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Swansons
FAMILY MEDICINE
REVIEW
A PROBLEM - ORIENTED APPROACH
Alfred F. Tallia
Joseph E . Scherger
Nancy W. Dickey *
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Swanson’s
FAMILY MEDICINE
REVIEW
Swanson’s
FAMILY MEDICINE
REVIEW8th Edition A PROBLEM-ORIENTED APPROACH
Editor-in-Chief
Alfred F. Tallia, Professor and Chair

Family Medicine and Community Health
MD, MPH Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey
Co-Editors
Joseph E. S
cherger, Vice President, Primary Care
Marie E. Pinizzotto, MD Chair of Academic Affairs
MD, MPH Eisenhower Medical Center
Rancho Mirage, California
Nancy W. Dickey, President Emerita, Texas A&M Health Science Center

Professor, Family and Community Medicine
MD Professor and Interim Chair, Clinical and Translational
Medicine
Executive Director, Rural and Community Health Institute
Texas A&M Health Science Center College of Medicine
College Station, Texas
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
SWANSON’S FAMILY MEDICINE REVIEW, EIGHTH EDITION ISBN: 978-0-323-35632-9
Copyright © 2017 by Elsevier, Inc. All rights reserved.

Previous editions copyrighted 2013, 2009, and 2003
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechan-
ical, including photocopying, recording, or any information storage and retrieval system, without permission in
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sions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
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With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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Library of Congress Cataloging-in-Publication Data
Names: Tallia, Alfred F., editor. | Scherger, Joseph E., editor. | Dickey,
Nancy, editor.
Title: Swanson’s family medicine review : a problem-oriented approach /
editor-in-chief, Alfred F. Tallia, co-editors, Joseph E. Scherger, Nancy
W. Dickey.
Other titles: Family medicine review
Description: 8th edition. | Philadelphia, PA : Elsevier, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2015049807 | ISBN 9780323356329 (pbk. : alk. paper)
Subjects: | MESH: Family Practice | Examination Questions
Classification: LCC RC58 | NLM WB 18.2 | DDC 616.0076--dc23 LC record available at
http://lccn.loc.gov/2015049807
Content Strategist: Suzanne Toppy

Content Development Specialist: Janice Gaillard
Publishing Services Manager: Patricia Tannian
Project Manager: Ted Rodgers
Design Direction: Amy Buxton
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To the lasting memory of
Dr. Richard Swanson
An extraordinary physician and educator
Contributors
Lani K. Ackerman, MD Noemi C. Doohan, MD, PhD

Associate Professor Family Physician
Family Medicine Ukiah Valley Medical Center
Texas A&M Health Science Center College Ukiah, California
of Medicine,
College Station, Texas Kinder Fayssoux, MD
Family physician Center for Family Medicine
Scott and White Clinic Eisenhower Medical Associates,
College Station, Texas La Quinta, California
Adity Bhattacharyya, MD, FAAFP Negin Field, MD

Assistant Professor Resident Physician
Family Medicine and Community Health Family Medicine
Rutgers Robert Wood Johnson Medical School Eisenhower Medical Center
New Brunswick New Jersey Rancho Mirage, California
Michael Bogey, MD Kory Gill, DO

Emergency Medicine Program Director
Eisenhower Medical Center, Family Medicine and Sports Medicine
Rancho Mirage, California Texas A&M Health Science Center College of Medicine
Family Medicine Residency
Robert Chen, MD College Station, Texas
Clinical Assistant Professor
Family Medicine and Community Health David F. Howarth, MD, MPH
Rutgers Robert Wood Johnson Medical School Associate Professor of Family Medicine
New Brunswick, New Jersey Department of Family Medicine and Community
Health Director of Geriatric Training
Amanda Curnock, MD Rutgers Robert Wood Johnson Medical School
Physican and Co-Director Argyros 365 Primary care New Brunswick, New Jersey
Eisenhower Medical Center
La Quinta, California Alexandra G. Ianculescu, MD, PhD
Resident Physician
André de Leon, MD, MS Internal Medicine
Core Faculty Eisenhower Medical Center
Non-Surgical Sports Medicine/Family Medicine Rancho Mirage, California
Eisenhower Family Medicine Residency
Rancho Mirage, California Glenn M. Jabola, MD
Family Medicine
Tate de Leon, MD, MS Eisenhower Medical Center
Core Faculty Rancho Mirage, California
Family Medicine
Eisenhower Family Medicine Residency James D. King II, MD
Rancho Mirage, California Primary Care and Sports Medicine
Baylor Scott & White
Nancy W. Dickey, MD College Station, Texas
President Emerita, Texas A&M Health Science Center Orthopedist
Professor, Family and Community Medicine Baylor Scott and White Healthcare
Professor and Interim Chair, Clinical and Translational College Station, Texas
Medicine
Executive Director, Rural and Community Health Martha Lansing, MD
Institute Associate Professor and Vice Chair
Texas A&M Health Science Center College of Medicine Family Medicine and Community Health
College Station, Texas Rutgers Robert Wood Johnson Medical School
C o n tr i b u to rs vii
Anna Lichorad, MD Damoun A. Rezai, MD

Assistant Professor Resident Physician
Family Medicine Family Medicine
Texas A&M College of Medicine, Eisenhower Medical Center
Bryan, Texas La Quinta, California
Benjamin Mahdi, MD, MPH Beatrix Roemheld-Hamm, MD, PhD

Family Medicine Professor
Eisenhower Medical Center Family Medicine and Community Health
Rancho Mirage, California Rutgers Robert Wood Johnson Medical School
Laura E. Marsh, MS, MD, CAQSM
Clinical Associate Professor Joseph E. Scherger, MD, MPH
Family Community Medicine Vice President, Primary Care
Texas A&M Health Science Center Marie E. Pinizzotto, MD Chair of Academic Affairs
Bryan, Texas Eisenhower Medical Center
Physician Rancho Mirage, California
Central Texas Sports Medicine and Orthopaedics
Bryan, Texas John F. Simmons, MD
Assistant Professor
Barbara Jo McGarry, MD Family Medicine
Associate Professor Director of the Advanced Obstetrical Track
Family Medicine and Community Health Texas A&M Family Medicine Residency
Program Director, Family Medicine Residency Bryan, Texas
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey Alex Spinoso, MD
Family Medicine
Carmen Morales-Litchard, MD Eisenhower Medical Center
Universidad Xochicalco Rancho Mirage, California
Tijuana, Mexico
Family Medicine Maureen Strohm, MD, MSEd
Eisenhower Medical Center Vice President of Graduate Medical Education/DIO
Palm Desert, California HCA Far West Division
Henderson, Nevada
Gregory A. Pecchia, DO
Staff Physician Alfred F. Tallia, MD, MPH
Family and Geriatric Medicine Professor and Chair
Eisenhower Medical Center Family Medicine and Community Health
Rancho Mirage, California Rutgers Robert Wood Johnson Medical School,
Director New Brunswick, New Jersey
Eisenhower Wellness Institute
Eisenhower Medical Center K. Douglas Thrasher, DO, FAAFP
La Quinta, California Chairman
Department of Family Medicine
Bhavika Shivlal Rakholia, BA, MD Eisenhower Medical Center
Resident Physician La Quinta, California
Family Medicine
Eisenhower Medical Center Sangeetha Vinayagam, MD
Rancho Mirage, California Family Medicine
Eisenhower Medical Center
Joshua J. Raymond, MD, MPH Rancho Mirage, California
Assistant Professor
Family Medicine and Community Health
Rutgers Robert Wood Johnson Medical School
Preface
This is the eighth edition of Swanson’s Family Medicine As with the previous edition, distinguished family
Review. As an enduring and marvelous educational tool physicians Nancy W. Dickey, MD, President Emerits
for several generations of clinicians, this text is a testi- of the Texas A&M Health Science Center and professor
mony to the founding genius of Dr. Richard Swanson, of family and community medicine in the Texas A&M
the family physician who gave birth to the Review. The College of Medicine, and Joseph E. Scherger, MD, MPH,
text continues to be not only an effective tool for family Vice President for Primary Care and Academic Affairs
physicians preparing for certification or recertification, at Eisenhower Medical Center and founding dean of the
but also an excellent review for clinicians simply desiring Florida State University College of Medicine, served as
to hone their familiarity with the basic concepts pertinent my co-editors on this edition. As a team, we reviewed
to primary care. the chapters and case problems for relevance, and chose
The primary goals of the eighth edition are to update areas of emphasis and ways to organize the content. We
the content and retain the special essence that made selected the content to reflect the broad core of knowl-
previous editions such valued and popular educational edge required of every family physician. We also received
instruments. The book is divided into 11 sections. Ten valuable input from other family medicine clinicians with
represent a clinical area of Family Medicine, while the special expertise in specific content areas.
eleventh section is a popular illustrated review. We recruited as chapter authors the finest practicing
Each section contains chapters covering specific sub- family medicine experts from academic centers across
jects relevant to that section. Each chapter presents clini- the United States. They reaffirmed and updated chapter
cal cases that simulate actual clinical situations, providing content on the basis of thorough needs analyses, includ-
the learner with a sense of reality designed to enhance ing opinions of readers, participants, and faculty in live
retention of content. Each clinical case is followed by continuing medical education conferences, expert opin-
questions concerning diagnosis and management. The ion, and other accepted methodologies. The editors and
question section is followed by an answer section, which authors anticipate that the reader will both enjoy and
provides a detailed discussion relevant to each question. profit from the work that went into preparing this vol-
Finally, each chapter contains a short summation of key ume. Happy studying and learning!
learning points and selected readings and references,
including websites. This time tested learning methodol- Alfred F. Tallia, MD, MPH
ogy is designed to increase retention and to expand and Editor-in-Chief
refine the reader’s knowledge of the diagnostic methods,
therapeutics, and patient management techniques pre-
sented by each case.
Acknowledgments
As editor-in-chief, I am indebted to many individuals Thanks to Janice Gaillard, Suzanne Toppy, Ted
for their support and assistance in the preparation of odgers, and the staff at Elsevier for their inspiration and
R
the eighth edition of Swanson’s Family Medicine Review. support. Finally, much gratitude to our colleagues in the
To begin, I wish to thank my two co-editors, Nancy W. academic and clinical communities that we call home for
Dickey, MD, and Joseph E. Scherger, MD, MPH, for their help and understanding of the demands that prepa-
their hard work and understanding. ration of this edition required.
Collectively, we would like to thank our spouses, Eliz-
abeth Tallia, Carol Scherger, and Frank Dickey; and our Alfred F. Tallia, MD, MPH
entire families, as well as those of the authors, for their Editor-in-Chief
sacrifice of time and their understanding as we prepared
this edition.
Contents
SECTION ONE 22 Acute Coronary Symptoms and Stable Angina

