Table of Contents

The Issue in Brief

The Family Contribution to Health Status: A Population-Level Estimate
By Robert Ferrer, MD, MPH, and colleagues
Can family and community have a substantial influence on a person�s health? Yes, according to this study by Ferrer and colleagues. Based on the results of a telephone survey of 35,000 adults in 60 US cities, the study found that between 4.5% and 26.1% of individual health was influenced by the family. Aspects of the family environment can have positive or negative effects on health. These include quality of housing, neighborhood conditions, transportation, access to medical care, health beliefs and behaviors, physical environments, common stresses, and interpersonal relations.

Long Term Results From a Randomized Controlled Trial to Increase Cancer Screening Among Attendees of Community Health Centers
By Richard G. Roetzheim, MD, MSPH, and colleagues
As described in the November/December 2004 issue of the Annals, a system was developed to promote three cancer screening tests (mammograms, Pap smears, and fecal occult blood tests) in primary care clinics that serve disadvantaged patients. In this follow-up study, researchers found that after 2 years, the system had an ongoing, but modest, effect on screening for cancer. Patients who received care at a clinic using the system were up-to-date on a greater number of targeted screening tests and had 26% greater odds of mammography screening compared with other patients. The system still had an effect after 2 years, but the effect was less than it had been at 1 year. Further work is needed to develop longer term solutions.

Liability Implications of Physician-Directed Care Coordination
By Mark A. Hall, JD, and colleagues
Primary care doctors help coordinate and manage the care of their patients across different medical specialties and different types of treatment. Some doctors may be reluctant to take on expanded coordination of patient care for fear of increased exposure to medical liability. In fact, a representative sample of 1,238 practicing physicians found that almost one-half listed legal liability as 1 of the 2 main barriers to care coordination. In an article in this issue of the Annals, Hall and colleagues found no strong basis for these reservations; instead, they found that care coordination done well may lower liability risks. Liability insurers interviewed as part of the study were not reluctant to insure physicians who coordinate care for patients with multiple chronic conditions and did not have a strong tendency to view this role as having higher risk.

Outpatient Colonoscopy by Rural Family Physicians
By Robert J. Newman, MD, and colleagues
Colorectal cancer is the second leading cause of cancer deaths in the United States. Colonoscopy�a test that allows a doctor to look at the interior lining of the large intestine�can help detect colorectal cancer. Only a small percentage of eligible patients receive colonoscopies, however, in part because there are not enough medical professionals trained to conduct the procedure. This study found that colonoscopies can be performed safely and competently by properly trained family physicians in the outpatient setting. The study examined data from 2 family physicians performing colonoscopies. The physicians met or exceeded all of the target goals for high-quality colonoscopy examinations. Patients who had an office colonoscopy reported high levels of satisfaction with the procedure.

Office-based Unsedated Ultrathin Esophagoscopy in a Primary Care Setting
By Thad Wilkins, MD, and colleague
Ultrathin esophagoscopy is a new technology that allows physicians to view the patient�s esophagus. Because endoscope is thinner and more flexible, patients can be examined without sedation. This study finds that it is feasible for a family physician to perform unsedated ultrathin esophasgoscopy (UUE) in the office setting. Patients were willing to undergo the procedure, and most (95%) tolerated it; 90.6% of patients did not require further endoscopy after UUE. UUE could help in the diagnosis of diseases, such as Barrett�s esophagus. Such diseases are increasingly common as more people suffer from heartburn caused by gastroesophageal reflux disease (GERD). Further studies are needed to determine the utility, safety, accuracy and cost-effectiveness of UUE in primary care.

Transferrin Saturation, Dietary Iron Intake, and Risk of Cancer
By Arch G. Mainous III, and colleagues
In this study, the risk of developing cancer was increased in people with high levels of serum transferrin saturation, an indicator in those whose diets were high in iron intake (more than 18 mg of iron per day). No increased risk of cancer was found among those with high transferrin saturation whose diets were not high in iron. Simple dietary restrictions may help to reduce the cancer risk associated with high transferrin saturation.

Patients� Beliefs About Racism, Preferences for Physician Race, and Satisfaction With Care
By Frederick M. Chen, MD, MPH, and colleagues
Latino and black patients who perceive racism in the health care system prefer and are more satisfied with physicians from the same race or ethnicity. Analyzing a national survey of more than 3,800 blacks, Latinos, and whites, Chen and colleagues find that nearly one quarter of blacks and one third of Latinos prefer that their personal physician is of their same race or ethnicity. In turn, those patients who have racial preferences for their physicians are more likely to rate their physician highly if the physician is of the same race. Blacks who prefer a black physician and have a black physician are nearly 3 times as likely to rate their physician as excellent than are blacks who prefer a black physician and have a nonblack physician (57% vs 20%). Though not statistically significant, Latinos who prefer and have a Latino physician rate their physician higher than Latinos who prefer a Latino physician but have a non-Latino physician (40% vs 29%). These results suggest that addressing discrimination in the health care system, increasing access to minority physicians, and improving the ways patients can choose physicians may be effective ways to reduce inequalities in health care.

Opening the Black Box: Cognitive Strategies in Family Practice
By Robert E. Christensen, MD, and colleagues
This study analyzed the ways in which 18 family physicians make decisions during patient visits. The family physicians used specific, highly individualized, styles for structuring tasks. In addition, features of the decision-making behavior of family physicians were similar to those of expert decision makers in other fields. The authors call for tailoring practice improvement efforts to the different cognitive styles of physicians.

The Practice of Acupuncture: Who are the Providers and What Do They Do?
By Karen J. Sherman, PhD, and colleagues
Despite the growing popularity of acupuncture in the United States, little is known about acupuncturists� training or practice. A study of acupuncturists was conducted in 2 states, Massachusetts and Washington. The most common reasons for visiting an acupuncturist were musculoskeletal pain and headaches, although acupuncturists treated a wide range of other conditions. About one half of acupuncture patients were also being treated by a doctor; however, there was little communication between the acupuncturist and doctor. The authors recommend that doctors ask patients about the acupuncture treatment they are receiving.

Interpersonal Continuity of Care and Care Outcomes: A Critical Review
By John W. Saultz, MD, and colleague
Continuity of care�the ongoing relationship between an individual doctor and patient�is a core principle: of family medicine. A review of 41 existing research studies found that continuity of care is associated with improved preventive care and lower rates of hospitalization. A review of 20 studies found an association between interpersonal continuity and lower medical costs.

Screening for Primary Open-Angle Glaucoma in the Primary Care Setting: An Update for the U.S. Preventive Services Task Force Screening for Glaucoma: Recommendation Statement
By Craig Fleming, MD, and colleagues, and the U.S. Preventive services Task Force
Primary open-angle glaucoma is a leading cause of blindness and vision-related disability. Based on existing studies of glaucoma screening and treatment, the U.S. Preventive Services Task Force has updated its 1996 recommendations for glaucoma screening. They find that there is insufficient evidence to recommend for or against screening adults for glaucoma. A review of existing evidence found no benefit of early recognition and treatment of glaucoma in patients who weren�t showing symptoms. Moreover, the Task Force notes that the potential benefits of screening and treatment must be weighed against the known harms, which include local eye irritation and an increased risk for cataracts.
Ecological Change and the Future of the Human Species: Can Physicians Make a Difference?
By Roger A. Rosenblatt, MD, MPH, MFR
In this essay, a family physician calls for health care professionals to adopt an ecosystem health perspective�helping people avoid unwanted pregnancies, using resources wisely, staying engaged in the natural world�to help prevent the collapse of the biological systems upon which all we all depend.