout.

I think that Dr. Wendy Dean, a psychiatrist at the Henry M. Jackson Foundation for the Advancement of Military Medicine, and her colleagues are correct in identifying a different culprit. They contend that the real issue is that we are “increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients.”¹ To redefine the problem of burnout, Dr. Dean uses a different term to label this phenomenon of exhaustion, demoralization, and depersonalization. She calls it “moral injury.”

“Moral injury . . . describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.”¹

So what needs to change? No amount of yoga, mindfulness, meditation, or exercise will be sufficient, although these are great therapeutic activities. Office redesign, however, has already been shown to be highly effective in reducing physician burnout. For example, in an intensive practice redesign project in Colorado that included hiring more medical assistants, physician burnout declined from 56% to 25% in the first practice and from 40% to 0% in the second practice!²

One of the oldest examples of using team care to reduce physician burnout was implemented by Dr. Peter Anderson in 2003.³ Dr. Anderson was on the brink of throwing in the towel when he hired a second nurse and redistributed many tasks to the nurses. In a few years he had a thriving and satisfying practice for himself, his staff, and his patients.

These are only 2 examples of many successful redesign projects around the country. If you are getting burned out, change your practice, not yourself.

In this issue of JFP, Weinstein and Worster provide a wealth of information about prescribing marijuana. Medical marijuana (Cannabis) is now legal in the majority of states, so it’s likely that some of your patients are using marijuana for symptom relief. For those physicians who elect to prescribe marijuana, reading this review will help you avoid harming patients while maximizing potential benefits.

I say “potential benefits” because the research evidence to support benefit for most conditions and symptoms is weak at best. In addition to the JAMA meta-analysis cited by Weinstein and Worster,¹ several meta-analyses and systematic reviews published since January 2018 reach similar conclusions.^2-4

Marijuana can provide significant relief from chemotherapy-induced nausea and vomiting, and it is effective in reducing intractable seizures in 2 rare pediatric seizure disorders. There may be some benefit for treatment of spasticity, and there may be some therapeutic value for relief of neuropathic pain, although the evidence is not strong. Interestingly, there is some preliminary evidence that cannabis can improve gastrointestinal symptoms in patients with Crohn's disease and ulcerative colitis.^5,6

Why do people use marijuana as medicine? A meta-analysis found that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons.⁷ People use marijuana for a plethora of other conditions and symptoms, which is reflected in the long list of “approved” conditions in most state medical marijuana laws. The problem I have with prescribing cannabis for non-neuropathic pain, anxiety, and depression is that there is no good randomized trial evidence of its effectiveness beyond a placebo effect (which is probably quite strong considering the psychotropic effects of marijuana). And, as Weinstein and Worster point out, there is evidence of increased mental health symptoms in chronic marijuana users.

It behooves us to be prepared to discuss the pros and cons of Cannabis use with our patients—even if we decide not to prescribe it.

Regardless of the scientific evidence, use of cannabis for symptom relief is unlikely to be a passing fad. Surveys show that about 70% of users believe they receive benefit from it.⁸ Therefore, it behooves us to be prepared to discuss the pros and cons of cannabis use with our patients—even if we decide not to prescribe it. Warn patients with anxiety and depression that it is unlikely to be effective and may make matters worse.

There is intense interest in medical marijuana and better research will likely change the way we use cannabis for medical purposes in the future. So, for now, our best approach is to stay informed as the research unfolds.

In this issue of JFP, Weinstein and Worster provide a wealth of information about prescribing marijuana. Medical marijuana (Cannabis) is now legal in the majority of states, so it’s likely that some of your patients are using marijuana for symptom relief. For those physicians who elect to prescribe marijuana, reading this review will help you avoid harming patients while maximizing potential benefits.

I say “potential benefits” because the research evidence to support benefit for most conditions and symptoms is weak at best. In addition to the JAMA meta-analysis cited by Weinstein and Worster,¹ several meta-analyses and systematic reviews published since January 2018 reach similar conclusions.^2-4

Marijuana can provide significant relief from chemotherapy-induced nausea and vomiting, and it is effective in reducing intractable seizures in 2 rare pediatric seizure disorders. There may be some benefit for treatment of spasticity, and there may be some therapeutic value for relief of neuropathic pain, although the evidence is not strong. Interestingly, there is some preliminary evidence that cannabis can improve gastrointestinal symptoms in patients with Crohn's disease and ulcerative colitis.^5,6

Why do people use marijuana as medicine? A meta-analysis found that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons.⁷ People use marijuana for a plethora of other conditions and symptoms, which is reflected in the long list of “approved” conditions in most state medical marijuana laws. The problem I have with prescribing cannabis for non-neuropathic pain, anxiety, and depression is that there is no good randomized trial evidence of its effectiveness beyond a placebo effect (which is probably quite strong considering the psychotropic effects of marijuana). And, as Weinstein and Worster point out, there is evidence of increased mental health symptoms in chronic marijuana users.

