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Annals of Family Medicine 5:270-272 (2007)
© 2007 Annals of Family Medicine, Inc.
doi: 10.1370/afm.712
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On TRACK: Primary Care Opportunities for Filling Unmet Need

Kurt C. Stange, MD, PhD, Editor

EXPANDED PRIMARY CARE CAN FILL CRITICAL HOLES IN HEALTH CARE

The study of outpatient treatment of opioid addiction in the last issue of Annals1 stimulated a dialogue between the lead author2–4 and an international group of clinicians sharing their experience with buprenorphine-naloxone and relevant literature, pharmacology, and politics.5–8 Together, these comments point the way toward expanded use, training, and research on this important intervention in primary care.

The study of a primary care response to Hurricane Katrina9 kindled sharing of a parallel response from those caring for evacuees in the Houston Astrodome.10 Commentary from public health and emergency care experts11–13 draws the larger lessons about the holes in the emergency response system and the vital role of primary care in meeting emergency needs. "This pragmatic study needs to be read by every community-based department of health and disaster planner."13

Coyne14 challenges an inference by Gaynes et al that depressed patients should be treated as aggressively in primary care as in psychiatric care.15 He calls for reinterpretation of "potentially misleading implications," as well as further research on representative patient samples using semistructured interviews for diagnosis of depression.

Keller’s discussion16 of the Wadland study17 linking primary care practice with quit lines provides evidence and expert interpretation of this promising and challenging strategy for expanding tobacco control.

The risk adjustment models used by James and colleagues18 generated gratitude for their utility in preventing those providing care by rural hospitals from being unjustifiably maligned19,20 and detailed discussion of the challenges of adjusting for confounding.21,22

DTC PHARMACEUTICAL MARKETING

The discussion of direct to consumer (DTC) marketing started by the study by Frosch and colleagues23 continued to percolate, further stimulated by an editorial24 and a news item from one of the Annals’ sponsoring organizations in the last issue.25 Among several discussants,26,27 Krueger notes the conflict of interest of a wide variety of media outlets that have become dependent on DTC pharmaceutical ads, yet are responsible for reporting adverse effects of drugs as part of their news reporting. Frey suggests that DTC advertising bans could be a potent portion of presidential candidates’ health care plans.28 Shropshire calls for redirecting American Academy of Family Physicians (AAFP) leadership away from support for the pharmaceutical industry toward "our patients’ ultimate well-being...."29 Rather than banning DTC ads,30 Hallgren suggests that "our lobbying bodies (AAFP, American Medical Association) should be campaigning against it and providing the outlets of unbiased information."31

OTHER THREADS OF DISCUSSION

Diverse discussants of research capacity building32–35 bring out multiple opportunities for stimulating primary care research, while challenging us to examine the impact of that research.36

The discussion of the study by Krist et al37 advances our understanding of the appropriate outcomes for use of patient decision aids.38,39

The study of standardized patients40 raises important questions41 and experiential validation and interpretation of this method42–44 of growing importance for health care research.

The challenge and need for expanding clinical performance measurement45 is well articulated in discussion by Milstein,46 de Brantes,47 and Bennett.48 These calls for increased rigor in performance assessment are echoed somewhat differently in reaction to the essay on jazz as a metaphor for the art of improvisation in the medical encounter.49 This essay stimulated analysis and experience-based reflection,50,51 and a call for increased training in the "seventh competency" of reflective practice.52

Please join the exchange of ideas at http://www.AnnFamMed.org.

