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Peritonsillar abscess, the most common deep infection of the head and neck that occurs in adults, is typically formed by a combination of aerobic and anaerobic bacteria. The presenting symptoms include fever, throat pain, and trismus. Ultrasonography and computed tomographic scanning are useful in confirming a diagnosis. Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess. After performing aspiration, appropriate antibiotic therapy (including penicillin, clindamycin, cephalosporins, or metronidazole) must be initiated. In advanced cases, incision and drainage or immediate tonsillectomy may be required. [ABSTRACT FROM AUTHOR]

You may be surprised by the number of your patients using CAM therapy. This primer provides the background and tips you'll need to have a productive conversation about it. [ABSTRACT FROM AUTHOR]

Background and Objectives: Burnout impacts medical students, residents, and practicing physicians. Existing research oversimplifies characteristics associated with burnout. Our study examined relationships between burnout, depressive symptoms, and evidence-based risk factors., Methods: Our study questions were part of a larger survey conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA), from May 9-23, 2020. Three emails were used to recruit a national sample of family medicine residents (n=283; questions completed via Survey Monkey). We determined descriptive statistics (frequency, means) for demographic and work environment characteristics, UCLA Loneliness Scale items, health behaviors, burnout (emotional exhaustion, depersonalization), and depressive symptoms. Multivariate data analysis included developing three logistic regression (LR) equations (emotional exhaustion, depersonalization, depressive symptoms) based on four blocks of potential risk factors (demographics, work environment characteristics, UCLA Loneliness items, and health behaviors)., Results: Rates of psychological distress included 33.1% emotional exhaustion, 31.1% depersonalization, and 53.0% depressive symptoms. We determined stepwise forward-entry LR models for emotional exhaustion (feel isolated OR=6.89, low quality of wellness program OR=5.91, and low companionship OR=4.82); depersonalization (feel isolated OR=5.59, low quality of wellness program OR=15.11, graduate US osteopathic medical school OR=0.329, and African American OR=7.55); and depressive symptoms (feel isolated OR=5.31, inadequate time for restful sleep OR=0.383, and no dependent children OR=2.14)., Conclusions: Current findings document substantial social disconnection, substandard residency wellness programs, inadequate time for exercise, sleep, and other forms of self-care in addition to substantial levels of emotional exhaustion, depersonalization, and depressive symptoms. We explore implications for the design of future burnout prevention efforts and research.

Background: Academic physician burnout is concerning. Too little is known about factors associated with residency programme director burnout. Continued uncertainty risks adverse outcomes including graduate medical education leadership turnover and negative impact on recruiting and retaining under-represented minority residency programme directors., Objective: This study assessed symptoms of burnout (emotional exhaustion, depersonalization) and depression along with evidence-based individual and environmental risk factors in a U.S. sample of family medicine residency programme directors., Methods: The omnibus 2018 Council of Academic Family Medicine Education Research Alliance survey was used to contact programme directors at all Accreditation Council for Graduate Medical Education accredited U.S. family medicine residency programmes via email. Descriptive data included programme director and programme characteristics, Areas of Worklife (workload, values and control), loneliness (lack companionship, feel left out and feel isolated), burnout (emotional exhaustion, depersonalization) and depressive symptoms. Chi-square tests contrasted descriptive variables with burnout and depressive symptoms. Logistic regression (LR) modelled associations between significant descriptive variables and burnout and depressive symptoms., Results: The survey response rate was 45.2% (268/590). Programme directors reported: emotional exhaustion (25.0%), depersonalization (10.3%) and depressive symptoms (25.3%). LR models found significant associations with emotional exhaustion (Workload: lacking time and other work-related resources); lack of companionship, depersonalization (North West Central residency region; Workload and lack of companionship) and depressive symptoms (Black/African American ethnicity)., Conclusions: One-quarter of U.S. programme directors report burnout or depressive symptoms. Future research should consider associated variables as possible intervention targets to reduce programme director distress and turnover., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In October 2000 the family of family medicine convened the Keystone III conference at Cheyenne Mountain Resort. Keystone III participants included members of Generation I (entered practice before 1970), Generation II (entered 1970-1990), and Generation III (entered after 1990). They represented a wide range of family physicians, from medical students to founders of the discipline, and from small-town solo practice to academic medicine. During the conference, the three generations worked together and separately thinking about the past, present, and future of family medicine, our roles in it, and how the understanding of a family physician and our discipline had and would continue to evolve. After the conference, the 10 Generation III members wrote the article published here, reflecting on our experiences as new physicians and physicians in training, and the similarities and differences between our experiences and those of physicians in Generations I and II. Key similarities included commitment to whole-person care, to a wide scope of practice, to community health, and to ongoing engagement with our discipline. Key differences included our understanding of availability, the need for work-life balance, the role of technology in the physician-patient relationship, and the perceptions of the relationship between medicine and a range of outside forces such as insurance and government. This article, presented with only minor edits, thus reflects accurately our perceptions in late 2000. The accompanying editorial reflects our current perspective.

