Practical and Contextual Issues
===============================

* Kurt C. Stange

The *Annals* online discussion has brought out practical and contextual concerns about articles in the last issue.

## PRACTICAL ISSUES

The cost-effective analysis of expanded testing for primary HIV infection generated a call for consideration of practical issues.1,2 The time needed to discuss HIV testing during “the frequent (and often pleasingly quick) viral illness visit,”3 could result in difficult tradeoffs for the physician’s workday. Focusing on identification of patients with at least one specific behavior that constitutes a risk factor may be a partial solution.4

This discussion points out the need to consider the effect of new interventions on the totality of care provided. This includes the trade-offs in which additional interventions may bump other aspects of care off the agenda of patient visits, how the growing agenda for those receiving care may affect access to care for others with less entrée, and how the growing number of options for care affects the providers of care. Indeed, Sykes4 reminds us “that, in this time of limited resources, it is not enough to determine if a program or policy is cost-effective according to some arbitrary standard. To utilize limited resources effectively, what we must ask is, which policy is MOST cost effective?”

## JOURNAL CLUB

The value of a good estimate of the prevalence of primary HIV infection in symptomatic outpatients was appreciated by Buzanowska and colleagues,5 who raise a number of concerns about implementing testing for primary HIV infection in low-risk general population settings. What is remarkable about this thoughtful commentary is that it comes from a student-run journal club. The editors applaud the initiative of these students in carefully reviewing a research article and in submitting their commentary to the online discussion. We invite other student and resident journal clubs and other groups to discuss *Annals* articles and to share the results of their discussions.

## THE IMPORTANCE OF THE SYSTEMS AND CULTURAL CONTEXT

Prunuske6 highlights the need for reimbursement system changes if the benefits of patient-centered communication found by Epstein et al7 are to be feasible.

The article by Crabtree et al8 generated dissent over its “overly pessimistic”9 interpretation of the challenges of improving prevention in practice.10 Discussants identify the need for office systems to support prevention9,11,12 and the important effects of the larger health care system context.13

Richardson14 and Bope15 hope that information from an international comparison of treatment of pneumonia in nursing home residents16 may guide reconsideration of the currently more aggressive treatment in the United States.

Rose17 believes that the “paper by Walter and Emery18 is novel because it tackles these issues (genetic risk and patient understanding) together and within a primary care population.… (I)n the consulting room the medical and sociological aspects present together and are often indecipherably intertwined.”

Regarding obesity treatment, Scott19 identifies “the root causes of the US obesity epidemic. Those causes are societal and structural and require policy and legislative solutions. We will be doing a disservice to our patients if we focus only on treating individual obese patients and fail to use our medical knowledge to promote intelligent design of our work places and our communities, as well as some reasonable regulation of the food industry.”

## CHOOSING PATIENTS FOR TREATMENT

A meta-analysis in the last issue of the *Annals* showed the effectiveness of antidepressant medication in primary care patients.20 Two discussants point out the modest treatment effect (slightly more than one half of patients respond).21–23 They raise questions about which patients respond, how this can be predicted and augmented, and how systems can be designed to facilitate care in practice.

Regarding the systematic review that found no effect of metformin for treatment of obesity,24 Woliner presents a rationale for identifying a subgroup of insulin-resistant patients, and raises the hypothesis that they may benefit from metformin.25

## SURVIVORS OF CHILDHOOD SEXUAL ABUSE

Readers informed by experience called for clinicians to ask about childhood abuse in sensitive ways26–28 by asking “How has abuse affected your life?” rather than “Have you ever been abused?” The danger of re-traumatizing27 highlights the need for sensitivity. The presence of a number of chronic conditions and a mismatch between affect and situations may serve as red flags to identify potential abuse survivors.28,29

## THE GOOD AND BAD OF CONTINUITY

Readers from multiple countries continue to resonate with the international survey of the importance of continuity of care to family physicians.30–34

Another physician,35 prompted by Dr. Neher’s essay in the last issue of the *Annals,*36 was highly critical of the effect of his strong doctor-patient relationship on possibly delaying the revelation of the past abuse of one of his patients. Although this delay was found to be not unusual by a family therapist discussant,28 this physician notes that “sometimes the relationship itself can be a barrier.”

Please join this discussion at [http://www.AnnFamMed.org](http://www.AnnFamMed.org). Click on “Discussion of articles” or follow the links for the article on which you wish to comment.

*   © 2005 Annals of Family Medicine, Inc.

## REFERENCES

1.  Coco AS. Cost-effectiveness of expanded testing for primary HIV infection. Ann Fam Med. 2005;3:391–399.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzM5MSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Simmons EM, et al. Coco reply [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/400#3588](http://www.annfammed.org/cgi/eletters/3/5/400#3588), 23 October 2005.
    
    

3.  Steinberg JD. Unmentioned, practical issue regarding expanded HIV screening [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/389#3536](http://www.annfammed.org/cgi/eletters/3/5/389#3536), 29 September 2005.
    
    

4.  Sykes DL. A comment on the call for expanded testing [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/391#3561](http://www.annfammed.org/cgi/eletters/3/5/391#3561), 6 October 2005.
    
    

5.  Buzanowska K, et al. Journal club discussion on prevalence of primary HIV infection and the cost-effectiveness of expanded HIV testing [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/400#3572](http://www.annfammed.org/cgi/eletters/3/5/400#3572), 18 October 2005.
    
    

6.  Prunuske JP. Patient centered health policy [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/415#3551](http://www.annfammed.org/cgi/eletters/3/5/415#3551), 6 October 2005.
    