Family, Community, and Population Health 1 Pectoris 99
Tate de Leon, Benjamin Mahdi
1 Family Influences on Health and Disease 1
23
Hyperlipoproteinemia 106
Martha Lansing
K. Douglas Thrasher
2 Clinical Decision Making 4
24
Heart Failure 113
Martha Lansing
Joseph E. Scherger, Alexandra G. Ianculescu
3 Consultation and Team Care 12
25
Hypertension 119
Martha Lansing
Kinder Fayssoux, Sangeetha Vinayagam
4 Managing Multiple Morbidities 15
26
Dysrhythmia 125
Martha Lansing
Joseph E. Scherger, Alexandra G. Ianculescu
5
Quality Improvement 18
27 Deep Venous Thrombosis and Pulmonary
Martha Lansing
Thromboembolism 128
6
Clinical Prevention 21 Alfred F. Tallia
Martha Lansing
28 Chronic Obstructive Pulmonary Disease 132
7
Tobacco Dependency 25 Robert Chen, Joshua J. Raymond
Martha Lansing
29
Asthma 139
8
Alcohol 30 Alfred F. Tallia
Martha Lansing
30 The Diagnosis and Management of Community-
9 Diet, Exercise, and Obesity 37 Acquired Pneumonia in the Adult 150
Martha Lansing Alfred F. Tallia
10 Trends in Cancer Epidemiology 41 31
Esophageal Disorders 154
11
Cardiovascular Epidemiology 44 32 Peptic Ulcer Disease 160
12
Bioterrorism 48 33 Hepatitis and Cirrhosis 164
13 Influenza and Other Emerging Diseases 52 34
Pancreatitis 170
35
Pancreatic Carcinoma 173
SECTION TWO
Alfred F. Tallia
Communication 59
36 Biliary Tract Disease 176
14
Domestic Violence 59 Alfred F. Tallia
K. Douglas Thrasher 37 Inflammatory Bowel Disease 180
15 How to Break Bad News 63 Alfred F. Tallia
Maureen Strohm 38 Irritable Bowel Syndrome 185
16 The Physician-Patient Relationship 68 Barbara Jo McGarry, Beatrix Roemheld-Hamm
Joseph E. Scherger 39
Acute Appendicitis 188
17
Palliative Care 72 Alfred F. Tallia
Joseph E. Scherger 40 Colorectal Cancer and Other Colonic Disorders 193
18 Ethical Decision-Making Issues 77 Alfred F. Tallia
Diabetes Mellitus 200
19
Integrative Medicine 83 Alfred F. Tallia
Joseph E. Scherger, Michael Bogey 42
Thyroid 217
20
Cultural Competence 88 Alfred F. Tallia
Joseph E. Scherger 43 Common Endocrine Diseases 225
Alfred F. Tallia
SECTION THREE
44 Immune-Mediated Inflammatory Disorders and
Adult Medicine 93
Autoimmune Disease 231
21 Acute ST-Segment Elevation Myocardial Joseph E. Scherger
Infarction 93 45 Human Immunodeficiency Virus Infection 235
Tate de Leon, Benjamin Mahdi Joseph E. Scherger
C ontents xi
46
Multiple Sclerosis 243 71 Vulvovaginitis and Bacterial Vaginosis 370
Joseph E. Scherger, Alexandra G. Ianculescu Adity Bhattacharyya
47
Fibromyalgia 247 72
Cervical Abnormalities 376
Joseph E. Scherger Adity Bhattacharyya
48 Chronic Fatigue Syndrome 252 73 Premenstrual Syndrome and Premenstrual Dysphoric
Joseph E. Scherger, Bhavika Shivlal Rakholia Disorder 382
49
Rheumatoid Arthritis 257 Adity Bhattacharyya
Postmenopausal Symptoms 386
50
Osteoarthritis 261 Adity Bhattacharyya
André de Leon 75
Dysmenorrhea 392
51 Acute Gout and Pseudogout 264 Adity Bhattacharyya
Joseph E. Scherger, Michael Bogey 76 Abnormal Uterine Bleeding 396
52 Acne, Rosacea, and Other Common Dermatologic Adity Bhattacharyya
Conditions 269 77
Ectopic Pregnancy 403
Glenn Jabola, Sangeetha Vinayagam Adity Bhattacharyya
53 Common Skin Cancers 273 78
Contraception 406
Glenn M. Jabola, Sangeetha Vinayagam Adity Bhattacharyya
54 Ear, Nose, and Throat Problems 277 79 Spontaneous and Elective Abortion 417
Alfred F. Tallia Adity Bhattacharyya
55 Disorders of the Eye 285 80 Sexually Transmitted Diseases 423
Alfred F. Tallia Adity Bhattacharyya
56
Headache 290 81
Infertility 434
Barbara Jo McGarry, Beatrix Roemheld-Hamm Adity Bhattacharyya
57
Seizures 297
SECTION FIVE
Robert Chen, Joshua J. Raymond
Maternity Care 439
58
Sleep Disorders 302
Robert Chen, Joshua J. Raymond 82 Family-Centered Maternity Care 439
59 Common Renal Diseases 307 Lani K. Ackerman
Joseph E. Scherger, Alexandra G. Ianculescu 83
Preconception Care 443
60
Renal Stones 312 Nancy W. Dickey
Joseph E. Scherger, Negin Sanchez 84 Routine Prenatal Care 447
61 Urinary Tract Infections 315 Lani K. Ackerman
Amanda Curnock 85 Immunization and Consumption of Over-the-Counter
62 Fluid and Electrolyte Abnormalities 320 Drugs During Pregnancy 453
Noemi C. Doohan Lani K. Ackerman
63
Anemia 323 86 Exercise and Pregnancy 457
Amanda Curnock Lani K. Ackerman
64 Certain Hematologic Conditions 330 87 Common Problems in Pregnancy 460
Amanda Curnock John F. Simmons
65 Breast, Lung, and Brain Cancer 337 88
Spontaneous Abortion 463
Gregory A. Pecchia John F. Simmons
66 Cancer Pain Management 341 89 Thyroid Disease in Pregnancy 466
Amanda Curnock John F. Simmons
67
Developmental Disabilities 348 90 Gestational Diabetes and Shoulder
Kinder Fayssoux, Carmen Morales-Litchard Dystocia 470
68
Travel Medicine 352 Anna Lichorad
Joseph E. Scherger, Alex Spinoso 91 Hypertension in Pregnancy 475
John F. Simmons
SECTION FOUR
92 Intrauterine Growth Restriction 478
Women’s Health 357
John F. Simmons
69
Osteoporosis 357 93
Postterm Pregnancy 482
Adity Bhattacharyya Anna Lichorad
70
Breast Disease 363 94
Labor 485
Adity Bhattacharyya John F. Simmons
xii Contents
95
Delivery Emergencies 489 121 Foot and Leg Deformities 608
John F. Simmons Kory Gill
96 Postpartum Blues, Depression, and Psychoses 493 122
Mononucelosis 612
John F. Simmons Anna Lichorad
123
Adolescent Development 617
SECTION SIX Nancy W. Dickey
Children and Adolescents 497 124
Adolescent Safety 620
97 Common Problems of the Newborn 497 Nancy W. Dickey
John F. Simmons
SECTION SEVEN
98
Infant Feeding 498
Geriatric Medicine 625
Lani K. Ackerman
99
Colic 506 125 Functional Assessment of the Elderly 625
Nancy W. Dickey David F. Howarth
100
Immunizations 508 126 Polypharmacy and Drug Reactions in the
Lani K. Ackerman Elderly 628
101
Fever 514 David F. Howarth
Nancy W. Dickey 127 The Propensity and Consequences of Falls among
102
Over-the-Counter Drugs 518 the Elderly 633
103 Diaper Rash and Other Infant Dermatitis 521 128 Urinary Incontinence in the Elderly 636
Lani K. Ackerman David F. Howarth
104 Failure to Thrive and Short Stature 526 129
Prostate Disease 642
105
Child Abuse 530 130
Pressure Ulcers 647
Kory Gill David F. Howarth
106
Common Cold 536 131 Constipation in the Elderly 653
Joseph E. Scherger, Alex Spinoso David F. Howarth
107
Otitis Media 541 132 Pneumonia and Other Common Infectious Diseases
Maureen Strohm of the Elderly 658
David F. Howarth
108 Croup and Epiglottitis 546
K. Douglas Thrasher, Alex Spinoso 133 Polymyalgia Rheumatica and Temporal
Arteritis 663
109 Bronchiolitis and Pneumonia 549
David F. Howarth
K. Douglas Thrasher, Alex Spinoso
134 Hypertension Management in the Elderly 667
110
Childhood Asthma 556
David F. Howarth
Lani K. Ackerman
135
Cerebrovascular Accidents 671
111
Allergic Rhinitis 563
David F. Howarth
Lani K. Ackerman
136 Depression in the Elderly 678
112
Viral Exanthems 567
David F. Howarth
Anna Lichorad
137 Dementia and Delirium 682
113
Cardiac Murmurs 574
David F. Howarth
Anna Lichorad
138
Parkinson Disease 689
114 Vomiting and Diarrhea 579
David F. Howarth
Anna Lichorad
139
Elder Abuse 694
115 Functional Abdominal Pain 585
David F. Howarth
Nancy W. Dickey
140 Emergency Treatment of Abdominal Pain in
116
Enuresis 589
the Elderly 697
Nancy W. Dickey
David F. Howarth
117 Lymphoma and Leukemia 592
Nancy W. Dickey
SECTION EIGHT
118 Sickle Cell Disease 596
Behavioral Health 701
Anna Lichorad
119 Physical Activity and Nutrition 599 141
Depressive Disorders 701
Lani K. Ackerman Joseph E. Scherger, Alexandra G. Ianculescu
120 The Limping Child 604 142
Bipolar Disorder 709
Kory Gill Joseph E. Scherger, Alexandra G. Ianculescu
C ontents xiii
143 Generalized Anxiety Disorder 714 159 Heat and Cold Illness 778
Joseph E. Scherger, Damoun A. Rezai Kory Gill
144 Posttraumatic Stress Disorder 719 160 High Altitude and Barotrauma 782
Joseph E. Scherger, Damoun A. Rezai Kory Gill
145
Obsessive-Compulsive Disorder 721
Joseph E. Scherger, Damoun A. Rezai SECTION TEN
146
Attention-Deficit/Hyperactivity Disorder 724 Sports Medicine 785
Joseph E. Scherger, Damoun A. Rezai 161
Preparticipation Evaluation 785
147 Conduct Disorder and Oppositional Defiant James D. King II
Disorder 729 162
Exercise Prescription 788
Joseph E. Scherger, Damoun A. Rezai Laura Marsh
148 Diagnosis and Management of Schizophrenia 732 163
Concussions 791
Joseph E. Scherger James D. King II
149
Drug Abuse 737 164 Acceleration and Deceleration Neck Injuries 796
Maureen Strohm James D. King II
150
Eating Disorders 742 165 Upper Extremity Injuries 798
Maureen Strohm Laura E. Marsh
151
Somatoform Disorders 745 166 Low Back Pain 801
Joseph E. Scherger Laura E. Marsh
152
Sexual Dysfunction 750 167 Lower Extremity Strains and Sprains 806
Joseph E. Scherger, Negin Field Kory Gill
153 Psychotherapy in Family Medicine 756 168 Joint and Soft Tissue Injections 809
Joseph E. Scherger Kory Gill
SECTION NINE 169

Fracture Management 812
Kory Gill
Emergency Medicine 761
170 Infectious Disease and Sports 815
154
Cardiac Arrest 761 James D. King II
Anna Lichorad 171 Female Athlete Triad 818
155 Advanced Trauma Life Support 766 Laura E. Marsh
Nancy W. Dickey
156
Diabetic Ketoacidosis 769 SECTION ELEVEN
John F. Simmons Illustrated Review 823
157 Acute and Chronic Poisoning 772 172
Illustrated Review 823
Anna Lichorad Alfred F. Tallia
158 Urticaria Angioneurotic Edema 775 173
Color Plates 834
Nancy W. Dickey
Tips on Passing the Board Examinations
This section briefly discusses the philosophy and tech- RULE 6: If there is a question in which one choice is sig-
niques of passing board examinations or other types of nificantly longer than the others and you do not know
medical examinations. Most examinations, such as the the answer, select the longest choice.
certification and recertification examinations of the RULE 7: If you are faced with an “all of the above” option,
American Board of Family Medicine, have moved to realize that these are correct far more often than they are
computer-based administration. If this applies to your incorrect. Choose “all of the above” if you do not know
examination, read and study the demonstrations provided the answer.
on the Internet or elsewhere. RULE 8: Become suspicious if you have selected more than
First, realize that you are “playing a game.” It is, of three choices of the same letter in a row. Two in a row
course, a very important game, but a game neverthe- of the same letter is common, three is less common, and
less. When answering each question ask yourself, “What four is extremely uncommon. In this case, recheck your
information does the examiner want?” How do you “out- answers.
fox the fox”? RULE 9: Answer choices tend to be very evenly distrib-
To find out, let us turn our attention to the most com- uted. In other words, the number of correct “a” choices
mon type of question, the multiple choice. Following is close to the number of correct “b” choices, and so on.
these simple rules will maximize your chances. However, there may be somewhat more “e” choices than
RULE 1: Allocate your time appropriately. At the begin- any other, especially if there is a fair number of “all of
ning of the examination, divide the number of questions the above” choices. If you have time, do a quick check to
by the time allotted. Pace yourself accordingly, and check reassure yourself.
your progress every half hour. RULE 10: Never change an answer once you have recorded
RULE 2: If using a computer-administered examination, it on the computer unless you have an extraordinary rea-
take time before the examination to become familiar with son for doing so. Many people taking multiple-choice
the mechanics of maneuvering through the examination examinations, especially if they have time on their hands
program. Learn whether you can return to questions you after completing questions, start second-guessing them-
weren’t sure about, or whether this is not allowed. selves and thinking of all kinds of unusual exceptions.
RULE 3: Answer every question in order. On some Resist this temptation.
computer-administered examinations you run the risk RULE 11: Before you choose an answer, always read each
of not being able to return to an unanswered ques- and every choice. Do not get caught by seeing what you
tion. Although American Board of Family Medicine believe is the correct answer jump out at you.
examinations allow you to return, not all examinations RULE 12: Scan the lead-in to the answers and the potential
permit this. Some examinations use unfolding ques- answers first, then read the clinical case/vignette. This
tion sequences that do not let you return to a previous way you will know what is being tested and will better
question. On paper-administered examinations, you attend to the necessary facts. Read each question care-
run the risk of mis-sequencing your answers and thus fully. Be especially careful to read words such as not,
submitting all answers out of order. except, and so on.
RULE 4: Do not spend more than your allotted time on Following these suggestions cannot guarantee success;
any one question. If you don’t know the answer and you however, I do believe that these tips will help you achieve
are not penalized for wrong answers, simply guess. better results on your board examinations.
RULE 5: Even if you are penalized for wrong answers
(most examinations no longer do this) and you can elim- Alfred F. Tallia, MD, MPH
inate even one choice, answer the question. Percentages Editor-in-Chief
dictate that you will come out ahead in the end.
Continuing Medical Education
PR O C ES S F O R O BTA I N I N G C M E C R ED I T section is indicated below. (The fees shown are based on a