REFERENCES

  1. Mintzer IL, Eisenberg M, Terra M, MacVane C, Himmelstein D, Woolhandler S. Treating opioid addiction with buprenorphine-naloxone in community-based primary care settings. Ann Fam Med. 2007;5(2):146–150.[Abstract/Free Full Text]
  2. Mintzer IL. Relapse and drug diversion [eletter]. http://www.annfammed.org/cgi/eletters/5/2/146#5515, 28 March 2007.
  3. Mintzer IL. Antagonist/antagonist roles [eletter]. http://www.annfammed.org/cgi/eletters/5/2/146#5573 2 April 2007.
  4. Mintzer IL. Dispensing buprenorphine/naloxone [eletter]. http://www.annfammed.org/cgi/eletters/5/2/146#5668, 30 April 2007.
  5. Blondell RD. Data for evidence-based practice guidelines are needed [eletter]. http://www.annfammed.org/cgi/eletters/5/2/146#5489, 27 March 2007.
  6. Albanese MJ. Opioid addiction treatment in primary care practice [eletter]. http://www.annfammed.org/cgi/eletters/5/2/146#5512, 28 March 2007.
  7. Fiscella K. Buprenorphine is underused by primary care physicians [eletter]. http://www.annfammed.org/cgi/eletters/5/2/146#5520, 28 March 2007.
  8. Hall RH. Routine family practice has treated fifty patients with suboxone [eletter]. http://www.annfammed.org/cgi/eletters/5/2/146#5653, 26 April 2007.
  9. Edwards TD, Young R, Lowe AF. Caring for a surge of hurricane Katrina evacuees in primary care clinics. Ann Fam Med. 2007;5(2):170–174.[Abstract/Free Full Text]
  10. Gavagan TF. Ongoing disaster response preparedness concerns post-Katrina [eletter]. http://www.annfammed.org/cgi/eletters/5/2/170#5585, 4 April 2007.
  11. Higgins W. Lessons from the JPS model [eletter]. http://www.annfammed.org/cgi/eletters/5/2/170#5568, 2 April 2007.
  12. Hick JL. The power of primary care [eletter]. http://www.annfammed.org/cgi/eletters/5/2/170#5507, 28 March 2007.
  13. Burkle FM. Exposing vulnerabilities: primary health care and surge capacity [eletter]. http://www.annfammed.org/cgi/eletters/5/2/170#5492, 27 March 2007.
  14. Coyne JC. Disseminating misleading information about major depression in primary care [eletter]. http://www.annfammed.org/cgi/eletters/5/2/126#5576, 4 April 2007.
  15. Gaynes BN, Rush A, Trivedi M, et al. Major depression symptoms in primary care and psychiatric care settings: a cross-sectional analysis. Ann Fam Med. 2007;5(2):126–134.[Abstract/Free Full Text]
  16. Keller PA. Performance feedback holds promise for integrating evidence-based tobacco treatment into family practice [eletter]. http://www.annfammed.org/cgi/eletters/5/2/135#5636, 23 April 2007.
  17. Wadland WC, Holtrop J, Weismantel D, Pathak P, Fadel H, Powell J. Practice-based referral rates to a tobacco cessation quit line: assessing the impact of comparative feedback vs general reminders. Ann Fam Med. 2007;5(2):135–142.[Abstract/Free Full Text]
  18. James PA, Li P, Ward M. Myocardial infarction mortality in rural and urban hospitals: rethinking measures of quality of care. Ann Fam Med. 2007;5(2):105–111.[Abstract/Free Full Text]
  19. Longenecker R. Rural contributes to the quality discussion [eletter]. http://www.annfammed.org/cgi/eletters/5/2/105#5527, 28 March 2007.
  20. Vinson DC. Thanks for a careful analysis of a challenging topic [eletter]. http://www.annfammed.org/cgi/eletters/5/2/105#5624, 14 April 2007.
  21. Oliver MN. Risk adjustment: old methods must change [eletter]. http://www.annfammed.org/cgi/eletters/5/2/105#5583, 4 April 2007.
  22. James PA. Author’s response [eletter]. http://www.annfammed.org/cgi/eletters/5/2/105#5587, 6 April 2007.
  23. Frosch DL, Krueger P, Hornik R, Barg F, Cronholm P. Creating demand for prescription drugs: a content analysis of television direct-to-consumer-advertising. Ann Fam Med. 2007;5(1):6–7.[Abstract/Free Full Text]
  24. Stange KC. Time to ban direct-to-consumer prescription drug marketing. Ann Fam Med. 2007;5(2):101–104.[Free Full Text]
  25. Kellerman R. AAFP supports improvement, not ban, on direct-to-consumer prescription drug ads. Ann Fam Med. 2007;5(2):180–181.[Free Full Text]