It behooves us to be prepared to discuss the pros and cons of Cannabis use with our patients—even if we decide not to prescribe it.

Regardless of the scientific evidence, use of cannabis for symptom relief is unlikely to be a passing fad. Surveys show that about 70% of users believe they receive benefit from it.⁸ Therefore, it behooves us to be prepared to discuss the pros and cons of cannabis use with our patients—even if we decide not to prescribe it. Warn patients with anxiety and depression that it is unlikely to be effective and may make matters worse.

There is intense interest in medical marijuana and better research will likely change the way we use cannabis for medical purposes in the future. So, for now, our best approach is to stay informed as the research unfolds.

In this issue of JFP, Weinstein and Worster provide a wealth of information about prescribing marijuana. Medical marijuana (Cannabis) is now legal in the majority of states, so it’s likely that some of your patients are using marijuana for symptom relief. For those physicians who elect to prescribe marijuana, reading this review will help you avoid harming patients while maximizing potential benefits.

I say “potential benefits” because the research evidence to support benefit for most conditions and symptoms is weak at best. In addition to the JAMA meta-analysis cited by Weinstein and Worster,¹ several meta-analyses and systematic reviews published since January 2018 reach similar conclusions.^2-4

Marijuana can provide significant relief from chemotherapy-induced nausea and vomiting, and it is effective in reducing intractable seizures in 2 rare pediatric seizure disorders. There may be some benefit for treatment of spasticity, and there may be some therapeutic value for relief of neuropathic pain, although the evidence is not strong. Interestingly, there is some preliminary evidence that cannabis can improve gastrointestinal symptoms in patients with Crohn's disease and ulcerative colitis.^5,6

Why do people use marijuana as medicine? A meta-analysis found that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons.⁷ People use marijuana for a plethora of other conditions and symptoms, which is reflected in the long list of “approved” conditions in most state medical marijuana laws. The problem I have with prescribing cannabis for non-neuropathic pain, anxiety, and depression is that there is no good randomized trial evidence of its effectiveness beyond a placebo effect (which is probably quite strong considering the psychotropic effects of marijuana). And, as Weinstein and Worster point out, there is evidence of increased mental health symptoms in chronic marijuana users.

It behooves us to be prepared to discuss the pros and cons of Cannabis use with our patients—even if we decide not to prescribe it.

Regardless of the scientific evidence, use of cannabis for symptom relief is unlikely to be a passing fad. Surveys show that about 70% of users believe they receive benefit from it.⁸ Therefore, it behooves us to be prepared to discuss the pros and cons of cannabis use with our patients—even if we decide not to prescribe it. Warn patients with anxiety and depression that it is unlikely to be effective and may make matters worse.

There is intense interest in medical marijuana and better research will likely change the way we use cannabis for medical purposes in the future. So, for now, our best approach is to stay informed as the research unfolds.

When the Joint Commission dubbed pain assessment the “fifth vital sign” in 2001 and insisted that all outpatients be assessed for pain at each office visit, they had no idea of the unintended consequences that would result.

The problem they wanted to solve was undertreatment of postoperative pain, but the problem they helped create far outweighed any benefit to hospitalized patients. They would have been wise to listen to R.E.M.’s song “Everybody Hurts” and recognize that pain is a fact of life that doesn’t always require medical intervention. Combined with aggressive marketing of opioids by pharmaceutical companies, these 2 factors led to the opioid epidemic we currently find ourselves in.

We were part of the problem and must be part of the solution.

The good news is that there has been a significant drop in opioid prescribing in recent years. Between 2014 and 2017, opioid prescriptions declined from 7.4% to 6.4%, based on a national electronic health record review.¹ Reducing opioid prescribing for patients with chronic noncancer pain, however, is difficult. Although there are no truly evidence-based methods, the Centers for Disease Control and Prevention has provided expert advice on improving opioid prescribing, and Drs. Mendoza and Russell provide thoughtful recommendations for tapering opioids in patients on chronic therapy in this issue of JFP.

In addition, Patchett et al describe their experience with a practice-wide approach to reducing chronic opioid prescribing in their practice at Mayo Clinic in Scottsdale, Ariz. Using a systematic approach, they were able to reduce the number of patients on chronic opioid therapy by 22%.

And there is more good news from a 2018 JAMA study.²Patients with moderate to severe chronic back, hip, or knee pain were randomized to either an opioid-based pain treatment regimen or a nonopioid-based plan. While pain-related functional status was similar in both groups after 12 months, the patients in the nonopioid group had significantly better pain control than those in the opioid group. Amazing to find that the nonopioid approach was superior! Who would have guessed?

All family physicians should share the results of this study with their chronic pain patients and follow Pachett’s lead in a practice-wide approach to reducing opioid prescribing. We were part of the problem and must be part of the solution.

When the Joint Commission dubbed pain assessment the “fifth vital sign” in 2001 and insisted that all outpatients be assessed for pain at each office visit, they had no idea of the unintended consequences that would result.