charge of $12.00 per credit hour for individual sections.)
In order to obtain CME credits, it is necessary to log in to As our costs can vary, Rutgers reserves the right to mod-
the Rutgers Robert Wood Johnson Medical School CME ify this fee schedule at any time. The latest fee schedule
web site. The address is: http://cme.rwjms.rutgers.edu will be available on our web site.
During registration you will be asked to complete a
pre-test and questionnaire designed to elicit evaluation Section Maximum Fee
data. Payment is by credit card (Visa, MasterCard, Amer- Credit
ican Express, or Discover). After reading the materials in Hours
the text you must complete the post-test, after which you
will be able to print a certificate for credits earned. 1. Family, Community, & 6 $72.00
Our CME administrator is: Population Health
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Swanson’s
FAMILY MEDICINE
REVIEW
SECTION ONE
Family, Community,
and Population Health
CHAPTER 1
b. family risk outcomes are not modifiable
c. family risk need not be ascertained because there is
Family Influences on Health nothing you can do about it
and Disease d. family disease susceptibility is absolutely
transmittable
C L I N I CA L CA S E PR O B L E M 1 e. family risk is not ascertainable by current methods
of genetic screening
A Calculated Risk
A 32-year-old African-American man comes to your C L I N I CA L CA S E PR O B L E M 2
office for the first time requesting a health maintenance
All in the Family
visit. He is married and the father of two young children.
He works as an accountant. His firm has just offered Two 75-year-old patients are hospitalized after both had
a new health insurance plan, which pays for a preven- a stroke resulting in a left-sided hemiparesis. The size
tive health maintenance examination. He wants to stay and location of the thrombotic events in these patients
healthy and to live longer than both his parents. are almost identical, as is the initial degree of impair-
ment. Treatment received is also the same. One patient
lives alone and has a younger sibling living in a distant
S EL ECT T H E B EST A N SW ER TO T H E
state. The other patient is part of an extended family
F O L LOW I N G Q U EST I O N S
with many social supports nearby, including grandchil-
1. Regarding his risk, you would ask him about which of dren who visit her often while she is in the hospital.
the following?
a. diet history 4. What outcomes would you predict for these patients
b. exercise type and frequency on the basis of their family social circumstances?
c. smoking history a. identical outcomes are likely given the identical
d. family history lesions and initial impairments
e. alcohol intake b. it is impossible to predict outcomes
f. all of the above c. the patient with more family supports is likely to
g. none of the above have a better outcome
2. You discover that his father had his first heart attack d. the patient with fewer family supports is at lesser
at age 42 and died at age 49 following a second heart risk of acute mortality
attack. His mother had diabetes, hypertension, and e. outcomes achieved are independent of any family
congestive heart failure and died at age 73. Consider- social factors
ing this information you would recommend which of
the following screening tests at this time? C L I N I CA L CA S E PR O B L E M 3
a. order a complete blood chemistry
Risks of Omission and Commission
b. order a cardiac non–stress test
c. perform a resting electrocardiogram (ECG) now A 28-year-old woman presents to your office for the
d. screen for lipids now first time for prenatal care. She is 14 weeks into her
e. none of the above because he is still less than 35 first pregnancy. She is human immunodeficiency virus
years old (HIV) positive but stopped antiretroviral agents because
3. Which is true about family and risk? she had heard that taking medication during pregnancy
a. family is one of the major influences on disease inci- could harm the baby. She has a half-pack per day
dence and prevalence smoking habit that she has been unable to stop despite
1
2 S ECTION O N E Family, Community, and Population Health
many attempts at quitting. She drinks at least a glass recognized competence. In future visits, anticipatory
of wine with dinner each night. She works in sales at a guidance in this family should probably take into con-
local food bar. She asks you what she can do to give her sideration which of the following?
child a better chance in life than she had. a. family beliefs about child discipline
b. family influences on exercise and diet
5. At this time, it is most appropriate to advise her of c. family beliefs about health and illness
which of the following? d. none of the above
a. perinatal transmission of the HIV virus poses the e. a, b, and c
child’s greatest risk
A N SW ER S
b. smoking is by far the most hazardous factor in her
prenatal history 1. f. Family influences on health and disease are
c. alcohol consumption during pregnancy is a major numerous and multifactorial. These influences can be
risk factor for fetal alcohol syndrome expressed across individual and family life cycles. One
d. she must restart antiretroviral medications immedi- of the most pronounced family effects is on genetic
ately or risk certain death and disease susceptibility. Although all the histori-
e. none of the above cal elements listed are important, the family history,
often recorded in the medical record pictorially as
C L I N I CA L CA S E PR O B L E M 4 a genogram, will provide a constant guide for the
assessment of symptoms as they are manifested across
Unwanted Advice
the individual life cycle.
A 25-year-old mother presents for the first time with her
2-week-old infant, her first child. Hovering in the back- 2. d. The U.S. Preventive Services Task Force
ground are the two grandmothers. The mother is visibly (USPSTF) recommends that men who are at
concerned that the baby is “only” at the same weight increased risk for coronary heart disease be screened
as he was at birth. One grandmother chimes in that for lipid disorders between the ages of 20 and 35.
she knew breastfeeding was a bad idea, and the other The preferred screening test is fasting or nonfasting
insists that it is time to introduce cereal to the baby’s serum lipid levels (cholesterol, high-density lipo-
diet. They start arguing among themselves until you protein, and low-density lipoprotein). Risk factors
escort everyone but the mother and the infant from the include family history of cardiovascular disease, along
examination room. with diabetes, history of previous coronary heart dis-
ease, or atherosclerosis, tobacco use, hypertension,
6. In addition to giving the mother accurate advice about and obesity.
breastfeeding and nutrition, which of the following is There is insufficient evidence to screen with a resting or
an appropriate intervention at this time? exercise ECG. Based on his family history it would also
a. refocus the attention of the grandmothers to some be reasonable to screen for diabetes and hypertension at
other facet of the family experience this time.
b. establish and reinforce the competency of the
mother in her breastfeeding 3. a. Disease incidence and prevalence are directly
c. use your expert authority as the physician to set related to the interplay of family genetics, behaviors,
family rules for decision making in the mother’s and the host environment. Physicians should attend to
favor known cues of family historical factors that can often
d. acknowledge and reinforce the expert authority of foreshadow overt disease in patients. Changes in diet,
the grandmothers exercise, and smoking habits can modify outcomes for
e. a, b, and c are correct those with family risk factors.
7. Possible positive aspects of the previous family situa- 4. c. A large literature exists on the influence of fam-
tion include which of the following? ily on survival and disease progression. Strong family
a. evidence of closeness and connectedness supports are protective and promote healing in acute
b. a lack of criticism and blame disease circumstances. Studies of disease outcomes in
c. the absence of protectionism and rigidity myocardial infarction and stroke reveal striking sup-
d. all of the above portive effects of family supports even when other
e. none of the above variables are controlled for.
8. You handle the situation with skill and care, and the 5. a. Family influence on prenatal and perinatal dis-
grandmothers leave feeling reassured of your careful ease transmission is another important influence of
attention to their first and only grandson, and they the family on health and disease. In 2005, of the 68
are impressed with his mother’s newly identified and children diagnosed with AIDS in the United States,
C H A P TER 1 Family Influences on Health and Disease 3
67 had been infected perinatally. Pregnant women legal, coercive, referent, and reward), this can readily
with HIV can reduce the risk of transmitting HIV be accomplished.
to their babies to less than 1% if they take antiretro-
viral drugs during pregnancy. This mother can help 7. a. Although answers b and c can be positive aspects
her child’s future most by resuming her antiretroviral of family, they are absent in this situation.
therapy.
8. e. Understanding of family influences on health and
6. e. How many of us have been confronted by the case disease is essential for effective practice as a family
illustrated? Most experienced family physicians will physician. Understanding allows not only appropri-
recognize the situation. Dealing with family members ate interventions in acute disease but also anticipatory
beyond the presumed present patient is a common guidance in the prevention of morbidity and future
occurrence in family medicine. In fact, skillful use illness, and the promotion of health and well-being.
of family resources is a therapeutic advantage in the Family factors that have protective influence on health
family physician’s armamentarium if it is done care- and illness include closeness and connectedness;
fully. The supportive closeness of this family must be well-developed problem-focused coping skills; clear
counterbalanced by the reinforcement of the compe- organization and decision making; and direct commu-
tence of the mother in this scenario. Although being nication. Family pathologies that can adversely influ-
careful not to alienate the grandmothers is important, ence health and illness include intrafamily hostility,
the mother’s competence and her decision-making criticism, and blame; perfectionism and rigidity; lack
authority must ultimately be reinforced. Because the of extrafamily support systems; and the presence of
physician possesses all forms of social power (expert, chronic psychopathology.
S U M M A RY
The effects of family on health and disease are large and 3. C hild rearing and nurturing
multifactorial. They are expressed across the individual Belief systems ranging from when to have children to
and family life cycles. Family physicians and other health how children should be raised and whether and how
care providers must be cognizant of these influences and much children should be held are all part of the
help individuals and families navigate the positive and less family influences on having and raising children.
positive effects. The potential effects of family on health 4. Nutrition and lifestyle
and illness include the following. Family traditions and socioeconomics play an im-
1. Genetics and disease susceptibility portant role in access to adequate nutrition. Many
Family effects through genetics are particularly lifestyle behaviors, such as smoking, diet, exercise,
strong. Although they can be moderated by envi- and alcohol consumption, are influenced by our
ronment and behavior, the effects are with us for parents and extended family and by their habits
a lifetime. Certain diseases, such as Huntington and beliefs.
disease and Tay-Sachs disease, are directly relat- 5. Access to and quality of care
ed to our parents; others, such as coronary heart Again, family socioeconomics along with race and
disease, hypertension, and diabetes, are strongly ethnicity are factors that influence the ability to ac-
mediated by family factors. Use of genetic testing cess health care and successfully navigate complex
and expanded family history tools will be increas- health care systems.
ingly important in the twenty-first century, and 6. Spread of infectious disease
physicians will need to evaluate such testing and its Family living situations and contacts are major in-
uses wisely. A reliable resource for understanding fluences on the spread of many infectious diseases
genetic testing can be found at www.ncbi. ranging from Mycoplasma pneumonia to influenza.
nlm.nih.gov/sites/GeneTests/?ob=GeneTests. Many infectious illnesses are passed from one fam-
2. Prenatal and perinatal transmission of disease ily member to others in a household, and families
Generations of families have experienced prenatal are important vectors in times of epidemics.
or perinatal transmission of diseases ranging from 7. Outcomes in acute and chronic illness
syphilis to HIV infection. In many areas of the Multiple studies have demonstrated different out-
world, this family influence has charted the des- comes in acute and chronic illness based on the
tiny of countless children. These risk factors can degree of social supports available in families.
be modified in many circumstances and should Similarly, family dysfunction can be a major con-
be addressed when appropriate by the family tributor to illness and adverse health outcomes in
physician. many individuals.
Continued
S U M M A RY—c o n t ’d
Family factors that have protective influence on systems; and the presence of chronic psychopa-
health and illness include closeness and connect- thology.
edness; well-developed problem-focused coping Family-level interventions used by family phy-
skills; clear organization and decision making; and sicians to reduce risk factors and to increase
direct communication. Family pathologies that protective functioning of families include
can adversely influence health and illness include various psychoeducational and psychotherapeu-
intrafamily hostility, criticism, and blame; perfec- tic techniques to address and enhance family
tionism and rigidity; lack of extrafamily support relationships.
Suggested Reading
Alvarez GF, Kirby AS. The perspective of the families of Ensenauer RE, Reinke SS, Ackerman MJ, et al. Primer on med-
the critically ill patient: their needs. Curr Opin Crit Care. ical genomics for the practicing physician. Mayo Clin Proc.
2006;12:614–618. 2003;78:846–857.
Baptiste-Roberts K, Gary TL, Beckles GLA, et al. Family Valdez R, Yoon PW, Qureshi N, et al. Family history in public
history of diabetes, awareness of risk factors, and health health practice: a genomic tool for disease prevention and
behaviors among African Americans. Am J Public Health. health promotion. Annu Rev Public Health. 2010;31:69–87.
2007;97:907–912. Wattendorf DJ, Hudley DW. Family history: the three genera-
Berg CA, Upchurch R. A developmental-contextual model of tion pedigree. Am Fam Physician. 2005;72:441–448.
couples coping with chronic illness across the life span. Psy-
chol Bull. 2007;133:920–954.
Centers for Disease Control and Prevention (CDC): HIV
among pregnant women, infants, and children. www.cdc.
gov/hiv/risk/gender/pregnantwomen/organizations.htm.
CHAPTER 2
d. all of the above
Clinical Decision Making e. none of the above
C L I N I CA L CA S E PR O B L E M 1 2. The most common problem related to clinical deci-

sion making by practicing physicians is:
A Third-Year Medical Student Who Wants to
a. not formulating enough hypotheses
Know How to Think
b. not formulating the correct hypotheses
A third-year medical student asks you to teach her the c. not attending to all the patient-relevant cues
secrets of clinical decision making, or how you think d. not knowing the prevalence of the condition
when you approach and treat a patient. You agree to e. not using time appropriately in treatment plans
take her to see a patient in the emergency depart-
ment. After you talk with the patient, you ask the stu- 3. The student returns with you to the office and sees a
dent to describe everything she has seen and heard. patient on her own initially to gather historical and
You carefully note that she has missed approximately physical examination data, which she then presents
half of what happened in the conversation between to you. After seeing the patient, she is absolutely
you and the patient and even more in the physical convinced the patient has a particular diagnosis. You
examination. take her with you to see the patient, and you obtain
more historical information and examine the patient.
As you ask her questions about her reasoning, she
proceeds to ignore a whole variety of things that do
not support her original diagnostic hypothesis. She
1. This case represents a problem with which step(s) of has made which of the following errors in clinical
the clinical decision-making process? decision making?
a. cue acquisition a. failure to acquire a cue
b. hypothesis formation b. failure to generate hypotheses
c. the search process c. premature closure
C H A P TER 2 Clinical Decision Making 5
d. all of the above c. 75.0%

e. none of the above d. 61.5%
e. 11.0%
C L I N I CA L CA S E PR O B L E M 2
7. What is the negative predictive value (NPV) of test A
A 25-Year-Old Medical Student Who Is
in the diagnosis of disease B?
Having Anxiety Regarding His Upcoming
a. 37.0%
Epidemiology Examination
b. 89.0%
A 25-year-old medical student comes to your office in a c. 25.0%
state of extreme anxiety manifested by palpitations and d. 75.0%
sweating throughout the previous week. He tells you he e. 61.5%
is scheduled to have a clinical epidemiology examina-
tion in 24 hours. 8. What is the likelihood ratio for test A in disease B?
On physical examination, his blood pressure is 120/70 a. 0.39
mm Hg, pulse is 90 beats per minute and regular, and b. 1.95
respirations are 24 per minute. His physical examination c. 3.80
is normal. You order a thyroid-stimulating hormone test to d. 0.79
exclude hyperthyroidism. You explain to him that given the e. 1.51
low prevalence of thyroid disease in his age group and the
higher prevalence of anxiety in his medical school popu- 9. What is the prevalence of disease A in this population?
lation of students, the negative predictive value of the test a. 15.5%
will be helpful. He looks confused and more anxious. b. 23.5%
In an attempt to deal with his symptoms, you decide c. 40.0%
to spend some time tutoring the student in basic epide- d. 10.5%
miologic concepts. You begin by explaining the basics e. 18.4%
of a 2 × 2 table that relates positive and negative test Consider the data in Table 2-2 illustrating the prevalence
results to the presence or absence of disease in a spe- of disease X in various populations. On the basis of this
cific population (Table 2-1). information about disease prevalence and assuming the
Use the data from Table 2-1 for questions 4 to 9. sensitivity of test A for disease X is 80% and the spec-
ificity of test A for disease X is 90%, answer questions
4. What is the sensitivity of test A for disease B? 10 to 13.
a. 25.0%
b. 37.5% 10. What is the PPV of test A in the diagnosis of disease
c. 75.0% X in the general population?
d. 62.5% a. 0.4%
e. 11.0% b. 1.3%
c. 5.4%
5. What is the specificity of test A for disease B? d. 15.7%
a. 25.0% e. 39.6%
b. 37.5%
c. 75.0% 11. What is the PPV of test A in disease X in women
d. 61.5% aged 50 years of age or older?
e. 11.0% a. 0.4%
b. 3.9%
6. What is the positive predictive value (PPV) of test A
in the diagnosis of disease B?
a. 37.5% TA BLE 2 - 2 Prevalenceof Disease X
b. 25.0% in Certain Populations
Prevalence
Relationship
TA B L E 2-1 between Test A Setting (Cases/100,000)
and Disease B General population 50
Disease B Disease B Women, ≥50 years 500
Present Absent
Women, ≥65 years, with a 40,000
Test A result positive 30 50 suspicious finding on clinical
Test A result negative 10 80 examination
Sensitivity
TA B L E 2-3 and Specificity of Blood Blood
TA BLE 2 -4 Pressure Readings versus
Glucose Levels in the Diagnosis of Visit Number
Diabetes Mellitus Mean Diastolic Blood
Blood Glucose Levels 2 Visit Number Pressure (mm Hg)
Hours after Eating Sensitivity Specificity 1 99.2
>140 mg/100 (7.8 mmol/L) 57% 99.4% 2 91.2
3 90.7
c. 10.7%
d. 23.6%
e. 52.7% c. accuracy
d. mean
12. What is the PPV of test A in disease X in women e. variation
older than 65 years of age with a suspicious finding
on clinical examination? 17. Which of the following is not a measure of central
a. 0.4% tendency?
b. 5.6% a. mean
c. 34.7% b. median
d. 84.2% c. mode
e. 93.0% d. standard deviation
e. none; all of the above are measures of central ten-
13. If the PPV of a test for a given disease in a given pop- dency Gaussian distribution
ulation is 4%, how many true positive test results are Consider the following experimental data: In a trial of
there in a sample of 100 positive test results? the effect of reducing multiple risk factors on the sub-
a. 4 sequent incidence of coronary artery disease, high-risk
b. 10 patients were selected for study. Elevated blood pressure
c. 40 was one of the risk factors for people to be considered.
d. 96 People were screened for inclusion in the study on three
e. none of the above consecutive visits. Blood pressures at those visits, before
To answer question 14, consider the data in Table 2-3 any therapeutic interventions were undertaken, were as
regarding the sensitivity and specificity in the diagnosis listed in Table 2-4. Use the data in Table 2-4 to answer
of diabetes mellitus in the population. question 18.
14. Given that the data are correct, if the sensitivity of 18. Which of the following statements regarding these
the test for a given blood glucose level is 36%, which data is true?
of the following would be the most likely value for a. these results are very strange: consider publication
specificity? in any journal specializing in irreproducible results
a. 99.2% b. this is an example of regression to the mean
b. 98.7% c. this is an example of natural variation
c. 92.4% d. the most likely explanation is either interobserver
d. 87.3% or intraobserver variation
e. 100.0% e. we are probably dealing with faulty equipment in
this case; the most likely reason for this would be
15. The validity of a test is best defined as which of the failure to calibrate all of the blood pressure cuffs
following? Consider the following experimental data: A population
a. the reliability of the test of heavy smokers (men smoking more than 50 cigarettes
b. the reproducibility of the test per day) are divided into two groups and observed for a
c. the variation in the test results period of 10 years.
d. the degree to which the results of a measurement Use the data from Table 2-5 to answer question 19.
correspond to the true state of the phenomenon
e. the degree of biologic variation of the test 19. Regarding these results, which of the following state-
ments is true?
16. Which of the following terms is synonymous with a.
these results prove that screening chest radio-
the term reliability? graphs improve survival time in lung cancer
a. reproducibility b.
these results prove that screening chest radio-
b. validity graphs should be considered for all smokers
TA B L E 2 -5 Ten-Year Mortality Data 23. Regarding clinical epidemiology in relation to the