  26. Alevizos AG. Effects of DTC advertising [eletter]. http://www.annfammed.org/cgi/eletters/5/1/6#5630, 17 April 2007.
  27. Noon S. Creating new patient population [eletter]?? http://www.annfammed.org/cgi/eletters/5/1/6#5477, 21 March 2007.
  28. Frey JJ. Selling drugs [eletter]. http://www.annfammed.org/cgi/eletters/5/1/6#5245, 11 February 2007.
  29. Shropshire JH. Disappointment with AAFP leadership on direct to consumer ads [eletter]. http://www.annfammed.org/cgi/eletters/5/2/180#5503, 27 March 2007.
  30. Rafool G. Direct to consumer ads are a disgrace to medicine [eletter]. http://www.annfammed.org/cgi/eletters/5/2/101#5509, 28 March 2007.
  31. Hallgren JD. Dissenting opinion [eletter]. http://www.annfammed.org/cgi/eletters/5/2/101#5646, 23 April 2007.
  32. Mahoney MC. Mahoney MC, Verma P, Morantz S. Research productivity among recipients of AAFP foundation grants. Ann Fam Med. 2007;5(2):143–145.[Abstract/Free Full Text]
  33. Longo DR. Building research capacity in family medicine: various strategies are required [eletter]. http://www.annfammed.org/cgi/eletters/5/2/143#5658, 30 April 2007.
  34. Diamond JJ. An enviable record [eletter]. http://www.annfammed.org/cgi/eletters/5/2/143#5655, 28 April 2007.
  35. Rosemann T. Grant programs for general practice in Germany [eletter]. http://www.annfammed.org/cgi/eletters/5/2/143#5649, 24 April 2007.
  36. Askew D. What counts when you measure research productivity? [eletter]. http://www.annfammed.org/cgi/eletters/5/2/143#5633, 17 April 2007.
  37. Krist AH, Woolf SH, Johnson R, Kerns J. Patient education on prostate cancer screening and involvement in decision making. Ann Fam Med. 2007;5(2):112–119.[Abstract/Free Full Text]
  38. Pignone MP. The effect of a decision aid on patient participation in decision making [eletter]. http://www.annfammed.org/cgi/eletters/5/2/112#5571, 2 April 2007.
  39. McNutt R. Shared decision making [eletter]. http://www.annfammed.org/cgi/eletters/5/2/112#5581, 4 April 2007.
  40. Fiscella K, Franks P, Srinivasan M, Kravitz R, Epstein RM. Ratings of physician communication by real and standardized patients. Ann Fam Med. 2007;5(2):151–158.[Abstract/Free Full Text]
  41. Mauksch LB. More questions than answers—evidence of study value [eletter]. http://www.annfammed.org/cgi/eletters/5/2/151#5617, 14 April 2007.
  42. Carney PA. Important standardized patient research [eletter]. http://www.annfammed.org/cgi/eletters/5/2/151#5494, 27 March 2007.
  43. Fiscella K. Unique perspective of standardized patients [eletter]. http://www.annfammed.org/cgi/eletters/5/2/151#5517, 28 March 2007.
  44. Howley LD. Trained evaluators increase validity of outcomes [eletter]. http://www.annfammed.org/cgi/eletters/5/2/151#5535, 29 March 2007.
  45. Werner RM, Asch D. Clinical concerns about clinical performance measurement. Ann Fam Med. 2007;5(2):159–163.[Abstract/Free Full Text]
  46. Milstein AS. Rather than deemphasize measures, measure what’s important [eletter]. http://www.annfammed.org/cgi/eletters/5/2/159#5542, 29 March 2007.
  47. de Brantes FS. Measuring the hard way [eletter]. http://www.annfammed.org/cgi/eletters/5/2/159#5504, 27 March 2007.
  48. Bennett IM. Quality measures may require more time [eletter]. http://www.annfammed.org/cgi/eletters/5/2/159#5498, 27 March 2007.
  49. Haidet P. Jazz and the ‘art’ of medicine: improvisation in the medical encounter. Ann Fam Med. 2007;5(2):164–169.[Abstract/Free Full Text]
  50. Graffam B. Metaphors we learn by [eletter]. http://www.annfammed.org/cgi/eletters/5/2/164#5579, 4 April 2007.
  51. Stange JP. Supportive communication: doctors are the band as well as improvisers [eletter]. http://www.annfammed.org/cgi/eletters/5/2/164#5547, 1 April 2007.
  52. Longenecker R. Improvisation and a seventh competency [eletter]. http://www.annfammed.org/cgi/eletters/5/2/164#5529, 28 March 2007.




This Article
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PubMed
Right arrow Articles by Stange, K. C.

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