The problem they wanted to solve was undertreatment of postoperative pain, but the problem they helped create far outweighed any benefit to hospitalized patients. They would have been wise to listen to R.E.M.’s song “Everybody Hurts” and recognize that pain is a fact of life that doesn’t always require medical intervention. Combined with aggressive marketing of opioids by pharmaceutical companies, these 2 factors led to the opioid epidemic we currently find ourselves in.

We were part of the problem and must be part of the solution.

The good news is that there has been a significant drop in opioid prescribing in recent years. Between 2014 and 2017, opioid prescriptions declined from 7.4% to 6.4%, based on a national electronic health record review.¹ Reducing opioid prescribing for patients with chronic noncancer pain, however, is difficult. Although there are no truly evidence-based methods, the Centers for Disease Control and Prevention has provided expert advice on improving opioid prescribing, and Drs. Mendoza and Russell provide thoughtful recommendations for tapering opioids in patients on chronic therapy in this issue of JFP.

In addition, Patchett et al describe their experience with a practice-wide approach to reducing chronic opioid prescribing in their practice at Mayo Clinic in Scottsdale, Ariz. Using a systematic approach, they were able to reduce the number of patients on chronic opioid therapy by 22%.

And there is more good news from a 2018 JAMA study.²Patients with moderate to severe chronic back, hip, or knee pain were randomized to either an opioid-based pain treatment regimen or a nonopioid-based plan. While pain-related functional status was similar in both groups after 12 months, the patients in the nonopioid group had significantly better pain control than those in the opioid group. Amazing to find that the nonopioid approach was superior! Who would have guessed?

All family physicians should share the results of this study with their chronic pain patients and follow Pachett’s lead in a practice-wide approach to reducing opioid prescribing. We were part of the problem and must be part of the solution.

When the Joint Commission dubbed pain assessment the “fifth vital sign” in 2001 and insisted that all outpatients be assessed for pain at each office visit, they had no idea of the unintended consequences that would result.

The problem they wanted to solve was undertreatment of postoperative pain, but the problem they helped create far outweighed any benefit to hospitalized patients. They would have been wise to listen to R.E.M.’s song “Everybody Hurts” and recognize that pain is a fact of life that doesn’t always require medical intervention. Combined with aggressive marketing of opioids by pharmaceutical companies, these 2 factors led to the opioid epidemic we currently find ourselves in.

We were part of the problem and must be part of the solution.

The good news is that there has been a significant drop in opioid prescribing in recent years. Between 2014 and 2017, opioid prescriptions declined from 7.4% to 6.4%, based on a national electronic health record review.¹ Reducing opioid prescribing for patients with chronic noncancer pain, however, is difficult. Although there are no truly evidence-based methods, the Centers for Disease Control and Prevention has provided expert advice on improving opioid prescribing, and Drs. Mendoza and Russell provide thoughtful recommendations for tapering opioids in patients on chronic therapy in this issue of JFP.

In addition, Patchett et al describe their experience with a practice-wide approach to reducing chronic opioid prescribing in their practice at Mayo Clinic in Scottsdale, Ariz. Using a systematic approach, they were able to reduce the number of patients on chronic opioid therapy by 22%.

And there is more good news from a 2018 JAMA study.²Patients with moderate to severe chronic back, hip, or knee pain were randomized to either an opioid-based pain treatment regimen or a nonopioid-based plan. While pain-related functional status was similar in both groups after 12 months, the patients in the nonopioid group had significantly better pain control than those in the opioid group. Amazing to find that the nonopioid approach was superior! Who would have guessed?

All family physicians should share the results of this study with their chronic pain patients and follow Pachett’s lead in a practice-wide approach to reducing opioid prescribing. We were part of the problem and must be part of the solution.

In this issue of JFP, Rajesh and colleagues present a scholarly review that details why it makes sense to integrate behavioral health into primary care. There is strong evidence that the presence of behavioral health care managers in primary care practices improves outcomes for patients with anxiety and depression. The mental health–trained care manager serves as a link between the primary care physician and mental health professional and can provide psychotherapy, as well.

A more integrated model, however, includes a full range of behavioral health services on site. Although not as well studied, co-location is a powerful pairing of physical and mental health treatment. Primary care physicians benefit because referral and feedback are immediate and seamless through warm hand-offs and easy access to medical and mental health notes in a common medical record. Patients benefit because they are more likely to engage with treatment when the physician introduces them to the mental health professional and expresses confidence in his or her abilities.

Patients are more likely to engage with treatment when the physician introduces them to the mental health professional and expresses confidence in his or her abilities.

We know that trust improves treatment outcomes. What better way to encourage trust than with a warm smile and handshake when a patient is most vulnerable? In addition, integrating behavioral health into primary care helps patients avoid the stigma of going to a “mental health clinic.”

Integrating medical and mental health professionals into one practice is hardly a new idea and is spreading quickly in some parts of the country. It is perhaps no coincidence that Rajesh refers to a study of behavioral health integration in Colorado family practice offices. Recently, I (JH) presented a CME program to family physicians in Colorado, and, after reviewing recent studies of anxiety and depression, I asked how many participants had mental health professionals working in their practices. A full third raised their hands.