discipline of family medicine, which of the following
Average statements is true?
Diagnosed S
urvival a. clinical epidemiology is higher mathematics that
with Lung Time from bears little relation to the world in general, much
Group Description Cancer Diagnosis less the specialty of family medicine
Group 1 490 individuals 37 14 months b. clinical epidemiology was invented to create anxi-
(experimental with annual chest ety and panic attacks that mimic hyperthyroidism
group) radiographs in medical students and residents
c. clinical epidemiology is unlikely to contain any
Group 2 510 individuals 39 8 months useful information for the average practicing fam-
(control group) with no annual ily physician
chest radiograph d. clinical epidemiology is a passing fad; fortunately
for all concerned, we have moved on to evi-
dence-based medicine
c. these results are most likely a result of lead-time e. none of the above statements about clinical epide-
bias miology is true
d. these results are most likely an example of length-
A N SW ER S
time bias
e. these results do not make any sense; the experi- 1. a. The clinical decision-making process in family
ment should be repeated medicine involves four iterative steps: cue acqui-
sition, hypothesis formation, the search, and plan.
20. Length-time bias with respect to cancer diagnosis is Cues come in a variety of different forms, including
defined as which of the following? traditional patient-specific historical cues and physi-
a. bias resulting from the detection of slow-growing cal examination, and laboratory data cues. Clinicians
tumors also attend to sensory cues, such as what we see,
b. bias resulting from the length of time a cancer was smell, hear, and feel about a patient and his or her
growing before any symptoms occurred story; contextual cues, such as physical location of
c. bias resulting from the length of time a cancer was the encounter; and temporal cues, such as frequency,
growing before somebody started to ask some ques- repetitions, intensity, and persistence of symptoms or
tions and perform some laboratory investigations signs. All these different cues are part of our clinical
d. bias resulting from the length of time between the thinking. The major mistake we make as clinicians in
latent and more rapid growth phases of any cancer cue acquisition is either missing or ignoring a cue or
e. none of the above cues. From research we know that experienced clini-
cians do not attend to all cues to arrive at a correct
Concerning population and disease measurement,
21. diagnosis. Inexperienced clinicians such as medical
prevalence is defined as which of the following? students often fail to identify key cues, and as a result
a. the fraction (proportion) of a population having a they often fail to consider proper hypotheses about
clinical condition at a given point in time what is going on to explain the chief complaint of the
b. the fraction (proportion) of a population initially patient.
free of a disease but that develops the disease
during a given period 2. b. Hypotheses are explanatory models of what we
c. equivalent to incidence believe is going on in a patient. Traditionally, they
d. mathematically as (a + b)/(a + b + c + d) in a 2 × 2 lead to or are diagnoses. Hypotheses are generated
table relating sensitivity and specificity to PPV and rank ordered on the basis of the cues acquired.
e. none of the above Knowledge of mortality and morbidity linked to cues
helps clinicians to generate and rank order hypoth-
Concerning population and disease measurement,
22. eses. Other factors that influence hypotheses for-
incidence is defined as which of the following? mation include experience, curiosity, and novelty.
a. the fraction (proportion) of a population having a A variety of hypotheses are possible and important
clinical condition at a given point in time to consider, but hypotheses can be broadly placed
b. the fraction (proportion) of a population initially into biomedical and psychosocial categories. The
free of a disease but that develops the disease average skilled clinician will actively consider an
during a given period average of five active hypotheses at any one time.
c. equivalent to prevalence The major error in clinical decision making over-
d. of little use in epidemiology all is failure to generate or to consider the correct
e. none of the above hypothesis.
3. c. The search process gathers more cues to test the Disease
TA BLE 2 - 6 X
hypotheses being considered, and it is based on
the science of probability. Hypotheses are weighed Disease Disease
on the basis of sensitivity, specificity, and predictive X Present X Absent
value of cues in support or refute of a hypothesis. The Test A result positive 30 (a) TP 50 (b) FP
search process relies on knowledge of prevalence of
Test A result negative 10 (c) FN 80 (d) TN
conditions in different populations and knowledge
of the value of the cue with respect to the hypoth- FN, False negative; FP, false positive; TN, true negative; TP, true positive.
esis. The major error is making assumptions about
the sensitivity, specificity, or predictive value of data the disease as having the disease. In Table 2-6, speci-
and coming to premature closure about a hypothesis ficity is defined as the number of true negatives (TNs)
under consideration. The inexperienced or not very divided by the number of true negatives plus false pos-
careful decision maker often tries to squeeze as many itives (FPs). That is:
cues into the incorrect hypothesis and often ignores Specificity = TN/(TN + FP)
nonsupporting cues.
The plan can be diagnostic or therapeutic or both. The Specificity = d/(d + b) = 80/130 = 61.5 %
plan should be patient-centered, and often it is negoti-
ated with the patient. Diagnostic and therapeutic plans A specific test is useful to confirm, or rule in, a diagnosis
may involve use of time, laboratory studies, pharmaco- that has been suggested by other tests or data. Thus, a
therapy or behavioral therapy, and consultation to gather specific test is rarely positive in the absence of disease,
new cues, to test hypotheses, or to provide definitive care. that is, it gives few false-positive test results. Tests with
Follow up is essential and is a hallmark in the patient- high specificity are needed when false-positive results can
physician relationship that facilitates decision making in harm the patient physically, emotionally, or financially.
family medicine. The major error in plan formation is Thus, a specific test is most helpful when the test result
not listening to the patient and not considering the needs is positive.
and desires of the patient. Patient nonadherence is often There is always a trade-off between sensitivity and
a direct result of this major failure to engage the patient specificity. In general, if a disease has a low prevalence,
in the plan. choose a more specific test; if a disease has a high preva-
Table 2-6 illustrates the answers to questions 4 to 9. lence, choose a more sensitive test.
4. c. Sensitivity is defined as the proportion of people 6. a. PPV is defined as the probability of disease in
with the disease who have a positive test result. A sen- a patient with a positive (abnormal) test result. It is
sitive test rarely will miss patients who have the dis- the proportion of people with a positive test result
ease. In Table 2-6, sensitivity is defined as the number that are true positives. In Table 2-6, the PPV is as
of true positives (TPs) divided by the number of true follows:
positives plus the number of false negatives (FNs).
That is: PPV = a/(a + b) = 30/80 = 37.5 %
Sensitivity = TP/(TP + FN)
7. b. NPV is defined as the probability of not hav-
Sensitivity = a/(a + c) = 30/40 = 75 % ing the disease when the test result is negative. It
is the proportion of people with a negative test
A sensitive test (one that is usually positive in the pres- that are true negatives. In Table 2-6, the NPV is as
ence of disease) should be selected when there is an follows:
important penalty for missing the disease. This would
be the case if you had reason to suspect a serious but NPV = d/(c + d) = 80/90 = 89 %
treatable condition, for example, obtaining a chest
radiograph in a patient with suspected tuberculosis or 8. b. The likelihood ratio of a positive test result is the
Hodgkin disease. In addition, sensitive tests are use- probability of that test result in the presence of dis-
ful in the early stages of a diagnostic workup of disease divided by the probability of the test result in the
ease, when several possibilities are being considered, absence of disease. In Table 2-6, the likelihood ratio
to reduce the number of possibilities. Thus in situa- is as follows:
tions such as this, diagnostic tests are used to rule out
diseases. Likelihood ratio ( + ) test results a/(a + c) divided by b/(b + d)
or 30/(30 + 10) divided by 50/(50 + 80) = 1.95
5. d. Specificity is defined as the proportion of people
without the disease who have a negative test result. A 9. b. The prevalence of a disease in the population
specific test rarely incorrectly classifies people without at risk is the fraction or proportion of a group with
Calculations
TA B L E 2-7 Involved in a estimate his or her pretest probability (prevalence)
of the disease in question. Next, put appropriate
General 2 × 2
column summation numbers at the bottom of the
Target Disorder columns (a + c) and (b + d). The easiest way to
Present Absent do this is to express your pretest probability (or
prevalence) as a decimal three places to the right.
Test result Cell a = (sensitivity) Cell b = (b + d ) − d
This result is (a + c), and 1000 minus this result is
positive (a + c)
(b + d).
Test result Cell c = (a + c) − ble Cell d = (specificity) Step 4: Start to fill in the cells of the 2 × 2 table. Multi-
negative (b + d ) ply sensitivity (expressed as a decimal) by (a + c) and
Column sums a+c Total − (a + c) put the result in cell a. You can the calculate cell c by
simple subtraction.
Total = a + b +
Step 5: Similarly, multiply specificity (expressed as a dec-
c+d
imal) by (b + d) and put the result in cell d. Calculate
cell b by subtraction.
Step 6: You now can calculate PPVs and NPVs for
a clinical condition at a given point in time. Preva- the test with the prevalence (pretest probability)
lence is measured by surveying a defined population used.
containing people with and without the condition of For example, to calculate the PPV for test A in the diag-
interest (at a given point in time). Prevalence can be nosis of disease in women older than 65 years with a sus-
equated with pretest probability. In Table 2-6, preva- picious finding on clinical examination, use the following
lence is defined as follows: equation:
Prevalence = (a + c) / (a + b + c + d) Prevalence = 40, 000 cases/100, 000 = 400/1000
That is: Setting the total number equal to 1000,
(a + c) divided by (a + b + c + d) (a + c) / (a + b + c + d) = 400/1000
= (30 + 10) / (30 + 10 + 50 + 80) = 23.5
Therefore,
As prevalence decreases, PPV must decrease along with it
and NPV must increase. (a + c) = 400 and (b + d) = 600
10. a. Answers 10 and 11 are explained in answer 12, Thus,