Background: Scholarly activity as a component of residency education is becoming increasingly emphasized by the Accreditation Council for Graduate Medical Education. "Limited or no evidence of resident or faculty scholarly activity" is a common citation given to family medicine residency programs by the Review Committee for Family Medicine., Objective: The objective was to provide a model scholarly activity curriculum that has been successful in improving the quality of graduate medical education in a family medicine residency program, as evidenced by a record of resident academic presentations and publications., Methods: We provide a description of the Clinical Scholars Program that has been implemented into the curriculum of the Trident/Medical University of South Carolina Family Medicine Residency Program., Results: During the most recent 10-year academic period (2000-2010), a total of 111 residents completed training and participated in the Clinical Scholars Program. This program has produced more than 24 presentations during national and international meetings of medical societies and 15 publications in peer-reviewed medical journals. In addition, many of the projects have been presented during meetings of state and regional medical organizations., Conclusions: This paper presents a model curriculum for teaching about scholarship to family medicine residents. The success of this program is evidenced by the numerous presentations and publications by participating residents.

Background: Several organizations emphasize that medical education should include how to improve patient outcomes effectively using quality improvement (QI) methods. In spite of the importance of teaching QI principles, limited literature exists on the implementation and evaluation of these in residency programs., Methods: The Clinical Scholars Program was established in 1996 to provide residents an opportunity to participate in a scholarly activity. The program, fully integrated into a community-based, university-affiliated family medicine residency program, is currently structured as a longitudinal educational experience, with specific time lines in which all second- and third-year residents are required to participate in and successfully complete a project before graduation. Factors influencing project success are also presented., Results: During the five-year period evaluated, 61 residents completed 53 Scholars projects, 39.6% of which were QI projects. Residents have delivered 86 local presentations, 50 state presentations, 11 national presentations, and 8 international presentations. Nine resident projects have been published in peer-reviewed journals. Factors associated with successful interventions include focus on a topic relevant and common in primary care practice, change in the system of patient care (for example, use of group visits, providing patient education directly to the patient prior to his or her visit), use of the electronic medical record to provide relevant clinical information during office visits, and interdisciplinary team participation in the project., Conclusion: This program is an example of the successful integration of scholarly activity and QI education into a residency program. It serves as a potential model for other residency programs to meet the needs of residency training and to promote QI and research in primary care practices.

Although many complementary therapies are promoted for the treatment of obesity, few are truly therapeutic. Evidence suggests that food containing diacylglycerol oil, acupuncture, and hypnosis are the only evidence-based complementary therapies for the treatment of obesity, and, at best, these should be used as adjuvants to the more conventional therapies of calorie restriction and exercise.

The American Medical Student Association (AMSA) Foundation is the programming arm of AMSA. The AMSA Foundation has administered several Title VII contracts designed to enhance the primary care education, leadership development, and cultural competence of the next generation of physicians, dentists, and other graduate-level health professionals. The authors discuss several AMSA programs developed with Title VII funding: Generalist Physicians in Training; Promoting, Reinforcing, and Improving Medical Education; National Primary Care Week; Leadership Seminar Series; and Achieving Diversity in Dentistry and Medicine. This article summarizes the work of these programs and discusses the impact that decreased funding has had on the training of our nation's future health professionals.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Purpose: The possible mechanisms of action of emergency contraception (EC) include preventing ovulation, fertilization, or implantation of an embryo. Differences in the use of terminology between medical personnel and the general public could be misleading to patients who would use EC. This cross-sectional survey evaluated women's beliefs regarding pregnancy and EC's possible mechanisms of actions., Methods: An anonymous questionnaire was developed and pilot tested for an appropriate reading level and ease of analysis. It collected information on demographics and beliefs about pregnancy and EC. During an 8-week period, the questionnaire was given to a convenience sample of female patients aged 18 to 50 years visiting 2 academic family medicine clinics in the southeastern United States. Descriptive statistics and logistic regression models were used for analysis., Results: A total of 178 women completed questionnaires. Nearly one-half (47%) of respondents believed that pregnancy begins with fertilization; however, less than one-third (30%) believed that life begins with fertilization. Thirty-eight percent of respondents stated that they would use EC only if they believed it worked before fertilization or implantation. Generally similar proportions thought that EC works before fertilization (24%) and before implantation (36%), or were unsure about when it works (34%). Younger age was associated with higher odds of believing that EC works before fertilization; none of the other demographic factors studied conferred either higher or lower odds., Conclusions: Many women are uninformed about the possible mechanisms of action of EC, and we found no reliable predictors for those who were better informed. This study raises questions regarding women's understanding of EC and demonstrates the need to better educate them about its possible mechanisms of action.

