New Guidelines

The Problem: The experts have overbooked our time. In the area of prevention, if we complied with just the top 50% of proposed screening and prevention guidelines, we would have to spend 7.4 hours every day just to accomplish the tasks. In the management of just the top 10 chronic medical conditions (e.g., hypertension, diabetes, heart failure, asthma, etc.), given the current levels of relatively poor disease control, it would take another 10.6 hours per day. Thus the experts are obliging us for 18 hours per day BEFORE we even get to the chief complaint. This is a broken system, and it is no wonder that family physicians and others in primary care are experiencing disillusionment and burn-out.

The Solution: The physicians actually practicing on the front lines need to draft their own set of guidelines for management of all the common conditions. In this part of the web site, I am going to post my own suggestions, adding a new guideline suggestion each week. The unifying principles of my suggested guidelines are:

            1. The typical office visit is just too busy. When there is always too much to be done, nothing gets done.
            2. The 80/20 principle is the organizing principle for the solution. Across human endeavors it has been widely observed that approximately 80% of all your best results and accomplishments come from only 20% of your efforts. The intelligent response to this universal truth is simply to do more of that 20% that works and to drop as much of the 80% whose return is negligible.
            3. The human mind can only grapple efficiently with a limited number of elements at any one time. Thus the scope of each visit and the number of components for each element of the visit need to be limited in number. I propose a maximum of three major elements as the focus for each visit (e.g., a chief complaint and 2 chronic problems, or 3 chronic problems), and I propose a maximum of 7 descriptor items for each element.
            4. Conventional systems of medical documentation are poorly suited to the task. They tend to be linear and text-based only even in sophisticated electronic medical records. I propose that progress notes, the central blue print for each visit, be organized along the principles of Mind-Mapping--starting with a central image or symbol, and with radiant spokes from each to represent the essential features of care (up to 7 for each). See my examples on the "Note Templates" page. A small collection of images to represent the main points of focus for each visit is more efficient both for remembering your larger mission and for recording only the essential data.

New [4/13/2008] The only Cancer Screening Guideline You'll Ever Need. Do the informed consent right ONCE, and then just follow the plan. What intimidates every one about appropriate cancer screening is just having the (incredible complicated) discussion. This has led many to just screen without discussion, which I view as fairly barbaric and totally inconsiderate of patient respect and autonomy. The irony is that there is a very good answer out there (lifestyle) which is more effective than all the other technology put together and it barely requires any consent at all. Just document that your patient wants the most effective cancer preventive available. Consider the following documents to stimulate your own thinking.

New [4/14/2007] Atrial Fibrillation

    For the otherwise well patient (no major comorbid diseases) with stable vital signs, acceptable first line management need be no more elaborate than:
        1. Test for TSH: Hyperthyroidism is a major cause of atrial fibrillation. When atrial fibrillation is caused by hyperthyroidism, anticoagulation is not necessary if the hyperthyroidism is corrected.
                Note: It is not necessary to perform an echocardiogram. The size of the atrium does not correlated with ultimate rhythm or outcomes. There is no adequate evidence suggesting that a scan for thrombi is                       necessary, needs to be treated if present, or that such intervention improves ultimate outcomes.
        2. Establish rate control with either a beta-blocker or a calcium channel blocker.
        3. Perform thrombotic risk assessment. The easiest and most flexible form of risk assessment is the CHADS₂Score:

                        C: episode of CHF within 90 days (1 point)
                        H: any history of Hypertension whether on current treatment or not (1 point)
                        A: Age > 75 years (1 point)
                        D: Diabetes (1 point)
                        S2: any history of Stroke or TIA (2 points)

                                Classification of Risk is user-defined. I use 0-2 as LOW RISK; 3-4 as INTERMEDIATE RISK; and 5-6 as HIGH RISK, but you are free to set your own dividing lines between risk categories.

        4. Treat thrombotic risk according to risk classification:
                (a) LOW RISK: treat with ASA (325 mg qd)
                (b) INTERMEDIATE RISK: (following the British system) Let the patient decide for himself/herself upon appropriate discussion of risk and benefits of ASA vs. warfarin.
                (c) HIGH RISK: Recommend consideration of warfarin anticoagulation IF AND ONLY IF the patient has been adequately informed and makes a commitment to accept the costs and risk of warfarin anticoagulation.

5. Discharge patient home from the ED. Do not admit.
Note: Cardioversion is an ineffective treatment for atrial fibrillation with a 68% relapse rate in 6 months; there is no correlation between successful cardioversion and ultimate rhythm outcome or overall outcome.