including Table 2-7.
Cell a = sensitivity × 400 = 0.8 × 400 = 320
11. b. See answer 12. Cell b = 400 − 320 = 80
12. d. The respective PPVs for test A in the diagnosis of Similarly,
disease X in the general population, in women older
than 50 years, and in women older than 65 years with Cell d = Specificity × 600 = 0.9 × 600 = 540
a suspicious finding on clinical examination are 0.4%, Cell b = 600 − 540 = 60
3.9%, and 84.2%, respectively.
To perform the calculations necessary to obtain these Calculate the positive predictive value as follows:
answers, the following steps are recommended:
Step 1: Identify the sensitivity of the sign, symptom, or PPV = a/ (a + b) = 320/ (320 + 60) = 84.2 %
diagnostic test that you plan to use. Many of these are
published. If you are not certain, consider asking a Similar calculations can be made for the general popula-
consultant with expertise in the area. tion (prevalence = 50/100,000) and for women older than
Step 2: Using a 2 × 2 table, set your total equal to an 50 years (prevalence = 500/100,000).
even number (consider, for example, 1000 as a good
choice). Therefore, 13. a. If the PPV of a test for a given disease is 4%, then
only 4 of 100 positive test results will be true posi-
a + b + c + d = 1000 tives; the remainder will be false positives. Further
testing (often invasive) and anxiety will be inflicted on
Step 3: Using whatever information you have about the 96% of the population with a positive test result
the patient before you apply this diagnostic test, but without the disease.
Thus, careful consideration should be given to the PPV this is called regression to the mean. The following is
of any test for any disease in a given population before the best explanation of regression to the mean.
ordering it. Patients who are singled out from others because they
have a laboratory test result that is unusually high or low
14. e. Remember the inverse relationship between sensi- can be expected, on average, to be closer to the center
tivity and specificity: if the sensitivity increases, then the of the distribution (normal or Gaussian) if the test is
specificity decreases. The only value that is greater than repeated. Moreover, subsequent values are likely to be
the previous specificity of 99.4% is 100%; therefore, more accurate estimates of the true value (validity), which
it is the most likely correct value of the values listed could be obtained if the measurement were repeated for a
for the specificity of the test. The value in the table is particular patient many times.
actually the case at a cutoff blood glucose level of 180
mg/100 mL 2 hours after eating. If we use this value 19. c. This is an example of lead-time bias. Lead time is
for the cutoff, there will be even more false-negative the period between the detection of a medical condi-
results than at 140 mg/100 mL. That is, we will incor- tion by screening and when it ordinarily would have
rectly label more individuals who actually have diabetes been diagnosed as a result of symptoms.
as being normal, although we will not label anyone who For lung cancer, there is absolutely no evidence that chest
does not have diabetes as having diabetes. radiographs have any influence on mortality. However,
if, as in this case, the experimental group had chest radio-
15. d. Validity is the degree to which the result of a graphs done, their lung cancers would have been diagnosed
measurement of a test actually corresponds to the at an earlier time and it would appear that they were longer
true state of the phenomenon being measured. survivors. The control group most likely would have had
their lung cancers diagnosed when they developed symp-
16. a. Reliability is the extent to which repeated mea- toms. In fact, however, the survival time would have been
surements of a relatively stable phenomenon fall exactly the same; the only difference would have been that
close to each other. Reproducibility and precision are men in the experimental group would have known that
other words for this characteristic. they had lung cancer for a longer period.
17. d. Central Tendency in a normal, or Gaussian, dis- 20. a. Length-time bias occurs because the proportion
tribution is characterized by the following measures: of slow-growing lesions diagnosed during a cancer
(1) Mean: the sum of the values for observations divided screening program is greater than the proportions
by the number of observations; of those diagnosed during usual medical care when
(2) Median: the value point where the number of obser- symptoms appear. The effect of including a greater
vations above equals the number of observations number of slow-growing cancers makes it seem that
below; and the screening and early treatment programs are more
(3) Mode: the most frequently occurring value. effective than they really are.
Expressions of Dispersion in the same normal, or
Gaussian, distribution are the following: 21. a. Prevalence is defined as the fraction (proportion)
(1) Range: the difference between the lowest value and of a population with a clinical condition at a given
the highest value in a distribution; point in time. Prevalence is measured by surveying a
(2) Standard deviation: the absolute value of the average dif- defined population in which some patients have and
ference of individual values from the mean; and some patients do not have the condition of interest at
(3) Percentile: the proportion of all observations falling a single point in time. It is not the same as incidence,
between specified values. and as previously discussed in relation to sensitivity,
The most valuable measure of dispersion in a normal, or specificity, and PPV in a 2 × 2 table, it is defined in
Gaussian, distribution is the standard deviation (SD). It is mathematical terms as (a + c)/(a + b + c + d).
defined as follows:
( √∑ ) 22. b. Incidence in relation to a population is defined
SD = x − x2 / (n − 1) as the fraction (proportion) initially free of a disease
or condition that go on to develop it during a given
In a normal, or Gaussian, distribution, 68.26% of the val- period. Commonly, it is known as the number of new
ues lie within ±1 SD from the mean, 95.44% of values lie cases per population in a given time.
within ±2 SD from the mean, and 99.72% of values lie
within ±3 SD from the mean. 23. e. Clinical epidemiology is a specialty that will
assume increasingly more importance in the specialty
18. b. As can be seen in this trial, there was a progres- of family medicine. It allows us to understand disease,
sive and substantial decrease in mean blood pressure to understand laboratory testing, and to understand
between the first and third visits. The explanation for why we should do what we should do and why we
should not do what we should not do. More important, will allow us to understand the difference between
as family physicians are called on by governments, “defensive” medicine and defensible medicine (the
patients, licensing bodies, and boards to justify clin- latter being what we are trying to achieve) in the
ical decisions and treatments, clinical epidemiology interest of optimizing the health care of patients.
S U M M A RY
1. T he process of clinical decision making in family med- the patient, and it can involve use of time, laboratory
icine is essentially a four-step iterative process: cue studies, pharmacotherapy or behavioral therapy, and
acquisition, hypotheses formation, the search, and consultation to gather new cues, to test hypotheses, or
plan. to provide definitive care. Follow-up is essential, and
2. Cues come in a variety of different forms, including tra- it is a hallmark in the patient-physician relationship
ditional patient-specific historical, physical examination, that facilitates decision making in family medicine.
and laboratory data cues as well as sensory cues (e.g., The major error in plan formation is not listening to
what we see, smell, hear, and feel about patients and the patient and not considering the needs and desires
their stories). There are contextual cues, such as phys- of the patient. Patient nonadherence is often a direct
ical location (e.g., the emergency department, office, result.
hospital, and home), and temporal cues (e.g., frequency, 6. The summary of calculations related to search process
repetitions, intensity, and persistence of signs and statistics is described by the following 2 × 2 table:
symptoms). The major mistake we make as clinicians in
cue acquisition is either missing cues or ignoring cues. Disease or Disease or
We know, however, that experienced clinicians do not Hypothesis Hypothesis
attend to all cues to arrive at a correct diagnosis. Present Absent
3. Hypotheses are explanatory models of what we believe
is going on in a patient. Traditionally, they lead to or Test result or cue a b
are diagnoses. A variety of hypotheses are possible and positive
important to consider, but hypotheses can be broadly Test result or cue c d
classified into biomedical or psychosocial categories. negative
Hypotheses are generated and rank ordered on the Prevalence = (ble + c)/(a + b + c + d)
basis of the cues acquired. Knowledge of mortality and Sensitivity = a/(a + c)
morbidity linked to the cues acquired also helps cli- Specificity = d/(b + d )
nicians to generate and rank order hypotheses. Other Positive predictive value = a/(a + b)
factors that influence hypothesis formation include Negative predictive value = d /(c + d )
experience, curiosity, and novelty. The typical skilled Likelihood ratio positive test results = a/(a + c) ÷ b/(b + d )
clinician will actively consider an average of five active
hypotheses at any one time. The major error in clini- 7. R emember the importance of sensitivity, specific-
cal decision making with respect to hypothesis forma- ity, and especially PPV; understand that the lower
tion is failure to generate or to consider the correct the prevalence (or likelihood) of a condition in the
hypothesis. patient about to be tested, the lower the PPV of the
4. The search process gathers more cues to test the test. In outpatient, low-prevalence situations, NPV
hypotheses being considered and is based on the sci- is often more useful, if it is known.
ence of probability. Hypotheses are weighed on the 8. Understand the importance of false-negative results
basis of sensitivity, specificity, and predictive value of and especially of false-positive results in the labora-
the cue with respect to the hypothesis. The major error tory tests that you order.
is making assumptions about the sensitivity, specific- 9. Be prepared to draw a 2 × 2 table and calculate the
ity, or predictive value of data and coming to prema- PPV of a test given the sensitivity, specificity, and
ture closure about a hypothesis under consideration. prevalence of the condition in the population.
5. The plan can be diagnostic or therapeutic or both. It 10. Misinterpretations of survival statistics in cancer are
should be patient-centered and often is negotiated with often caused by lead-time bias and length-time bias.
Suggested Reading
Evidence-Based Medicine Toolkit. EBM Glossary; June 2013. Guyatt GH, Rennie D: Users’ guides to the medical literature:
www.aafp.org/journals/afp/authors/ebm-toolkit. a manual for evidence-based clinical practice, JAMA online.
Greenberg RS. Medical epidemiology. ed 4. New York: McGraw- Petrie A, Sabin C. Medical statistics at a glance. Malden, Mass:
Hill; 2005. Blackwell Science; 2000.
CHAPTER 3 b. ask the patient to return to the consultant for

another visit to get a clearer understanding of the
Consultation and Team Care recommendations and plan
c. not using this consultant again
C L I N I CA L CA S E PR O B L E M 1 d. seeking the opinion of another consultant if the
communication does not improve
Who Ya Gonna Call?
e. asking the receptionist to fax the consultant’s letter
You are a recently graduated family physician new to a of consultation if there is one
community practice made up of two other family physi-
cians, a family nurse practitioner, and a physician assis- 5. You later learn from the patient that the consultant
tant. You see a 47-year-old patient for several visits and had referred the patient to another consultant with-
are concerned about whether or not he should undergo out your knowledge. Circumstances and reasons why
a cardiac catheterization because of a 2-year history of this is a problem for both you and the patient include
intermittent but stable chest pain and a strong family which of the following?
history of premature cardiac mortality. a. such behavior disrupts continuity of care
b. it may result in unnecessary use of additional resources
c. the problem may have been handled by you
d. it may add unnecessary inconvenience and expense
for the patient
1. Which of the following is (are) among the factors you e. all of the above
will consider in choosing the consultant?
a. the skill and reputation of the cardiologist C L I N I CA L CA S E PR O B L E M 2
b. the geographic convenience for the patient
c. the experience of other practitioners in your prac-
Who’s on First, What’s on Second?
tice with the subspecialist You attend your first meeting of the practice clinicians
d. the skill of the consultant is the only important and staff. The practice leader says she wants to improve
consideration teamwork in the office. She defines teamwork as people
e. a, b, and c are correct working together cooperatively and effectively. Knowing
f. a and c are correct that you have just graduated from a residency program
known for its team-based care, she asks your advice.
2. After choosing the appropriate consultant, you elec-
tronically send her a consultation request. The con- 6. Factors that improve practice functioning and team-
tent should include all of the following except: work include all of the following except:
a. a brief history a. building trusting relationships
b. a brief physical examination b. having a diversity of perspectives
c. a directive that catheterization be done as soon as c. using mostly written communication
possible d. encouraging varied interactions
d. the type of help you are asking for e. b and d
e. any supporting laboratory data
7. Techniques to build some of these factors include all
3. Your communication expectations of the consultant of the following except:
should reasonably include which of the following? a. create opportunities for interprofessional education
a. clear response regarding the diagnosis and manage- b. expand skills in feedback, negotiation, and conflict
ment plan resolution
b. justification for the course of action outlined c. have practice leaders model the desired behavior
c. communication about the patient by telephone or d. isolate and ignore behaviors that inhibit
in writing or both collaboration
d. a and b e. develop a routine for managing conflict
e. a, b, and c
8. You decide it is time to implement an electronic med-
4. Your patient sees the consultant and returns to see you ical record (EMR) in your practice. Reasonable expec-
3 weeks later confused by what was told to him by the tations of what a working system will bring to the
consultant. You call the consultant but are told by the practice include which of the following?
receptionist that she is too busy right now to come to a. communication is likely to improve
the phone. Options at this time include all of the fol- b. office efficiency is likely to improve
lowing except: c. patient care is likely to improve
a. ask to speak to the physician later that day when she d. billing is likely to improve
is available e. none of the above
C H A P TER 3 Consultation and Team Care 13
of care, and it makes a joke of the idea of a medical

A N SW ER S
home for patients. In addition to unnecessary incon-
1. e. There are many factors to consider in choos- venience and expense for the patient, it may result in
ing a consultant. Certainly the expertise and skill unnecessary use of additional resources for a prob-
set of the consultant are important. Whether or lem that may have been handled by you in the first
not the consultant participates in the health plan place; and in the worst-case scenario, it may lead to
of the patient and whether or not the consultant is iatrogenesis.
within a reasonable distance geographically are two
other considerations. The family physician is also 6. c. Teamwork can be defined as people working
in a good position to match patient to consultant together cooperatively and effectively for some com-
in terms of personality type. Prior experience with mon purpose. Teamwork in family medicine offices is
a consultant is a good guiding factor in consider- dependent on good work relationships among team
ing subsequent use. Did the patients have a good members. Characteristics of work relationships asso-
experience? Did you have a good experience as the ciated with successful practices have been studied
referring physician? and include the following: high levels of trust among
team members; the presence of respectful, mindful,
2. c. Good communication is essential to the and heedful interactions among all parties; a toler-
patient-physician relationship and also for the phy- ance for the expression of a diversity of ideas; a mix
sician-consultant-patient triad. At a minimum, you of rich (face-to-face) and lean (written) communica-
should provide written communication that out- tion; and the presence of both social and task-oriented
lines a brief history, physical and laboratory find- interactions.
ings, and a clear statement of the type of help you
are seeking. 7. d. There are a number of ways to successfully
build some of the work relationship characteristics
3. e. The consultant, at a minimum, should provide listed in answer 6 that are associated with success-
timely, clear written information about the help ful practices. These include creating opportunities
you are seeking, which may include a clear response for interprofessional education, such as noontime
regarding the help you were requesting, a diagnosis interdisciplinary seminars and lunches; holding
and recommended management plan, and justification training sessions to expand and model everyone’s
for the course of action outlined. In urgent situations, skills in feedback, negotiations, and conflict reso-
communication by telephone or in person is appro- lution; engaging practice leaders to model desired
priate, to be followed up by written communication. behaviors; and developing a routine for identifying
and managing conflict so that behaviors that inhibit
4. b. What to do about a consultant who has not ful- collaboration are not ignored but surfaced and suc-
filled expectation is a common problem. In this cessfully addressed. Building successful work rela-
instance, 3 weeks is more than enough time to expect tionships is difficult, but it is necessary for good
written communication regarding a consultation. patient care. Done correctly, it can enhance work-
Of course, direct communication is imperative, and place productivity and contribute to the growth and
you may have been the victim of an overly protective enjoyment of one’s role as a team member in effec-
staff member, or the consultant may have been gen- tive health care delivery.
uinely unable to come to the telephone. Requesting
the consultant notes or other information is perfectly 8. e. Implementing an EMR is being promoted by
reasonable, but in this case, it should not substitute many quality-oriented organizations as an important
for a formal form of written communication. In any step toward safer and more effective health care for
event, the patient should not bear the burden of the patients. Used properly under the correct conditions,
noncommunication. If communication difficulties it can add immensely to improvements in quality of
become a pattern, use of another consultant in the care and efficiency of a practice. However, multiple
future is an option. studies have demonstrated that it is not the panacea
many have proposed it to be. An EMR will not make
5. e. The ping-ponging of patients among consultants a dysfunctional office functional. Careful attention to
without the involvement and coordination of the pri- the underlying work relationships is more important
mary care physician is one of the main contributing to problem solving than implementing an EMR. Oth-
factors to poor quality and high costs of health care in erwise, what you will get is an office with the same old
the United States. Such behavior disrupts continuity problems plus an EMR.
S U M M A RY
No physician is an island, and the arts of consultation and Similarly, teamwork in the office, hospital, or other set-
collaboration are essential for good patient care, partic- tings requires relationship building among people car-
ularly for patient safety. In many respects, consultation ing for patients. Work relationships within primary care
is about communication skills, and, like every interpro- practices affect the functioning and quality of care deliv-
fessional encounter, communication is a two-way street. ered by practices. Characteristics of work relationships
Among the factors that should be considered in choos- associated with successful practices include:
ing a consultant are: • high levels of trust
• skill and reputation of the consultant • the presence of respectful, mindful, and heedful inter-
• convenience and “match” with the needs and person- actions
ality of the patient • tolerance for diversity of ideas
• previous experience with the consultant • a mix of rich and lean communication
The requestor of the consultation should provide the • the presence of both social and task-oriented interac-
following: tion
• brief history Enhanced work relationships invest all members in
• brief physical examination practice goals, empower everyone to share insights that
• pertinent laboratory data improve information flow and decision making, and
• clear communication about the type of help one is enable a process of continuous reflection and renewal
requesting that facilitates practice improvement.
In return, it is reasonable to expect the following from the Techniques to build better work relationships
consultant in an appropriate and reasonable time frame: include:
• clear response regarding the diagnosis and recom- • creating opportunities for interprofessional educa-
mended management plan tion
• justification for the course of action outlined • expanding everyone’s skills in feedback, negotiation,
• communication about the patient by telephone or in and conflict resolution
writing or both • modeling desired behavior (especially by leaders)
• return of the patient to you for coordination of any • directly confronting behaviors that inhibit collab-
additional care that is needed, unless you request oration through the development of a routine for
otherwise managing conflict
Suggested Reading
Gerardi D, Fontaine DK. True collaboration: envision- Reichman M. Optimising referrals and consults with a stan-
ing new ways of working together. AACN Adv Crit Care. dardized process. Fam Pract Manag. 2007;14:38–42.
2007;18:10–14. Smith SM, Allwright S, O’Dowd T. Effectiveness of shared care
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communi- across the primary-specialty care interface in chronic disease
cation and information transfer between hospital-based and management. Cochrane Database Syst Rev. 2004;3:CD004910.
primary care physicians: implications for patient safety and Tallia AF, Lanham HJ, McDaniel Jr RR, et al. Seven charac-
continuity of care. JAMA. 2007;297:831–841. teristics of successful work relationships. Fam Pract Manag.
O’Malley AS, Reschovsky JD. Referral consultation communi- 2006;13:47–50.
cation between primary care and specialist: finding common
ground. Arch Intern Med. 2011;171:56–65.
C H A P TER 4 Managing Multiple Morbidities 15
CHAPTER 4 Results from the Medical Outcomes Study suggest