Background and Objectives: The effect of a research requirement on initial Match rates in family medicine has not been previously studied. This study's purpose was to examine the relationship between family medicine residency programs with a research requirement and initial Match rates for those programs in the National Resident Matching Program (NRMP)., Methods: Using information from the American Academy of Family Physicians (AAFP) and the NRMP, program characteristics were obtained, and the 2005 initial and 5-year aggregate Match rates were calculated. The relationship between the presence of a research requirement and fill rates (initial and 5-year aggregate) was analyzed using analysis of variance. To control for variables known to affect Match rates, multivariate analysis was conducted., Results: About one third of residency programs (31.4%) indicated that they have a resident research requirement. No significant difference in the initial Match rates nor the 5-year aggregate was noted between programs with or without a research requirement. The association did not change after controlling for program location, structure, and size of program., Conclusions: A research requirement in a family medicine residency program does not significantly affect Match rates in the NRMP.

Introduction: Results from previous studies evaluating the effect of nail polish on oxygen saturation (SpO(2)) determined by pulse oximeter monitors are inconsistent. Establishing the effect of nail polish on SpO(2) is relevant to clinical practice, since removing nail polish requires clinical time and supplies., Objective: The objective of this study was to determine if fingernail polish affects SpO(2) as measured by two different pulse oximeter machines., Methods: Absorption spectra of 10 nail polish colors were obtained by spectrophotometry. Twenty-seven healthy volunteers with SpO(2)> or =95% participated. Using the Nellcor N20 and N595 pulse oximeters, the mean SpO(2) was measured on each of 10 nails with and without nail polish and using a side-to-side configuration. Means were compared using paired t-tests., Results: Mean SpO(2) had a statistically significant decrease with brown and blue nail polish using both machines (p<0.05) but this was not clinically significant (<1% difference). Using the side-to-side configuration, the N595 oximeter had a statistically significant decrease in mean SpO(2) with red nail polish but again this was not clinically significant., Conclusion: Fingernail polish does not cause a clinically significant change in pulse oximeter readings in healthy people.

An increasing percentage of Internet users are seeking health information online. The purpose of our study was to determine the extent of Internet access and online health-seeking and the feasibility of implementing Internet services for our urban, residency-based practice. Using a self-administered survey, we obtained information on use of the Internet, demographics and socioeconomic profile, presence of a chronic medical condition and self-rated health from 300 consecutive patients. Complete surveys were obtained by 203 (68 percent). Responses were compared based on demographic, socioeconomic, and medical variables using Chi-square analysis. Results showed that our sample population tended to be under age 50, female, non-Hispanic Black, low income, and healthy. Seventy-seven percent of respondents had accessed the Internet at least once, 79 percent had used the Internet to find health-related information, 73 percent used the online information to make a health-related decision, 50 percent shared the information with their provider. In conclusion, we confirmed a high rate of Internet usage in our specific patient population, characterized by low socioeconomic status, low education level, and high minority percentages. Our patients not only access online health information, but also make changes based on this information, with only about half of all patients sharing this information with their physicians. It is unclear how this system of 'virtual medical care' influences overall patient health.

The purpose of this study was to evaluate the accessibility and utility of a common Internet search strategy so physicians might provide this guidance to their patients seeking health information on chronic disease. We selected three common chronic diseases: diabetes, hypertension, and osteoarthritis. We then formulated basic questions from a patient perspective about diagnosis, treatment, and prognosis. A non-medical professional attempted to answer these questions by typing the disease name into the Google search engine. Focusing on the first ten web sites on the Google list was a successful strategy for finding sites that could answer the study questions (average of 61% of the time). The average number of clicks required to answer any question was 1.6. Web sites sponsored by government agencies (89% success) and hospitals (100% success) yielded answers to the questions more often than other sites. In conclusion, despite the multitude of web sites that appear when the name of a chronic disease is entered into a search engine, the top ten results are usually adequate to provide relevant information on common clinical questions to the average patient. Physicians can guide patients to relevant information by instructing them to type the name of the disease itself into a search engine and focusing on government and hospital-sponsored Web sites.

