PrimeCuts: This Week in the Journals

September 28, 2009

sealions21Daria B. Crittenden MD

Faculty Peer Reviewed

While health care reform is being hotly debated around the country, one aspect of reform on which most people can probably agree is that better preventive care would benefit us as individuals and as a society. The literature this week echoes this theme of preventive care.
The most recent Annals of Internal Medicine features an article investigating how often young adults utilize the primary care outpatient system and if they receive appropriate preventive care. This study looked at cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to characterize the ambulatory care of non-pregnant young adults, ages 20 to 29. This group has a high prevalence of substance abuse, psychological distress, sexually transmitted diseases, and motor vehicle accidents. According to the article, approximately one third of young adults are uninsured. Perhaps not surprisingly, young men in this age group had fewer visits to the doctor than adolescent boys or older men. They also had fewer visits than young women in the same age range (1.10 versus 2.31 annual visits per capita), with young black and Hispanic men having the fewest visits. The study found that only 30.6% of doctors’ visits by young adults included preventive counseling, with significantly less counseling directed toward mental health, sexually transmitted diseases, and injury prevention [1]. Under-reporting of counseling may be an issue, but the study nonetheless suggests that opportunities for preventive care are being missed.

At the other end of the age spectrum, the September edition of the Archives of Internal Medicine looked at physical activity in the very old to see if this had a survival benefit. This study was an 18-year longitudinal cohort study looking at 1861 subjects in Jerusalem from the ages of 70 to 88 years of age. There was a distinct mortality benefit in subjects who were active versus those who were sedentary. Adjusting for risk factors, the hazard ratios for mortality at ages 70, 78, and 85 were 0.61 (95% confidence interval 0.38-0.96), 0.69 (95% confidence interval 0.48-0.98), and 0.42 (95% confidence interval 0.25-0.68) respectively. Being active was defined as engaging in physical activity for at least 4 hours a week, with some participants participating in vigorous sports at least twice weekly or simply engaging in more regular activity such as our-hour daily walks. The beneficial effect of physical activity was not dose-dependent, so even a modest goal of at least four hours a week of activity may benefit those over 70 [2].

Looking at a population seen more commonly in internal medicine practices, the most recent Circulation featured an article investigating the relationship between the metabolic syndrome, inflammation, and the development of symptomatic peripheral artery disease (PAD). The study used C-reactive protein (C-RP) and intercellular adhesion molecule-1 as markers for inflammation. This was a prospective cohort study looking at 27,111 women over the age of 45 who participated in the Women’s Health Study. The authors found that the metabolic syndrome was associated with a modestly increased risk of symptomatic PAD – adjusted hazard ratio 1.48 (95% confidence interval 1.01 to 2.18). They postulate that this may be mediated by inflammation, given the significantly higher levels of C-RP and intercellular adhesion molecule-1 in subjects with the metabolic syndrome [3]. More data are needed to understand this possible mechanism and help patients successfully modify their risk of disease.

Even closer to home, JAMA featured two articles addressing primary care physician well-being and internal medicine resident fatigue and distress, both of which may affect patient care. We are all aware that there has been a decrease in graduates entering primary care and attrition among current providers. Burnout may be a factor. An article by Michael Krasner et al studies whether a continuing medical education program that teaches primary care physicians about mindfulness, communication, and self-awareness could improve physician well-being, reduce distress and burnout, and improve capacity to relate to patients. Mindfulness can be loosely defined as being “present in the moment.” Seventy primary care physicians in Rochester, New York, enrolled in the study, which consisted of an 8-week intensive phase (2.5 hours per week with a 7-hour retreat) followed by a 10-month maintenance phase (2.5 hours per month). The average number of hours attended was 33.6 out of a possible 52 hours. Sessions included didactic material, meditation, and use of written narrative and group discussions to promote communication and reinforce positive experiences. Mindfulness and other outcomes were measured by surveys throughout the study. Participants showed improvements in mindfulness with decreased burnout, and reported improvements in mood, conscientiousness, and emotional stability. These benefits were sustained over the duration of the study period [4]. The personal significance and long-term sustainability of these changes for the individuals who participated is difficult to characterize. A benefit of such training among a larger physician population, and the feasibility of such training, remains uncertain without further research. Nevertheless, this study does give us reason to pause and recall the old proverb physician, heal thyself.