    1. Get plenty of exercise
    2. Eat a high-fiber, lots of fruits and vegetables diet. Better yet, eat a Mediterranean Diet. (i.e. avoid dairy and red meat; eat plenty of grains, legumes & nuts, vegetables, fruits, fish, and monounsaturated cooking oils)
    3. Consume extra calcium.
    4. Consume a supplemental vitamin with folic acid.
            A report in the Journal of the American Medical Association cited a substantial benefit of folic acid in preventing colon cancer: among men who had taken folic acid supplements for 10 years there was a 25% reduction in colon cancer risk; among women who had taken folic acid supplements for 15 years there was a 75% reduction. [Fairfield KM. Vitamins for chronic disease prevention in adults: Scientific review. JAMA 2002; 287: 3116]
    5. Lead a healthy lifestyle as defined by not smoking, exercising, eating a Mediterranean diet, and consuming a little bit of alcohol daily. This has been shown to reduce your overall risk of cancer (not just colon cancer) by 50%. [See the Hale Study report on this site.]

6. Forget about Fecal Occult Blood Testing (FOBT), sigmoidoscopy, and colonoscopy.

Rationale: Colon cancer is eminently preventable. Lifestyle and diet will prevent 60-75%. So why do anything else? If you read the technology oriented American medical literature, you will discover that all of the rather elaborate programs cited by the United States Preventive Services Task Force (USPSTF) only can achieve a 33% reduction in your risk of dying of colon cancer with no reduction at all in your risk of dying at any given age (all-cause mortality). So why would any reasonable person want their doctor to insert multiple foreign objects (fingers and scopes) up their butts on a recurring regular basis to achieve a lesser result at considerably greater cost than lifestyle and diet? If you check with the "insiders" (physicians), you will find that they rarely comply with such protocols (and this is well-documented in the literature, but I challenge you to carry out a persona survey among the physicians you know). Generally, if the insiders don't want a product or service, the average consumer should stay away. When you compare the cost of something simple like folic acid ( < 1¢ a day) with its 25-75% risk reduction potential, why would you ever buy annual rectal exams and colonic endoscopy at 5-10 year intervals. The only logical reason that I can see is that patients are likely to have to pay for their own vitamins and diet (although not for exercise) when, if they have good insurance, they may have to pay nothing for repeated colonoscopies.
There is good reason to beware of the standard fecal occult blood testing recommendation (FOBT) which begins at age 50. Take a typical 50 year old man and his well-defined risk of colon cancer within a year is only 57 per 100,000 men. This is a pretty low risk. The FOBT test is not a very good test. It misses 66% of colon cancers present and is falsely positive in 2-10% of cases. When you're looking at a baseline risk of 57 per 100,000, the FOBT test is going to generate 2,000-10,000 FALSE positive results. Unfortunately, there is no adequate way of distinguishing the false positives from the true positives, so 2000-10,000 people out of every 100,000 screened have to undergo full testing with colonoscopy to complete the program. This causes a lot of lost time, discomfort, and time lost from work with little benefit. It is not a very rational bargain. There is so much confusion about the value of the various technological ways of screening for colon cancer that the USPSTF cannot even make a clear recommendation of any one over the others. The other major problem with the recommendations from the 'experts' is that there simply are not enough gastroenterologists to carry out the recommended endoscopic procedures on the entire population. Thus they end up getting reserved only for those with the best health insurance (who, as a matter of fact, are those at lowest risk of cancer).

    For those who feel they absolutely have to do something technological to the butt of the average patient, there are two major strategies worth considering:
        a. perform colonoscopy every 10 years (without any associated FOBT testing) until the patient has a life expectancy less than 10 years.
        b. perform colonoscopy once for every adult over the age of 50 years: This is an interesting strategy. This strategy makes concessions to real world obstacles like not enough health insurance dollars, and not enough gastroenterologists, and not a lot of patient interest in serial colonoscopy, which are all serious problems. In addition, it takes advantage of the scientifically sound "first pass" principle. The first time you carry out any screening intervention in a population who has not been exposed to the intervention before, you achieve your highest yield. Any subsequent colonoscopic screening will have far lower yields because the majority of colon cancers will have been detected on the first screening. This odd proposal is actually the most cost-effective of any of the technology-based proposals.

