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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Family history in practice
Teachable moment for genetics in family medicine
Family physicians and the "new" genetics
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Bernard Ewigman, MD, MSPH, Chicago, USA Professor and Chair, Dept of Family Medicine, The University of Chicago
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The study reporting family physician self-efficacy with screening for inherited cancer risk in the current issue of Annals led me to ponder my own practice experience. In my practice of 18 years I “regularly” composed genograms and found them quite useful. My practice partners at times found my habit amusing, and perhaps a bit academic. I say I used them regularly because that was my intention, but I know that a systematic chart review would have revealed that I was inconsistent in this habit. Was I deficient? Did I just need more training? As a clinical researcher and teacher of evidence based medicine in the other half of my time, I was reasonably on top of what I was “supposed” to be done when it came to clinical preventive services such as assessing family cancer risk. I just found it difficult. Here are a few reasons: 1) Many of the things I was supposed to do had nothing to do with why the patients’ came to see me or what my patients thought I was supposed to do. When squeezed, being patient centered trumped most other stuff. 2) I was squeezed a lot. There were always plenty of patients, phone calls to return and paperwork. 3) Sometimes I just forgot. 4) When my patients agreed that these “extras” like prevention were important too, and I took the time, and I remembered to think about what I knew needed to be done, there was one more barrier. I got punished. Not in any overt way; the punishment was more subtle, but powerful. My nurses gently chided me for keeping them late. My productivity figures would rank me as a suboptimal doctor, quietly embarrassing me in front of my colleagues. Our practice income dictated our financial viability, even in our community health center practice, where number of visits determined amount of subsidy. Training competent family physicians is essential. However, once trained, we need the time, the staff support, the information systems, and the incentives aligned with the performance expected Documenting our deficiencies is important. It is also important to understand that much of the shortfall in the delivery of clinical preventive services is a failure of system design and financial disincentives, not a personal shortcoming. Most importantly, we need to continue to create, demonstrate and evaluate innovative systems for integrating the delivery of clinical preventive services into primary care practice. Hopefully, the New Model described in the supplement to this issue of Annals, and colleagues who have already implemented such innovations in their practices, will help all of us get closer the kind of practice that will be better for our patients and for ourselves. Competing interests: None declared |
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Sean P David, Providence, RI, USA Assistant Professor of Family Medicine, Brown Medical School
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The article by Gramling et al (1) provides yet more evidence that while the knowledge and skill sets of generalist physicians on screening for inherited cancer risk are limited (2-4), generalist physicians are amenable to educational interventions aimed at improving such skills (5,6). We now know that minimal interventions such as sending educational booklets and pocket cards are effective in changing behavior and improving adherance to screening guidelines based on evidence from a randomized trial(6) and a non-randomized follow-up study(5). What's more, the article by Gramling et al. sheds light on one aspect of why generalist physicians might be able to adapt quickly to educational interventions. Social learning theory posits that behavior change is likely to occur if self- efficacy is improved through increases in positive outcome expectations(confidence)and reduction of perceived barriers to achieving the desired behavior and by gaining the perspective that such behavior change is consonant with social norms(7). Based on these results it seems an opportune time, indeed a teachable moment, in which to craft skill- based educational interventions and the computer-support systems to support them for the broader generalist physician community. Leaders in the primary care genetics community have already established core educational guidelines (8) and office systems for clinical implementation (9,10). Successfully disseminating these skills will require a major national effort and agreement on which screening guidelines to recommend. However, with the rapid pace of innovations in preventive genetics, pharmacogenetics, and pharmacogenomics generalist physicians now more than ever must be prepared to discuss and advise patients on genetics-based risk reduction. 