3.
which of the following is (are) true regarding systems
Managing Multiple Morbidities of care for this patient?
a. optimal clinical outcomes are best achieved when
C L I N I CA L CA S E PR O B L E M 1 care is provided by a generalist
b. optimum clinical outcomes are best achieved when
A Case of Discontinuous Maximus
care is provided by subspecialists
A new patient presents to your office after moving c. costs of care and resource use tend to be lower when
to your community from a different state. She is a care is provided by generalists
55-year-old, recently divorced marketing executive d. similar clinical outcomes are achieved when care is
with a history of recent-onset diabetes, long-standing provided by either a generalist or subspecialists
hypertension, moderate obesity, and depression. She e. c and d
smokes half a pack of cigarettes per day, gets insuffi-
cient exercise, travels often, and follows an erratic diet. 4. This case points out that which of the following is (are)
She complains of headaches that are worsening with among the skills needed to manage patients with mul-
stress and seasonal allergies, intermittent fatigue with tiple morbidities?
snoring and daytime somnolence, and hot flushes. She a. the capacity to thrive on managing complex medi-
is taking six medications from six different physicians cal problems
she has irregularly seen in her previous locale, but she b. the ability to integrate all of the medical and per-
has not been seen in follow-up by any of them for the sonal issues facing an individual
past 4 months. c. the ability to break down medical terms and com-
plex medical issues to make it easier for patients to
understand
d. the capacity to know and understand an individual’s
limitations, problems, and personal beliefs when
Given her symptom complex, at this time she is
1. deciding on a treatment
likely to need the services of which of the following e. all of the above
subspecialists?
a. cardiologist 5. In addition to reviewing all her current medica-
b. psychiatrist tions, obtaining any previous medical records you
c. sleep specialist can, and ordering some laboratory data, your next
d. endocrinologist step in management should include which of the
e. none of the above following?
On examination, vital signs are blood pressure 150/85 a. assessing the patient’s understanding of her health
and pulse 85/minute. Body mass is 30. She appears well problems
developed, overnourished, neat, and well spoken. There b. getting a sense of the patient’s priorities in dealing
are boggy nasal passages, nicotine staining on her buccal with her health problems
mucosa, clear lungs, and a normal-sounding heart. Abdo- c. reordering all her medications and stressing the
men is obese; skin is warm and dry. Extremities are with- importance of compliance
out clubbing, cyanosis, or edema. Peripheral pulses are d. identifying community resources that can be
normal and symmetrical. Affect is appropriate, but mood brought to bear in a treatment plan
seems depressed. e. a, b, and d
2. What laboratory data would you like to obtain at this 6. You decide to enter your patient in your office-based
time? disease registry. Which of the following is (are) true
a. complete blood count (CBC), comprehensive met- regarding disease registries?
abolic profile (CMP), lipid profile, and electrocar- a. they are a useful way for tracking practice adoption
diogram (ECG) of disease- and patient-centered guidelines
b. CBC, CMP, lipid profile, hemoglobin A1c, and b. they require the use of an electronic medical
ECG record
c. CBC, CMP, lipid profile, hemoglobin A1c, ECG, c. they can facilitate population-based interventions
and thyroid-stimulating hormone such as hemoglobin A1c tracking or influenza
d. CBC, CMP, lipid profile, hemoglobin A1c, and immunizations
chest radiograph d. a and c
e. No new testing is necessary at this time; obtain old e. they are primarily a research tool of little use
records first clinically
7. Regarding adapting your practice to dealing with the ability to integrate all of the medical and personal issues
complexities of patients with multiple morbidities, all facing an individual and his or her family members; the
of the following are true except: ability to break down medical terms and complex med-
a. as the population ages, the problem of multiple ical issues to make it easier for patients to understand;
morbidities is generally exacerbated the capacity to develop long-term healing relationships
b. implementing a self-audit and feedback function in with patients; the capacity to know and understand peo-
a practice is a valid way of assessing overall practice ple’s limitations, problems, and personal beliefs when
performance deciding on a treatment; the ability to provide care
c. using information from administrative data sets pro- that includes long-term behavioral change interven-
vides more than adequate understanding of practice tions that lead to better health; the ability to empower
performance in treating different conditions patients with information and guidance that are needed
d. enlisting all practice members in quality-focused to maintain health; the ability to link patients to appro-
initiatives builds practice capacity for dealing with priate community resources; and, finally, the ability to
patient complexity mobilize and facilitate proper use of and communica-
e. understanding the epidemiology and interaction tion among those resources. The family physician, by
of multiple risk factors is increasingly important in virtue of his or her training, is uniquely positioned to
patients with multiple morbidities deliver these skills to patients with multiple morbidities.
A N SW ER S
5. e. Without a clear knowledge of the patient’s under-
1. e. You are a long way from consulting or referring standing of her medical conditions or an assessment of
to anyone. You must first get a clearer understanding the patient’s priorities in dealing with her health prob-
of this patient’s problems and how they interrelate. As lems, reordering of all her medications is likely to be a
the family physician, you are in the best position to do wasted opportunity to identify and prioritize the patient’s
so, and it is your responsibility to do so. needs and conditions. Without this information, stress-
ing the importance of compliance is a waste of time. This
2. b. Normally, it would be best to get old records is also an opportunity to identify community resources
before obtaining laboratory tests, particularly if the that can be brought to bear in a treatment plan.
situation is not urgent. However, in the case of the
previously fractured care experienced by this patient 6. d. Disease registries are a useful way for tracking
and the time since the last visit to all the subspecial- practice adoption of disease- and patient-centered
ists, the likelihood of receiving information in a timely guidelines. It is a common misunderstanding that to
manner in the absence of a shared electronic record have a disease registry you need an electronic medical
is limited. Therefore, obtaining baseline information record. This is not the case. Registries can facilitate
in this patient’s situation is most appropriate. Of the population-based interventions such as hemoglobin
combinations listed, that of CBC, CMP, lipid profile, A1c tracking or influenza immunizations as well as
hemoglobin A1c, and ECG is most reasonable to cover facilitate and track other patient-centered interven-
this patient’s multiple morbidities listed in the history. tions. Although some have been used in practice-based
research, their primary application is in clinical care.
3. e. The Medical Outcomes Study is the classic
well-designed comprehensive study that compared 7. c. As the population ages, the problem of multi-
outcomes of care by generalists and subspecialists after ple morbidities is exacerbated. Many clinicians have
controlling for patient mix. Reported in The Journal implemented a self-audit and feedback function in
of the American Medical Association and other medical their practice, and they have found these to be valid
journals, the comprehensive study found no difference ways of assessing overall practice performance. The
in outcomes between generalists and subspecialists use of information from administrative data sets in an
for patients with diabetes and hypertension who were attempt to provide an understanding of practice per-
observed for 7 years. Outcomes included measures of formance in treating different conditions has been a
physical and emotional (functional) health, mortality, common practice of insurance companies for many
and disease-specific physiologic markers. However, years. However, these databases have been fraught with
there were significant differences with regard to lower poor quality of data and are generally inadequate to
resource use and cost for patients of primary care phy- measure individual practice or provider performance.
sicians because of more judicious use of tests, proce- Combined with chart audit, they become more useful.
dures, drugs, office visits, and hospitalizations. Enlisting all practice members in quality-focused ini-
tiatives builds practice capacity for dealing with patient
4. e. Multiple skills are needed to manage patients with complexity. Understanding of the epidemiology and
multiple morbidities. These include the capacity to interaction of multiple risk factors is increasingly
thrive on managing complex medical problems; the important in patients with multiple morbidities.
C H A P TER 4 Managing Multiple Morbidities 17
S U M M A RY
Managing patients with multiple morbidities is one of the • the ability to provide care that includes long-term
primary problems confronting the health care system in behavioral change interventions that lead to better
the twenty-first century. This problem is especially well health
suited for the skill set of primary care physicians. Com- • the ability to empower patients with information
plexities increase as problems multiply, and dealing with and guidance that are needed to maintain
complexity is a particular skill set of the family physician. health
The specific skills needed to deal with patients with mul- • the ability to link patients to appropriate community
tiple morbidities include: resources and the ability to mobilize and facilitate
• the capacity to thrive on managing complex medical proper use of and communication among those re-
problems sources
• the ability to integrate all of the medical and personal Modifying the practice to equip all members to contrib-
issues facing an individual and his or her family mem- ute to the problem of managing patients with multiple
bers morbidities is important, as is developing systems and
• the ability to break down medical terms and complex processes to monitor practice performance. Effective
medical issues to make it easier for patients to under- methodologies include the use of patient disease regis-
stand tries to monitor populations in need of particular care
• the capacity to develop long-term healing relation- and the use of audit and feedback to assess practice and
ships with patients physician performance with respect to particular condi-
• the capacity to know and understand people’s limitations or groups of conditions.
tions, problems, and personal beliefs when deciding
on a treatment
Suggested Reading
Bagley B, Mitchel J. Registries made simple. Fam Pract Manag. Shi L, Macinko J, Starfield B, et al. Primary care, social inequal-
2007;18:11–14. ities, and all-cause heart disease, and cancer mortality in U.S.
Baicker K, Chandra A. Medicare spending, the physician counties. Am J Public Health. 2005;95:674–680.
workforce, and beneficiaries’ quality of care. Health Aff. Valderas JM, Starfield B, Sibbald B, et al. Defining comorbid-
2004;23:184–197. ity: implications for understanding health and health ser-
Greenfield S, Rogers W, Mangotich M, et al. Outcomes of vices. Ann Fam Med. 2009;7:357–363.
patients with hypertension and non–insulin-dependent
diabetes mellitus treated by different systems and special-
ties. Results from the Medical Outcomes Study. JAMA.
1995;274:1436–1444.
CHAPTER 5 the time to reflect on your patient care practices, to

assimilate new and existing scientific evidence into your
Quality Improvement care of patients, and always to seek ways to improve
patient care.
4. Among the following measures you consider taking in
Quality Matters
your office practice to improve quality, which has been
An official from one of the insurance companies shown to be most effective?
you participate with sets up an appointment to dis- a. systematic collection and analysis of information
cuss quality improvement measures you are think- about the clinical care provided in the context of
ing about implementing in your office. In preparation evidence-based guidelines
for the meeting, you review the literature on quality b. systematic analysis of practice experience, including
improvement. feedback from patients, families, and the community
c. regularly engaging staff in learning activities to
advance competence and performance
d. only c has been shown to be effective
e. a, b, and c are effective
Among the many possible online Internet sources
1.
for information about quality improvement, you find 5. Which of the following is (are) the essential element(s)
which of the following to be most reliable? of high-performing family medicine practices?
a. the American Academy of Family Physicians a. an electronic patient clinical information system
(www.aafp.org) b. open and direct communication among all mem-
b. the Agency for Healthcare Research and Quality bers of the practice
(www.ahrq.gov) c. a leader who tolerates little deviance of accepted
c. the National Committee for Quality Assurance thought from employees
(www.ncqa.org) d. a and b are correct
d. all of the above e. a and c are correct
e. none of the above
One of the products of the National Committee
2.
Measuring Quality
for Quality Assurance that you run across online is
HEDIS. Which of the following is true about HEDIS? You decide to implement performance measures in your
a. HEDIS stands for Health Employer Data and practice based on evidence of effectiveness targeting
Information Services several major diseases in your patient population. In this
b. HEDIS contains measures of health care effective- process, you rely on performance measures for ambu-
ness and patient safety latory care derived from the National Quality Forum.
c. HEDIS measures are not concerned about cost, just
quality 6. Which of the following is (are) a reasonable perfor-
d. HEDIS measures are designed to be primarily mance measure(s) of your practice to assess preventive
applicable to patients with Medicare insurance care delivery?
e. HEDIS measures are updated every 5 years a. rates of fecal occult blood testing for the past
year in eligible men and women aged 50 years or
3. Examples of HEDIS effectiveness of care measures older
applicable to family medicine outpatient practice b. the percentage of women between the age at onset
include which of the following? of sexual activity and 65 years who have had one or
a. measures of childhood immunization status more Pap tests in the past 2 years
b. colorectal cancer screening rates c. the percentage of patients who smoke who received
c. measures of influenza vaccination rates advice to quit smoking in the past year
d. measures of frequency of prenatal visits d. a and c
e. all of the above e. a, b, and c
C L I N I CA L CA S E PR O B L E M 2 7. Which of the following is not a reasonable perfor-

