FP essentials
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Until recently, most initiatives to address physician burnout have focused on improving the resilience of individual physicians. These measures are necessary but insufficient since it is now recognized that organizations have a major role in causing, preventing, and mitigating physician burnout. Burnout must be addressed by organizational change. ⋯ Results of assessments can be used to engage clinicians in open conversations on issues and potential solutions. Specific leadership behaviors and positive organizational cultures decrease burnout and enhance engagement. There must be an institutional commitment to enhancing physician autonomy and transparent communication, improving the meaning of work, reducing administrative and regulatory burdens, and reducing the stigma related to seeking care.
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Integrative medicine, including acupuncture, dry needling, and cupping, is being used increasingly in the United States. Evidence regarding their efficacy in the management of musculoskeletal conditions is heterogeneous and subject to several limitations. Despite these limitations, acupuncture consistently has been shown to be more effective than no treatment and is relatively safe. ⋯ Wet cupping appears to decrease low back and neck pain. Patients should be referred to appropriately credentialed clinicians. Health insurance companies may not provide coverage for these therapies.
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Injections often are used in the management of common musculoskeletal conditions. Physicians should understand the disease pathophysiology and evidence supporting available injections when determining appropriate therapy. These therapies include corticosteroid injections (CSIs), hyaluronic acid (HA) injections, hypertonic dextrose prolotherapy, platelet-rich plasma (PRP) injections, mesenchymal stem cell (MSC) injections, and trigger point injections (TPIs). ⋯ There is low-quality evidence showing MSC injections improve pain and function in OA and tendinopathies. It is unclear whether TPIs are effective because of a lack of high-quality evidence. Ultrasonography guidance has been shown to improve accuracy of delivery and clinical outcomes in injection therapies.
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Labor is defined as contractions with cervical change and active labor starts when the cervix is dilated 6 cm. Updated labor curves and definitions should be used to define labor dystocia. Oxytocin and amniotomy have important roles in the management of labor dystocia. ⋯ Epidural analgesia is used in more than half of all births in the United States. It is not associated with an increase in the rate of cesarean deliveries but is associated with a longer second stage of labor. Interventions that may reduce the need for cesarean delivery include use of the new definitions of labor dystocia, a trial of manual rotation of occiput posterior presentations, use of cervical ripening agents for induction of labor with an unfavorable cervix, and encouragement of women with previous cesarean deliveries to attempt vaginal delivery.
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Smoking cessation for patients who smoke should be a top priority for physicians. Nicotine dependence should be considered a chronic disease, with the expectation that relapse is normal. The US Preventive Services Task Force (USPSTF) recommends that physicians screen all adults for tobacco use, advise them to stop using tobacco, and provide behavioral interventions and Food and Drug Administration-approved pharmacotherapy for cessation to adults who use tobacco. ⋯ However, if these methods are unlikely to be effective, pharmacotherapy can be offered after a discussion about risks and benefits. The behavioral method with the most evidence of efficacy is group therapy. Nicotine replacement therapy (eg, gums, lozenges, transdermal patches, inhalers, nasal sprays), bupropion SR, and varenicline are approved by the Food and Drug Administration for management of nicotine withdrawal during smoking cessation.