In This Issue: Many Arrows Rather than Magic Bullets

If we were to be reflective and honest about the pathways between medical interventions and patient outcomes, we would diagram many arrows between the intervener, the intervenee, multiple intermediate steps, and the desired (or sometimes unintended) outcomes. Each of the articles in this issue of Annals show that paying attention to these many arrows is likely to be more helpful than putting on blinders and wishing for magic bullet solutions to complex problems.

A theory-based interactive multimedia computer program designed to improve colorectal cancer screening and its sociopsychological antecedents is evaluated by Jerant et al in a clinical trial in a multiethnic sample.¹ The intervention improves colorectal cancer knowledge, efficacy, readiness, the specificity of patients’ test preferences, amount of discussion and recommendation—everything except colorectal cancer screening rates. This study shows the challenges of achieving the desired outcomes even with a tailored intervention strategy, and even when all the steps in the causal chain, as is it understood, are successfully taken.

One of the many steps in implementing guidelines for statin use is identifying not only hyperlipidemia, but also cardiovascular risk. A study by Johansen and colleagues shows that undervaluation of cardiovascular risk appears to be a reason for apparent under use of statins.² These findings are relevant to discussion about the recent American College of Cardiology / American Heart Association guidelines.^3–6 This article is featured as the Annals Journal Club selection.⁷

Multiple facets of medication taking for coronary artery disease are examined in a systematic review and qualitative synthesis by Rashid et al.⁸ The study points to different arrows on the cause chain in medication adherence, from patient self-perceptions and disease understanding, to communication and relationships with clinicians, to care transitions.

A cluster randomized trial among 3 practice-based research networks teases out the individual and conjoint effects of practice facilitation and learning collaboratives, added to performance feedback and academic detailing, in helping primary care practices to implement asthma guidelines.⁹ The findings show the helpful effects of practice facilitation.

In addressing familial illness, knowing the family medical history is an important first step. A prospective study by Emery et al finds strong performance characteristics of a family history screening questionnaire for cancers, diabetes, and heart disease familial risk.¹⁰

An approach for contextualizing research, practice, self-care, caregiving, and policy for people living with multiple chronic conditions is elucidated in a policy article written by a diverse group of stakeholders from government and private organizations, and including patients, caregivers, researchers, clinicians, and policy makers.¹¹

Another special article addresses the challenges of guidelines for people with multiple chronic conditions, summarizing recent policy work by the US Department of Health and Human Services and the Institute of Medicine.¹²

An article by Phillips et al provides a role definition for family physicians that encompasses complex tasks and meaningful relationships.¹³

Three essays address different aspects of the pathways between medical interventions and patient outcomes. Elwyn shows how clinicians can draw upon principles from both shared decision making and motivational interviewing to provide patient-centered care across the spectrum of health care issues.¹⁴ A heartening essay by Colgan puts a face on the “poetry of the commonplace” that sustains and nourishes a physician’s love of medicine.¹⁵

Finally, in this issue we launch a new occasional feature edited by Rob Williams. This inaugural Point / Counterpoint feature examines the question “Do clinical guidelines still make sense?” Basing their answers in part on 4 articles in this issue that examine various aspects of clinical guidelines,^1,2,9,12 Upshur and Sox provide provocative new insights into when and how guidelines may be relevant to improving patient care and outcomes.^16,17

We welcome your reflections at AnnFamMed.org.

• © 2014 Annals of Family Medicine, Inc.