Second Hand Smoke

Tough day in the office.   My last patient was a 35 year old woman with asthma exacerbation.  Her kids have it too (they saw my partner last week).  Ironically, I saw them leaving the office last week in the parking lot.  They all enthusiastically said hello to me as the drove away .. and I was struck by the father's cigarette fuming away in the car .. as they all smiled at me.

Dad is the only smoker in the house, and .. as mom says … "he doesn't agree with how smoking is bad for us."  At frist I didn't believe her.  So I went out to the (empty) waiting room while she was getting her nebulizer (peak flow went from 200 to 400).  I suggested that his smoking may play a role in the health of his family.  His father smoked and he doesn't have asthma.  He knows that I am wrong because of this. 

This episode only briefly preceded dinner at our house .. where we were joined by my father-in-law .. who states medical "facts" at the dinner table so preposterous that I simply cannot respond.

Nor shoudl I.  These are his health beliefs, and I have no business "correcting" them simply because I went to medical school.

But how to I educate our wayward smoking father?  Don't I have an obligation (to his family) to correct his beliefs? How do I educate him? 

Trolling the Internet this evening, I have found some educational materials .. but nothing yet that fits the bill.  The resource must be:

    1. Easy to read.  4th or 5th grade level
    2. Evidence based.  We need facts .. not conclusions.  "second-hand smoke causes asthma" won't work.  We need a document that will say something like:
      • 100 families with smokers in them will have 20 kids with asthma
      • 100 nonsmoking families will have 10 kids with asthma.

Alas .. I can't find this (yet) .. but I have found some interesting data:

… the range of new cases of asthma annually attributable to ETS (Environmental Tobacco Smoke) exposure is 13,000 to 60,000. This report concludes that, in addition to inducing new cases of asthma, ETS exposure increases the number and severity of episodes among this country's 2 million to 5 million asthmatic children. This chapter considers exposure to parental smoking to be a major aggravating factor to approximately 10%, or 200,000, asthmatic children. Estimates of the number of asthmatics whose condition is aggravated to some degree by ETS exposure are very approximate but could run well over 1 million.

Pubmed links:
Parental smoking and respiratory tract infections in children.

Prevalence of bronchial asthma and association with environmental tobacco smoke exposure in adolescent school children in Chandigarh, north India.

Clinical Assessment of the Reliability of the Exam (CARE)

As you know from the Rational Clinical Examination Series in JAMA1, the all-too-common study of the accuracy and precision of the clinical examination comprises 4 experts examining 40 patients, the latter selected to confirm the biases and reputations of the former. The pioneering work of the US-Canadian Co-operative Research Group on the Clinical Exam reversed this trend, but even it has faced formidable problems in participation rates and patient numbers.

This is ground-breaking work.  They're doing studies on UTI and sore throat.  Their pre-op study is complete.

AMA study: Physicians’ use of internet steadily rising

A few years ago, I was involved in a medical-internet-startup company.  No .. not oncalls .. it was Medremote.  The "product" of medremote is the technology behind transcription.  They provide all of the technology that enables physicians to dictate, transfer, and receive (and retreive) their progress notes.  It's good stuff, and the poeple at Medremote are extraordinary.  They "get it" .. so it was easy for me to work with them.  Back in the dark ages of the www, there was of course much excitement .. and many "experts" told us what doctors wanted.  "Stock Quotes" we were told … "disease management" and so on .. The truth, of course, is that we just want good tools to do our work.  Medremote .. like some other companies .. managed to keep their focus on just that .. delivering to the physicians the tools that made it easier and more efficient to get the work done.  Period.  As the fluff falls away .. and the meat of the internet survives .. it's no surprise that more physicians are embracing these tools:

Almost half of physicians report that the World Wide Web has had a major impact on the way they practice medicine, according to a new study released today by the American Medical Association (AMA). The rising influence of the Internet on clinical medicine has propelled an increase in the frequency and duration of Web use among the 78% of physicians who now make use of cyberspace.Almost half of physicians report that the World Wide Web has had a major impact on the way they practice medicine, according to a new study released today by the American Medical Association (AMA). The rising influence of the Internet on clinical medicine has propelled an increase in the frequency and duration of Web use among the 78% of physicians who now make use of cyberspace.

What is the difference between a family physician and a GP?

In the US, the specialty of Family Practice remains poorly understood.  While we care for millions of patients, there are many more who have never been cared for by a family physician and/or consider what we do equivalent to the "GP" that they had "years ago."

Family Practice was established as a specialty in 1969.  A short history of the establishment of this specialty can be found on the American Board of Family Practice Website:

The American Board of Family Practice was born many years before it was officially recognized in February, 1969 as the 20th primary medical specialty.

The history of the Board is a fascinating saga of travails, with frustrations and impediments punctuating its formative days. Despite the fact that by the early 1960's the number of physicians in a general type of practice was dwindling rapidly, the medical establishment opposed the creating of a specialty that would fill this void. Therefore, the founding fathers of the Board deemed it necessary and rational, particularly in the face of this opposition, to document meticulously and persuasively the need for the specialty.

Various studies in the 1950's and 1960's concluded that "General Practice" was moribund. An analysis was made of specialty distribution of all graduates of every medical school by five-year periods since 1900 and from this data it was learned that the number of general practitioners was rapidly and steadily dwindling. In 1964, the percentage of graduates going into General Practice fell to 19% down from 47% in 1900 and continuously diminishing. It was also noted that the ratio of physicians in private practice was dropping rather rapidly, and the deficit was obviously in what was termed the "Family Physician Potential."

The general response to this precipitous decline was, "this is an age of specialization." The founders of the Board could only affirm this fact, believing that this response to the dearth of General Practitioners strengthened their argument for a new generalist-type of specialty called "Family Practice." Many students expressed the concern that the broad body of knowledge required for general practice was too great. This concern was also based in truth, in light of the tremendous expansion of medical knowledge and skills in the past few decades. Four years of medical school and a year of internship was indeed not adequate. The inadequacy of this training could be remedied only by having residency programs in a new specialty, Family Practice, argued the proponents of the specialty.

Additional factors explaining the decline were the lack of "prestige" assigned to the general practitioner in comparison to his/her more "specialized" colleagues as well as the difficulty experienced by the general practitioner in obtaining hospital privileges which were being given increasingly only to those physicians who were board certified.

In view of the data gathered by the Board proponents, it was proposed that:

  • Family Practice IS a specialty, and
  • as a specialty, Family Practice deserves well-defined but flexible graduate training programs, and
  • that a Board of Family Practice is essential for the certification of competency of Family Physicians and for the participation in the guidance and approval of training programs.

The specialty of Family Practice, based on the heritage of General Practice, would have graduate programs (residencies) for physicians whose training would encompass 1) first contact care; 2) continuous care; 3) comprehensive care; 4) personal care (caritas); 5) family care; and, 6) competency in scientific general medicine.

The key difference, then, between family practice and the General Practitioners trained in the 1960's and before is that we have been explicitly trained to practice primary care.  The GPs did a rotating internship (usually in the hospital) for one year after medical school and then went out to practice medicine.  While many of them were (are) wonderful physicians, many (appropriately) argue that they were inadequately trained to skillfully manager the complexity of problems that we face on a daily basis.

New Colon Cancer Screening Guidelines released by USPSTF

The US Public Services Task Force has updated the screening guidelines for colon cancer:

The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer. Grade A recommendation.

The USPSTF found fair to good evidence that several screening methods are effective in reducing mortality from colorectal cancer. The USPSTF concluded that the benefits from screening substantially outweigh potential harms, but the quality of evidence, magnitude of benefit, and potential harms vary with each method.

The USPSTF found good evidence that periodic fecal occult blood testing (FOBT) reduces mortality from colorectal cancer and fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. The USPSTF did not find direct evidence that screening colonoscopy is effective in reducing colorectal cancer mortality; efficacy of colonoscopy is supported by its integral role in trials of FOBT, extrapolation from sigmoidoscopy studies, limited case-control evidence, and the ability of colonoscopy to inspect the proximal colon. Double-contrast barium enema offers an alternative means of whole-bowel examination, but it is less sensitive than colonoscopy, and there is no direct evidence that it is effective in reducing mortality rates. The USPSTF found insufficient evidence that newer screening technologies (for example, computed tomographic colography) are effective in improving health outcomes.

There are insufficient data to determine which strategy is best in terms of the balance of benefits and potential harms or cost-effectiveness. Studies reviewed by the USPSTF indicate that colorectal cancer screening is likely to be cost-effective (less than $30,000 per additional year of life gained) regardless of the strategy chosen.

It is unclear whether the increased accuracy of colonoscopy compared with alternative screening methods (for example, the identification of lesions that FOBT and flexible sigmoidoscopy would not detect) offsets the procedure's additional complications, inconvenience, and costs.