mance measure of your practice to assess care of
Improving Practice Quality
patients with coronary artery disease (CAD) or heart
After reviewing the literature and reflecting on what you failure?
have found, you decide that good physicians should a. percentage of patients with CAD who were pre-
actively learn from their practices. This means taking scribed a lipid-lowering therapy
C H A P TER 5 Quality Improvement 19
b. percentage of patients with heart failure and left of care, costs of care, and health plan description and
ventricular systolic dysfunction who were pre- stability.
scribed an angiotensin-converting enzyme inhibi-
tor or receptor blocker 3. e. Examples of effectiveness of care measures in
c. percentage of patients with three or more risk fac- HEDIS include measures of childhood immunization
tors and without contraindications who are taking rates, colorectal cancer screening rates, and influenza
aspirin vaccination rates for applicable populations. Measures
d. percentage of patients with atrial fibrillation who of frequency of ongoing prenatal visits are examples
are receiving anticoagulation therapy of utilization measures. For a complete listing of
e. percentage of patients with CAD who had an exer- the HEDIS measures, visit the NCQA website at
cise stress test in the past year www.ncqa.org.
8. Which of the following is not a reasonable perfor- 4. e. All measures described have been shown to
mance measure of your practice to assess care of improve the quality of care delivered by primary
patients with diabetes? care practices. Systematic collection and analysis of
a. percentage of patients with diabetes with one or information about the clinical care provided in the
more hemoglobin A1c tests conducted during the context of evidence-based guidelines lead to under-
past year standing of where changes can be made to improve
b. percentage of patients with diabetes seen by a podi- care. Systematic analysis of the practice experience,
atrist during the past year including specific feedback from patients, their
c. percentage of patients with diabetes who had their families, and members of the community through
blood pressure documented in the past year to be surveys and focus groups, can provide useful infor-
less than 130/80 mation to improve access and the quality of the
d. percentage of patients who received a retinal or process of care. Regularly engaging staff in learning
dilated eye examination by an eye care professional activities to advance competence and performance is
during the past year or during the previous 2 years also a successful method for improving patient care
if the patient is at low risk for retinopathy quality.
e. percentage of patients with most-recent low-
density lipoprotein cholesterol level of less than 5. b. A large body of literature supports the finding that
100 mg/dL primary care practices are not just small businesses
but complex organizations whose success is depen-
A N SW ER S
dent on all members of the organization, including
1. d. There are many sources of reliable information on staff as well as physicians. In addition, studies have
quality improvement measures and interventions on demonstrated that the quality of work relationships
the Internet. For the family physician, reliable sources among members of the practice is important for the
include the websites of the American Academy of successful functioning and delivery of patient care.
Family Physicians (AAFP), the federal Agency for Characteristics of work relationships associated with
Healthcare Research and Quality (AHRQ), and the successful practices include high levels of trust; the
National Committee for Quality Assurance (NCQA). presence of respectful, mindful, and heedful interac-
The AAFP website (www.aafp.org), for example, tion; a tolerance for diversity of ideas; a mix of rich
contains links to practice management and clinical (e.g., face-to-face) and lean (e.g., manuals and memos)
care and research information. The AHRQ web- communication; and the presence of both social and
site (www.ahrq.gov) contains links to evidence-based task-oriented interactions. Although electronic med-
practice reports, clinical practice guidelines, and infor- ical information systems can be useful to practices in
mation on preventive services. The NCQA website the care of patients, they are not essential. What is
(www.ncqa.org) contains information on a variety of essential is a well-organized team with common goals
accepted quality measures, including the widely used that puts the patient first.
HEDIS measures.
6. e. There are a host of reasonable measures one could
2. b. HEDIS stands for Health Effectiveness Data and use based on U.S. Preventive Services guidelines. Per-
Information Set. It is a set of widely used measures formance measures should be chosen and tailored to
for assessing health care quality produced by the patient populations of the individual practice.
NCQA. Updated yearly and applicable to all health
insurance plans, HEDIS contains measures that 7. e. Exercise stress testing is not recommended on
cover a variety of quality domains, including mea- an annual basis for all patients with CAD. All other
sures of effectiveness of care, access and availability measures are reasonable and built on evidence-based
of care, satisfaction with the experience of care, use guidelines.
8. b. Although proper foot care is important for patients with diabetes. Other measures listed are rea-
patients with diabetes, there is no evidence that an sonable and approved by various organizations on the
annual visit to the podiatrist reduces morbidity in basis of effectiveness studies.
S U M M A RY
1. P oor-quality care leads to sicker patients, more disabil- measures of effectiveness of care, access and availabil-
ities, higher costs, and lower confidence in the health ity of care, satisfaction with the experience of care, use
care system. Overwhelming evidence exists that pri- and cost of care, and health plan descriptions and mea-
mary care reduces mortality and costs, and it improves sures of stability.
overall quality of the health care of the nation. Fam- 5. There are a host of reasonable, evidence-based per-
ily physicians are in key positions to serve patients as formance measures that physicians can implement in
navigators through our often dysfunctional health care their practices. Systematic collection and analysis of
system by seeking and obtaining data about quality of information about the clinical care provided in the
care. context of evidence-based guidelines lead to under-
2. Being good physicians also means actively learn- standing of where changes can be made to improve
ing from our practices and continually seeking to care. Systematic analysis of survey feedback from
improve care provided. This means taking the time to patients, their families, and members of the commu-
reflect on our patient care practices and to assimilate nity can provide useful information to improve access
new and existing scientific evidence into our care of and the process of care. Regularly engaging staff in
patients. learning activities to advance competence and per-
3. Reliable sources of information about quality improve- formance is also a successful method for improving
ment include websites of the American Academy of patient care quality.
Family Physicians, the Agency for Healthcare Quality 6. Quality of work relationships among practice mem-
and Research, and the National Committee for Qual- bers is important to successful functioning and
ity Assurance. Other organizations involved include delivery of patient care. Characteristics of work
the Institute of Medicine, the Leapfrog Group, and relationships associated with successful practices
The Joint Commission. include high levels of trust; the presence of respect-
4. HEDIS is a widely used measurement for assessing ful, mindful, and heedful interactions; a tolerance for
health care quality. Produced by the National Com- diversity of ideas; a mix of rich (e.g., face-to-face)
mittee for Quality Assurance, it is updated yearly and and lean (e.g., manuals and memos) communication;
is applicable to all health insurance plans. HEDIS and the presence of both social and task-oriented
measures cover a variety of quality domains, including interactions.
Suggested Reading
Fan E, Laupacis A, Pronovost PJ, et al. How to use an Tallia AF, Lanham HJ, McDaniel R, et al. Seven characteristics
article about quality improvement. JAMA. 2010;304: of successful work relationships in primary care practices.
2279–2287. Fam Pract Manag. 2006;13:47–57.
C H A P TER 6 Clinical Prevention 21
CHAPTER 6 4. Which of the following statements regarding a health

maintenance visit is (are) true?
Clinical Prevention a. the visit in itself may be therapeutic and provide the
patient with reassurance
C L I N I CA L CA S E PR O B L E M 1 b. the visit provides an opportunity to learn the
patient’s wishes and to update information in the
A 51-Year-Old Man Who Presents for an
medical record
“Executive” Examination
c. the visit can reinforce the primary care office as the
A 51-year-old man comes to your office requesting patient’s medical home and best source for health
an executive examination. He has been in the habit of care advice and guidance
receiving a yearly executive examination at work but d. the visit may establish and enhance the patient’s
recently has changed jobs. His new employer does not self-management skills
offer these services. The patient had been told by a health e. all of the above
professional at his previous job that “a complete physi-
cal, head to toe, with lots of tests is the best method of C L I N I CA L CA S E PR O B L E M 2
ensuring maintenance of good health.” He recently heard
A 52-Year-Old Male Technophile
a radio advertisement for a company that “specializes” in
executive examinations but decided to see you instead. A 52-year-old long-time “worried well” male patient of
yours schedules an appointment to discuss a newspa-
per report of a new cancer screening test now being
offered locally. In addition to downloads from all his
personal health tracking devices, he brings the article,
With regard to the relative effectiveness of yearly
1. which recommends a new imaging procedure to search
executive examinations, which of the following state- for lung cancer in former smokers. Your patient is a for-
ments is most accurate? mer smoker with a less than one pack year history, and
a. the efficacy of yearly executive examinations has he asks if he should have the test now available at the
been confirmed in randomized controlled clinical local imaging facility. The test costs $2000 and is not
trials covered by insurance. Yet the article claims that the
b. the effectiveness of yearly executive examinations test picks up 80% of “even tiny lung cancers” not seen
has been confirmed by anecdotal evidence on other “screening tests.” He mentions that when he
c. the efficacy of yearly executive examinations has called the facility to ask the physician questions about
been demonstrated in case-control trials the procedure, he was told, “Ask your family doctor.”
d. the efficacy of yearly executive examinations has
been confirmed in population cohort studies 5. Which of the following statements regarding health
e. none of the above screening interventions is (are) true?
a. health screening interventions such as mammogra-
2. Which of the following is (are) a criterion (criteria) for phy are a form of primary prevention
effective periodic health screening interventions? b. interventions that target low-prevalence conditions
a. the condition tested must have a significant effect are acceptable if costs are low
on quality of life c. if questions of efficacy of an intervention exist,
b. the disease must have an asymptomatic phase it is better to err on the side of commission than
during which detection and treatment significantly omission
reduce morbidity and mortality d. many interventions fail to demonstrate a benefi-
c. acceptable treatment methods must be available cial effect on mortality despite high sensitivity and
d. tests must be available at a reasonable cost specificity
e. all of the above e. none of the above
Good reasons to consider recommending a health

3. 6. The U.S. Preventive Services Task Force (USPSTF)
maintenance visit for an asymptomatic adult include is an excellent source of screening recommendations
which of the following? for which of the following reasons?
a. to learn the patient’s wishes regarding his or her a. the task force is made up of family physicians
health care b. the task force uses an expert opinion approach for
b. to perform or order preventive health service issuing recommendations
interventions c. the evidence for and against an intervention is weighed
c. to maximize your income d. recommendations are fixed in stone and will stand
d. a and b up in court
e. a, b, and c e. a and c
7. Which of the following statements is (are) true regard- been a primary diagnostic tool throughout much of
ing false-positive findings of screening tests? the twentieth century, there is little if any evidence in
a. false-positive findings can create needless patient the literature to support its efficacy or effectiveness
anxiety as a screening tool. The yearly physical examination
b. false-positive findings often initiate an “interven- should not be confused with the health maintenance
tion cascade” assessment, for which there is ample evidence sup-
c. false-positive findings place a substantial burden on porting its efficacy. The health maintenance assess-
the entire health care system ment is an assessment targeted at specific age- and
d. a and b gender-related causes of morbidity and mortality.
e. a, b, and c Recommendations for the periodic health mainte-
nance examination are derived from epidemiologic
8. Which of the following statements is true regarding data that assess population risk and intervention ben-
patient perceptions of yearly executive examination efit. Specific evidence-based screening and counsel-
and related laboratory tests? ing interventions are part of the health maintenance
a. many patients believe that a routine executive, com- examination. The USPSTF is the preeminent body
plete physical examination, along with a complete for the assessment and recommendation of interven-
laboratory profile, will diagnose the majority of tions that are a part of the periodic health mainte-
illnesses nance examination.
b. most patients understand the meaning of the term
health maintenance examination 2. e. The criteria for effective periodic health screen-
c. most patients understand the importance of a ing are as follows: (1) the condition for which the phy-
focused, regional examination sician is testing must have a significant effect on the
d. patients are generally sensitive to the costs of rou- quality of the patient’s life; (2) acceptable treatment
tine physical examinations and routine laboratory methods must be available for that particular condi-
tests tion; (3) the disease must have an asymptomatic phase
e. none of the above during which detection and treatment significantly
reduce morbidity and mortality; (4) treatment during
C L I N I CA L CA S E PR O B L E M 3 the asymptomatic phase must yield a result superior to
that obtained by delaying treatment until symptoms
A 35-Year-Old Woman Who Presents for a
appear; (5) tests must be available at a reasonable cost;
Health Maintenance Examination
(6) tests must be acceptable to the patient; and (7) the
A 35-year-old woman has come to your office for a prevalence of the condition must be sufficient to jus-
health maintenance examination. You examine the skin tify the cost of screening.
in an effort to identify dysplastic nevi, other unusual
nevi, or other skin lesions. 3. d. See answer 4.
9. Which of the following statements is true? 4. e. Reasons to perform a periodic health mainte-
a. the examination for skin cancer in a health main- nance examination in asymptomatic adults include
tenance examination is highly sensitive and highly the following: (1) to establish or reinforce a good
specific patient-physician relationship; (2) to provide oppor-
b. the examination for skin cancer in a health main- tunity to learn the patient’s wishes and augment
tenance examination is highly sensitive but of low information in the medical record; (3) to reinforce
specificity the primary care office as the patient’s medical home
c. the examination for skin cancer in a health mainte- and best source for advice and guidance; (4) to pro-
nance examination is neither sensitive nor specific vide the therapeutic benefit of touch; (5) to perform
d. the examination for skin cancer in a health main- appropriate periodic health screening interventions;
tenance examination is highly specific but of lower (6) to reinforce patient education, especially lifestyle
sensitivity and nutritional counseling; (7) to realistically reassure
e. the examination for skin cancer is of variable sensi- the patient (and the physician); (8) to establish and
tivity and specificity, depending on the skill of the enhance the patient’s self-management skills; (9) to
examiner determine if the patient is indeed asymptomatic; and
(10) to avoid giving the patient the impression that he
A N SW ER S
or she must have symptoms to be examined.
1. e. Efficacy studies answer the question: Does it
work? Effectiveness studies answer the question: 5. d. Recently, there has been an avalanche of health
Does it work in the real world? Although the yearly screening recommendations emanating from a variety
examination including executive examinations had of sources, some of which must be viewed as suspect
C H A P TER 6 Clinical Prevention 23
because of the secondary benefits accrued by the rec- common in the face of low test sensitivity and speci-
ommenders. It is difficult to pick up a newspaper and ficity and low prevalence of the condition in the pop-
not find a new test or procedure being touted as the ulations tested. Even if a test has high sensitivity and
next best thing since free air. How does the family specificity, the more tests or maneuvers that are per-
physician help patients sort it all out? formed on the same individual, the higher the likeli-
Health screening interventions, such as mammography hood of a false-positive result. Also, the likelihood that
and colonoscopy, are a form of secondary prevention, a positive test result is a true positive (positive predic-
designed to detect a disease process early in its asymp- tive value) is directly related to the prevalence of the
tomatic stage. Primary prevention interventions such as condition in the target population. Performing exam-
immunization prevent the disease from occurring. Ter- inations in populations in which the condition has a
tiary preventions favorably alter the course of an illness low prevalence will thus generate a high false-positive
by preventing complications, an example of which is anti- rate. False-positive test results create needless anxiety
coagulation for stroke prevention in atrial fibrillation. in both patients and physicians. More important, such
Answer 2 discussed the criteria for a good screening results often lead to an “intervention cascade,” ini-
intervention. Interventions that target low-prevalence tiating further testing of greater invasiveness, which
conditions are unacceptable even if costs are low because increases the potential for iatrogenic harm. A good
they are a waste of money and may have untoward effects, example of this is the finding of a slightly enlarged
such as false-positive test results that may lead to iatro- ovary (you think) on pelvic bimanual examination, a
genesis. Thus, if questions of efficacy of an intervention situation in which a benign cause is much more likely
exist, it is better to err on the side of not performing the than a malignant cause. From this may result routine
test. Many interventions fail to demonstrate a beneficial ultrasound examination, followed perhaps by com-
effect on mortality despite high sensitivity and specificity. puted tomography scanning and possibly laparoscopy
This was found to be the case with certain very sensitive to rule out a malignant tumor of very low prevalence.
imaging procedures for populations at low risk for lung We all must ask ourselves before initiating any inter-
cancer. The family physician should be the best source of vention: What is the evidence that this action is likely
information about screening interventions if the patient’s to do the patient any good?
interests are kept at the forefront. The USPSTF is the
best source of evidence-based recommendations to guide 8. a. Many patients believe that an executive complete
screening procedures. examination, along with a large number of laboratory
tests, will diagnose the majority of illnesses. This is
6. c. Although family physicians have led the way in obviously a mistaken impression. Sadly, some health
the United States with the first scientific studies advo- professionals have taken financial advantage of this
cating targeted screening examinations based on the misconception, playing off patients’ needs for reas-
epidemiology of problems seen in patients at differ- surance. Conversely, most patients are unaware of
ent ages and in different genders, the USPSTF is now the hazards of unnecessary interventions and testing,
multidisciplinary, adding to its strength and legit- and many physicians do not take the time to educate
imacy as a body that issues recommendations based their patients of the hazards. As in any intervention,
on the strength and weight of the evidence available. patients should be informed of the rationale (evidence
Recommendations for screening procedures are care- and expected outcomes), risks, benefits, and alterna-
fully weighed on the basis of available evidence for tives of laboratory testing.
or against a procedure. A five-category rating system Despite efforts aimed at increasing public awareness
informs both the physician and patient about the and understanding, many patients do not understand
strength of a recommendation or whether insufficient the concept of health maintenance visits or of focused
evidence for or against a procedure exists. So-called examinations. In addition, many patients are still not very
expert opinion is not a factor in decisions, and rec- sensitive about costs of “routine” tests. Further patient
ommendations have been known to change if the education efforts are necessary to inform patients about
scientific evidence one way or another evolves. For these important issues.
these reasons, USPSTF recommendations are con-
sidered the gold standard of periodic health screening 9. e. The clinical examination of the skin can have
interventions. Recommendations and the evidence significant variability in terms of sensitivity and spec-
supporting them are available for review at the ificity, depending on the variability of the examin-
Agency for Healthcare Research and Quality website er’s expertise. Although studies have demonstrated
(www.ahrq.gov). the effectiveness of family physicians in skin cancer
screening relative to other specialists, variability exists
7. e. The same excessive compulsiveness that serves as in this or any other procedure. The greater the train-
a survival skill in medical training is often dysfunc- ing and expertise in skin lesion diagnosis and treat-
tional in medical practice. False-positive findings are ment, the higher the sensitivity and specificity of
the examination. Another excellent example of this on behalf of the patient is: Are study conditions likely
phenomenon is reading of mammograms by radiol- to be seen in my practice environment? It may be that
ogists. The more training the radiologist has and the the 1/1000 to 1/3000 risk of major complications in
more mammograms the radiologist reads, the higher colonoscopy reported in the literature is really 1/500
the sensitivity and specificity of mammograms. Most to 1/1000 in the community. The family physician’s
studies report test results obtained under optimal role is to be a patient advocate and a skeptic when it
conditions. Similarly, adverse outcomes, such as per- comes to everything “new” and “better.” Demand to
foration rates in colonoscopy, are often derived from see the scientific evidence before recommending and
ideal study conditions. An important question to ask subjecting patients to the latest intervention.
S U M M A RY
1. E fficacy studies answer the question about an inter- screening interventions, such as mammography and
vention: Does it work? Effectiveness studies answer colonoscopy, are a form of secondary prevention,
the question: Does it work in the real world? Both are designed to detect a disease process early in its asymp-
important to ask and answer in weighing patient inter- tomatic stage. Tertiary prevention interventions
ventions geared toward prevention. favorably alter the course of an illness by preventing
2. There is little if any evidence that yearly “executive complications, an example of which is anticoagulation
physicals” are efficacious or effective or address issues for stroke prevention in atrial fibrillation.
and conditions that are preventable. The health main- 5. Criteria for effective periodic health screening inter-
tenance assessment, in contrast, is an assessment tar- ventions are as follows:
geted at specific age- and gender-prevalent causes of a. The condition for which the physician is testing
morbidity and mortality. Recommendations for the must have a significant effect on the quality of the
periodic health maintenance examination are derived patient’s life or mortality.
from epidemiologic data that assess population risk b. Acceptable treatment methods must be available for
and intervention benefit. Specific evidence-based that particular condition.
screening and counseling interventions are part of the c. The disease must have an asymptomatic phase
health maintenance examination. during which detection and treatment significantly
3. The USPSTF is the preeminent body for the assess- reduce morbidity and mortality.
ment and recommendation of interventions that are a d. Treatment during the asymptomatic phase must
part of the periodic health maintenance examination. yield a result superior to that obtained by delaying
USPSTF recommendations are evidence-based, and treatment until symptoms appear.
the evidence for or against a particular intervention is e. Tests must be available at a reasonable cost.
rated and weighed. f. Tests must be acceptable to the patient.
4. Primary prevention interventions such as immuni- g. The prevalence of the condition must be sufficient
zation prevent the disease from occurring. Health to justify the cost of screening.
Suggested Reading
The following are some of the historical, classic articles that Frame PS. A critical review of adult health maintenance. Part 3:
challenged the established practice of yearly complete prevention of cancer. J Fam Pract. 1986;22:511–520.
physicals:. Frame PS. A critical review of adult health maintenance. Part 4:
Breslow L, Somers AR. The lifetime health monitoring pro- prevention of metabolic, behavioral, and miscellaneous con-
gram. N Engl J Med. 1997;296:601–608. ditions. J Fam Pract. 1986;23:29–39.
Frame PS. A critical review of adult health maintenance. The full scope of the USPSTF recommendations may be viewed
Part 1: prevention of atherosclerotic disease. J Fam Pract. at the website www.ahrq.gov; click on “Preventive Services”
1986;22:341–346. under “Clinical Information.” You can also register for peri-
Frame PS. A critical review of adult health maintenance. odic updates from the USPSTF by e-mail through this site.
Part 2: prevention of infectious diseases. J Fam Pract.
1986;22:417–422.
C H A P TER 7 Tobacco Dependency 25
CHAPTER 7 b. a pharmacologic agent as a part of the smoking