I (JH) had an excellent psychologist in my practice as far back as 1980, and he was an integral member of the care team. It seems that behavioral health integration has been a long time coming, and as a health care community we would be wise to spread this model of whole-person care to all primary care practices.

In this issue of JFP, Rajesh and colleagues present a scholarly review that details why it makes sense to integrate behavioral health into primary care. There is strong evidence that the presence of behavioral health care managers in primary care practices improves outcomes for patients with anxiety and depression. The mental health–trained care manager serves as a link between the primary care physician and mental health professional and can provide psychotherapy, as well.

A more integrated model, however, includes a full range of behavioral health services on site. Although not as well studied, co-location is a powerful pairing of physical and mental health treatment. Primary care physicians benefit because referral and feedback are immediate and seamless through warm hand-offs and easy access to medical and mental health notes in a common medical record. Patients benefit because they are more likely to engage with treatment when the physician introduces them to the mental health professional and expresses confidence in his or her abilities.

Patients are more likely to engage with treatment when the physician introduces them to the mental health professional and expresses confidence in his or her abilities.

We know that trust improves treatment outcomes. What better way to encourage trust than with a warm smile and handshake when a patient is most vulnerable? In addition, integrating behavioral health into primary care helps patients avoid the stigma of going to a “mental health clinic.”

Integrating medical and mental health professionals into one practice is hardly a new idea and is spreading quickly in some parts of the country. It is perhaps no coincidence that Rajesh refers to a study of behavioral health integration in Colorado family practice offices. Recently, I (JH) presented a CME program to family physicians in Colorado, and, after reviewing recent studies of anxiety and depression, I asked how many participants had mental health professionals working in their practices. A full third raised their hands.

I (JH) had an excellent psychologist in my practice as far back as 1980, and he was an integral member of the care team. It seems that behavioral health integration has been a long time coming, and as a health care community we would be wise to spread this model of whole-person care to all primary care practices.

In this issue of JFP, Rajesh and colleagues present a scholarly review that details why it makes sense to integrate behavioral health into primary care. There is strong evidence that the presence of behavioral health care managers in primary care practices improves outcomes for patients with anxiety and depression. The mental health–trained care manager serves as a link between the primary care physician and mental health professional and can provide psychotherapy, as well.

A more integrated model, however, includes a full range of behavioral health services on site. Although not as well studied, co-location is a powerful pairing of physical and mental health treatment. Primary care physicians benefit because referral and feedback are immediate and seamless through warm hand-offs and easy access to medical and mental health notes in a common medical record. Patients benefit because they are more likely to engage with treatment when the physician introduces them to the mental health professional and expresses confidence in his or her abilities.

Patients are more likely to engage with treatment when the physician introduces them to the mental health professional and expresses confidence in his or her abilities.

We know that trust improves treatment outcomes. What better way to encourage trust than with a warm smile and handshake when a patient is most vulnerable? In addition, integrating behavioral health into primary care helps patients avoid the stigma of going to a “mental health clinic.”

Integrating medical and mental health professionals into one practice is hardly a new idea and is spreading quickly in some parts of the country. It is perhaps no coincidence that Rajesh refers to a study of behavioral health integration in Colorado family practice offices. Recently, I (JH) presented a CME program to family physicians in Colorado, and, after reviewing recent studies of anxiety and depression, I asked how many participants had mental health professionals working in their practices. A full third raised their hands.

I (JH) had an excellent psychologist in my practice as far back as 1980, and he was an integral member of the care team. It seems that behavioral health integration has been a long time coming, and as a health care community we would be wise to spread this model of whole-person care to all primary care practices.

Just like the 2018 hypertension treatment guidelines, the 2018 Guidelines on the Management of Blood Cholesterol developed by the American College of Cardiology and the American Heart Association (ACC/AHA) have made treatment decisions much more complicated. In this issue of JFP, Wójcik and Shapiro summarize the 70-page document to help family physicians and other primary health care professionals use these complex guidelines in everyday practice.

The good news is that not much has changed from the 2013 ACC/AHA cholesterol guidelines regarding the treatment of patients with established cardiovascular disease and diabetes mellitus, and those with familial hyperlipidemia—the groups at highest risk for major cardiovascular events. Most of these patients should be treated aggressively, and a target low-density lipoprotein of 70 mg/dL is recommended.

I find the recommendations for adults ages 75 and older and for children and teens to be problematic.

The new guidelines recommend using ezetimibe or a PCSK9 inhibitor if the goal of 70 mg/dL cannot be achieved with a statin alone. There is randomized trial evidence to support the benefit of this aggressive approach. Generic ezetimibe costs about $20 per month,¹ but the PCSK9 inhibitors are about $500 per month,^2,3 so cost may be a treatment barrier for the 2 monoclonal antibodies approved for cardiovascular prevention: evolocumab and alirocumab.

