Guest Blog: Morbidity

Dr. Ed Pullen is a family physician who practices at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog, DrPullen.com.

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When I was a first-year medical student, the term morbidity was brand new to me, and I have to say it seemed pretty simple to understand. Mortality is death or the rate of death from a given condition, and morbidity is all of the other negative aspects of a medical condition. Another definition is the rate of a specific disease in a given community. Still, as I have practiced medicine for 30 years now, I have come to have much more respect for this simple term, and all of its subtle and not so subtle aspects.

Almost every decision I make in the office every day is related to trying to minimize both mortality and morbidity, and at the same time almost every choice I make has the potential to cause morbidity and sometimes mortality. Nearly everything we do in life is really to improve our odds. We cross the street when the signal says Walk, knowing that the chances of being hit by an auto are much lower than if we cross when the signal says Don’t Walk. We brush our teeth twice a day to reduce our chances of having a cavity, but have no guarantee that we won’t need a filling at the dentist. We treat patients with acute appendicitis knowing that they are less likely to die of sepsis (mortality) or to have a long miserable hospitalization with intra-abdominal abscesses (morbidity) than if we choose not to subject them to surgery. Still, they could die of an anesthetic complication, but the overall odds favor appendectomy.

Frequently, though, the decisions are much less straightforward and more nuanced than the appendectomy example. The issues with PSA testing are really more about morbidity than mortality. Men seem to fear prostate cancer more than most other health concerns. PSA testing can clearly find and diagnose many asymptomatic prostate cancers. Unfortunately, it is becoming apparent that if there is any reduction in mortality from these early diagnoses, some would argue from this overdiagnosis, then it is very tiny. If you accept that there is not much reduction in mortality from PSA screening, then the issue boils down to morbidity. Is there more morbidity related to treatment of these cancers that were diagnosed long before they would ever become symptomatic, or is there more morbidity from the cancers after they become symptomatic that is avoided by pre-symptomatic diagnosis and treatment? The consensus of many experts is that there is more morbidity from the diagnosis and treatment, and that, therefore, we should not be doing PSA screening. We are likely causing more urinary incontinence, impotence, radiation therapy complications, and emotional angst of being a cancer patient by these pre-symptomatic diagnoses than we are avoiding morbidity from advanced prostate cancer.

Often the decisions faced by physicians and their patients are less dramatic but no less challenging. Look at acute sinusitis. There is a lot of evidence suggesting that acute sinusitis of less than 10 days' duration usually resolves without antibiotic therapy in about the same number of days and with about the same severity of symptoms as with antibiotic therapy. The morbidity related to an episode of acute sinusitis that has not been present long is therefore about the same with or without antibiotic therapy. Antibiotic therapy itself can lead to significant morbidity, both the individual treated and to the larger community. Antibiotic complications like C. difficile related pseudomembranous colitis is becoming more common and antibiotic resistant. So physicians face the challenge of convincing patients who have been treated for their sinusitis with antibiotics for years and usually get well within days of treatment (as they would usually without treatment) that they are better treated with saline nasal rinses, analgesics and tincture-of-time.

These are just a few of the issues we face daily in considering the morbidity of one choice vs. another. Really most of what we do deals with morbidity, not mortality. Maybe the MMWR has it right in calling their weekly newsletter the Morbidity and Mortality Weekly Report, and not the Mortality and Morbidity Weekly Report. Most important things first, right?

The difference between health care costs and investments

Now that the NFL lockout has ended, even sports fans can follow without distraction the ongoing spectacle of federal gridlock leading the government ever closer to defaulting on its more than $14 trillion in loans. With the abundance of fiery, uncompromising rhetoric and arcane terminology such as grand bargains, caps and balances, you may be forgiven for feeling, as I do, we are watching a rerun of the health reform non-debate in late 2009 and early 2010. Indeed, decisions over the next several days have almost as much potential to affect the quality of health care in the U.S., as funds for graduate medical education (and training of family doctors) are on the chopping block in proposals from both parties. While I hope that the advocacy efforts of primary care organizations and their supporters are enough to #SaveGME, the outcome is far from certain.