    

7.  Epstein RM, Franks P, Shields C, et al. Patient centered communication and diagnostic testing. Ann Fam Med. 2005;3:415–421.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzQxNSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

8.  Crabtree BF, Miller WL, Tallia AF, et al. Delivery of clinical preventive services in family medicine offices. Ann Fam Med. 2005;3:430–435.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzQzMCI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

9.  Dietrich AJ. Don’t throw out the baby with the bathwater [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/430#3576](http://www.annfammed.org/cgi/eletters/3/5/430#3576), 18 October 2005.
    
    

10. Taplin SH. What more have we learned [eletter]? [http://www.annfammed.org/cgi/eletters/3/5/430#3559](http://www.annfammed.org/cgi/eletters/3/5/430#3559), 6 October 2005.
    
    

11. Frame PS. Systems needed to facilitate preventive care [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/430#3548](http://www.annfammed.org/cgi/eletters/3/5/430#3548), 6 October 2005.
    
    

12. Parchman ML. Preventive services and family medicine offices: the dynamics of patient care [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/430#3534](http://www.annfammed.org/cgi/eletters/3/5/430#3534), 29 September 2005.
    
    

13. Dietrich AJ. Addendum to babies and bathwater [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/430#3578](http://www.annfammed.org/cgi/eletters/3/5/430#3578), 19 October 2005.
    
    

14. Richardson JP. Aggressive care for demented nursing home residents with pneumonia may not be effective [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/422#3553](http://www.annfammed.org/cgi/eletters/3/5/422#3553), 6 October 2005.
    
    

15. Bope ET. Treating terminally ill patients [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/422#3557](http://www.annfammed.org/cgi/eletters/3/5/422#3557), 6 October 2005.
    
    

16. Kruse RL, Mehr DR, van der Steen JT, et al. Antibiotic treatment and survival of nursing home patients with lower respiratory infection: a cross-national analysis. Ann Fam Med. 2005;3:422–429.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzQyMiI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

17. Rose PW. Better understanding of the patient perception of family history will improve care [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/405#3541](http://www.annfammed.org/cgi/eletters/3/5/405#3541), 30 September 2005.
    
    

18. Walter FM, Emery J. ‘Coming down the line’- patients’ understanding of their family history of common chronic disease. Ann Fam Med. 2005;3:405–414.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzQwNSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

19. Scott JG. Metformin for obesity [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/457#3539](http://www.annfammed.org/cgi/eletters/3/5/457#3539) , 29 September 2005.
    
    

20. Arroll B, Macgillivray S, Ogston S, et al. Efficacy and tolerability of tricyclic antidepressants and SSRIs compared with placebo in primary care treated depression. A meta-analysis. Ann Fam Med. 2005;3:449–456.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzQ0OSI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

21. Gallo JJ. Comments on Arroll et al [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/449#3527](http://www.annfammed.org/cgi/eletters/3/5/449#3527), 29 September 2005.
    
    

22. Barrett JE Jr. Comment on article by Arroll et al [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/449#3522](http://www.annfammed.org/cgi/eletters/3/5/449#3522), 29 September 2005.
    
    

23. Barbui C. Efficacy of antidepressants in primary care [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/449#3518](http://www.annfammed.org/cgi/eletters/3/5/449#3518), 29 September 2005
    
    

24. Levri K, Slaymaker E, Last A, et al. Metformin as treatment for overweight and obese adults: a systematic review. Ann Fam Med. 2005;3:457–461.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzQ1NyI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

25. Woliner KN. Choosing patients wisely [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/457#3546](http://www.annfammed.org/cgi/eletters/3/5/457#3546), 2 October 2005.
    
    

26. Lott J. Thank you [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/462#3595](http://www.annfammed.org/cgi/eletters/3/5/462#3595), 27 October 2005.
    
    

27. Tucker S. To tell or not to tell [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/462#3593](http://www.annfammed.org/cgi/eletters/3/5/462#3593), 27 October 2005.
    
    

28. Cole-Kelly K. Kudos to Dr Neher [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/462#3585](http://www.annfammed.org/cgi/eletters/3/5/462#3585), 21 October 2005.
    
    

29. Zink T. A reminder of what we know [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/462#3583](http://www.annfammed.org/cgi/eletters/3/5/462#3583), 20 October 2005.
    
    

30. Ramarao V. Re: the role of family practitioners [eletter]. [http://www.annfammed.org/cgi/eletters/3/4/353#3505](http://www.annfammed.org/cgi/eletters/3/4/353#3505), 7 September 2005.
    
    

31. Al-Yousifi KR. The role of family practitioners [eletter]. [http://www.annfammed.org/cgi/eletters/3/4/353#3503](http://www.annfammed.org/cgi/eletters/3/4/353#3503), 3 September 2005.
    
    

32. Daintree JLC. Surprise at the original question [eletter]. [http://www.annfammed.org/cgi/eletters/3/4/353#3490](http://www.annfammed.org/cgi/eletters/3/4/353#3490), 31 August 2005.
    
    

33. Taylor NA. Trust and personal relationship with GP is vital [eletter]. [http://www.annfammed.org/cgi/eletters/3/4/353#3488](http://www.annfammed.org/cgi/eletters/3/4/353#3488), 31 August 2005.
    
    

34. Alice S. Continuity of care [eletter]. [http://www.annfammed.org/cgi/eletters/3/4/DC1#3590](http://www.annfammed.org/cgi/eletters/3/4/DC1#3590), 23 October 2005.
    
    

35. Cronholm PF. Continuity of care and domestic violence [eletter]. [http://www.annfammed.org/cgi/eletters/3/5/462#3514](http://www.annfammed.org/cgi/eletters/3/5/462#3514), 27 September 2005.
    
    

36. Neher JO. The decade dance. Ann Fam Med. 2005;3:462–463.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy81LzQ2MiI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMy82LzU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)