For primary prevention, the new guidelines are much more complicated. They divide cardiovascular risk into 4 tiers depending on the 10-year risk for atherosclerotic cardiovascular disease calculated using the “pooled cohort equation.” Treatment recommendations are more aggressive for those at higher risk. Although it intuitively makes sense to treat those at higher risk more aggressively, there is no clinical trial evidence to support this approach’s superiority over the simpler approach recommended in the 2013 guidelines.

I find the recommendations for screening and primary prevention in adults ages 75 and older and for children and teens to be problematic. A meta-analysis of 28 studies found no statin treatment benefit for primary prevention in those older than 70.⁴ And there are no randomized trials showing benefit of screening and treating children and teens for hyperlipidemia.

On a positive note, most patients do not need to fast prior to having their lipids measured.

Read the 2018 cholesterol treatment guideline summary in this issue of JFP. But as you do so, remember that guidelines are guidelines; they are not mandates for treatment. You may need to customize these guidelines for your practice and your patients. In my opinion, the simpler 2013 cholesterol guidelines remain good guidelines.

Just like the 2018 hypertension treatment guidelines, the 2018 Guidelines on the Management of Blood Cholesterol developed by the American College of Cardiology and the American Heart Association (ACC/AHA) have made treatment decisions much more complicated. In this issue of JFP, Wójcik and Shapiro summarize the 70-page document to help family physicians and other primary health care professionals use these complex guidelines in everyday practice.

The good news is that not much has changed from the 2013 ACC/AHA cholesterol guidelines regarding the treatment of patients with established cardiovascular disease and diabetes mellitus, and those with familial hyperlipidemia—the groups at highest risk for major cardiovascular events. Most of these patients should be treated aggressively, and a target low-density lipoprotein of 70 mg/dL is recommended.

I find the recommendations for adults ages 75 and older and for children and teens to be problematic.

The new guidelines recommend using ezetimibe or a PCSK9 inhibitor if the goal of 70 mg/dL cannot be achieved with a statin alone. There is randomized trial evidence to support the benefit of this aggressive approach. Generic ezetimibe costs about $20 per month,¹ but the PCSK9 inhibitors are about $500 per month,^2,3 so cost may be a treatment barrier for the 2 monoclonal antibodies approved for cardiovascular prevention: evolocumab and alirocumab.

For primary prevention, the new guidelines are much more complicated. They divide cardiovascular risk into 4 tiers depending on the 10-year risk for atherosclerotic cardiovascular disease calculated using the “pooled cohort equation.” Treatment recommendations are more aggressive for those at higher risk. Although it intuitively makes sense to treat those at higher risk more aggressively, there is no clinical trial evidence to support this approach’s superiority over the simpler approach recommended in the 2013 guidelines.

I find the recommendations for screening and primary prevention in adults ages 75 and older and for children and teens to be problematic. A meta-analysis of 28 studies found no statin treatment benefit for primary prevention in those older than 70.⁴ And there are no randomized trials showing benefit of screening and treating children and teens for hyperlipidemia.

On a positive note, most patients do not need to fast prior to having their lipids measured.

Read the 2018 cholesterol treatment guideline summary in this issue of JFP. But as you do so, remember that guidelines are guidelines; they are not mandates for treatment. You may need to customize these guidelines for your practice and your patients. In my opinion, the simpler 2013 cholesterol guidelines remain good guidelines.

Just like the 2018 hypertension treatment guidelines, the 2018 Guidelines on the Management of Blood Cholesterol developed by the American College of Cardiology and the American Heart Association (ACC/AHA) have made treatment decisions much more complicated. In this issue of JFP, Wójcik and Shapiro summarize the 70-page document to help family physicians and other primary health care professionals use these complex guidelines in everyday practice.

The good news is that not much has changed from the 2013 ACC/AHA cholesterol guidelines regarding the treatment of patients with established cardiovascular disease and diabetes mellitus, and those with familial hyperlipidemia—the groups at highest risk for major cardiovascular events. Most of these patients should be treated aggressively, and a target low-density lipoprotein of 70 mg/dL is recommended.

I find the recommendations for adults ages 75 and older and for children and teens to be problematic.

The new guidelines recommend using ezetimibe or a PCSK9 inhibitor if the goal of 70 mg/dL cannot be achieved with a statin alone. There is randomized trial evidence to support the benefit of this aggressive approach. Generic ezetimibe costs about $20 per month,¹ but the PCSK9 inhibitors are about $500 per month,^2,3 so cost may be a treatment barrier for the 2 monoclonal antibodies approved for cardiovascular prevention: evolocumab and alirocumab.

For primary prevention, the new guidelines are much more complicated. They divide cardiovascular risk into 4 tiers depending on the 10-year risk for atherosclerotic cardiovascular disease calculated using the “pooled cohort equation.” Treatment recommendations are more aggressive for those at higher risk. Although it intuitively makes sense to treat those at higher risk more aggressively, there is no clinical trial evidence to support this approach’s superiority over the simpler approach recommended in the 2013 guidelines.