It's as good a time as any to discuss the difference between health care costs and investments. According to the Centers for Medicare and Medicaid Services (CMS), the U.S. spent $2.5 trillion on health care in 2009, or more than $8000 per person. But this figure doesn't distinguish spending that resulted in health gains from spending that did nothing to improve health. To be fair, no one's really sure how many health care dollars are wasted, beyond administrative costs, but considering how many Americans are overtreated, it could easily run into the hundreds of billions. Whether in the form of payments for bogus preventive health screenings or unproven coronary CT scans, those wasted dollars are the "costs" of health care, money that pays salaries and makes profits for groups providing the services, but doesn't help anyone live longer or better.

In contrast, I think of health care "investments" as spending that actually reduces morbidity and mortality. For example, family medicine professor Steven Woolf has previously made the strong case that although few clinical preventive services save money, the vast majority of screening and counseling interventions recommended by the U.S. Preventive Services Task Force offer excellent value for every dollar spent. Similarly, programs that produce primary care physicians (threatened by current deficit-reduction plans) are good investments because study after study has found that areas with stronger primary care workforces have better health outcomes.

Public health spending, which the nonprofit Trust for America's Health reported has been falling since 2008, is another neglected budget item where modest investments result in large health gains. A recently published study in Health Affairs found that between 1993 and 2005, each 10 percent increase in local public health spending led to reductions in mortality between 1 and 7 percent. The authors put these figures in context:

Achieving this same mortality reduction by increasing the number of primary care physicians would require an additional twenty-seven physicians in the average metropolitan community, based on a recent analysis of physician supply. Increasing the physician supply by this amount would probably require new spending considerably in excess of the amount needed to achieve the mortality reduction through public health spending.

Unfortunately, essential investments in primary care and public health are likely to become casualties of budget cuts - if not directly through federal funding of graduate medical education, indirectly through the further tightening of already strapped state budgets. Meanwhile, thanks in large part to misguided advocacy groups, patients will continue to get their ineffective PSA tests, Provenge for prostate cancer, and Avastin for breast cancer. And policymakers will keep scratching their heads and wondering why U.S. health care costs so much and yields so little in the way of improvements in health.

Reasons to visit U.S. News & World Report's "Top Doctors"

If you've been reading this blog for long, you are probably aware of my skepticism about health care rankings in general, whether these rankings are of hospitals, medical schools, or doctors. Staying true to form, I would advise you to take with a grain of salt U.S. News & World Report's just-released Top Doctors, which purports to identify the top primary care and specialist physicians across the U.S., based on a peer nomination process.

Still, it's well worth visiting the Top Doctors page to read some excellent patient-oriented pieces on "How to Find the Right Doctor," "How to Maximize a Doctor Visit," and "9 Signs You Should Fire Your Doctor," which include advice from me as well as prominent health experts such as Dr. Carolyn Clancy, my former boss at the Agency for Healthcare Research and Quality. Finally, you can also check out my latest Healthcare Headaches blog post on "Decoding Doctor-Speak: Translations of Common Medical Terms."

Preparing for bioterrorism and other medical emergencies

In the aftermath of 9/11 and the anthrax attacks of 2001, the journal American Family Physician published a review article on "Recognition and Management of Bioterrorism," recognizing that primary care clinicians would be on the front lines of any future bioterrorist attack. Other critical resources for physicians and patients now include the Centers for Disease Control and Prevention's Bioterrorism resource page, the MedlinePlus collection on Biodefense and Bioterrorism, and the American Academy of Family Physicians' Preparedness Manual for Disasters and Public Health Emergencies.

Although the unpredictable threat of bioterrorism can seem distant from day-to-day practice, Drs. Mark Harris and Kevin Yeskey remind us in an editorial in the July 1st issue of AFP that primary care clinicians continue to play a "vital role" in protecting all Americans from the consequences of these attacks:

The first diagnosis of anthrax in the 2001 attack was in an emergency department. A salmonella outbreak in Oregon in 1984 that was later found to be bioterrorism-related was discovered after primary care physicians reported to their health department large numbers of patients with diarrhea who had eaten at two local restaurants. This type of passive surveillance is the early warning system for naturally occurring outbreaks, and for bioterrorism events. An astute physician who diagnoses a reportable illness and alerts the local health department may be detecting a bioterrorism attack, possibly saving his or her patient and many others.