    1. For patients of all ages (0-∞) recommend adequate intakes of calcium, vitamin D, and exercise.
    2. Take an inventory of risk factors (or better yet have patients take responsibility and do it themselves online):
        a. small, thin frame
        b. Caucasian or Asian
        c. postmenopausal
        d. early, surgically-induced menopause
        e. take high-risk medications:
            i. thyroid hormone
            ii. immunosuppressive medications
            iii. systemic steroids
            iv. cancer chemotherapy
        f. diet low in dairy products or calcium supplements
        g. little regular exposure to sunlight
        h. lack of regular exercise
        i. smoking
        j. excessive alcohol use
    3. Conduct formal Osteoporosis Risk Assessment at regular health visits (q 5 years until 65, then annually):
        a. for patients at "high" risk prescribe (you guessed it--calcium, vitamin D, and exercise).
        b. for patients at "intermediate" risk prescribe calcium, vitamin D, and exercise
        c. for patients at "low" risk prescribe calcium, vitamin D, and exercise
        d. for patients with a confirmed history of fragility fractures, consider prescribing a bisphosphonate. Current data support risedronate as the most effective but the differences are relatively small. The effectiveness for preventing future fragility is only clearly confirmed for patients with previous fragility fractures and is only cost-effective for patients with previous fragility fractures. The use of bisphosphonates for patients who have multiple risk factors but no confirmed fragility fractures is not clearly effective (with the exception of patients on chronic steroid therapy). The benefit of bisphosphonates for patients with bone mineral density tests (BMD) < -2.5 Standard Deviations from the norm remains questionable and makes no sense if these patients are not already taking calcium, vitamin D, and exercise.

The recommended osteoporosis risk assessment instrument (oddly enough) is the Osteoporosis Risk Assessment Instrument (ORAI). A little known fact to most clinicians is that the United States Preventive Services Task Force does not specifically recommend Bone Mineral Density testing (BMD); they just mention it as one option. Another option that they specifically describe as well is the ORAI, a simple 3-item historical rule, which works as follows:

Rationale: Osteoporosis intervention has fallen victim to a typical American bad habit--it has been technologized. Most physicians act as though they don't have a clue in the world what to do to prevent osteoporosis without their trusty (revenue-generating) BMD machines. This is completely unnecessary. The decision to get a BMD should be a non-decision. Why do you need it? The ORAI above has 94% sensitivity for detecting osteoporosis (and this is good enough) and 41% specificity. Remember in this case our interest should be in sensitivity (we don't want to undertreat), not specificity (it is OK to overtreat as long as your treatment consists of calcium, vitamin D, and exercise). The only hard part about osteoporosis prevention is the decision whether to use bisphosphonates or not. To routinely use bisphosphonates in any context other than in the presence of documented fragility fractures goes beyond the current evidence and is not cost-effective. If you want to avoid the tough decision about whether to start bisphosphonates in a woman who has had no previous fragility fractures but has a BMD < -2.5 SD; the easy way out of this dilemma is just not to order the BMD test.

1. The common cold: Take care of it in 2 minutes or less. Face the reality--It doesn't matter what you do: Give a decongestant; don't give a decongestant. Give a cough syrup; don't give a cough syrup. Give an antibiotic; don't give an antibiotic. It simply doesn't matter. If a patient can identify something that works for them--use it (even if it is an antibiotic, as long as this is not occurring more than 2 or 3 times a year). The goal, of course, should be to avoid an antibiotic, but this is not the only goal. In the bigger picture, be mindful of the fact that colds are what bring patients into the office more than anything else. Hence, this is your opportunity to do those things that are important for health but which rarely get adequately attended to (e.g. prevention). Therefore, it is critical NOT to WASTE MUCH TIME on the issue of the cold. Get it over with so you can have the remaining 10-13 minutes to do something worthwhile. Except for the higher level opportunity presented, managing colds is not worthwhile. The problem with taking a lot of time to do the education about viruses and antibiotics are obvious: that you waste a lot of time, often without persuading anyone, both sides end up frustrated, and the patient often ends up 'dissatisfied.' The optimal way to manage the patient who truly believes that an antibiotic will help him/her when you don't is to use a "delayed prescription," which overall reduces the antibiotic usage by 50% (i.e., only 50% or less of such 'delayed prescriptions' ever get filled).

Rationale: While the experts have made us somewhat paranoid about how our use of antibiotic is responsible for the dramatic increase in antibiotic-resistant microorganisms, this is a bald-faced lie. The major contribution to increasing antibiotic resistance in primary care derives from chronic prophylaxis for otitis media, which does not account for a significant proportion of our overall antibiotic prescriptions. The reality is that the real culprits in our problem of increasing microbial resistance to antibiotics are those same very experts themselves--in the hospital. These are the folks who sit on the various hospital pathway committees for CAP and recommend not one superduper, killer IV antibiotic for every CAP patient, but two, when the literature actually suggest that a single, simple oral antibiotic will do fine. Don't let anyone lay the blame for the antibiotic-resistance problem on you. Choose instead to get something done during each visit for a cold. N.B. Furthermore, while the logic of increasing antibiotic resistance seems compelling as a likely cause of adverse outcomes in primary care outpatient work, there is, in fact, no outcomes based data that unequivocally demonstrate ill-effects to primary care patients. BACK