I find the recommendations for screening and primary prevention in adults ages 75 and older and for children and teens to be problematic. A meta-analysis of 28 studies found no statin treatment benefit for primary prevention in those older than 70.⁴ And there are no randomized trials showing benefit of screening and treating children and teens for hyperlipidemia.

On a positive note, most patients do not need to fast prior to having their lipids measured.

Read the 2018 cholesterol treatment guideline summary in this issue of JFP. But as you do so, remember that guidelines are guidelines; they are not mandates for treatment. You may need to customize these guidelines for your practice and your patients. In my opinion, the simpler 2013 cholesterol guidelines remain good guidelines.

Acetylsalicylic acid has been around for nearly 200 years. It traces its history back to a French chemist (Charles Frederic Gerhardt) and 2 German chemists (Felix Hoffmann and Arthur Eichengrün) who worked at Bayer, the company that launched the pain reliever under the name “aspirin” in 1899. It is now one of the most commonly used medications in the world.

No wonder our patients are confused!

With aspirin's anti-inflammatory properties in mind, researchers conducted randomized trials for secondary prevention of heart attacks in the 1970s; low-dose aspirin was proven effective in reducing risk for a second myocardial infarction. These trials led to speculation that aspirin might be effective for primary prevention as well. Indeed, in the 1980s the large Physicians' Health Study found aspirin reduced the incidence of first heart attack in healthy physicians by 44%.¹ Unfortunately, there was no reduction in mortality from heart disease and it was only effective for those older than 50.

The downside of aspirin was a slight increase in the incidence of hemorrhagic stroke and bleeding requiring transfusion. Nonetheless, many healthy adults started taking daily aspirin hoping to prevent a heart attack.

In this issue of JFP, Smith and colleagues summarize the 2016 recommendations of the US Preventive Services Task Force (USPSTF) regarding aspirin for primary prevention, as well as the 4 large aspirin prevention trials published in 2018 subsequent to the USPSTF recommendations. The USPSTF recommended aspirin for adults ages 50 to 59 with a 10-year cardiovascular risk of at least 10% (B recommendation). For those ages 60-69, the USPSTF recommendation for aspirin as primary prevention has a “C” rating, meaning that patient preference is important to consider in balancing benefit and harms. For those 70 and older, the USPSTF gave aspirin an “I” (insufficient evidence) rating because of increased risk for bleeding. It is important to note that the positive B recommendation for those ages 50-59 is based not only on cardiovascular risk reduction but also on a slight risk reduction for colon cancer for those taking aspirin for at least 10 years.

The 4 new, large randomized trials published in 2018, however, cast doubt on the USPSTF recommendations because the results of these trials were negative for the most part. The bottom line is that daily aspirin for prevention is definitely not for everyone and perhaps not for anyone except those who have established vascular disease or are at high risk for vascular disease and low risk for bleeding.

No wonder patients are confused!
Smith recommends that, before prescribing aspirin to healthy adults for prevention, we assess each individual’s personal cardiovascular and bleeding risk using an online decision tool called Aspirin-Guide (www.aspiringuide.com). I agree.

Acetylsalicylic acid has been around for nearly 200 years. It traces its history back to a French chemist (Charles Frederic Gerhardt) and 2 German chemists (Felix Hoffmann and Arthur Eichengrün) who worked at Bayer, the company that launched the pain reliever under the name “aspirin” in 1899. It is now one of the most commonly used medications in the world.

No wonder our patients are confused!

With aspirin's anti-inflammatory properties in mind, researchers conducted randomized trials for secondary prevention of heart attacks in the 1970s; low-dose aspirin was proven effective in reducing risk for a second myocardial infarction. These trials led to speculation that aspirin might be effective for primary prevention as well. Indeed, in the 1980s the large Physicians' Health Study found aspirin reduced the incidence of first heart attack in healthy physicians by 44%.¹ Unfortunately, there was no reduction in mortality from heart disease and it was only effective for those older than 50.

The downside of aspirin was a slight increase in the incidence of hemorrhagic stroke and bleeding requiring transfusion. Nonetheless, many healthy adults started taking daily aspirin hoping to prevent a heart attack.

In this issue of JFP, Smith and colleagues summarize the 2016 recommendations of the US Preventive Services Task Force (USPSTF) regarding aspirin for primary prevention, as well as the 4 large aspirin prevention trials published in 2018 subsequent to the USPSTF recommendations. The USPSTF recommended aspirin for adults ages 50 to 59 with a 10-year cardiovascular risk of at least 10% (B recommendation). For those ages 60-69, the USPSTF recommendation for aspirin as primary prevention has a “C” rating, meaning that patient preference is important to consider in balancing benefit and harms. For those 70 and older, the USPSTF gave aspirin an “I” (insufficient evidence) rating because of increased risk for bleeding. It is important to note that the positive B recommendation for those ages 50-59 is based not only on cardiovascular risk reduction but also on a slight risk reduction for colon cancer for those taking aspirin for at least 10 years.