Additional free AFP online resources to help physicians and other health professionals prepare for a variety of natural and man-made medical emergencies include a clinical review of emergency preparedness in office practice and a Curbside Consultation on professional training for emergency situations.

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The above is a slightly edited version of a post that was originally published on the AFP Community Blog.

Common Sense Family Doctor Turns Two: Top Posts

On Sunday, Common Sense Family Doctor will celebrate its second birthday! Many thanks to those of you who have been reading this blog since my very first post, as well as those who started reading sometime along the way. As an early birthday present for both groups, here is a look back at 10 "top posts" that have attracted the most all-time page views to date.

1. The meeting that wasn't, and a surprise announcement (November 1, 2010)

2. Family medicine leadership (October 19, 2010)

3. "Preventive health screenings" that are hardly a Life Line (February 7, 2011)

4. 4 reasons not to be screened for lung cancer (January 13, 2011)

5. PSA testing: will science finally trump politics? (February 28, 2011)

6. Outsiders' perspectives on primary care (May 31, 2010)

7. Spain: an unlikely primary care model for the U.S. (August 14, 2010)

8. "Politics trumped science": the stories behind the sound bite (January 17, 2011)

9. Book Review: "Overdiagnosed" and the paradox of cancer survivorship (April 12, 2011)

10. Direct primary care: health reform's missing piece? (November 18, 2010)

In addition, here are the top 5 most-viewed posts for my Healthcare Headaches blog at U.S. News and World Report:

1. Health reform: 4 changes to expect at your doctor's office (August 23, 2010)

2. Thinking of trying a low-carb diet plan? 3 things to consider (September 28, 2010)

3. Healthy habits are hard to maintain - even if you know what lies ahead (January 27, 2011)

4. Food-borne illnesses still a threat, despite new food safety law (February 23, 2011)

5. A doctor's practical guide to prescription drugs (March 30, 2011)

Finally, I recently launched a Facebook fan page, which you can "Like" in order to follow and comment on new posts to Common Sense Family Doctor, Healthcare Headaches, and the AFP Community Blog.

Guest Blog: Advocacy groups threaten evidence-based guidelines

Josh Freeman, MD is Chair of the Department of Family Medicine at the University of Kansas School of Medicine. The following is an excerpt from a post first published on his blog, Medicine and Social Justice.

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Two recent “Commentaries” in the same issue of JAMA address different challenges to the implementation of evidence-based practice guidelines. One, “Direct-to-consumer cardiac screening and suspect risk evaluation,” addresses the challenges posed by the potential for profit that occurs when companies market screening tests directly to the consumer (DTC) that may not be indicated, may not be indicated for the people who it is marketing to, or may even be harmful to the recipients of such screening. This harm can be physical, as in untoward events, or in risks inherent in the further procedures for those who “screen positive” but turn out to have been “false positives.” The harm is also financial, for there is a cost to doing these tests – to the individual (sometimes) or to their insurer; in the latter case, whether that insurance is public (e.g., Medicare, Medicaid) or private, the cost is to all of us. And, of course, that cost is the reason for such marketing, as it is what translates into profit for the company selling the test.

In the case of cardiac screening, Lovett and Liang, using the recommendations of the US Preventive Services Task Force (USPSTF), the American Heart Association/American College of Cardiology Foundation (ACCF/AHA), describe heavily-marketed tests that can cause more harm than benefit to the many people who are not in the narrowly-targeted group for whom the tests are indicated; other tests which have valid indications although, again, in the appropriate populations; and finally tests for which there is little or no evidence. The marketing of these tests can incur anxiety or fear in people who have no reason to be worried about these conditions and may occur outside the physician-patient relationship, thereby not allowing people to get the physician’s analysis of the results even when the test is indicated, and cost a great deal of money. This is particularly true when a possibly-positive test needs to be followed up with a number of other tests to rule it out, this time covered by insurance. They make several suggestions for how DTC companies should be regulated. They conclude that, “DTC cardiac testing may pose more harm than benefit to many consumers. Oversight efforts are needed to protect the public from inappropriate testing and to ensure that the health care dollar is spent on care promoting health in an evidence-based fashion.” I would say that is a mild suggestion!

