John Hickner, MD, MSc

When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.

That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.

We need to ask our young patients a single question: "Are you being bullied?"The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.¹ Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.^2,3

What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.

Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.

When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.

That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.

We need to ask our young patients a single question: "Are you being bullied?"The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.¹ Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.^2,3

What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.

Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.

When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.

That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.

We need to ask our young patients a single question: "Are you being bullied?"The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.¹ Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.^2,3

What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.

Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.

In this issue of JFP, Wiskirchen and colleagues discuss the appropriate use of antibiotics in outpatient settings, providing stewardship advice for several conditions we frequently see in primary care practice.

One of the symptoms for which we most frequently battle requests for antibiotics is acute cough. Despite the fact that more than 90% of cases of acute cough illness (aka acute bronchitis) are caused by viruses, the prescribing rate for it in the United States remains about 70%.¹

Over the years, I’ve honed a “spiel” that I use with patients with acute cough illness to help keep my antibiotic prescribing to a minimum. It must be working; my prescribing rate is less than 20%. What follows are some of my catch phrases and techniques.

1. Acknowledge the patient’s misery. “Sounds like you have a really bad bug."

Patients may be less likely to ask for an antibiotic if you refer to acute bronchitis as a "chest cold."

2. Tell the patient what he or she doesn’t have. “Your lungs sound good, and your throat does not look too bad, so that means you don’t have strep throat or pneumonia. That’s good news.”

3. Explain what viruses are “making the rounds.” If you have surveillance data, that’s even better. “I have seen several other patients with symptoms just like yours this week.” Over 25 years ago, Jon Temte, an FP from Wisconsin, drove down prescribing rates for acute bronchitis below 20% in family medicine residencies by providing feedback to physicians and patients about the viruses circulating in their communities.²

4. Set realistic expectations. Tell patients how long their cough is likely to last. The duration of the typical cough is (unfortunately) about 17 days.³ Most patients (and even some doctors) think a bad cold should be gone in 7 days.³

5. Choose your terms carefully. Don’t use the term “acute bronchitis.” It sounds bad and worthy of an antibiotic. “Chest cold” sounds much more benign; patients are less likely to think they need an antibiotic for a chest cold.⁴

6. When all else fails, consider a delayed prescription. I reserve this strategy for patients who are insistent on getting an antibiotic even though their illness is clearly viral. Randomized trials of the delayed strategy show that fewer than 50% of patients actually fill the prescription.⁵

Develop your own spiel to reduce unnecessary antibiotic prescribing. You’ll find that it works a good deal of the time.

In this issue of JFP, Wiskirchen and colleagues discuss the appropriate use of antibiotics in outpatient settings, providing stewardship advice for several conditions we frequently see in primary care practice.

One of the symptoms for which we most frequently battle requests for antibiotics is acute cough. Despite the fact that more than 90% of cases of acute cough illness (aka acute bronchitis) are caused by viruses, the prescribing rate for it in the United States remains about 70%.¹

Over the years, I’ve honed a “spiel” that I use with patients with acute cough illness to help keep my antibiotic prescribing to a minimum. It must be working; my prescribing rate is less than 20%. What follows are some of my catch phrases and techniques.

1. Acknowledge the patient’s misery. “Sounds like you have a really bad bug."

Patients may be less likely to ask for an antibiotic if you refer to acute bronchitis as a "chest cold."

2. Tell the patient what he or she doesn’t have. “Your lungs sound good, and your throat does not look too bad, so that means you don’t have strep throat or pneumonia. That’s good news.”

3. Explain what viruses are “making the rounds.” If you have surveillance data, that’s even better. “I have seen several other patients with symptoms just like yours this week.” Over 25 years ago, Jon Temte, an FP from Wisconsin, drove down prescribing rates for acute bronchitis below 20% in family medicine residencies by providing feedback to physicians and patients about the viruses circulating in their communities.²

4. Set realistic expectations. Tell patients how long their cough is likely to last. The duration of the typical cough is (unfortunately) about 17 days.³ Most patients (and even some doctors) think a bad cold should be gone in 7 days.³

5. Choose your terms carefully. Don’t use the term “acute bronchitis.” It sounds bad and worthy of an antibiotic. “Chest cold” sounds much more benign; patients are less likely to think they need an antibiotic for a chest cold.⁴

6. When all else fails, consider a delayed prescription. I reserve this strategy for patients who are insistent on getting an antibiotic even though their illness is clearly viral. Randomized trials of the delayed strategy show that fewer than 50% of patients actually fill the prescription.⁵

Develop your own spiel to reduce unnecessary antibiotic prescribing. You’ll find that it works a good deal of the time.

In this issue of JFP, Wiskirchen and colleagues discuss the appropriate use of antibiotics in outpatient settings, providing stewardship advice for several conditions we frequently see in primary care practice.

One of the symptoms for which we most frequently battle requests for antibiotics is acute cough. Despite the fact that more than 90% of cases of acute cough illness (aka acute bronchitis) are caused by viruses, the prescribing rate for it in the United States remains about 70%.¹

Over the years, I’ve honed a “spiel” that I use with patients with acute cough illness to help keep my antibiotic prescribing to a minimum. It must be working; my prescribing rate is less than 20%. What follows are some of my catch phrases and techniques.

1. Acknowledge the patient’s misery. “Sounds like you have a really bad bug."

Patients may be less likely to ask for an antibiotic if you refer to acute bronchitis as a "chest cold."

2. Tell the patient what he or she doesn’t have. “Your lungs sound good, and your throat does not look too bad, so that means you don’t have strep throat or pneumonia. That’s good news.”

3. Explain what viruses are “making the rounds.” If you have surveillance data, that’s even better. “I have seen several other patients with symptoms just like yours this week.” Over 25 years ago, Jon Temte, an FP from Wisconsin, drove down prescribing rates for acute bronchitis below 20% in family medicine residencies by providing feedback to physicians and patients about the viruses circulating in their communities.²

4. Set realistic expectations. Tell patients how long their cough is likely to last. The duration of the typical cough is (unfortunately) about 17 days.³ Most patients (and even some doctors) think a bad cold should be gone in 7 days.³

5. Choose your terms carefully. Don’t use the term “acute bronchitis.” It sounds bad and worthy of an antibiotic. “Chest cold” sounds much more benign; patients are less likely to think they need an antibiotic for a chest cold.⁴

6. When all else fails, consider a delayed prescription. I reserve this strategy for patients who are insistent on getting an antibiotic even though their illness is clearly viral. Randomized trials of the delayed strategy show that fewer than 50% of patients actually fill the prescription.⁵

Develop your own spiel to reduce unnecessary antibiotic prescribing. You’ll find that it works a good deal of the time.

One of my brothers has adult onset bipolar disorder. As luck would have it, he also has type 2 diabetes mellitus. He struggles constantly with blood sugar control since he needs to take 2 psychotropic medications, both of which cause weight gain.