The 4 new, large randomized trials published in 2018, however, cast doubt on the USPSTF recommendations because the results of these trials were negative for the most part. The bottom line is that daily aspirin for prevention is definitely not for everyone and perhaps not for anyone except those who have established vascular disease or are at high risk for vascular disease and low risk for bleeding.

No wonder patients are confused!
Smith recommends that, before prescribing aspirin to healthy adults for prevention, we assess each individual’s personal cardiovascular and bleeding risk using an online decision tool called Aspirin-Guide (www.aspiringuide.com). I agree.

Acetylsalicylic acid has been around for nearly 200 years. It traces its history back to a French chemist (Charles Frederic Gerhardt) and 2 German chemists (Felix Hoffmann and Arthur Eichengrün) who worked at Bayer, the company that launched the pain reliever under the name “aspirin” in 1899. It is now one of the most commonly used medications in the world.

No wonder our patients are confused!

With aspirin's anti-inflammatory properties in mind, researchers conducted randomized trials for secondary prevention of heart attacks in the 1970s; low-dose aspirin was proven effective in reducing risk for a second myocardial infarction. These trials led to speculation that aspirin might be effective for primary prevention as well. Indeed, in the 1980s the large Physicians' Health Study found aspirin reduced the incidence of first heart attack in healthy physicians by 44%.¹ Unfortunately, there was no reduction in mortality from heart disease and it was only effective for those older than 50.

The downside of aspirin was a slight increase in the incidence of hemorrhagic stroke and bleeding requiring transfusion. Nonetheless, many healthy adults started taking daily aspirin hoping to prevent a heart attack.

In this issue of JFP, Smith and colleagues summarize the 2016 recommendations of the US Preventive Services Task Force (USPSTF) regarding aspirin for primary prevention, as well as the 4 large aspirin prevention trials published in 2018 subsequent to the USPSTF recommendations. The USPSTF recommended aspirin for adults ages 50 to 59 with a 10-year cardiovascular risk of at least 10% (B recommendation). For those ages 60-69, the USPSTF recommendation for aspirin as primary prevention has a “C” rating, meaning that patient preference is important to consider in balancing benefit and harms. For those 70 and older, the USPSTF gave aspirin an “I” (insufficient evidence) rating because of increased risk for bleeding. It is important to note that the positive B recommendation for those ages 50-59 is based not only on cardiovascular risk reduction but also on a slight risk reduction for colon cancer for those taking aspirin for at least 10 years.

The 4 new, large randomized trials published in 2018, however, cast doubt on the USPSTF recommendations because the results of these trials were negative for the most part. The bottom line is that daily aspirin for prevention is definitely not for everyone and perhaps not for anyone except those who have established vascular disease or are at high risk for vascular disease and low risk for bleeding.

No wonder patients are confused!
Smith recommends that, before prescribing aspirin to healthy adults for prevention, we assess each individual’s personal cardiovascular and bleeding risk using an online decision tool called Aspirin-Guide (www.aspiringuide.com). I agree.

Even the best physicians make mistakes.

Each of us can recall a patient for whom our initial diagnosis was incorrect, or conversely, where we uncovered the correct diagnosis. My memorable mistake was missing an obvious case of hypothyroidism, and my happier encounter was correcting an incorrect diagnosis of asthma when the patient actually had primary pulmonary fibrosis. These patients came to mind as I read this month’s cover story, “COPD and asthma: Diagnostic accuracy requires spirometry.”

In a previous editorial, “When our biases derail the diagnosis,”¹ I discussed types of cognitive bias that can lead us to the wrong conclusion. Today, I want to address diagnostic errors in medicine as a patient safety issue.

Listening closely to the patient's and family's concerns can lead in a direction other than my initial impression.

The patient safety movement gained traction in 1999 with the publication of the Institute of Medicine (IOM, now National Academy of Medicine) report, To Err is Human: Building a Safer Health System. That report focused on health care system issues and had little to offer regarding improving diagnoses. It was not until 2015, with the publication of the IOM report Improving Diagnosis in Health Care, that serious national attention was directed to accurate diagnosis. It is worth reading the summary of this report, which includes 8 goals and is available at nas.edu/improvingdiagnosis.

The recommendations most pertinent to family physicians are to: 1) facilitate more effective teamwork among health care professionals, patients, and families, 2) teach health care professionals about the diagnostic process, 3) ensure that technology supports proper diagnosis, 4) establish a work culture that supports diagnostic processes, and 5) identify diagnostic errors and learn from them.

Teamwork. The first recommendation is intriguing because the focus on teamwork includes patients and their families. I have found that listening closely to the patient’s and family’s concerns can lead me in a direction other than my initial impression—especially when they are insistent about a particular diagnosis.

Technology. Despite all of their “warts,” electronic health records are gradually incorporating clinical decision support tools that really do help steer us in the right direction. I have found that electronic point-of-care references can be very helpful in establishing an accurate diagnosis in the exam room—and can help convince patients that my diagnosis is correct when they read it for themselves!