The issue raised by the other article is probably more insidious; because it lacks the obvious profit motive present in DTC marketing, we may be less wary. In "Health advocacy organizations and evidence-based medicine," Sheila Rothman examines the tendency for groups created around a single disease (e.g., breast cancer, epilepsy, autism, etc.) to push for screening tests, diagnostic tests, and treatments for “their” disease whether or not there is evidence to support their use. In response to an Institute of Medicine (IOM) survey that sought to identify what tests and treatments should be included in a basic benefits package, “They contended that EBM [evidence-based medicine] should serve merely as an aid in medical decision making, not as the basis for it. Outcome data, they insist, should not limit patient choice or restrict available services.”

This is truly remarkable. These groups are basically saying “our disease is so important we should screen everyone, everyone who screens positive should have diagnostic tests, and everyone who has it should be able to get any treatment that they want, even if there is weak or no evidence for its efficacy. And, of course, someone else should pay for it.” This would probably be unreasonable if there was only one such disease, but there are hundreds and each is the “most important” for its advocacy organization. The reason that this is more insidious is that these groups are not seeking to make a profit on these tests and treatments (usually); they are (usually) functioning as advocates for people who are truly suffering. However, the fact that people are suffering does not mean that society should screen large numbers of low-risk people for all of these conditions.

Sometimes, advocacy groups may have a financial interest in a test or treatment, but even when they do not, they may push for policies that allow physicians to prescribe expensive brand-name drugs even when generic drugs have not been tried. Or they may demand the availability of expensive but unproven treatments: “’Autism Speaks’ criticized insurance companies that refused to pay $300,000 for 4 years of applied behavior analysis therapy for toddlers, despite a lack of evidence of effectiveness.” That is a lot of money even if we know a treatment is effective, but it is an awful lot when we do not. The issue is that this organization is focused only on people with “its” disease, and has no concern for what the money could otherwise be used for to treat other people with proven therapies. Maybe this is their role, but there is no reason that the rest of society must buy into this logic.

Cancer, of course, has the strongest set of advocacy organizations. In this context, the Food and Drug Administration recently approved several new drugs for metastatic prostate cancer. The cost can be over $90,000 for each treatment cycle and might exceed $500,000. In the June 28, 2011 NY Times article, “New prostate cancer drugs extend lives but raise costs”, Andrew Pollack notes that Medicare is going to look into whether to pay for these drugs, but that “…some patient advocates and politicians portrayed the review as a step toward rationing.” Excuse me? Don’t we already have rationing based on whether or not one has money or insurance? It is not okay for “patient advocates” to advocate for some people to get any kind of treatment paid for by someone else (e.g., Medicare) when everyone who has that medical need is not able to get care. And since there will be more things to spend money on than there is money, there needs to be a more rational system than “Me first!” This system is the use of evidence-based guidelines.

Rothman concludes her commentary: “However valuable independent advocacy organizations are for a democratic society and however important their services provided to targeted populations, their advocacy positions and the related underlying assumptions must be scrutinized with the same diligence as those of other stakeholders. There should be no automatic assumption that all health advocacy organizations deserve special standing or represent the common good.”

And for good reason - because they probably do not.

How politically unpopular research helps us make better medical decisions

When a new drug goes on the market for, say, diabetes, doctors are typically bombarded by advertising messages that promote it. Patients may see television commercials touting the new drug’s advantages over older ones and advising them to "talk to your doctor" about obtaining a prescription. But since the U.S. Food and Drug Administration only requires drug companies to prove that new drugs work better than placebos (sugar pills), there’s often little or no reliable information about whether a new drug is actually an improvement over existing therapies.

How, then, can a doctor like me make good choices about which treatment to give each patient? To provide answers, last year's health reform law devoted billions of dollars over the next decade to "comparative effectiveness" research, or research that directly compares different tests and treatments to determine which are better at improving health in particular groups of patients.