1.Gramling R, Nash J, Siren K, Eaton C, Culpepper L. Family physician self-efficacy with screening for inherited cancer risk. Ann Fam Med. 2004; 2:130-132. 2.Emery J, Watson E, Rose P, Andermann A. A systematic review of the literature exploring the role of primary care in genetic services. Fam Pract. 1999 Aug;16(4):426-45. 3.Rose PW, Watson E, Yudkin P, Emery J, Murphy M, Fuller A, Lucassen A. Referral of patients with a family history of breast/ovarian cancer-- GPs' knowledge and expectations Fam Pract. 2001 Oct;18(5):487-90. 4.Walter FM, Kinmonth AL, Hyland F, Murrell P, Marteau TM, Todd C. Experiences and expectations of the new genetics in relation to familial risk of breast cancer: a comparison of the views of GPs and practice nurses. Fam Pract. 2001 Oct;18(5):491-4. 5.Lucassen A, Watson E, Harcourt J, Rose P, O'Grady J. Guidelines for referral to a regional genetics service: GPs respond by referring more appropriate cases. Fam Pract. 2001 Apr;18(2):135-40. 6.Watson E, Clements A, Yudkin P, Rose P, Bukach C, Mackay J, Lucassen A, Austoker J. Evaluation of the impact of two educational interventions on GP management of familial breast/ovarian cancer cases: a cluster randomised controlled trial. Br J Gen Pract. 2001 Oct;51(471):817- 21. 7.Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977 Mar; 84(2):191-215. 8.Burke W, Emery J. Genetics education for primary-care providers. Nat Rev Genet. 2002 Jul;3(7):561-6. 9.Emery J, Walton R, Murphy M, Austoker J, Yudkin P, Chapman C, Coulson A, Glasspool D, Fox J. Computer support for interpreting family histories of breast and ovarian cancer in primary care: comparative study with simulated cases. BMJ. 2000 Jul 1;321(7252):28-32. 10.Braithwaite D, Sutton S, Smithson WH, Emery J. Internet-based risk assessment and decision support for the management of familial cancer in primary care: a survey of GPs' attitudes and intentions. Fam Pract. 2002 Dec;19(6):587-90. Competing interests: None declared |
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June C Carroll, Toronto, Canada Associate Professor, Dept of Family Medicine, University of Toronto, Mount Sinai Hospital
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Gramling et al report survey results that most family physicians (87%) agreed that screening patients for inherited cancer risk was important to their practice but only 62% were confident of their own screening effectiveness.<1> A similar lack of knowledge and confidence in providing genetic services has been reported by Canadian physicians.<2,3> Qualitative research with Canadian family physicians found that participants were “anxious” and “overwhelmed” facing the challenge of genetic services, and that their “current knowledge and role in genomic medicine were both inadequate”.<4> In the discussion, the authors conclude that improving physicians’ self-efficacy in this area would lead to behaviour change. Self-efficacy is only one of the components of behaviour change. It is important to keep in mind that physicians have also expressed concern about the limitations of genetic testing and discomfort discussing genetic risk unless they can offer effective interventions.<4> The authors also comment on a previous finding that physicians were optimistic that their patients would increase preventive behaviour in response to findings of inherited cancer susceptibility. Physicians may be optimistic about this but Marteau and Lerman, in their review of the literature, found that screening among those with a family history of bowel and prostate cancer was below recommended levels and did not differ from those at average risk.<5> They report initial results that adherence to mammography recommendations did not improve after receiving positive BRCA1/2 testing results.<5> I agree with the authors’ conclusions that future research is needed into the most effective methods of supporting primary care physicians in integrating genetic services into their practices. References: 1. Gramling R, Nash J, Siren K, Eaton C, Culpepper L. Family Physician Self-Efficacy With Screening for Inherited Cancer Risk. Ann Fam Med 2004;2:130-132. 2. Bottorff, J.L., Blaine, S., Carroll, J.C., Esplen, M.J., Evans, J., Nicolson Klimek, M.L., Meschino, W., & Ritvo, P. (in review). The educational needs and professional roles of Canadian physicians and nurses regarding genetic testing and adult onset hereditary disease. Community Genetics (submitted December 2003). 3. Hunter A, Wright P, Cappelli M, Kasaboske A, Surh L. Physician knowledge and attitudes towards molecular genetic (DNA) testing of their patients. Clin Genet 1998;53:447-55. 4. Carroll JC, Brown JB, Blaine S, Glendon G, Pugh P, Medved W. Genetic susceptibility to cancer: Family physicians’ experience. Can Fam Physician 2003;49:45-52. 5. Marteau TM, Lerman C. Genetic risk and behavioural change. BMJ 2001;322:1056-9. Competing interests: None declared |
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