The Complexity of and Opportunity for Screening in Primary Care =============================================================== * Kurt C. Stange This issue features articles on the early detection of disease and risk factors. Four of these articles1,–4 and an editorial5 showcase colorectal cancer screening. Three of these studies evaluate the role of primary care in colorectal cancer early detection. A study using nationally representative data1 shows that colorectal cancer screening rates are associated with having a personal clinician, as well as with social factors. In contrast, Jimbo and colleagues2 find that primary care physician decisions are a major factor in patients not undergoing complete evaluation for a positive fecal occult blood screening test. To further complicate the picture of the role of primary care physicians in colorectal cancer screening, Wilkins conducts a meta-analysis of 12 studies of colonoscopy by primary care physicians, finding quality parameters similar to those in studies of specialists.4 The fourth colorectal cancer screening study, featured as this issue’s *Annals* Journal Club selection, is a clinical trial of a pragmatic intervention that links fecal occult blood testing to influenza immunization clinics. The dramatic effect shows that, when properly configured, complementary services can represent competing opportunities6 rather than competing demands.7 Several other studies in this issue address screening for other conditions. Jeppesen and colleagues find complementary value in several different brief screens for health literacy.8 Gjerdingen et al9 find that the optimal strategy for identifying women with postpartum depression may be a 2-stage screening procedure that involves using a 2-item initial screen, followed by a 9-item instrument for those whose screening test was positive. Rhodes et al,10 screening for intimate partner violence among men seen in an urban emergency department, find the highest rate of mental health symptoms occur among men who disclose both victimization and perpetration. This finding shows that the simplistic label of victim or perpetrator masks a more complex problem. A clinical policy guideline based on a systematic review11 finds strong evidence for screening patients for depression after myocardial infarction and moderate to strong evidence for treatment. A population-based study of children with asthma finds greater prescribing variability in younger children.12 Patient requests for specific new prescriptions are found in 3.5% of patient visits to clinicians in a practice-based research network.13 Although physicians reported that the requested medication was not their first choice for treatment, in 62% of these instances, the medication was prescribed 53% of the times it was requested. Despite this finding, clinicians reported a negative impact from these requests, stimulated by direct-to-consumer advertising, in only 10% of visits. An essay by Buetow uses the art concept of negative space to help us see patients and situations (and sometimes ourselves) in relief, separated from preconception and focused on the moment.14 Please share your insights on these articles and your experience with the important topics they bring up by joining the *Annals* online discussion at [http://www.AnnFamMed.org](http://www.AnnFamMed.org). * © 2009 Annals of Family Medicine, Inc. ## REFERENCES 1. Cardarelli R, Thomas JE. Having a personal health care provider and receipt of colorectal cancer testing. Ann Fam Med. 2009;7(1):5–10. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NToiNy8xLzUiO3M6NDoiYXRvbSI7czoyMDoiL2FubmFsc2ZtLzcvMS8yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 2. Jimbo M, Myers RE, Meyer B, et al. Reasons patients with a positive fecal occult blood test do not undergo complete diagnostic evaluation. Ann Fam Med. 2009;7(1):11–16. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzExIjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 3. Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh JME. Offering annual fecal occult blood tests during flu shot clinics increases colorectal cancer screening rates. Ann Fam Med. 2009;7(1):17–23. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzE3IjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 4. Wilkins T, LeClair B, Smolkin M, et al. Screening colonoscopies by primary care physicians: a meta-analysis. Ann Fam Med. 2009;7(1):56–62. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzU2IjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 5. Berg AO. The aftermath of efficacy. Ann Fam Med. 2009;7(1):3–4. [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NToiNy8xLzMiO3M6NDoiYXRvbSI7czoyMDoiL2FubmFsc2ZtLzcvMS8yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 6. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract. 1998;46(5):363–368. [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=9597993&link_type=MED&atom=%2Fannalsfm%2F7%2F1%2F2.atom) [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000073544100010&link_type=ISI) 7. Jaén CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract. 1994;38(2):166–171. [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=8308509&link_type=MED&atom=%2Fannalsfm%2F7%2F1%2F2.atom) [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=A1994MW68000015&link_type=ISI) 8. Jeppesen KM, Coyle JD, Miser WF. Screening questions to predict limited health literacy: a cross-sectional study of patients with diabetes mellitus. Ann Fam Med. 2009;7(1):24–31. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzI0IjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 9. Gjerdingen D, Crow S, McGovern P, Miner M, Center B. Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9. Ann Fam Med. 2009;7(1):63–70. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzYzIjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 10. Rhodes KV, Houry D, Cerulli C, Straus H, Kaslow NJ, McNutt L. Intimate partner violence and comorbid mental health conditions among urban male patients. Ann Fam Med. 2009;7(1):47–55. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzQ3IjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 11. Post–Myocardial Infection Depression Clinical Practice Guideline Panel. AAFP Guideline for the detection and management of post–myocardial infarction depression. Ann Fam Med. 2009;7(1):71–79. [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzcxIjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 12. Zuidgeest MGP, van Dijk L, Spreeuwenberg P, et al. What drives prescribing asthma medication to children? A multilevel population-based study. Ann Fam Med. 2009;7(1):32–40. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzMyIjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 13. Parnes B, Smith PC, Gilroy C, et al. Lack of impact of direct-to-consumer advertising on the physician-patient encounter in primary care: a SNOCAP report. Ann Fam Med. 2009;7(1):41–46. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzQxIjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 14. Buetow SA. Something in nothing: negative space in the clinician-patient relationship. Ann Fam Med. 2009;7(1):80–83. [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNy8xLzgwIjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS83LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)