Funding for comparative effectiveness studies was recently targeted for budget cuts by politicians who argue that such research may limit patients' treatment choices and lead to the withdrawal of insurance coverage for drugs that are found to be costly or ineffective. In reality, however, that’s not necessarily the case. For example, when the FDA recently concluded that the cancer drug Avastin does not help patients with breast cancer (and often causes serious side effects such as bleeding, heart attacks, and heart failure), officials were quick to assure the public that the Medicare program will continue to pay for it anyway.

What has been lost in the political debate is the value of comparative effectiveness studies in helping doctors and patients make better treatment decisions. For example, the Effective Health Care Program at the Agency for Healthcare Research and Quality (AHRQ), which sponsors comparative effectiveness research for many conditions that I commonly treat among my patients, recently published a patient-friendly guide to medicines for type 2 (adult-onset) diabetes that clearly spells out the advantages and disadvantages of the many drugs available to lower blood sugar. Patients can read this guide online or print out a copy to take with them to their doctor. (Full disclosure: I am a former employee of AHRQ, but was not involved with this program.)

Also, in a 2009 study published in the Archives of Internal Medicine, Mayo Clinic researchers concluded that a "decision aid" for patients with diabetes based on a previous version of the AHRQ medication guide improved patients' knowledge and involvement in their care. This decision aid consisted of six flash cards containing basic information about the effects of five types of diabetes drugs on weight change, blood sugar levels, side effects, and ease of use (when to take it and how often blood sugar testing is required).

In a highly charged political environment, it’s tempting to score points (and scare patients) by falsely equating comparative effectiveness research with “rationing.” But I believe that the valuable information obtained from this research, rather than restricting patients' treatment options, will instead empower them and their doctors to make better decisions about their health care.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Doctors, don't "dispense as written"

I've always favored prescribing generic drugs over handing out brand-name samples, since the latter, while initially "free" for patients, can actually be less effective and cost them more money in the long run. In fact, the only patient for whom I can remember routinely writing "Dispense as Written" (forcing the pharmacy to dispense the brand-name drug rather than the generic) on prescriptions was a special case: she insisted that I do so, because she believed that the brand-name worked better for her condition than the generic did. (And she may very well have been right, although she would have been a rare exception to the rule that generics are therapeutically equivalent to the brand-name drugs they replace.)

In an excellent story published in yesterday's Washington Post, however, health columnist and fellow Georgetown faculty physician Ranit Mishori reports that up to half of U.S. doctors prescribe brand-name drugs because they erroneously believe that generics are less effective, costing the U.S. health care system up to $8 billion per year. And that's only the cost savings associated with the differential in drug prices, which, in the case of the cholesterol drug Zocor (generic name: simvastatin), can be nearly $400 per month. Mishori goes on to write:

But the cost benefits may run deeper, because several studies also show that patients taking generics are more likely to take them properly. According to [Harvard Medical School professor William] Shrank, patients paying more for pharmaceuticals are “less likely to take their medication” as prescribed. Financially burdened by the cost of their drugs, they are more likely to skip doses so that their drug lasts longer, to cut the pill in half or, when they see the price rung up at the checkout counter, to leave the pharmacy with no medication at all. “And that,” he says, “is bad for clinical outcomes.” And expensive, too, when you consider the added burden to the system of people unwell because they are priced out of the medications they require.

The importance of mentors in family medicine

Saying that my medical alma mater, NYU School of Medicine, isn't known as a school that produces family physicians is a gross understatement. Actually, it routinely ranks last in the nation in the number of students matching to Family Medicine residency programs. My class of 2001, which sent 4 students to such programs, was a one-time aberration.

So how did I get started in family medicine? I give a great deal of credit to the Reading Hospital and Medical Center, which allowed me to do an elective rotation in their residency program from June through July 2000. But what inspired me to look into family medicine rotations in the first place? I recently came across a 13-year old letter I wrote to my cousin's husband (then a family medicine resident training in Minnesota) that gives part of the answer, and speaks to the vital importance of finding mentors for medical students who are interested in primary care careers.