Objective: To report a case of successful anticoagulation using a modified dosing weight (DW) for unfractionated heparin (UFH) therapy in a morbidly obese female., Case Summary: A 54-year-old morbidly obese (182.4 kg, 155 cm) white female presented to the emergency department with tachycardia, shortness of breath, and chest pain, and was diagnosed with a pulmonary embolism. Anticoagulation with UFH was initiated. A modified DW of 120 kg was obtained from the average of the actual body weight (ABW) and ideal body weight ( approximately 50 kg). We selected this modified DW to account for heparin's altered volume of distribution in an obese patient and avoid potentially supratherapeutic activated partial thromboplastin times (aPTTs) using ABW and subtherapeutic aPTTs using DW. Therapy was initiated with a bolus dose of 9600 units (80 units/kg x 120 kg) and continuous infusion rate of 2160 units/h (18 units/kg/h x 120 kg). This infusion rate was maintained throughout the course of heparin therapy and was successful in maintaining therapeutic aPTTs., Discussion: Proper diagnosis and rapid initiation of therapy prevent mortality in patients with PE. Although weight-based heparin nomograms provide standardization through initial bolus and continuous infusion recommendations, many do not address dosing in morbidly obese patients. Several retrospective studies have evaluated actual, dosing, and ideal body weights for heparin therapy in obese patients; however, none has evaluated modified DW. In our patient, successful anticoagulation was objectively confirmed., Conclusions: Further investigation is necessary to determine the optimal DW for UFH in morbidly obese patients presenting with acute thrombosis.

Objective: To determine if rural minority children ages 3-71 months are more likely than similar aged urban minorities to have delays in their immunization status., Methods: Secondary analysis of the National Health Interview Survey (NHIS) for the years 1993-2001., Findings: There were no substantial differences between the up-to-date immunization status of children living in metropolitan areas compared to children living in rural areas. There does appear to be a delay in introducing new vaccines into rural areas compared to metropolitan areas during the first 2 years of the vaccine recommendation. There were no significant differences in immunization status between Whites, Blacks and Hispanics living in metropolitan and rural areas., Conclusions: Rural minority children are no more likely than other children to have delayed immunizations.

Patients in this study were most comfortable receiving primary care services from physicians trained in primary care specialties. There was, however, a racial difference in the comfort level of primary care being provided by non-physician providers with minority populations being more comfortable with non-physician providers. More research is needed to understand the role that non-physician providers play in the primary care delivery system in the United States.

Objectives: The purpose of this study is to determine whether influenza vaccine rates have increased in states where pharmacists can give vaccines., Methods: Secondary analysis of the Behavioral Risk Factor Surveillance System (BRFSS) from the years 1995 and 1999. Information regarding legislation allowing pharmacists to administer vaccines was obtained from the American Pharmaceutical Association., Results: Individuals aged 65 years and older who lived in states where pharmacists could provide vaccines had significantly higher (P < 0.01) influenza vaccine rates than individuals of this age who resided in states where pharmacists could not provide vaccines., Conclusions: Allowing pharmacists to provide vaccinations is associated with higher influenza vaccination rates for individuals aged 65 years and older.

Background: We wanted to determine whether variations exist in use of a chaperone during the performance of a pelvic examination by family physicians., Methods: A self-administered questionnaire was mailed to 5,000 randomly selected active members of the American Academy of Family Physicians., Results: There were 3,551 survey responses (71% response rate) and 2,748 useable questionnaires. Most respondents (75.4%) reported routinely using a chaperone in the room during the collection of a Papanicolaou (Pap) smear. Significantly (P < .00001) more male physicians (84.1%) than female physicians (31.4%) reported using a chaperone. Physicians reporting routine use of a chaperone were significantly younger (P = .01) and did fewer Pap smears per month (P < .00001). Regional reporting of chaperone use varied significantly (P < .00001), with 71.6% reporting use in the Northeast, 89.0% in the South, 65.7% in the Midwest, and 72.4% in the West., Conclusion: Family physicians vary considerably in the reported use of a chaperone during the collection of a Pap smear. The variation could reflect different regional or local norms, efficiency or resource issues in high-volume clinical settings, or other interpersonal factors. These issues need to be explored in more depth.