I mistakenly told a patient that her beta-blocker wasn't interfering with her weight loss.His situation has prompted me to think about the responsibility we have as we care, and advocate, for our patients with major mental illness who require these effective medications. At a minimum, we must be knowledgeable about the adverse metabolic effects of these drugs, avoid prescribing them when possible, and advocate for dose reductions when feasible. Knowing, for example, that these drugs fall on a spectrum, with haloperidol causing the least weight gain and olanzapine causing the most, is important.¹

An eye-opener. The article by Saunders in this issue provides advice on avoiding medications that commonly cause weight gain when prescribing for overweight or obese patients with diabetes, hypertension, and/or depression. I was unaware that some of the drugs on the list contribute to the problem. For example, I saw a new patient last week who has hypertension and is obese; she has been taking the beta-blocker metoprolol for the past 8 years. She has tried unsuccessfully to lose weight. She asked me if the metoprolol could be interfering with weight loss, and I mistakenly told her “No.” Thankfully, we decided to discontinue it anyway. I will admit to her my knowledge gap when I see her next month for follow-up. Errors are great teachers, especially when no harm is done.

The scope of the Saunders article is not meant to be comprehensive, since it focuses on medications for diabetes, hypertension, and depression. I think all of us are aware of the weight gain associated with other commonly prescribed drugs, such as systemic corticosteroids and long-acting progesterone for contraception. Thankfully, combination oral contraceptives do not appear to be associated with weight gain²—answering one of the more common questions I receive from patients about weight and medications.

The bottom line. Avoid prescribing medications that can cause weight gain in overweight and obese patients when possible, use the lowest effective dose when such agents are necessary, and warn patients of this adverse effect so that they can take precautions, such as walking an extra mile a day or giving up that high-calorie latte in the morning.

1. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382:951-962.

2. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;CD003987.

One of my brothers has adult onset bipolar disorder. As luck would have it, he also has type 2 diabetes mellitus. He struggles constantly with blood sugar control since he needs to take 2 psychotropic medications, both of which cause weight gain.

I mistakenly told a patient that her beta-blocker wasn't interfering with her weight loss.His situation has prompted me to think about the responsibility we have as we care, and advocate, for our patients with major mental illness who require these effective medications. At a minimum, we must be knowledgeable about the adverse metabolic effects of these drugs, avoid prescribing them when possible, and advocate for dose reductions when feasible. Knowing, for example, that these drugs fall on a spectrum, with haloperidol causing the least weight gain and olanzapine causing the most, is important.¹

An eye-opener. The article by Saunders in this issue provides advice on avoiding medications that commonly cause weight gain when prescribing for overweight or obese patients with diabetes, hypertension, and/or depression. I was unaware that some of the drugs on the list contribute to the problem. For example, I saw a new patient last week who has hypertension and is obese; she has been taking the beta-blocker metoprolol for the past 8 years. She has tried unsuccessfully to lose weight. She asked me if the metoprolol could be interfering with weight loss, and I mistakenly told her “No.” Thankfully, we decided to discontinue it anyway. I will admit to her my knowledge gap when I see her next month for follow-up. Errors are great teachers, especially when no harm is done.

The scope of the Saunders article is not meant to be comprehensive, since it focuses on medications for diabetes, hypertension, and depression. I think all of us are aware of the weight gain associated with other commonly prescribed drugs, such as systemic corticosteroids and long-acting progesterone for contraception. Thankfully, combination oral contraceptives do not appear to be associated with weight gain²—answering one of the more common questions I receive from patients about weight and medications.

The bottom line. Avoid prescribing medications that can cause weight gain in overweight and obese patients when possible, use the lowest effective dose when such agents are necessary, and warn patients of this adverse effect so that they can take precautions, such as walking an extra mile a day or giving up that high-calorie latte in the morning.

1. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382:951-962.

2. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;CD003987.

One of my brothers has adult onset bipolar disorder. As luck would have it, he also has type 2 diabetes mellitus. He struggles constantly with blood sugar control since he needs to take 2 psychotropic medications, both of which cause weight gain.

I mistakenly told a patient that her beta-blocker wasn't interfering with her weight loss.His situation has prompted me to think about the responsibility we have as we care, and advocate, for our patients with major mental illness who require these effective medications. At a minimum, we must be knowledgeable about the adverse metabolic effects of these drugs, avoid prescribing them when possible, and advocate for dose reductions when feasible. Knowing, for example, that these drugs fall on a spectrum, with haloperidol causing the least weight gain and olanzapine causing the most, is important.¹

An eye-opener. The article by Saunders in this issue provides advice on avoiding medications that commonly cause weight gain when prescribing for overweight or obese patients with diabetes, hypertension, and/or depression. I was unaware that some of the drugs on the list contribute to the problem. For example, I saw a new patient last week who has hypertension and is obese; she has been taking the beta-blocker metoprolol for the past 8 years. She has tried unsuccessfully to lose weight. She asked me if the metoprolol could be interfering with weight loss, and I mistakenly told her “No.” Thankfully, we decided to discontinue it anyway. I will admit to her my knowledge gap when I see her next month for follow-up. Errors are great teachers, especially when no harm is done.

The scope of the Saunders article is not meant to be comprehensive, since it focuses on medications for diabetes, hypertension, and depression. I think all of us are aware of the weight gain associated with other commonly prescribed drugs, such as systemic corticosteroids and long-acting progesterone for contraception. Thankfully, combination oral contraceptives do not appear to be associated with weight gain²—answering one of the more common questions I receive from patients about weight and medications.

The bottom line. Avoid prescribing medications that can cause weight gain in overweight and obese patients when possible, use the lowest effective dose when such agents are necessary, and warn patients of this adverse effect so that they can take precautions, such as walking an extra mile a day or giving up that high-calorie latte in the morning.

1. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382:951-962.

2. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;CD003987.

Health care has not been at the top of the agenda in this presidential campaign, but it remains a highly contentious political issue. Because the Affordable Care Act (aka Obamacare) was all about expanding health care coverage and not much about cost containment, it is not surprising that health care insurance costs continue to escalate.

The Accountable Care Organization demonstrations around the country have shown that some, but not all, health care organizations are able to bend the steep cost incline downward using incentives, bundled payments, excellent primary care access, and care coordination. But we are once again seeing large increases in insurance premiums, and no one is happy about that.

Take your pick of candidates, but don't expect a difference in your practice "hassle factor"—or paycheck.

Practical solutions are scarce. Good solutions for controlling rising health care costs are difficult to come by in the United States. There are a variety of suggestions and approaches favored by one party or the other that will be decided through political and administrative channels. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-based Incentive Payment System (MIPS), and alternative payment models (APMs) are the federal government’s new programs that have been set out to encourage quality, while controlling costs in outpatient settings.¹ These programs have bipartisan support and are not going away.

In addition, each state is reorganizing Medicaid in an attempt to improve quality and reduce costs. Usually these cost control/quality improvement programs are foisted on us by federal or state governments (which pay for about 64% of health care costs in the United States), by insurers, or both. Fortunately, the American Academy of Family Physicians has been putting the interests of family physicians in front of legislators and policy makers to try to ease the pain as much as possible.

