In episode 427, James and Mike invite Mark McConnell back to the podcast to discuss the philosophy around how not to do what didn’t need to be done. You start with a differential diagnosis then think about what are the possible causes of this presentation? Next, is the patient a candidate for the end product (med/surgery/device) should a diagnosis be found and are they interested in it (their values and preferences)? Then consider the best test(s) to diagnosis it if the patient makes that informed choice.

Show notes

1) Do You Need That Test?

April 8, 2012 NY Times

2) Trends in Use of Medical Imaging in US Health Care Systems and in Ontario, Canada, 2000-2016

JAMA. 2019;322(9):843-856. doi:10.1001/jama.2019.11456

3) Toward a positive theory of consumer choice

Journal of Economic Behavior & Organization 1980;1:39-60

4) Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

JAMA Intern Med. doi:10.1001/jamainternmed.2019.1739

5) Treatment of Fatty Liver Disease—Time to Implement Common Sense Measures

JAMA Intern Med. 2019;179(9):1272-1273. doi:10.1001/jamainternmed.2019.2244

6) Competing demands and opportunities in primary care

Canadian Family Physician 2017;63:664-8

7) Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017

Mayo Clinic Proceedings 2019;94:1681-94

In episode 426, James and Mike discuss in a PREMIUM way the first large RCT of the polypill. This single pill version contained aspirin, atorvastatin, hydrochlorothiazide, and either enalapril or valsartan. Have a listen and find out what happened.

Show notes

Effectiveness of polypill for primary and secondary prevention of cardiovascular diseases (PolyIran): a pragmatic, cluster-randomised trial 

Lancet. 2019 Aug 24;394(10199):672-683. doi: 10.1016/S0140-6736(19)31791-X

In episode 425, James and Mike invite Samantha back again to talk about the evidence around the incidence of opioid use disorder that we cause by prescribing opioids. The key issue seems to be whether or not your patient has a history of substance abuse. 

Show notes

Tools For Practice

What is the Incidence of Iatrogenic Opioid Use Disorder?

In episode 424, James and Mike continue chatting with Samantha Moe about a number of useful studies in primary care. We talk about blood pressures in the elderly, negative urine cultures, melatonin and migraine, dementia and driving, and complementary health products for the common cold.

Show notes

Useful studies handout

In episode 423, James and Mike welcome Samantha Moe, a pharmacist and clinical evidence expert with the College of Family Physicians, to the podcast. We discuss studies on cannabis and risk of schizophrenia, the harms of PPIs, H pylori infections and duration of treatment, and blood pressure measurements over clothes or a bare arm.

Show notes

Useful studies handout

In episode 422, James and Mike, go MEGA-PREMIUM and discuss the most recent meta-analysis (yes, yet another one) around the use of statins in older people. We then quickly review an article that looks at whether or not the guidelines for monitoring chronic conditions in primary care are evidence based. We are “shocked” when we find out “There is no evidence to support frequency of testing of any test in any of the guidelines”.  

Show notes

1) Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials

Lancet. 2019 Feb 2;393(10170):407-415. doi: 10.1016/S0140-6736(18)31942-1

2) Are guidelines for monitoring chronic disease in primary care evidence based?

BMJ. 2019 Jun 13;365:l2319. doi: 10.1136/bmj.l2319

In episode 421, Mike and James discuss the best available evidence around the newer and typically more expensive iron formulations used for iron deficiency anemia. We find the newer iron formulations are inferior to older ferrous salts when it comes to treating anemia and the evidence that newer formulations have less adverse effects is at best inconsistent.

Show notes

Tools for Practice

Iron-ing Out the Wrinkles in Anemia Management

In episode 420, James and Mike welcome back Bruce Arroll to talk about approaches to how we should talk about, discuss, chart and treat mental health issues. We discuss avoiding psychiatric labels, consider giving transdiagnostic labels, and doing functional assessments around work, love, and play.

Show notes

1) Transdiagnostic Symptom Clusters and Associations With Brain, Behavior, and Daily Function in Mood, Anxiety, and Trauma Disorders

JAMA Psychiatry. 2018 Feb 1;75(2):201-9

2) The psychopathology of James Bond and its implications for the revision of the DSM-(00)7

Med J Aust. 2015 Dec 14;203(11):452-6.

3) Saving Normal: An Insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma and the medicalization of ordinary life

Psychotherapy in Australia, Vol. 19, No. 3, May 2013: 14-18

4) brucearroll.com

5) Reforming disease definitions: a new primary care led, people-centred approach

BMJ Evidence Based medicine doi:10.1136/ bmjebm-2018-111148 

FACT- work/love/play

Limit the problem focus

1) work – 1 to 10

2) love (friends) – 1 to 10

3) love (intimates) – 1 to 10 

4) love (family) – 1 to 10 

5) play  – 1-10

In episode 419, Tina, Mike and James finish talking about managing opioid use disorder in primary care.  We find that positive reinforcement and brief counseling can be of some value but not the opposite – we realize we should treat this in a similar way to a chronic condition. We also realize that the evidence around urine drug testing and contracts is at best confusing and very limited. 

Show notes

Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews

Can Fam Physician. 2019 May;65(5):e194-e206

Managing opioid use disorder in primary care: PEER simplified guideline

Can Fam Physician. 2019 May;65(5):321-330

In episode 418, Tina, Mike and James continue to talk about managing opioid use disorder in primary care. We talk about tools used for case finding and decide the POMI tool is the most useful. We also discuss whether or not tapering is useful and look at the naltrexone data.

Show notes

Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews

Can Fam Physician. 2019 May;65(5):e194-e206

Managing opioid use disorder in primary care: PEER simplified guideline

Can Fam Physician. 2019 May;65(5):321-330