In This Issue: Through the Lens of a Clinician

PRIMARY CARE WORKFORCE EXPANSION

In this issue, an analysis of the primary care workforce predicts that the United States will need 52,000 more primary care physicians by 2025.¹ Population growth will be the single, most important driver, 10-fold more than expansion of insurance coverage—but insurance expansion will occur soonest and most abruptly. The new estimate recognizes that not all primary care physicians practice full time in the office; it is based on the current average across all primary care physicians of 48 office visits with patients per week (rather than 76 visits per week for a physician in full-time office practice).

CLINICALLY RELEVANT RESEARCH

As a family physician, I am fascinated by the variety of clinically relevant articles in this issue. Because almost all of this research was conducted—and much of it generated—in primary care, it can directly help us to understand and improve what we do.

• The systematic review and meta-analysis by Johnson et al compares more- and less-effective ways to increase influenza and pneumococcal immunization rates, which are currently below national targets.²

• A 12-country study reveals the prevalence of undiagnosed asthma or chronic obstructive pulmonary disease in unselected patients with acute cough.³

• A companion article shows a low yield of actionable incidental findings on chest radiographs of patients with acute cough in primary care.⁴

• Systematically asking women's pregnancy intentions and contraceptive method as a vital sign increases documentation.⁵ One goal is to prevent prescribing of teratogenic medications (eg, statins, angiotensin-converting enzyme inhibitors) to fertile women. Including men in this vital sign might further enhance the vital preventive effort to implement effective contraception for everyone who wants or needs it.

• Karaca describes a method for treating ingrown toenails that prevents recurrences.⁶ The Annals editors thought that, were we to adopt this procedure, we would probably substitute local anesthetic without a vasoconstrictor, recognizing that it is common practice in the United States not to use epinephrine in digital blocks.

• A placebo-controlled trial among vitamin D-deficient people found vitamin D helpful for nonspecific muscular aches and pains.⁷ Does this agree with your clinical experience?

• A birthing center located in a rural family practice serving Amish women offers childbirth care tailored to the community—and “an opportunity to look at the effects of local culture and practices that support vaginal birth and [successful] TOLAC [trial of birth after cesarean].”⁸

These studies range from case series to randomized controlled trials, with many different research techniques. To further develop research capacity, Peterson et al⁹ report that they have defined research architecture, processes, and requirements of software to support community practice-based translational research: eg, recruitment of participants, collection of aggregated anonymous data, and retrieval of identifiable data from previously consented adults across hundreds of practices.

PREVENTION ‘NUMERACY’

In this issue you will find a research study,¹⁰ an essay,¹¹ and a guest editorial¹² on screening. In their essay Hoffman and colleagues caution guideline makers to “avoid distracting primary care clinicians from providing services with proven benefit and value for patients.”¹¹ Indeed, many preventive interventions have proven benefit. Yet Hudson et al present the quandary that many patients appear willing to undergo preventive care on the basis of “overly optimistic expectations of the benefits of preventive interventions and screening.”¹⁰ Are they innumerate or overly optimistic? What about policy makers? What about clinicians?

We hope you will share your thoughts about the articles in this issue. Join the discussion at http://www.AnnFamMed.org.