What can YOU do? If you have the time and the stomach for it, join forces with AAFP to become involved in the politics of health care reform and speak up for family medicine and primary care. In your own office or clinic, put the “Choosing Wisely” campaign² (from the American Board of Internal Medicine) into practice: Focus on reducing unnecessary tests and treatments.

In the end, no matter which party occupies the White House for the next 4 years, health care payment reform is inevitable. Both parties agree that the steep rise in health care costs is unsustainable. So take your pick of presidential candidates, but don’t expect that choice to make a lot of difference in your practice “hassle factor”—or paycheck.

Health care has not been at the top of the agenda in this presidential campaign, but it remains a highly contentious political issue. Because the Affordable Care Act (aka Obamacare) was all about expanding health care coverage and not much about cost containment, it is not surprising that health care insurance costs continue to escalate.

The Accountable Care Organization demonstrations around the country have shown that some, but not all, health care organizations are able to bend the steep cost incline downward using incentives, bundled payments, excellent primary care access, and care coordination. But we are once again seeing large increases in insurance premiums, and no one is happy about that.

Take your pick of candidates, but don't expect a difference in your practice "hassle factor"—or paycheck.

Practical solutions are scarce. Good solutions for controlling rising health care costs are difficult to come by in the United States. There are a variety of suggestions and approaches favored by one party or the other that will be decided through political and administrative channels. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-based Incentive Payment System (MIPS), and alternative payment models (APMs) are the federal government’s new programs that have been set out to encourage quality, while controlling costs in outpatient settings.¹ These programs have bipartisan support and are not going away.

In addition, each state is reorganizing Medicaid in an attempt to improve quality and reduce costs. Usually these cost control/quality improvement programs are foisted on us by federal or state governments (which pay for about 64% of health care costs in the United States), by insurers, or both. Fortunately, the American Academy of Family Physicians has been putting the interests of family physicians in front of legislators and policy makers to try to ease the pain as much as possible.

What can YOU do? If you have the time and the stomach for it, join forces with AAFP to become involved in the politics of health care reform and speak up for family medicine and primary care. In your own office or clinic, put the “Choosing Wisely” campaign² (from the American Board of Internal Medicine) into practice: Focus on reducing unnecessary tests and treatments.

In the end, no matter which party occupies the White House for the next 4 years, health care payment reform is inevitable. Both parties agree that the steep rise in health care costs is unsustainable. So take your pick of presidential candidates, but don’t expect that choice to make a lot of difference in your practice “hassle factor”—or paycheck.

Health care has not been at the top of the agenda in this presidential campaign, but it remains a highly contentious political issue. Because the Affordable Care Act (aka Obamacare) was all about expanding health care coverage and not much about cost containment, it is not surprising that health care insurance costs continue to escalate.

The Accountable Care Organization demonstrations around the country have shown that some, but not all, health care organizations are able to bend the steep cost incline downward using incentives, bundled payments, excellent primary care access, and care coordination. But we are once again seeing large increases in insurance premiums, and no one is happy about that.

Take your pick of candidates, but don't expect a difference in your practice "hassle factor"—or paycheck.

Practical solutions are scarce. Good solutions for controlling rising health care costs are difficult to come by in the United States. There are a variety of suggestions and approaches favored by one party or the other that will be decided through political and administrative channels. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-based Incentive Payment System (MIPS), and alternative payment models (APMs) are the federal government’s new programs that have been set out to encourage quality, while controlling costs in outpatient settings.¹ These programs have bipartisan support and are not going away.

In addition, each state is reorganizing Medicaid in an attempt to improve quality and reduce costs. Usually these cost control/quality improvement programs are foisted on us by federal or state governments (which pay for about 64% of health care costs in the United States), by insurers, or both. Fortunately, the American Academy of Family Physicians has been putting the interests of family physicians in front of legislators and policy makers to try to ease the pain as much as possible.

What can YOU do? If you have the time and the stomach for it, join forces with AAFP to become involved in the politics of health care reform and speak up for family medicine and primary care. In your own office or clinic, put the “Choosing Wisely” campaign² (from the American Board of Internal Medicine) into practice: Focus on reducing unnecessary tests and treatments.

In the end, no matter which party occupies the White House for the next 4 years, health care payment reform is inevitable. Both parties agree that the steep rise in health care costs is unsustainable. So take your pick of presidential candidates, but don’t expect that choice to make a lot of difference in your practice “hassle factor”—or paycheck.

Origin of pain: Brain vs body. Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body. In this issue of JFP, Davis and Vanderah discuss this type of pain as “a third kind” that needs to be treated in a manner that completely differs from that for peripherally generated pain. They refer to the traditional kinds of pain as either nociceptive (resulting from tissue damage or insult), or neuropathic (due to dysfunctional stimulation of peripheral nerves). The neurophysiology of the third kind of pain, which I will call “centrally generated pain,” is not fully understood, but neuroimaging and other sophisticated methods are identifying areas of the brain that become activated by psychological trauma, leading to significant painful suffering in the absence of tissue damage, or that is far out of proportion to physical insult.

The bad news for primary care physicians is that this third kind of pain is difficult, if not impossible, to treat with our traditional armamentarium of pain medications and physical modalities. In fact, these patients are often at risk for addiction, as doses of ineffective narcotics are escalated.

Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body.

The good news is that clinical researchers have begun to identify ways to effectively treat centrally generated pain. For example, Schubiner et al used a novel psychological approach that involved helping patients "learn that their pain is influenced primarily by central nervous system psychological processes, and to enhance awareness and expression of emotions related to psychological trauma or conflict."¹ Thirty percent of the 72 participants in the preliminary, uncontrolled trial experienced a 70% reduction in pain. Dr. Schubiner’s research is ongoing and supported by funding from the National Institutes of Health.

Proper diagnosis is paramount. Of course, proper diagnosis is paramount because an individual may suffer from more than one of the 3 kinds of pain and require different approaches for each. Thorough evaluation at a multidisciplinary pain clinic is a good place to start. Once the diagnoses are sorted out, it will then be possible to treat each component of pain appropriately.

Dr. Schubiner’s methods and other new and developing treatment approaches to chronic pain will help us better relieve patients’ suffering, reduce narcotic overuse, and relieve our own anxiety about caring for these challenging patients.

1. Burger AJ, Lumley MA, Carty JN, et al. The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: a preliminary, uncontrolled trial. J Psychosom Res. 2016;81:1-8.

Origin of pain: Brain vs body. Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body. In this issue of JFP, Davis and Vanderah discuss this type of pain as “a third kind” that needs to be treated in a manner that completely differs from that for peripherally generated pain. They refer to the traditional kinds of pain as either nociceptive (resulting from tissue damage or insult), or neuropathic (due to dysfunctional stimulation of peripheral nerves). The neurophysiology of the third kind of pain, which I will call “centrally generated pain,” is not fully understood, but neuroimaging and other sophisticated methods are identifying areas of the brain that become activated by psychological trauma, leading to significant painful suffering in the absence of tissue damage, or that is far out of proportion to physical insult.