Directly tying physician well-being to patient care, a study out of the Mayo Clinic investigates the association between fatigue and distress among internal medicine residents with rates of self-perceived major medical errors. This study followed 380 residents between 2003 and 2009, throughout which time the current work-hour regulations were in effect. Subjects completed quarterly surveys regarding self-assessments of medical errors, quality of life, fatigue, depression, and sleepiness. The investigators found higher rates of medical errors among those with greater fatigue (OR 1.14 per unit change in fatigue score, 95% confidence interval 1.03-1.16), and in those with components of distress such as burnout, depersonalization, emotional exhaustion, and depression. For example, residents with a positive depression screen were more likely to report having made a medical error, with OR 2.56 (95% confidence interval 1.76-3.72) [5]. The clinical significance of the self-reported medical errors is not elucidated in the trial, and the generalizability of these results to other residency programs is uncertain. Moreover, there may be overlap between fatigue and distress that makes the individual effects of these two commonplace entities difficult to assess. However, this study supports a hypothesis that many of us would probably believe from personal experience, which is that less stressed and better rested residents are less error-prone.

On an unrelated but important a public health note, the worldwide preparation for the swine flu was addressed in the news and the medical literature this week. This week’s Science documents the major vaccine program against H1N1 influenza already underway in China. As of mid-September, doctors, nurses, border staff, and the military have started to receive the vaccine, with school children coming next. Chinese authorities have 650,000 doses on hand already. They expect 7 million more by the end of the month, 50 million more by mid-October, and 18 million a week after that, with the hope of vaccinating a majority of their 1.3 billion people [6]. In the US, the effort is not far behind. One aspect of the vaccine effort in the US that is still up for debate, as reported in Nature Medicine is whether to allow adjuvants to be added to the vaccine to boost vaccine effectiveness. This could help stretch the vaccine supply, as lower doses may be required to achieve an adequate response. The European Medicines Agency appears poised to approve adjuvanted vaccines soon. The FDA is awaiting results from two trials using adjuvants, which should be available in late September or early October, to help make its decision [7]. Stay tuned. While efforts at mindfulness or decreased fatigue may seem like elusive goals this fall, getting vaccinated against H1N1 should be possible for all of us.

Dr. Crittenden is a 3rd year internal medicine resident at NYU Medical Center.

Peer reviewed by Michael Tanner MD, Section Editor, Clinical Correlations

1. Fortuna RJ, Robbins BW, Halterman JS. Ambulatory care among young adults in the United States. Ann Intern Med. 2009;151:379-385. (http://www.annals.org/cgi/content/abstract/151/6/379)

2. Stessman J, Hammerman-Rozenberg R, et al. Physical activity, function, and longevity among the very old. Arch Intern Med. 2009;169(16):1476-1483. (http://archinte.ama-assn.org/cgi/content/short/169/16/1476?home)

3. Conen D, Rexrode KM, et al. Metabolic Syndrome, Inflammation, and Risk of Symptomatic Peripheral Artery Disease in Women. Circulation. 2009;120:1041-1047. (http://circ.ahajournals.org/cgi/content/abstract/120/12/1041)

4. Krasner MS, Epstein RM, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009;302(12):1284-1293. (http://jama.ama-assn.org/cgi/content/short/302/12/1284?home)

5. West CP, Tan AD, et al. Association of resident fatigue and distress with perceived medical errors. JAMA 2009;302(12):1294-1300.
(http://jama.ama-assn.org/cgi/content/short/302/12/1294?home)

6. Stone R. China first to vaccinate against novel H1N1 virus. Science. 2009 Sep 18;325(5947):1482 – 1483. (http://www.sciencemag.org/cgi/content/short/325/5947/1482)

7. Schubert C. Swine flu agitates the adjuvant debate. Nature Medicine. 2009;15(9):986-987. (http://www.nature.com/nm/journal/v15/n9/full/nm0909-986.html)

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