2. Otitis Media: The literature is now clear that reasonable treatment alternatives range from 0 to 7 days of antibiotics. Abundant literature now confirms that the expected benefit is that 1 out of 7 treated patients will have 24 hours less of symptomatic discomfort. While this rather small likelihood of benefit (~15%) may not seem like much to many physicians, it is, in fact, quite likely to seem significant to many parents, whose wishes should be respected. For the physician wishing to reduce overall antibiotic use in this setting, the strategy of using a "delayed prescription" can be expected to reduce antibiotic use by 50% among those given such a prescription. BACK

3. Sinusitis: Again the literature supports using a range of 0 to 7 days of antibiotics for an appropriate diagnosis of 'sinusitis'. The difficulty lies in defining what is an appropriate diagnosis. The general weight of the literature supports antibiotic treatment of sinusitis when there is prominent facial pain, significant systemic symptoms, persistent purulent discharge, or symptoms persistent for more than 7 days. There is need for either x-ray, CT imaging, or other laboratory tests for diagnosis of acute, uncomplicated sinusitis. Note: While much of the older literature has emphasized that sinusitis needs a prolonged course of antibiotics (14-21 days), this all comes from the ENT literature, where the entity they are treating is "chronic sinusitis," an altogether different disorder than we treat. Once again, for the patient who seeks treatment, the offer of a 'delayed antibiotic' is probably the optimal course. BACK

4. Conjunctivitis: Of course, you don't treat allergic conjunctivitis with antibiotics. One should only consider treating 'acute infective' conjunctivitis with antibiotics, and, even then, since we all know that the vast majority of acute infective conjunctivitis (> 90%) is viral, one should logically be hesitant. The truth is that we have no sensible way of distinguishing the appropriate candidate for antibiotic treatment ("acute bacterial conjunctivitis") from viral conjunctivitis because it is silly and wasteful to perform cultures, which do not even distinguish infection from colonization. Thus the definition problem for "conjunctivitis" is insuperable. You have to just settle for treating a syndromic presentation of acute onset, minimal discomfort, mild mucous discharge and morning crusting of the eyelids. An article recently reviewed in FP Revolution (Volume 1 No 8 2007) reaches a similar conclusion for acute infective conjunctivitis as for otitis media above--treatment appears to result in an approximately 3-7% chance of benefit (shorter duration of symptoms) with negligible impact on overall recovery. For this particular diagnosis there is a strong, quite irrational, pressure from the schools to treat with something. There is literature suggesting that saline drops are as effective as toradol drops in this setting, but there is no head-to-head study of saline against an antibiotic. Once again the likely optimal treatment is a 'delayed prescription' for a topical antibiotic for those who desire treatment either for themselves or their children. Note: There is a distinct entity of acute bacterial conjunctivitis, which can be quite serious, but fortunately is rare. Examples include ophthalmia neonatorum and contact-lens (or other foreign body) conjunctivitis. These you don't want to miss, but such cases will usually offer distinctive historical clues. [Make sure you take a history.] BACK

5. Purulent rhinitis: A recent review in the same issue of FP Revolution also concluded that there was approximately an 18% likelihood of benefit from treating acute purulent rhinitis (< 10 days duration) with antibiotics. This is more benefit than the previous literature had shown, which was characterized by conflicting results. The trade-off for this benefit was an approximately 46% greater risk of adverse effects from the antibiotics. Thus, in this case, as in all the others above, it's a consumer's choice (not the physician's). Again, the best way to please all parties is probably a 'delayed prescription' for an antibiotic after explaining the relative risks and benefits. Remember, in all cases, this (or any other) resolution should be reached quickly. Never waste more than 3 minutes on a cold. BACK

Bottom Line: The proper treatment of a first visit for either a cold or any of its common complications consists of:
        a. A 2-minute history and physical exam
        b. Either conservative treatment according to patient's preference or a 'delayed antibiotic.' (1 minute)
        c. For a second visit for any of these entities you will need to put your thinking cap on and give the patient's problem your full attention. All of the probabilities change by the time of a second visit.

7. Pneumonia: At any age the diagnosis of pneumonia is based on clinical findings without testing. Pneumonia should be diagnosed and treated with appropriate antibiotics (amoxicillin) when the following are present:
        a. fever (significantly above normal)
        b. tachypnea by age-defined norms
        c. the patient feels significantly unwell (or in the case of infants is not behaving normally for them)

    Rationale: There is no need for either blood tests (no CBCs, no cultures, no ESR/CRP) nor a chest x-ray. Chest x-rays can be negative in early bacterial pneumonia and can be positive in viral pneumonia where there is no point to treating with antibiotics. They simply don't help significantly (false positives will always outnumber true positives and sensitivity never approaches 100%). So why bother?
    The 'Holy Grail' in the clinical management of pneumonia is to distinguish bacterial pneumonia (which needs antibiotics) from viral pneumonia (which does not). The only problem is that this is impossible no matter either how clinically astute you are or how much technology you bring to bear. Since this distinction is not something that you can accomplish, your next highest imperative is to fail to accomplish it inexpensively rather than expensively. The outcomes will be the same in either case.
    The downside to this particular scheme is that you will likely overtreat some patients who do not have bacterial pneumonia with antibiotics. This will rarely cause significant harm and does not cost much (and costs nothing compared to all those chest x-rays and blood tests).
    The upside is that it doesn't matter and you have time on your side. Many physicians behave as though, if they don't get the diagnosis of bacterial pneumonia right at the time of initial encounter, their patient will die. Not true. Using the low cost tool of follow-up within 24-48 hours you can verify whether the patient requires antibiotics or not, if you're uncomfortable with you initial decision. If you have prescribed antibiotics initially, failure to improve then becomes a bona fide indication for a chest x-ray. (And this is the only indication for a chest x-ray for pneumonia.) For the patient whom you initially chose not to treat, if they seem sicker, then you can always start your antibiotic then.
    Note that recent studies have shown that the ultimate outcomes for amoxicillin-treatment of confirmed community-acquired pneumonia (CAP) are equal to treat with the newer super quinolones and/or super-macrolides. Recent studies have also made it clear that choosing the "wrong" antibiotic in the treatment of CAP makes no difference in ultimate outcomes. So don't waste the money for super-drugs.

    1: Non-pharmacologic treatment:
        A. Education: definition, prognosis, treatment goals.
        B. Rehabilitation:
            i. Physical therapy: ROM and muscle strengthening exercises for hip and knee.
            ii. Occupational therapy: joint protection, energy conservation
            iii. Aerobic exercise program
            iv. Orthotics as necessary (adapted shoes, assistive devices for ambulation, etc.)

    2: Assess eligibility for chronic NSAID therapy
        A. Risk factors for peptic ulcer bleeding:
                    ☐ age > 75
                    ☐ hx of PUD or GI bleeding
                    ☐ steroid therapy
                    ☐ serious systemic illness (CAD, DM, etc.)
                    ☐ anticoagulant therapy
                    ☐ treatment with low-dose ASA or other NSAID
                    ☐ frailty (age 65-75)

    3: Prescribe appropriate NSAID:
        A. For patients at low risk of peptic ulcer bleeding (PUB): any conventional NSAID
        B. For patients at high risk of PUB:
            i. Celebrex, or
            ii. conventional NSAID plus gastroprotective agent (GPA): misoprostol (600 mg/d) or proton pump inhibitor.

    4: Assess for response or side-effects: Switch to another NSAID or add a gastroprotective agent.
    5: Monitor for adverse effects on BP, cardiac function (CHF), kidney, or anemia.
                ☐ normal blood pressure
                ☐ no clinical evidence of CHF
                ☐ BUN, creatinine, albumin to calculate MDRD estimated GFR.
                ☐ normal Hemoglobin
                ☐ no effect on appetite or presence of epigastric pain

    6: If response is still inadequate, refer to specialist.

Rationale: Most of us just assume that without any effort we can manage osteoarthritis adequately. This is not the case. Just dismissing the patient with a prescription for an NSAID is not adequate. We can do better, and the secret of improvement is not very complicated. The point is to be very systematic. NSAIDs in chronic use, especially in the elderly, should be considered dangerous drugs, and the patient's status should be monitored carefully. BACK

New [1/30/07] Noncalcified, asymptomatic pulmonary nodules

1. Be very sure you need the chest CT scan before you order it.
2. For nodules < 4 mm, repeat CT at 12 months; if there are no changes on CT, you can and your patient can stop worrying about this.
3. For nodules > 4 mm but < 6 mm, repeat imaging at 6 to 12 months and again at 18 to 24 months if no changes.
4. For nodules > 6 mm but < 8 mm, repeat imaging at 3 to 6 months, 9 to 12 months, and 24 months if no changes. BACK

New [1/15/07] Benign Prostatic Hyperplasia (BPH):

   1. For all men with lower urinary tract symptoms, perform an AUA or IPSS Symptom Score. [See the web site link above.]
   2. Offer the patient initial treatment with a generic alpha-blocker and document the outcome on a serial symptom scores.
   3. If symptoms persist or progress, consider the addition of a 5-alpha-reductase inhibitor.
   4. Instruct patients on what to do if they ever have an episode of acute urinary retention.
   5. You do not need to perform any specific physical exam, blood testing, or urine testing unless either the patient requests it or the patient has atypical symptoms beyond those covered in the AUA score.
   6. Refer to a urologist for uncontrolled symptoms or recurrent acute urinary retention.
   7. Don't confuse the patient by bringing up prostate cancer screening issues during the evaluation of BPH symptoms. PSA testing has not been proven useful in the general population, and it has not been proven useful in this population, who will, of course, have a much higher rate of abnormal tests.
Rationale: Most men will get some degree of BPH symptoms, and their symptoms should be managed empirically, inexpensively with alpha-blockers first, and 6-alpha-reductase inhibitors only if symptoms do not satisfactorily improve. There is no necessary diagnostic work-up. The physical exam is unuseful. Appropriate empiric treatment requires no formal diagnostic testing either to rule-out or to rule-in other diagnoses. The most important thing you can do for your patient is to separate any concern about screening for prostate cancer (a very complicated and largely futile endeavor) from the simple task at hand which is to improve lifestyle by improving nuisance symptoms.    BACK

1. Diagnosis: The patient has low back pain if s/he says s/he has low back pain. Enough said. Low back pain is a syndrome, not an etiologic diagnosis. Specific etiology is unimportant, with over 90% of it being simply mechanical low back pain related to soft tissue changes. The only important question in the history relates to the frequency and results of prior episodes of acute low back pain (i.e., Has the patient missed a lot of work or school for this reason, or otherwise had to limit normal activities? Is this really a case of chronic low back pain in disguise?)

2. Testing: Imaging is only appropriate in patients with 'red flags'.

3. Red Flag checklist:
[] 1. Age > 55 years

4. Physical exam:
            [] forward bending ___ ^o
            [] effect on lordosis:     reverses   flattens         no change
            [] SLRT: - + at ___ ^o     R     L
            [] DTRs: KJ 0    +    ++    +++    R      L
            [] visible splinting/muscle spasm:   +   -
            [] location of greatest pain/tenderness:   ___________

5. Treatment:
    a. Reassure patient of very favorable prognosis:
        i. > 90% recover with no specific intervention or testing
        ii. even if a disk injury were associated, 99% will still recover with just conservative therapy.
        iii. There is no way that you ever want to refer a patient for back surgery.
        iv. For the rare case of no improvement after 6 weeks, we will re-evaluate at 6 weeks and test and refer as appropriate.

    b. Advise patient to stay as active as possible.
    c. Prescribe medication as needed to restore function [Note: If the patient bothered to come to your office, s/he is probably looking for something stronger than ibuprofen.]:
            i. acetominophen: presumably the patient will have tried this at home.
            ii. NSAIDs: Most patients will have tried this already, so be prepared to move to the next step.
            iii. Narcotic analgesics: Don't hesitate to prescribe a minor narcotic (Tylenol #3 or Vicodin) as needed for a short course (~ 2-6 weeks)--particularly so as you have verified in your history that this is NOT chronic recurrent low back pain.
            iv. Muscle relaxants: The specific indication for these is a report that they were very helpful to the patient in the course of a prior episode of low back pain. Otherwise all they do is put you to sleep while being generally less effective for pain than the minor narcotic analgesics.
    d. Advise against bed rest.
    e. Don't hesitate to recommend spinal manipulation or chiropractic for pain relief. [These patients have similar outcomes to patients treated medically only, but tend to have greater satisfaction with their care.]
    f. Don't waste your time or the patient's time with a recommendation for specific back exercises. Recommend for all patients always light to moderate aerobic exercise (i.e., walking).

RATIONALE: Despite the more than 1,000,000 pages of text and journals that have been written about this subject, I don't think there is any more than this that you have to use to manage your patients. Even here I have gone overboard with my 6-item physical exam. No part of the physical exam has ever been shown to make a difference with respect to outcomes. Keep it simple since it just doesn't matter that much. If mismanaged, it can be a terrible time waster for everyone. Remember that what you're trying to do is to screen out the patients who don't need back surgery (which is almost all of them). The main focus for the other red flags is an occult diagnosis of cancer, which will, of course, be embarrassing if you miss it, but won't make much difference in the long run (which will be short in these cases). The only real diagnostic imperatives in acute back pain are bacterial infection (discitis, osteomyelitis, abscess) or impending neurologic catastrophe (where again the prognosis is not great, but you don't want to be responsible for making it worse). Don't hold your breath while waiting to make these diagnoses in your practice. What I have described above allows you to be impressively efficient while being adequately systematic, which is as good as it gets.    BACK

1. Hypertension:
    A. Initial Diagnosis:
        1. 3 blood pressure measurements over 140/90 mm Hg on separate occasions.
        2. History: The only important part of the history is the 10-item Cardiac Risk Assessment Profile (age, gender, family history, smoking status, exercise status, diabetes, hypertension, high cholesterol, metabolic syndrome, and chronic renal insufficiency) or any other risk calculator like the Framingham equation. This will tell you the level of global risk for cardiac disease, which in turn will drive all the management decisions for high blood pressure. For high-risk individuals good, tight control of blood pressure is essential. For low-risk individuals there is a lot of time to tolerate modest elevations of blood pressure while focusing on lifestyle changes.
        3. Physical exam: Despite the exhortations of various experts to auscultate the heart, palpate pulses, listen for bruits, and peer deep into the eyes, there is only one important part of the physical exam: the Blood Pressure reading today.
        4. Labs: Hemoglobin, BUN, creatinine, albumin, and urinalysis.
        5. Other cardiac assessment: The determination of left ventricular mass and wall hypertrophy is useful prognostic information to indicate the need for aggressive management (if LVH is present) or non-aggressive management if it is not. For this purpose an echocardiogram is far more useful than an EKG. Not everyone needs this, and you certainly don't need both.
        6. Treatment: Treatment starts with a thiazide diuretic (12.5-25 mg).
        7. Other Treatment: The most important component of treatment is lifestyle management (the lifestyle triad: exercise, a Mediterranean diet, and not smoking).

    B. Follow-up Management:
        1. History: focus on exercise, Mediterranean diet, and smoking status.
        2. History: ask about medication side-effects
        3. History: review any changes in the coronary artery disease risk profile. Remember that it is the degree of global cardiac risk that is the most important aspect of management.
        4. Exam: measure the blood pressure carefully with proper equipment.
        5. Treatment: If blood pressure is less than 140/90 mg Hg, just return to the 'lifestyle trial'.
            If the blood pressure is greater than 140/90 mm Hg, add a second agent (an ACE-inhibitor is the best second line agent).
        5. Follow-up: See the patient again in 1 month if medication needs to be adjusted. Otherwise see the patient again in 3 months.
        6. Annual screening: Repeat the CAD risk profile. Labs: BUN, creatinine, and albumin to calculate the Modified Diet in Renal Disease measure of renal function (GFR). Either a total cholesterol plus HDL or a full lipid panel for the CAD risk profile. And a urinalysis.

Rationale: While most of us were trained to have a fear of malignant hypertension, fortunately there is not much of that around these days. The mild-to-moderate hypertension that we see (systolic blood pressures 145 to 200 mm Hg; diastolic pressures 91 to 110 mm Hg) has no urgency other than in individuals at high global risk of coronary artery disease events. Thus the management of this problem should not require a lot of time and attention. Focus on the minimal set of relevant criteria and move on to the patient's other concerns.

Hyperlipidemia: [This should really be understood as any lipidemia in high-risk patients.] The most cost-effective approach is to follow the principles of the British Heart Study. (See FP Revolution 1 No 1 2007)
        1. Calculate global cardiac risk (using the 10 basic risk factors, the Framingham equation, the New Zealand Heart Foundation guideline, or whatever your favorite cardiac risk calculator is).
        2. Decide where you will set your own cut-offs for low-risk vs. intermediate risk, vs. high-risk.
        3. Treat all high-risk patients with the highest tolerated dose of a statin forever (or until subsequent global cardiac risk assessments show that the patient is no longer in the high-risk group).
        4. Do not order serial lipid panels.
        5. Do not attempt to titrate the dose other than to increase it to the limit of tolerability.
        6. Perform global cardiac risk assessment at least once a year.

Rationale: There is no good evidence to support the NCEP's policy of testing and re-testing lipids with repeat dose titration until you reach certain arbitrary targets. The British Heart Study shows that just picking a dose and leaving it without further testing achieves as much benefit in high-risk patients as the NCEP approach with far less cost and trouble. BACK

Sore Throat:
1. History: Basic: All you need are the elements for the Centor rule--absence of cough, and you have to decide whether you want to consider a history of fever as one of the elements or prefer to use only measured temperature in the office.

Centor Criteria
        a. fever (102 ^o F. or higher)
        b. severe enlargement or exudate
        c. tender cervical lymph nodes
        d. absence of cough.

    2. Physical exam: size of tonsils and presence of exudate and size and tenderness of lymph nodes.
    3. Decision-making: Assign 1 point for each criterion that is present.
        a. for a score of 0-1 you don't need any testing and you don't need to treat. Just reassure.
        b. for a score of 3 or 4 you don't need any testing, but you should treat with penicillin (V-K) 500
            mg bid for 7-10 days.
        c. for a score of 2, consider testing and deferring treatment until the results are known.

Rationale: The entity of sore throat is no longer a big deal. The incidence of the rheumatic complications of strept infections has spontaneously declined dramatically, and the efficacy of treatment for the prevention of suppurative complications and glomerulonephritis is both unclear and low at best. The only etiologic agent of concern is strept. There is no perfect algorithm for identifying all infections caused by strept or for excluding all infections not caused by strept. No matter which strategy you choose--culture, rapid strept antigen, empiric, or a decision-rule--you will misclassify a number of cases. The good thing is that there is no evidence that this misclassification matters. Accordingly your goal should be to resolve the patient's visit to the doctor in the most expeditious and low cost manner possible. You should also strive for a high degree of consistency in your management approach no matter which strategy you choose to try to classify the etiologic organism. BACK

Diabetes: Diabetes is a major cause of heart attacks, death, and disability in the U.S. Its prevalence is increasing dramatically as the population gets both more overweight and older. Most of diabetes care gets rendered in primary care physicians' offices, where the doctors are very busy. To manage both diabetes and overall health well physicians must be prepared and systematic. I suggest the ABCDEF mnemonic to cover the basics adequately and consistently.

A: Review a hemoglobin A1C every 3 months. If the level is 7.0 % or less, continue what you're doing. If it is greater than 7, intensify lifestyle and medication therapy and recheck in 3 months.

B. Check the Blood pressure to be sure it is less than 135/85 mm Hg for diabetic patients. If it is greater than 135/85 mm Hg, intensify lifestyle and medication therapy and recheck in 1 month.

C. Cholesterol: Insure that the LDL cholesterol is < 100 mg/dL and that the patient is taking a statin medication. The lipid panel should be checked every 6 months.

D. "D" stands for the MoDifieD Diet in Renal Disease (MDRD) equation for the assessment of renal function. To calculate it you will need to check a BUN, creatinine, and albumin every 6 months. You have to monitor this continuously since a decline in renal function indicates a worse cardiac prognosis and because metformin (the most commonly used initial oral agent) is contraindicated in the context of significant renal impairment.

    E. Eye check up: All patients should be seen by an ophthalmologist within 6 months of the initial diagnosis of type 2 diabetes and then every 2 years thereafter unless directed otherwise by the ophthalmologist. The primary physicians job is three-fold:
            a. make the referral to ophthalmology (and don't bother wasting your time doing a funduscopic examination)
            b. make sure that the patient kept the appointment
            c. make sure that you have a copy of the report from the ophthalmologist.

F. Do a Foot exam: This requires sock off and is best incorporated into the nurse's routine when she assists the patient into the exam room. This does not need to be done every visit--once every 6 months is enough. It is not necessary to perform pulse palpation, Semmes-Weinstein monofilament testing, or reflex testing. All you need to do is the observe the foot for obvious breaks in skin integrity or severe fungal disease of the nails.

Rationale: There is obviously much more that can be done for patients with this complicated disease. The fact is, however, that just about every time a survey of care is conducted, the results show less than 50% compliance with the most basic aspects of care. The above guideline is a perfect example of the 80/20 rule. While these 6 aspects of care represent only about 20% of what could be done for diabetic patients, it can be done in under 10 minutes and will achieve for you and your patient 80% of the desirable results. BACK

The Assessment of Mental Status: The conventional mental status exam is very time-consuming and in routine use is not associated with any proven benefits. Therefore, when you want to assess a patient's mental status for the evaluation of either dementia or delirium, you want an instrument that is quick and efficient. The Six-Item Screening test (SIS) below is as efficient as you can get.

For the SIS, the patient is requested to repeat 3 random words and is then asked the year, month, and day of the week. One point is scored for each of 6 possible correct answers. A score of 4 or lower is considered consistent with impairment.

An alternative is the Mini-Cog test: The patient is requested to repeat 3 random words (1 point for each correct answer) and to complete a clock-drawing test. A score of 0, or a higher score with an abnormal clock drawing is positive for impairment.

When compared with the Mini-Mental Status Examination (MMSE), the sensitivity was 94% for the SIS and 75% for the Mini-Cog (specificities of 86% and 85%, respectively; negative predictive value 98% and 93%). Agreement with the MMSE was 88% for the SIS and 83% for the Mini-Cog. This is a much better return for the time taken than the MMSE.
[Source: Wilber ST et al. An evaluation of two screening tools for cognitive impairment in older emergency department patients. Acad Emerg Med 2005; 2005; 12: 612; Emerg Med Abstracts 2005; 11/05: #8]