Adviser to family doctors lists points of advice

Attendees at the 2012 AAFP Scientific Assembly work on convention evaluations.
Attendees at the 2012 AAFP Scientific Assembly work on convention evaluations. (RYAN S. GREENBERG/ Staff Photographer)
Posted: October 21, 2012

An estimated 10,000 family physicians gathered in Philadelphia this week to fulfill their annual continuing medical education requirements by attending lectures on everything from acne to vertigo.

While the convention, sponsored by the American Academy of Family Physicians, was aimed at the professionals, Friday's session by Frank J. Domino had plenty of nuggets for anyone who has ever gotten sick or tried to avoid it. In other words, everyone.

Domino, a family physician at the University of Massachusetts Medical School in Worcester, specializes in helping primary-care doctors stay abreast of good practices based on the latest research. He edits and writes for familydoctor.org and other informational resources.

His talk was billed as "a review of new data that will change your practice," but it could have been called "well-intentioned things family doctors do that are actually ineffective, outdated, or potentially harmful."

A huge example: overprescribing antibiotics.

This problem is well-known. It's a major reason that pneumonias, tuberculosis, and sexually transmitted diseases are becoming resistant to antibiotics.

And yet, Domino said, one in every five children leaves a doctor's office with an antibiotic prescription.

Prescribing "azithromycin for earaches is my pet peeve," he said. "It is not the drug of choice; not even close. But parents love it because it's once a day for five days."

Even if the appropriate antibiotic is prescribed, a review of studies found that antibiotics were no better than observation in terms of children's recovery from earaches, and did not reduce eardrum perforations or repeated infections.

Indeed, almost a quarter of antibiotic prescriptions were for upper-respiratory infections that are not treatable with those drugs, one study found.

Instead of antibiotics, Domino said, consider probiotics - dietary supplements containing "good" bacteria. A 2009 study of preschoolers in day care found that compared with a placebo, twice-daily probiotics reduced episodes of fever, runny nose, cough, and courses of antibiotics.

Here is more of his sometimes unconventional wisdom:

A shot in the arm

Tdap, a booster vaccine against tetanus, diphtheria, and pertussis, is recommended for adolescents and adults, including pregnant women, because protection from childhood vaccination wanes. But surveys show that only about 8 percent of adults have gotten Tdap - a big reason whooping cough, or pertussis, is making an alarming, and deadly, comeback.

Another underused vaccine prevents rotavirus, the leading cause of potentially lethal diarrhea and dehydration in infants worldwide. The shot "could save 65,000 hospitalizations and countless ER visits," Domino said. "That's breathtaking."

Just say it: Obese

Doctors don't like saying that word any more than patients like hearing it. But treating obesity-related chronic illnesses including heart disease, diabetes, and back pain "won't help as much as losing weight," Domino said.

Studies also show that the best way to help fat kids lose weight is to teach parents to feed the whole family better - a trickle-down diet.

On a yummier note, studies have linked frequent chocolate consumption to lower weights and lower heart disease risk.

Mishap waiting to happen

Before U.S. laws required the use of seat belts and raised the legal drinking age, motor vehicle accidents were the leading cause of accidental death. Now, it's opioid pain meds. (Think Percocet, OxyContin, etc.)

Originally marketed as "safer" than other prescription painkillers, opioids make patients "hypersensitive to pain," so they need higher doses, which too often leads to abuse and addiction, Domino said.

Bottom line: Doctors should be penurious with that prescription pad.

Sleep on it

Sleep apnea - abnormal pauses in breathing during sleep - is now linked to heart disease and other ills, not to mention snoring and sleepiness. But diagnosing and treating it has become such a big industry that most people have heard of CPAP machines - gizmos that use mild air pressure to keep airways open.

If the patient's apnea isn't severe, Domino advocates a cheaper, lower-tech treatment: an acrylic "appliance" that looks like a mouth guard. "You can buy it online," he said, "with a money-back guarantee, for $60."

What's the risk?

Critics say the development of drugs to treat fill-in-the-blank (high cholesterol, low bone density, insomnia, bad moods) has led to the "medicalization" of many conditions that are within the norm.

To help put risks in perspective, Domino recommends certain online question-and-answer risk assessment tools. Qintervention.org, for example, calculates the individual's chance of diabetes, heart disease, or stroke over a decade, and shows how it could change with smoking cessation, losing weight, lowering blood pressure, or taking cholesterol-lowering statins. (It also shows unintended effects of statins.)

Screaming for screening

Domino concurs with the federal panel that last year ignited a firestorm by recommending against prostate cancer screening with the PSA blood test. It doesn't save lives, and it often leads to unnecessary treatment that causes impotence or incontinence.

But colon cancer screening is beneficial: "Colonoscopy cuts the chance of colon cancer death by 15 percent," he says.

Of course, the test is also invasive and unpleasant. As a fallback, he said, "testing three stool samples is helpful if you do it every year."

Humor him

A British Medical Journal study that compared the IQs and grip strength of some orthopedists and anesthesiologists found that the bone-and-joint fixers are superior. OK, the study was a spoof, playing on the stereotype of the strong but stupid orthopod. "I've had lots of knee surgeries," Domino said. "It's an inside joke."

Not funny? Check out this YouTube animation, "orthopedics vs. anesthesia" at www.philly.com/ortho.


Contact Marie McCullough at 215-854-2720 or mmccullough@phillynews.com.

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