Continue to: Finally, discussing our mistakes...

Finally, discussing our mistakes openly with our colleagues helps us—and them—to avoid that mistake in the future. Let’s be sure to keep that dialogue open. And let’s continue to refine our diagnostic skills so that we can continue to keep our patients safe.

Even the best physicians make mistakes.

Each of us can recall a patient for whom our initial diagnosis was incorrect, or conversely, where we uncovered the correct diagnosis. My memorable mistake was missing an obvious case of hypothyroidism, and my happier encounter was correcting an incorrect diagnosis of asthma when the patient actually had primary pulmonary fibrosis. These patients came to mind as I read this month’s cover story, “COPD and asthma: Diagnostic accuracy requires spirometry.”

In a previous editorial, “When our biases derail the diagnosis,”¹ I discussed types of cognitive bias that can lead us to the wrong conclusion. Today, I want to address diagnostic errors in medicine as a patient safety issue.

Listening closely to the patient's and family's concerns can lead in a direction other than my initial impression.

The patient safety movement gained traction in 1999 with the publication of the Institute of Medicine (IOM, now National Academy of Medicine) report, To Err is Human: Building a Safer Health System. That report focused on health care system issues and had little to offer regarding improving diagnoses. It was not until 2015, with the publication of the IOM report Improving Diagnosis in Health Care, that serious national attention was directed to accurate diagnosis. It is worth reading the summary of this report, which includes 8 goals and is available at nas.edu/improvingdiagnosis.

The recommendations most pertinent to family physicians are to: 1) facilitate more effective teamwork among health care professionals, patients, and families, 2) teach health care professionals about the diagnostic process, 3) ensure that technology supports proper diagnosis, 4) establish a work culture that supports diagnostic processes, and 5) identify diagnostic errors and learn from them.

Teamwork. The first recommendation is intriguing because the focus on teamwork includes patients and their families. I have found that listening closely to the patient’s and family’s concerns can lead me in a direction other than my initial impression—especially when they are insistent about a particular diagnosis.

Technology. Despite all of their “warts,” electronic health records are gradually incorporating clinical decision support tools that really do help steer us in the right direction. I have found that electronic point-of-care references can be very helpful in establishing an accurate diagnosis in the exam room—and can help convince patients that my diagnosis is correct when they read it for themselves!

Continue to: Finally, discussing our mistakes...

Finally, discussing our mistakes openly with our colleagues helps us—and them—to avoid that mistake in the future. Let’s be sure to keep that dialogue open. And let’s continue to refine our diagnostic skills so that we can continue to keep our patients safe.

Even the best physicians make mistakes.

Each of us can recall a patient for whom our initial diagnosis was incorrect, or conversely, where we uncovered the correct diagnosis. My memorable mistake was missing an obvious case of hypothyroidism, and my happier encounter was correcting an incorrect diagnosis of asthma when the patient actually had primary pulmonary fibrosis. These patients came to mind as I read this month’s cover story, “COPD and asthma: Diagnostic accuracy requires spirometry.”

In a previous editorial, “When our biases derail the diagnosis,”¹ I discussed types of cognitive bias that can lead us to the wrong conclusion. Today, I want to address diagnostic errors in medicine as a patient safety issue.

Listening closely to the patient's and family's concerns can lead in a direction other than my initial impression.

The patient safety movement gained traction in 1999 with the publication of the Institute of Medicine (IOM, now National Academy of Medicine) report, To Err is Human: Building a Safer Health System. That report focused on health care system issues and had little to offer regarding improving diagnoses. It was not until 2015, with the publication of the IOM report Improving Diagnosis in Health Care, that serious national attention was directed to accurate diagnosis. It is worth reading the summary of this report, which includes 8 goals and is available at nas.edu/improvingdiagnosis.

The recommendations most pertinent to family physicians are to: 1) facilitate more effective teamwork among health care professionals, patients, and families, 2) teach health care professionals about the diagnostic process, 3) ensure that technology supports proper diagnosis, 4) establish a work culture that supports diagnostic processes, and 5) identify diagnostic errors and learn from them.

Teamwork. The first recommendation is intriguing because the focus on teamwork includes patients and their families. I have found that listening closely to the patient’s and family’s concerns can lead me in a direction other than my initial impression—especially when they are insistent about a particular diagnosis.

Technology. Despite all of their “warts,” electronic health records are gradually incorporating clinical decision support tools that really do help steer us in the right direction. I have found that electronic point-of-care references can be very helpful in establishing an accurate diagnosis in the exam room—and can help convince patients that my diagnosis is correct when they read it for themselves!

Continue to: Finally, discussing our mistakes...

Finally, discussing our mistakes openly with our colleagues helps us—and them—to avoid that mistake in the future. Let’s be sure to keep that dialogue open. And let’s continue to refine our diagnostic skills so that we can continue to keep our patients safe.