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November 15, 1998

Dear Daniel,

I hope that life in Minnesota has been treating you well! So far I have been enjoying the second year of medical school at NYU. The classes have been much more interesting than last year’s, and while I still have a long way to go, I’m slowly beginning to believe that I might someday know enough to take care of patients.

Last month we had a speaker come to talk about rotations and residencies in Family Medicine, and that made me wonder how you were doing. Is this the first or second year of residency? How do you like it? How many years are left to go? Where (geographically and what kind of community) do you plan on practicing after it’s over?

Since I haven’t even started my clerkships, I don’t really know which field interests me most, but since NYU doesn’t have a Department of Family Medicine, I thought it might be a good idea to gather information from outside sources that I know I can trust. I’ve spent several summers working with children, so the natural choice would seem to be pediatrics, but I would love to hear your perspectives on taking care of families while raising one of your own.

Have a wonderful holiday season, and best wishes to you and the kids.

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Thank you, Dan.

Malpractice reform: unfinished business

In this week's Journal of the American Medical Association, cardiologist Peter Kowey, MD describes a case in which a young athlete sees him for a second opinion after a single episode of presyncope. Despite extensive cardiovascular testing that found no evidence to suggest that this young man had an increased risk of sudden cardiac death, another cardiologist had nonetheless recommended the implantation of a defibrillator. Why the overly aggressive recommendation? Dr. Kowey discovers that his colleague, who had endured a lawsuit about a patient with similar circumstances, was practicing "defensive medicine." He goes on to observe:

Defensive medicine is pervasive and takes many forms. It extends from ordering too many tests all the way to performing unnecessary surgical procedures. Lung nodules that used to be followed end up in a specimen jar in the pathology laboratory. Subcritical coronary artery lesions are dilated and stented. And the contamination is not just at the individual physician level. Practice guidelines are formulated by colleagues who hear the wolf at the door. In the absence of definitive data, wouldn't it be logical that recommendations about the frequency of prostate biopsy in patients with abnormal PSAs would be on the more frequent side for safety's sake? And once those guidelines are published, physicians who ignore them do so at their peril.

Indeed, malpractice reform is the "unfinished business" of the 2010 health reform legislation, which included few serious initiatives to address what physicians universally regard as a huge problem. Recent estimates that defensive medicine accounts for only a small fraction of excess health care costs are limited by the design of the studies, which typically compare costs in areas of the U.S. with malpractice award "caps" to those with no caps - thus ignoring the baseline ordering of unnecessary tests or procedures by physicians who are motivated to avoid being sued regardless of limits on individual awards.

Here's what I wrote in a post about this issue in September of 2009:

Tort reform is a good idea, whether it saves money or not. It is ridiculous that the only way that a patient (or grieving family member) can obtain money to provide for someone crippled by a bad health outcome is to sue the doctor, whether or not the doctor was "at fault" or not. As a result, the vast majority (greater than 90 percent) of patients who probably deserve compensation for medical errors never see a dime, and those who do receive compensation after years of litigation end up giving much of what they win to their lawyers.

Health reform would benefit greatly from including tort reforms modeled on existing no-fault compensation programs, such as the National Vaccine Injury Compensation Program or the Virginia Birth-Related Neurological Injury Compensation Program.

It's still absolutely true.

The Common Sense Family Doctor speaks

Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.com and Gary Schwitzer's HealthNewsReview, as well as the websites of major national newspapers such as the New York Times, the Wall Street Journal, and the Boston Globe. I have also written the consumer health blog Healthcare Headaches for U.S. News and World Report since August 2010.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak about any of these topics, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.

Upcoming events:

Overdiagnosed and Over-Prevented: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health
October 28, 2011

Past events:

Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians

Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Librarians Association

Medical Blogging and Other Professional Uses of Social Media
- Virginia Commonwealth University Medical Center

Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine

Health Promotion and Disease Prevention in Clinical and Community Settings
- Uniformed Services University of the Health Sciences

The Value of Preventive Health Services
- Employees of MetLife

COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians