The amazing, expanding primary-care visit
In 1992, researchers and government agencies added the detection of a host of medical and social ills to the agenda of the primary-care visit.
During a year when physicians were often in doubt about whether they would be reimbursed for comprehensive patient examinations, new scientific evidence showed that such primary-care evaluations can have a major impact on the incidence and outcome of leading killers, such as heart disease, cancer and stroke.
In 1992, striking benefits were revealed for a thorough physical, life-style and laboratory check on the patients least likely to receive one-healthy adults.
To aid prevention of heart attacks, a National Institutes of Health consensus panel recommended that all patients receive at least two routine HDL checks, with appropriate risk counseling for all patients in whom the ratio of total cholesterol over HDL tops 4.5.
The NIH panel stopped short of recommending triglyceride screening for everyone, but new data from Finland demonstrated the importance of lipid-lowering efforts in men with triglyceride levels over 203 mg/dl and LDLlHDL ratios greater than 5. At the start of the study these men faced almost a fourfold risk of heart attacks, but their risk was reduced 71 % after treatment with gemfibrozil.
The wisdom of cajoling nonathletic patients into moderate exercise, such as gentle bicycling, gardening or golf, was confirmed in a nine-year British study of 7,735 healthy middle-aged men. Those who exercised moderately had less than half the stroke rate of their inactive counterparts. Exercise also reduced blood pressure and blood coagulability.
On this side of the Atlantic, analysis of the Physicians’ Health Study showed that a weekly workout reduced the risk of non-insulin-dependent diabetes by 23%, with those exercising five or more times a week showing a 42% reduction.
In light of new data from Hawaii on the reduction of disease risk in patients who successfully quit smoking-quitting cuts lifetime lung cancer risk by 75% and helps prevent several other cancers-physicians were asked to become familiar with the most effective smoking-cessation programs.
This year, physicians could add pharmacologic aids to behavioral smoking-cessation strategies. Several nicotine patches were available. In a study from Creighton University in Omaha, Neb., the antianxiety agent buspirone boosted short-tel111 quitting rates from 50% to 79% and was associated with less recidivism at one year.
Obesity experts, while recognizing individual responsibility for controlling weight, nevertheless announced that it is the duty of the primary-care physician to warn patients about the health risks of obesity. And the information must be specific, according to Theodore Van Itallie, M.D., professor emeritus at St. Luke’s-Roosevelt Hospital Center in New York.
He wants physicians to heed a patient’s family history (obesity-related diseases such as diabetes, gallbladder disease, hypertension, hypercholesterolemia and heart disease) as well as body shape (fat in “pot bellies” has more of an impact on lipid and insulin metabolism than fat in hefty hips and thighs). Even more: A physician must work in concert with dietitians in order to guide the patient, not just take the “easy way out” and make a referral to a commercial program.
Recognizing that primary-care doctors represent the first line of defense against illness, several agencies called on the physicians to sharpen their lookout for medical and social problems that often reach debilitating proportions before they are diagnosed. Counseling sexually active patients continued to be a high priority, and family physicians learned that it is not just naive, but statistically a poor bet, to assume that teenage patients are not sexually active.
After a study revealed that most persons with dystonia consult between four and 25 different doctors prior to diagnosis, advocacy groups asked generalists to pay more attention to signs and symptoms of movement disorders.
In early 1992, an NIB panel issued guidelines asking primary-care physicians to improve skin examinations in order to detect melanomas earlier. And monitoring for cutaneous signs of Lyme disease is not enough following a tick bite; Denver physicians suggested prophylactic antibiotics in some endemic areas.
In January, Surgeon General Antonia Novello, M.D., asked primary-care physicians to routinely check patients for signs of abuse. The American Medical Association followed up last summer with specific protocols to help doctors detect signs of abuse in children, women and the elderly. At the October meeting of the American Academy of Family Physicians, attendees were told to use medical clues-such as frequent sprains-to identify the estimated one in six patients with an alcohol or substance-abuse problem.
So 1992 was a year for primary-care physicians to be acknowledged for their special role in protecting the health of patients-even while many feared for the health of their medical practices.