Background: Medical students often play a role in local curricular issues by assessing the curriculum and bringing consumers' perspectives to curricular committees., Purpose: To identify the formal roles that medical students play on curriculum committees., Methods: Mail survey to associate deans of medical education at all U.S. medical schools (N = 144)., Results: A total of 109 surveys were returned (response rate = 75.7%). Students had formal roles on the curricular committees at 100% of the respondent institutions. The majority of medical schools allow peers to elect their representatives to the committee (53.2%). Students have a right to vote on curricular changes at 86% of the respondent institutions. The vast majority of respondents (97.2%) felt that medical students were important in initiating curricular change., Conclusions: Medical students play an active role on curriculum committees at U.S. medical schools. Further research is needed to fully elucidate these specific roles.

Objective: Hypercholesterolemia is a major risk factor for the development of coronary artery disease. Studies have shown that several vitamins and nutritional supplements may contribute to a reduction in total and low-density lipoprotein cholesterol. This goal of this study was to document the use of vitamins and nutritional supplements that may treat or prevent hypercholesterolemia., Methods: Secondary analysis of the National Health and Nutrition Examination Survey III responses from 13,990 patients were available to use for making population estimates., Results: Of those individuals with a known diagnosis of hypercholesterolemia, 3.6% were taking at least one vitamin or nutritional supplement to decrease cholesterol levels. For individuals trying to prevent hypercholesterolemia, 1.2% were using one of these vitamin or nutritional supplements. Only 0.7% of individuals without or trying to prevent hypercholesterolemia used one of these specific supplements. We used multivariate analysis to control for several factors, and individuals with a diagnosis of hypercholesterolemia had an adjusted odds ratio of 2.10 (95% confidence interval, 1.38-3.21) for vitamin use compared with those without or trying to prevent high cholesterol. Those trying to prevent hypercholesterolemia had an adjusted odds ratio of 0.69 (95% confidence interval, 0.48-1.00) for vitamin use compared with those without or trying to prevent high cholesterol., Conclusions: The use of vitamins and nutritional supplements that may reduce total and low-density lipoprotein cholesterol levels is low in the United States. Future research is needed to confirm the effectiveness of these products, examine the quality and purity of currently available products, and explore whether using these supplements are an adequate low-cost alternative to pharmaceuticals now available.

Context: A growing number of complementary and alternative therapies are eligible for reimbursement by third party payers in the United States. No studies have examined current trends in the use of public funds for the payment of complementary and alternative medicine (CAM)., Objective: To determine the reimbursement polices of state Medicaid programs for CAM., Design: Cross-sectional study., Participants: 46 state Medicaid reimbursement specialists., Intervention: Telephone survey., Results: Of the 46 states participating in the study, 36 Medicaid programs (78.3%) provide coverage for at least 1 alternative therapy. The most commonly reimbursed therapies are chiropractic by 33 programs (71.7%), biofeedback by 10 programs (21.7%), acupuncture by 7 programs (15.2%), and hypnotherapy and naturopathy by 5 programs each (10.8%)., Conclusions: Many Medicaid programs are paying for the use of CAM. Further research is needed to determine if Medicaid recipients are aware of these reimbursement policies and the extent to which recipients are using CAM for their healthcare.

Objective: Previous studies have shown an association between attendance at religious services and health, particularly cardiovascular morbidity and mortality. Little research has focused on religious attendance and physiological markers of cardiovascular risk. The purpose of this study was to explore the relationship between religious attendance and inflammatory markers of cardiovascular risk., Method: Nationally representative sample of non-institutionalized United States adults aged 40 and over derived from the National Health and Nutrition Examination Survey III 1988-1994 (n = 10,059). The main outcome measures were the inflammatory system markers C-reactive protein, fibrinogen, and white blood cell count., Results: 40.8 percent of the population attended religious services 40 or more times in the previous year while 22.4 percent attended services less than 40 times and 36.8 percent attended no religious services at all. Non-attenders of religious services were more likely than attenders to have elevated white blood cell counts (p = .001), highly elevated C-reactive protein (p = .02), and elevated fibrinogen (p = .05). After adjusting for demographic variables, health status, and BMI, the association between religious attendance and cardiovascular markers remained. Once current smoking was added to the model the independent effect of religious attendance dropped below conventional confidence limits., Conclusions: These findings suggest that people who have attended religious services in the previous year are less likely to have elevated levels of certain inflammatory markers, however, current smoking has significant shared variance with religious attendance.