The bad news for primary care physicians is that this third kind of pain is difficult, if not impossible, to treat with our traditional armamentarium of pain medications and physical modalities. In fact, these patients are often at risk for addiction, as doses of ineffective narcotics are escalated.

Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body.

The good news is that clinical researchers have begun to identify ways to effectively treat centrally generated pain. For example, Schubiner et al used a novel psychological approach that involved helping patients "learn that their pain is influenced primarily by central nervous system psychological processes, and to enhance awareness and expression of emotions related to psychological trauma or conflict."¹ Thirty percent of the 72 participants in the preliminary, uncontrolled trial experienced a 70% reduction in pain. Dr. Schubiner’s research is ongoing and supported by funding from the National Institutes of Health.

Proper diagnosis is paramount. Of course, proper diagnosis is paramount because an individual may suffer from more than one of the 3 kinds of pain and require different approaches for each. Thorough evaluation at a multidisciplinary pain clinic is a good place to start. Once the diagnoses are sorted out, it will then be possible to treat each component of pain appropriately.

Dr. Schubiner’s methods and other new and developing treatment approaches to chronic pain will help us better relieve patients’ suffering, reduce narcotic overuse, and relieve our own anxiety about caring for these challenging patients.

1. Burger AJ, Lumley MA, Carty JN, et al. The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: a preliminary, uncontrolled trial. J Psychosom Res. 2016;81:1-8.

Origin of pain: Brain vs body. Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body. In this issue of JFP, Davis and Vanderah discuss this type of pain as “a third kind” that needs to be treated in a manner that completely differs from that for peripherally generated pain. They refer to the traditional kinds of pain as either nociceptive (resulting from tissue damage or insult), or neuropathic (due to dysfunctional stimulation of peripheral nerves). The neurophysiology of the third kind of pain, which I will call “centrally generated pain,” is not fully understood, but neuroimaging and other sophisticated methods are identifying areas of the brain that become activated by psychological trauma, leading to significant painful suffering in the absence of tissue damage, or that is far out of proportion to physical insult.

The bad news for primary care physicians is that this third kind of pain is difficult, if not impossible, to treat with our traditional armamentarium of pain medications and physical modalities. In fact, these patients are often at risk for addiction, as doses of ineffective narcotics are escalated.

Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body.

The good news is that clinical researchers have begun to identify ways to effectively treat centrally generated pain. For example, Schubiner et al used a novel psychological approach that involved helping patients "learn that their pain is influenced primarily by central nervous system psychological processes, and to enhance awareness and expression of emotions related to psychological trauma or conflict."¹ Thirty percent of the 72 participants in the preliminary, uncontrolled trial experienced a 70% reduction in pain. Dr. Schubiner’s research is ongoing and supported by funding from the National Institutes of Health.

Proper diagnosis is paramount. Of course, proper diagnosis is paramount because an individual may suffer from more than one of the 3 kinds of pain and require different approaches for each. Thorough evaluation at a multidisciplinary pain clinic is a good place to start. Once the diagnoses are sorted out, it will then be possible to treat each component of pain appropriately.

Dr. Schubiner’s methods and other new and developing treatment approaches to chronic pain will help us better relieve patients’ suffering, reduce narcotic overuse, and relieve our own anxiety about caring for these challenging patients.

1. Burger AJ, Lumley MA, Carty JN, et al. The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: a preliminary, uncontrolled trial. J Psychosom Res. 2016;81:1-8.

Why did testing stop at EKG—especially given family history?

AFTER COMPLAINING OF CHEST PAIN, a 37-year-old man underwent an electrocardiogram (EKG) examination. The doctor concluded that the pain was not cardiac in nature. Two years later, the patient died of a sudden cardiac event associated with coronary atherosclerotic disease.

PLAINTIFF’S CLAIM The decedent suffered from high cholesterol and had a family history of cardiac issues, yet no additional testing was performed when the patient’s complaints continued.

THE DEFENSE No information on the defense is available.

VERDICT $3 million settlement.

This case serves as a reminder that patients can have more than one disease of an organ system.

COMMENT This is déjà vu for me. A colleague of mine had a nearly identical case a few years ago, but the patient died several days later. In the case described here, the high cholesterol and family history were red flags. A normal EKG does not rule out angina. I do wonder what happened, however, in the 2 years between the office visit and the patient’s sudden death. The chest pain at the office visit may well have been non-cardiac, but it appears the jury was not convinced.

2 FPs overlook boy’s proteinuria; delay in Dx costs him a kidney

AN 11-YEAR-OLD BOY underwent a laparoscopic appendectomy that included a urinalysis. Following the surgery, the surgeon notified the family physician (FP) that the patient’s urinalysis showed >300 mg/dL of protein. The result was unusual and required follow-up. The surgeon felt that the urinalysis result might be related to the proximity of the appendicitis to the boy’s ureter. The boy was evaluated on several other occasions by the FP, but no work-up was performed.

Three years later, the boy saw a different FP, who noted that the child had elevated blood pressure and blurry vision—among other symptoms. The boy’s renal function tests were documented as abnormal; however, the patient and his mother were never notified of this. Also, the patient was never referred to a nephrologist or neurologist and there was no intervention for a potential kidney abnormality.

Two years later, an associate of the FP ordered further blood tests that showed a clear abnormality with regard to the integrity of the child’s kidney function. The boy was evaluated at a hospital and diagnosed with end-stage renal disease. He received a kidney transplant 3 months later and requires lifetime medical care as a result of the transplant. The boy will likely require further transplants in 10-year increments.

PLAINTIFF’S CLAIM Both FPs deviated from the accepted standard of care when they failed to order further testing as a result of the abnormal laboratory tests. Earlier intervention may have prolonged the life of the boy’s kidney, thereby postponing the need for kidney replacements.

THE DEFENSE No information on the defense is available.

VERDICT $1.25 million Massachusetts settlement.

COMMENT 300 mg/dL is a significant amount of proteinuria and requires further testing. Why didn’t the FP follow up? Was a summary of the hospitalization sent to him/her? Certainly the diagnosis should have been made by the second FP, and the patient should’ve been referred to a nephrologist. A lawsuit would most likely have been averted had this happened. Delayed diagnosis accounts for a high proportion of malpractice suits against FPs.

Duodenal ulcer mistakenly attributed to Crohn’s disease

A 47-YEAR-OLD MAN with a history of Crohn’s disease began experiencing persistent abdominal pain. He hadn’t had symptoms of his Crohn’s disease in over 12 years. Nevertheless, doctors diagnosed his pain as an aggravation of the disease and gave him treatment based on this diagnosis. In fact, though, the man had an acute duodenal ulcer that had progressed and perforated. The patient underwent 12 surgeries (with complications) and almost 2 years of near-constant hospitalization as a result of the misdiagnosis. He now requires 24-hour care in all aspects of his life.

PLAINTIFF’S CLAIM The doctors were negligent in their failure to consider and diagnose a peptic ulcer when the plaintiff’s symptoms indicated issues other than Crohn’s disease.

THE DEFENSE No information on the defense is available.

VERDICT $28 million Maryland verdict.

COMMENT I suspect this was a tough diagnosis, given the patient’s prior history of Crohn’s disease. We are not told the nature of the abdominal pain. If the patient had classic epigastric pain, peptic ulcer disease should have been investigated. This case serves as a reminder that patients can have more than one disease of an organ system, and it reminds us of the need for a careful history and close follow-up if a complaint does not resolve.

Why did testing stop at EKG—especially given family history?

AFTER COMPLAINING OF CHEST PAIN, a 37-year-old man underwent an electrocardiogram (EKG) examination. The doctor concluded that the pain was not cardiac in nature. Two years later, the patient died of a sudden cardiac event associated with coronary atherosclerotic disease.

PLAINTIFF’S CLAIM The decedent suffered from high cholesterol and had a family history of cardiac issues, yet no additional testing was performed when the patient’s complaints continued.

THE DEFENSE No information on the defense is available.

VERDICT $3 million settlement.

This case serves as a reminder that patients can have more than one disease of an organ system.

COMMENT This is déjà vu for me. A colleague of mine had a nearly identical case a few years ago, but the patient died several days later. In the case described here, the high cholesterol and family history were red flags. A normal EKG does not rule out angina. I do wonder what happened, however, in the 2 years between the office visit and the patient’s sudden death. The chest pain at the office visit may well have been non-cardiac, but it appears the jury was not convinced.

2 FPs overlook boy’s proteinuria; delay in Dx costs him a kidney

AN 11-YEAR-OLD BOY underwent a laparoscopic appendectomy that included a urinalysis. Following the surgery, the surgeon notified the family physician (FP) that the patient’s urinalysis showed >300 mg/dL of protein. The result was unusual and required follow-up. The surgeon felt that the urinalysis result might be related to the proximity of the appendicitis to the boy’s ureter. The boy was evaluated on several other occasions by the FP, but no work-up was performed.

Three years later, the boy saw a different FP, who noted that the child had elevated blood pressure and blurry vision—among other symptoms. The boy’s renal function tests were documented as abnormal; however, the patient and his mother were never notified of this. Also, the patient was never referred to a nephrologist or neurologist and there was no intervention for a potential kidney abnormality.

Two years later, an associate of the FP ordered further blood tests that showed a clear abnormality with regard to the integrity of the child’s kidney function. The boy was evaluated at a hospital and diagnosed with end-stage renal disease. He received a kidney transplant 3 months later and requires lifetime medical care as a result of the transplant. The boy will likely require further transplants in 10-year increments.

PLAINTIFF’S CLAIM Both FPs deviated from the accepted standard of care when they failed to order further testing as a result of the abnormal laboratory tests. Earlier intervention may have prolonged the life of the boy’s kidney, thereby postponing the need for kidney replacements.

THE DEFENSE No information on the defense is available.

VERDICT $1.25 million Massachusetts settlement.

COMMENT 300 mg/dL is a significant amount of proteinuria and requires further testing. Why didn’t the FP follow up? Was a summary of the hospitalization sent to him/her? Certainly the diagnosis should have been made by the second FP, and the patient should’ve been referred to a nephrologist. A lawsuit would most likely have been averted had this happened. Delayed diagnosis accounts for a high proportion of malpractice suits against FPs.

Duodenal ulcer mistakenly attributed to Crohn’s disease

A 47-YEAR-OLD MAN with a history of Crohn’s disease began experiencing persistent abdominal pain. He hadn’t had symptoms of his Crohn’s disease in over 12 years. Nevertheless, doctors diagnosed his pain as an aggravation of the disease and gave him treatment based on this diagnosis. In fact, though, the man had an acute duodenal ulcer that had progressed and perforated. The patient underwent 12 surgeries (with complications) and almost 2 years of near-constant hospitalization as a result of the misdiagnosis. He now requires 24-hour care in all aspects of his life.

PLAINTIFF’S CLAIM The doctors were negligent in their failure to consider and diagnose a peptic ulcer when the plaintiff’s symptoms indicated issues other than Crohn’s disease.

THE DEFENSE No information on the defense is available.

VERDICT $28 million Maryland verdict.

COMMENT I suspect this was a tough diagnosis, given the patient’s prior history of Crohn’s disease. We are not told the nature of the abdominal pain. If the patient had classic epigastric pain, peptic ulcer disease should have been investigated. This case serves as a reminder that patients can have more than one disease of an organ system, and it reminds us of the need for a careful history and close follow-up if a complaint does not resolve.

Why did testing stop at EKG—especially given family history?

AFTER COMPLAINING OF CHEST PAIN, a 37-year-old man underwent an electrocardiogram (EKG) examination. The doctor concluded that the pain was not cardiac in nature. Two years later, the patient died of a sudden cardiac event associated with coronary atherosclerotic disease.

PLAINTIFF’S CLAIM The decedent suffered from high cholesterol and had a family history of cardiac issues, yet no additional testing was performed when the patient’s complaints continued.

THE DEFENSE No information on the defense is available.

VERDICT $3 million settlement.

This case serves as a reminder that patients can have more than one disease of an organ system.

COMMENT This is déjà vu for me. A colleague of mine had a nearly identical case a few years ago, but the patient died several days later. In the case described here, the high cholesterol and family history were red flags. A normal EKG does not rule out angina. I do wonder what happened, however, in the 2 years between the office visit and the patient’s sudden death. The chest pain at the office visit may well have been non-cardiac, but it appears the jury was not convinced.

2 FPs overlook boy’s proteinuria; delay in Dx costs him a kidney

AN 11-YEAR-OLD BOY underwent a laparoscopic appendectomy that included a urinalysis. Following the surgery, the surgeon notified the family physician (FP) that the patient’s urinalysis showed >300 mg/dL of protein. The result was unusual and required follow-up. The surgeon felt that the urinalysis result might be related to the proximity of the appendicitis to the boy’s ureter. The boy was evaluated on several other occasions by the FP, but no work-up was performed.

Three years later, the boy saw a different FP, who noted that the child had elevated blood pressure and blurry vision—among other symptoms. The boy’s renal function tests were documented as abnormal; however, the patient and his mother were never notified of this. Also, the patient was never referred to a nephrologist or neurologist and there was no intervention for a potential kidney abnormality.

Two years later, an associate of the FP ordered further blood tests that showed a clear abnormality with regard to the integrity of the child’s kidney function. The boy was evaluated at a hospital and diagnosed with end-stage renal disease. He received a kidney transplant 3 months later and requires lifetime medical care as a result of the transplant. The boy will likely require further transplants in 10-year increments.

PLAINTIFF’S CLAIM Both FPs deviated from the accepted standard of care when they failed to order further testing as a result of the abnormal laboratory tests. Earlier intervention may have prolonged the life of the boy’s kidney, thereby postponing the need for kidney replacements.

THE DEFENSE No information on the defense is available.

VERDICT $1.25 million Massachusetts settlement.

COMMENT 300 mg/dL is a significant amount of proteinuria and requires further testing. Why didn’t the FP follow up? Was a summary of the hospitalization sent to him/her? Certainly the diagnosis should have been made by the second FP, and the patient should’ve been referred to a nephrologist. A lawsuit would most likely have been averted had this happened. Delayed diagnosis accounts for a high proportion of malpractice suits against FPs.

Duodenal ulcer mistakenly attributed to Crohn’s disease

A 47-YEAR-OLD MAN with a history of Crohn’s disease began experiencing persistent abdominal pain. He hadn’t had symptoms of his Crohn’s disease in over 12 years. Nevertheless, doctors diagnosed his pain as an aggravation of the disease and gave him treatment based on this diagnosis. In fact, though, the man had an acute duodenal ulcer that had progressed and perforated. The patient underwent 12 surgeries (with complications) and almost 2 years of near-constant hospitalization as a result of the misdiagnosis. He now requires 24-hour care in all aspects of his life.

PLAINTIFF’S CLAIM The doctors were negligent in their failure to consider and diagnose a peptic ulcer when the plaintiff’s symptoms indicated issues other than Crohn’s disease.

THE DEFENSE No information on the defense is available.

VERDICT $28 million Maryland verdict.

COMMENT I suspect this was a tough diagnosis, given the patient’s prior history of Crohn’s disease. We are not told the nature of the abdominal pain. If the patient had classic epigastric pain, peptic ulcer disease should have been investigated. This case serves as a reminder that patients can have more than one disease of an organ system, and it reminds us of the need for a careful history and close follow-up if a complaint does not resolve.

Although we reserve the term “PURL” for our popular feature, Priority Updates from the Research Literature, I’m proud to comment on the collection of articles in this issue of JFP, each of which contains important “pearls” of information for family physicians and other primary care clinicians.

Managing sport-related concussion. Revelations about serious head injuries in the National Football League have catalyzed important research regarding the management of sports-related head injuries, and the evidence for diagnosis and treatment is evolving. The article in this issue by Dr. Sprouse and colleagues provides some of the latest information regarding brain changes after concussion straight from the American Academy of Neurology’s 2016 Sports Concussion Conference held in Chicago in July, as well as valuable return-to-play recommendations.

Family medicine ultrasound. Because of advances in technology and reductions in the cost of portable machines, ultrasound use is rapidly moving into family medicine offices. Drs. Steinmetz and Oleskevich provide a no-nonsense review of the current uses of ultrasound in family medicine, leading me to wonder whether ultrasound might become the stethoscope of the future.

This month’s review of the current uses of ultrasound in family medicine made me wonder whether ultrasound might become the stethoscope of the future.

Shortness of breath. Although the diagnosis of shortness of breath is straightforward in many cases, misdiagnosis is not uncommon. Recently, I cared for a new patient who was diagnosed with asthma 15 years ago. Because of fine rales on exam, I suspected the patient’s diagnosis was incorrect. Indeed, he had pulmonary fibrosis, not asthma, and he is doing fine now without his asthma inhalers. Dr. Taggart outlines a thoughtful approach to the evaluation of shortness of breath, one that alerts you to when to suspect something beyond the usual culprits.

Cervical cancer screening. The days of yearly Pap smears for all women are over. Combined screening with cytology and human papillomavirus testing is now recommended at 5-year intervals for women 30 to 65 years of age who are at low risk for cervical cancer. In addition, Dr. Hofmeister reviews recent randomized trials that suggest HPV screening alone may be sufficient for low-risk women.

On-demand HIV prophylaxis. Our PURL for the month discusses an effective prevention strategy—other than condoms—that can be used as needed by people at high risk for human immunodeficiency virus.

We hope you enjoy this PURL—and the other “pearls”—this month. As diagnosis and treatments evolve, JFP will continue to bring you the information you need to provide the best possible care for your patients.

Although we reserve the term “PURL” for our popular feature, Priority Updates from the Research Literature, I’m proud to comment on the collection of articles in this issue of JFP, each of which contains important “pearls” of information for family physicians and other primary care clinicians.

Managing sport-related concussion. Revelations about serious head injuries in the National Football League have catalyzed important research regarding the management of sports-related head injuries, and the evidence for diagnosis and treatment is evolving. The article in this issue by Dr. Sprouse and colleagues provides some of the latest information regarding brain changes after concussion straight from the American Academy of Neurology’s 2016 Sports Concussion Conference held in Chicago in July, as well as valuable return-to-play recommendations.

Family medicine ultrasound. Because of advances in technology and reductions in the cost of portable machines, ultrasound use is rapidly moving into family medicine offices. Drs. Steinmetz and Oleskevich provide a no-nonsense review of the current uses of ultrasound in family medicine, leading me to wonder whether ultrasound might become the stethoscope of the future.

This month’s review of the current uses of ultrasound in family medicine made me wonder whether ultrasound might become the stethoscope of the future.

Shortness of breath. Although the diagnosis of shortness of breath is straightforward in many cases, misdiagnosis is not uncommon. Recently, I cared for a new patient who was diagnosed with asthma 15 years ago. Because of fine rales on exam, I suspected the patient’s diagnosis was incorrect. Indeed, he had pulmonary fibrosis, not asthma, and he is doing fine now without his asthma inhalers. Dr. Taggart outlines a thoughtful approach to the evaluation of shortness of breath, one that alerts you to when to suspect something beyond the usual culprits.

Cervical cancer screening. The days of yearly Pap smears for all women are over. Combined screening with cytology and human papillomavirus testing is now recommended at 5-year intervals for women 30 to 65 years of age who are at low risk for cervical cancer. In addition, Dr. Hofmeister reviews recent randomized trials that suggest HPV screening alone may be sufficient for low-risk women.

On-demand HIV prophylaxis. Our PURL for the month discusses an effective prevention strategy—other than condoms—that can be used as needed by people at high risk for human immunodeficiency virus.

We hope you enjoy this PURL—and the other “pearls”—this month. As diagnosis and treatments evolve, JFP will continue to bring you the information you need to provide the best possible care for your patients.

Although we reserve the term “PURL” for our popular feature, Priority Updates from the Research Literature, I’m proud to comment on the collection of articles in this issue of JFP, each of which contains important “pearls” of information for family physicians and other primary care clinicians.

Managing sport-related concussion. Revelations about serious head injuries in the National Football League have catalyzed important research regarding the management of sports-related head injuries, and the evidence for diagnosis and treatment is evolving. The article in this issue by Dr. Sprouse and colleagues provides some of the latest information regarding brain changes after concussion straight from the American Academy of Neurology’s 2016 Sports Concussion Conference held in Chicago in July, as well as valuable return-to-play recommendations.

Family medicine ultrasound. Because of advances in technology and reductions in the cost of portable machines, ultrasound use is rapidly moving into family medicine offices. Drs. Steinmetz and Oleskevich provide a no-nonsense review of the current uses of ultrasound in family medicine, leading me to wonder whether ultrasound might become the stethoscope of the future.

This month’s review of the current uses of ultrasound in family medicine made me wonder whether ultrasound might become the stethoscope of the future.

Shortness of breath. Although the diagnosis of shortness of breath is straightforward in many cases, misdiagnosis is not uncommon. Recently, I cared for a new patient who was diagnosed with asthma 15 years ago. Because of fine rales on exam, I suspected the patient’s diagnosis was incorrect. Indeed, he had pulmonary fibrosis, not asthma, and he is doing fine now without his asthma inhalers. Dr. Taggart outlines a thoughtful approach to the evaluation of shortness of breath, one that alerts you to when to suspect something beyond the usual culprits.

Cervical cancer screening. The days of yearly Pap smears for all women are over. Combined screening with cytology and human papillomavirus testing is now recommended at 5-year intervals for women 30 to 65 years of age who are at low risk for cervical cancer. In addition, Dr. Hofmeister reviews recent randomized trials that suggest HPV screening alone may be sufficient for low-risk women.

On-demand HIV prophylaxis. Our PURL for the month discusses an effective prevention strategy—other than condoms—that can be used as needed by people at high risk for human immunodeficiency virus.

We hope you enjoy this PURL—and the other “pearls”—this month. As diagnosis and treatments evolve, JFP will continue to bring you the information you need to provide the best possible care for your patients.

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

It’s been about 2 years since I had my first e-cigarette discussion with a patient. He was a smoker in his 30s and, since we routinely screen for tobacco use in our practice, I asked him if he was interested in quitting. He said he was cutting down by using e-cigarettes, but had not yet stopped smoking.

According to the 2 articles on e-cigarettes in this issue—one original research study about the prevalence of e-cigarette use in rural Illinois and one review of the safety of e-cigarettes—my experience with this patient is typical of e-cigarette users. Many are “dual users” who turn to e-cigarettes to try to cut down on their tobacco use.

As these 2 articles discuss, we still have a great deal to learn about the potential harms and benefits of e-cigarettes. What chemicals are people taking into their bodies and how dangerous are they? And even if they pose health risks, do e-cigarettes have value as smoking cessation aids if they are less harmful than tobacco?

One could simply take a “just say No” approach, as does my wife who says, “Any chemical you inhale into your lungs can’t be good for you!” Or, one can assume the more moderate lesser-of-two-evils stance of the British health system, which posits that there may be some benefit to e-cigarettes if they help people cut down or stop using tobacco products.

Are e-cigarettes a "gateway" to the use of tobacco and other substances of abuse? Or do they represent an effective way to quit smoking?

In writing this editorial, I conducted a quick literature search that yielded only 5 legitimate randomized trials of e-cigarettes to reduce or eliminate tobacco use, and the results were underwhelming. At best, e-cigarettes appear to be as effective as other forms of nicotine replacement, such as patches, which do not have chemical additives.

Fortunately, researchers are taking e-cigarettes seriously, and research is ongoing. Using the search term “e-cigarette” yielded 2058 references, indicating a respectable amount of e-cigarette research conducted over the past 6 years. Most of the research so far has been about the chemical constituents of the vapor people inhale or about use patterns. There is still a lack of definitive research on whether e-cigarettes are an effective smoking cessation method or a “gateway” to the use of tobacco and other substances of abuse.

Or perhaps they are both.

Hopefully, in 5 years we will know a great deal more, but until we do, I am happy to see that the US Food and Drug Administration has decided to regulate e-cigarettes like tobacco.

It’s been about 2 years since I had my first e-cigarette discussion with a patient. He was a smoker in his 30s and, since we routinely screen for tobacco use in our practice, I asked him if he was interested in quitting. He said he was cutting down by using e-cigarettes, but had not yet stopped smoking.

According to the 2 articles on e-cigarettes in this issue—one original research study about the prevalence of e-cigarette use in rural Illinois and one review of the safety of e-cigarettes—my experience with this patient is typical of e-cigarette users. Many are “dual users” who turn to e-cigarettes to try to cut down on their tobacco use.

As these 2 articles discuss, we still have a great deal to learn about the potential harms and benefits of e-cigarettes. What chemicals are people taking into their bodies and how dangerous are they? And even if they pose health risks, do e-cigarettes have value as smoking cessation aids if they are less harmful than tobacco?

One could simply take a “just say No” approach, as does my wife who says, “Any chemical you inhale into your lungs can’t be good for you!” Or, one can assume the more moderate lesser-of-two-evils stance of the British health system, which posits that there may be some benefit to e-cigarettes if they help people cut down or stop using tobacco products.

Are e-cigarettes a "gateway" to the use of tobacco and other substances of abuse? Or do they represent an effective way to quit smoking?

In writing this editorial, I conducted a quick literature search that yielded only 5 legitimate randomized trials of e-cigarettes to reduce or eliminate tobacco use, and the results were underwhelming. At best, e-cigarettes appear to be as effective as other forms of nicotine replacement, such as patches, which do not have chemical additives.

Fortunately, researchers are taking e-cigarettes seriously, and research is ongoing. Using the search term “e-cigarette” yielded 2058 references, indicating a respectable amount of e-cigarette research conducted over the past 6 years. Most of the research so far has been about the chemical constituents of the vapor people inhale or about use patterns. There is still a lack of definitive research on whether e-cigarettes are an effective smoking cessation method or a “gateway” to the use of tobacco and other substances of abuse.

Or perhaps they are both.

Hopefully, in 5 years we will know a great deal more, but until we do, I am happy to see that the US Food and Drug Administration has decided to regulate e-cigarettes like tobacco.

It’s been about 2 years since I had my first e-cigarette discussion with a patient. He was a smoker in his 30s and, since we routinely screen for tobacco use in our practice, I asked him if he was interested in quitting. He said he was cutting down by using e-cigarettes, but had not yet stopped smoking.

According to the 2 articles on e-cigarettes in this issue—one original research study about the prevalence of e-cigarette use in rural Illinois and one review of the safety of e-cigarettes—my experience with this patient is typical of e-cigarette users. Many are “dual users” who turn to e-cigarettes to try to cut down on their tobacco use.

As these 2 articles discuss, we still have a great deal to learn about the potential harms and benefits of e-cigarettes. What chemicals are people taking into their bodies and how dangerous are they? And even if they pose health risks, do e-cigarettes have value as smoking cessation aids if they are less harmful than tobacco?

One could simply take a “just say No” approach, as does my wife who says, “Any chemical you inhale into your lungs can’t be good for you!” Or, one can assume the more moderate lesser-of-two-evils stance of the British health system, which posits that there may be some benefit to e-cigarettes if they help people cut down or stop using tobacco products.

Are e-cigarettes a "gateway" to the use of tobacco and other substances of abuse? Or do they represent an effective way to quit smoking?

In writing this editorial, I conducted a quick literature search that yielded only 5 legitimate randomized trials of e-cigarettes to reduce or eliminate tobacco use, and the results were underwhelming. At best, e-cigarettes appear to be as effective as other forms of nicotine replacement, such as patches, which do not have chemical additives.

Fortunately, researchers are taking e-cigarettes seriously, and research is ongoing. Using the search term “e-cigarette” yielded 2058 references, indicating a respectable amount of e-cigarette research conducted over the past 6 years. Most of the research so far has been about the chemical constituents of the vapor people inhale or about use patterns. There is still a lack of definitive research on whether e-cigarettes are an effective smoking cessation method or a “gateway” to the use of tobacco and other substances of abuse.

Or perhaps they are both.

Hopefully, in 5 years we will know a great deal more, but until we do, I am happy to see that the US Food and Drug Administration has decided to regulate e-cigarettes like tobacco.

Since JFP’s launch of the PURL department in November of 2007, 122 PURLs—Priority Updates from the Research Literature—have been published. The Journal of Family Practice is the exclusive publication venue for these items. Because they have stood the test of time and are one of the more popular columns in JFP, I thought it would be worthwhile to describe the rigorous evaluation they undergo before they are published.

Many studies, but few PURLs. Each year, approximately 200,000 new human medical research studies are indexed on PubMed. Very few of these studies are pertinent to family medicine, however, and even fewer provide new patient-oriented evidence for primary care clinicians.

In 2005, the leaders of the Family Physician Inquiries Network (FPIN), which produces another popular JFP column, Clinical Inquiries, set about identifying high-priority research findings relevant to family medicine. A group of family physicians and librarians began combing the research literature monthly to find those rare randomized trials or high-quality observational studies that pertained to our specialty. To qualify as a PURL, a study had to meet 6 criteria. It had to be scientifically valid, relevant to family medicine, applicable in a medical care setting, immediately implementable, clinically meaningful, and practice changing. These criteria still stand today.

Making the cut. When a study is identified as a potential PURL, it is submitted to one of FPIN’s PURL review groups for a critical appraisal and rigorous peer review. If the group cannot convince the PURLs editors that the original research meets all 6 criteria, the study falls by the wayside. Most potential PURLs do not make the cut. I was one of the early PURL “divers,” and I was amazed at how few PURLs existed. Given the emphasis of research on subspecialties and the dearth of primary care research funding in the United States, I probably shouldn’t have been surprised.

Interested in research that is clinically meaningful and practice changing for family physicians? Then check out our PURLs column.

Holding their value. I reviewed all 122 PURLs this week and am proud to say that nearly all still provide highly pertinent, practice-changing information for family physicians and other primary care clinicians. For a quick review of our string of PURLs, go to www.jfponline.com, select “Articles” in the banner, and then “PURLs,” and read the short practice changer box for each one. I guarantee it will be time well spent!

If you would like to become part of the PURLs process, either by nominating or reviewing a PURL, please contact the PURLs Project Manager at purls@fpin.org.

Since JFP’s launch of the PURL department in November of 2007, 122 PURLs—Priority Updates from the Research Literature—have been published. The Journal of Family Practice is the exclusive publication venue for these items. Because they have stood the test of time and are one of the more popular columns in JFP, I thought it would be worthwhile to describe the rigorous evaluation they undergo before they are published.

Many studies, but few PURLs. Each year, approximately 200,000 new human medical research studies are indexed on PubMed. Very few of these studies are pertinent to family medicine, however, and even fewer provide new patient-oriented evidence for primary care clinicians.

In 2005, the leaders of the Family Physician Inquiries Network (FPIN), which produces another popular JFP column, Clinical Inquiries, set about identifying high-priority research findings relevant to family medicine. A group of family physicians and librarians began combing the research literature monthly to find those rare randomized trials or high-quality observational studies that pertained to our specialty. To qualify as a PURL, a study had to meet 6 criteria. It had to be scientifically valid, relevant to family medicine, applicable in a medical care setting, immediately implementable, clinically meaningful, and practice changing. These criteria still stand today.

Making the cut. When a study is identified as a potential PURL, it is submitted to one of FPIN’s PURL review groups for a critical appraisal and rigorous peer review. If the group cannot convince the PURLs editors that the original research meets all 6 criteria, the study falls by the wayside. Most potential PURLs do not make the cut. I was one of the early PURL “divers,” and I was amazed at how few PURLs existed. Given the emphasis of research on subspecialties and the dearth of primary care research funding in the United States, I probably shouldn’t have been surprised.

Interested in research that is clinically meaningful and practice changing for family physicians? Then check out our PURLs column.

Holding their value. I reviewed all 122 PURLs this week and am proud to say that nearly all still provide highly pertinent, practice-changing information for family physicians and other primary care clinicians. For a quick review of our string of PURLs, go to www.jfponline.com, select “Articles” in the banner, and then “PURLs,” and read the short practice changer box for each one. I guarantee it will be time well spent!

If you would like to become part of the PURLs process, either by nominating or reviewing a PURL, please contact the PURLs Project Manager at purls@fpin.org.

Since JFP’s launch of the PURL department in November of 2007, 122 PURLs—Priority Updates from the Research Literature—have been published. The Journal of Family Practice is the exclusive publication venue for these items. Because they have stood the test of time and are one of the more popular columns in JFP, I thought it would be worthwhile to describe the rigorous evaluation they undergo before they are published.

Many studies, but few PURLs. Each year, approximately 200,000 new human medical research studies are indexed on PubMed. Very few of these studies are pertinent to family medicine, however, and even fewer provide new patient-oriented evidence for primary care clinicians.

In 2005, the leaders of the Family Physician Inquiries Network (FPIN), which produces another popular JFP column, Clinical Inquiries, set about identifying high-priority research findings relevant to family medicine. A group of family physicians and librarians began combing the research literature monthly to find those rare randomized trials or high-quality observational studies that pertained to our specialty. To qualify as a PURL, a study had to meet 6 criteria. It had to be scientifically valid, relevant to family medicine, applicable in a medical care setting, immediately implementable, clinically meaningful, and practice changing. These criteria still stand today.

Making the cut. When a study is identified as a potential PURL, it is submitted to one of FPIN’s PURL review groups for a critical appraisal and rigorous peer review. If the group cannot convince the PURLs editors that the original research meets all 6 criteria, the study falls by the wayside. Most potential PURLs do not make the cut. I was one of the early PURL “divers,” and I was amazed at how few PURLs existed. Given the emphasis of research on subspecialties and the dearth of primary care research funding in the United States, I probably shouldn’t have been surprised.

Interested in research that is clinically meaningful and practice changing for family physicians? Then check out our PURLs column.

Holding their value. I reviewed all 122 PURLs this week and am proud to say that nearly all still provide highly pertinent, practice-changing information for family physicians and other primary care clinicians. For a quick review of our string of PURLs, go to www.jfponline.com, select “Articles” in the banner, and then “PURLs,” and read the short practice changer box for each one. I guarantee it will be time well spent!

If you would like to become part of the PURLs process, either by nominating or reviewing a PURL, please contact the PURLs Project Manager at purls@fpin.org.