cessation program
Tobacco Dependency c. the inclusion of a behavior modification compo-
nent to the program
C L I N I CA L CA S E PR O B L E M 1 d. physician advice to quit smoking
e. repeated office visits
A 40-Year-Old Who Smokes Three Packs of
Cigarettes a Day
5. Which of the following is (are) now considered a first-
A 40-year-old executive who smokes three packs of cig- line pharmacologic agent(s) that reliably increase(s)
arettes a day comes to your office for his routine health long-term smoking abstinence rates?
maintenance assessment. He states that he would like a. bupropion SR
to quit smoking but is having great difficulty. He has b. nicotine gum
tried three times before, but he says, “Pressures at work c. varenicline
mounted up, and I just had to go back to smoking.” d. nicotine patch
The patient has a history of mild hypertension. His e. all of the above
blood cholesterol level is normal. He drinks 1 or 2 oz
of alcohol per week. His family history is significant for Assuming patient interest in smoking cessation,
6.
premature cardiovascular disease and death. which of the following smoking cessation methods
results in the highest percentage of both short-term
and long-term success?
a. transdermal nicotine
b. a patient education booklet
1. Current evidence suggests that coronary artery dis- c. physician counseling and advice
ease (CAD) is strongly related to cigarette smoking. d. a contract for a “quit date”
What percentage of deaths from CAD is thought to e. a combination of all of the above
be directly related to cigarette smoking?
a. 5% 7. One of the best individual targeted smoking cessation
b. 10% programs is the widely recommended 5 “A”s approach
c. 20% (Ask, Advise, Assess, Assist, and Arrange) designed to
d. 30% identify and help the smoker who is willing to quit.
e. 40% Which of the following is true about this approach?
a. the approach includes implementation of an office-
Which of the following diseases has (have) been
2. wide system that ensures that for every patient
linked to cigarette smoking? at every visit, tobacco-use status is queried and
a. carcinoma of the larynx documented
b. hypertension b. smokers should be approached intermittently and
c. abruptio placentae gently to avoid provoking anger
d. Alzheimer disease c. smokers from households with other smokers
e. all of the above present should be advised to change domiciles
d. the approach fosters self-reliance without the sup-
3. Which of the following statements with respect to port of any outside organizations or individuals
passive smoking is false? e. the use of pharmacotherapy is reserved for coun-
a. spouses of patients who smoke are not at increased seling failures
risk for development of carcinoma of the lung
b. sidestream smoke contains more carbon monoxide 8. What is the approximate percentage of patients who
than mainstream smoke relapse after successful cessation of smoking?
c. infants of mothers who smoke absorb measurable a. 10%
amounts of their mothers’ cigarette smoke b. 50%
d. children of parents who smoke have an increased c. 75%
prevalence of bronchitis, asthma, and pneumonia d. 85%
e. the most common symptom arising from passive e. 99%
smoking is eye irritation
9. What is the most prevalent modifiable risk factor
4. Of the following factors listed, which is the most for increased morbidity and mortality in the United
important factor in determining the success of a States?
smoking cessation program in an individual? a. hypertension
a. the desire of the patient to quit smoking b. hyperlipidemia
c. cigarette smoking
A N SW ER S
d. occupational burnout
e. alcohol consumption 1. d. Of deaths from CAD, slightly more than 30%
are directly attributable to smoking. The incidence of
Nicotine replacement is especially important in
10. myocardial infarction and death from CAD is two to
which group(s) of patients who smoke cigarettes? four times more likely in cigarette smokers than in
a. those patients who smoke when work-related nonsmokers. In the United States, 1 in 5 of all deaths
stressors become unmanageable is caused by cigarette smoking.
b. those patients who smoke more than 20 cigarettes
a day 2. e. The health consequences of smoking are enor-
c. those patients who smoke within 30 minutes of mous. The major processes involved include active
awakening smoking, passive smoking, addiction, and acceler-
d. those patients who experience withdrawal ated aging. The following disease categories have
symptoms been directly linked to smoking: cancer, respiratory
e. all of the above diseases, and cardiovascular diseases. Pregnancy and
f. b, c, and d infant health and other miscellaneous conditions are
also affected by smoking.
Which of the following statements regarding the
11. The actual diseases involved include the following:
economic burden of smoking is (are) true? a. Cancer: (1) lung, (2) larynx, (3) mouth, (4)
a. the economic burden of smoking is placed not only pharynx, (5) stomach, (6) liver, (7) pancreas,
on the individual but also on society (8) bladder, (9) uterine cervix, (10) breast, (11)
b. in the United States, the costs related to cigarette brain, (12) bone marrow, and (13) colon and
smoking exceed $50 billion annually rectum.
c. smoking has a significant effect on work-related b. Respiratory diseases: (1) emphysema, (2) chronic
productivity bronchitis, (3) asthma, (4) bacterial pneumonia, (5)
d. it would cost an estimated $10 billion annually tubercular pneumonia, and (6) asbestosis.
to provide 75% of smokers aged 18 years and c. Cardiovascular diseases: (1) CAD, (2) hypertension,
older with the cessation interventions of their (3) aortic aneurysm, (4) arterial thrombosis, (5)
choice stroke, and (6) carotid artery atherosclerosis.
e. all of the above d. Pregnancy and infant health: (1) intrauterine
growth restriction, (2) spontaneous abortion, (3)
12. Which of the following statements about cigarette fetal and neonatal death, (4) abruptio placentae,
smoking in the United States is false? (5) bleeding in pregnancy not yet discovered,
a. in 2008, 1 in 5 U.S. adults were smokers (6) placenta previa, (7) premature rupture of the
b. the United States has the lowest prevalence of membranes, (8) preterm labor, (9) preeclampsia,
smoking is in the West (10) sudden infant death syndrome, (11) con-
c. cigarette smoking continued to decline rapidly in genital malformations, (12) low birth weight,
the first decade of the twenty-first century so that (13) frequent respiratory and ear infections in
by 2010, only 1 in 6 adults was a smoker children, and (14) higher incidence of mental
d. men are more likely than women to be current retardation.
smokers e. Other miscellaneous conditions: (1) peptic ulcer
e. Medicaid enrollees have nearly twice the smoking disease, (2) osteoporosis, (3) Alzheimer disease, (4)
rates of the general adult population wrinkling of the skin (crow’s-feet appearance on
the face), and (5) erectile dysfunction.
13. A Healthy People 2010 objective called for states to The mechanisms whereby the association between
enact “comprehensive smoke-free laws” by 2010. smoking and the aforementioned diseases occur are mul-
Which of the following statements is true about these tifactorial. What is striking, however, is the number of
laws? medical disease categories that smoking affects and the
a. “comprehensive smoke-free laws” means forbid- number of diseases within each category that smoking
ding smoking in public worksites and restaurants affects.
b. “comprehensive smoke-free laws” means forbid-
ding smoking in restaurants and bars 3. a. Tobacco smoke in the environment is derived
c. as of December 31, 2010, only 10 states had from either mainstream smoke (exhaled smoke) or
enacted comprehensive smoke-free laws sidestream smoke (smoke arising from the burning
d. in 2000 no state had comprehensive smoke-free end of a cigarette). Exposure to sidestream smoking
laws (also known as passive smoking) produces an increased
e. none of the above prevalence of bronchiolitis, asthma, bronchitis, ear
C H A P TER 7 Tobacco Dependency 27
infections, and pneumonia in infants and children and has no effect on reducing subjective satisfaction and
whose parents smoke. extinction of smoking behavior.
The most common symptom arising from exposure to
passive smoking is eye irritation. Other significant symp- 6. e. A metaanalysis of controlled trials of smoking
toms include headaches, nasal symptoms, and cough. cessation compared the effectiveness of smoking
Exposure to tobacco smoke also precipitates or aggra- cessation counseling, self-help booklets, nicotine
vates allergies. replacement, and establishing a contract and setting
Spouses of patients who smoke are at increased risk a quitting date. The study found that each modality
for development of lung cancer and CAD. For lung can- was effective, but no single modality worked sig-
cer, the average relative risk is 1.34 compared with people nificantly better than the others. When treatment
not exposed to passive smoke. This risk, in comparison, modalities were combined, however, the follow-
is greater than 100 times higher than the estimated effect ing results were obtained: two treatment modali-
of 20 years’ exposure to asbestos while living or working ties were more effective than one, three treatment
in asbestos-containing buildings. It is estimated that of modalities were more effective than two, and four
the 480,000 smoking-related deaths each year, 42,000 are treatment modalities were more effective than
associated with passive smoking. three.
4. a. The most important factor in determining the 7. a. The widely recommended 5 “A”s approach
success of a smoking cessation program is the desire (Ask, Advise, Assess, Assist, and Arrange) is designed
of the individual to quit. If the individual is not inter- to identify and intervene with the smoker who is
ested in quitting, the probability of success is very low. willing to quit. The following is taken from the
Physician advice to quit, behavior modification aids, Agency for Healthcare Research and Quality website
nicotine replacement, and repeated office visits are (www.ahrq.gov).
all important. However, without the will to quit, they Ask—Systematically identify all tobacco users at every
will not be effective. visit. Implement an officewide system that ensures
that for every patient at every clinic visit, tobacco-use
5. e. The first-line pharmacologic agents that may status is queried and documented. Expand the “vital
be considered for inclusion in a smoking cessa- signs” to include tobacco use, or use an alternative
tion program are nicotine (delivered by inhalation, universal identification system such as chart stickers
orally [chewing gum], or transdermally), bupro- or an electronic medical record alert.
pion or bupropion SR (Zyban), and varenicline Advise—Strongly urge all tobacco users to quit. In a
(Chantix). The use of the antidepressant bupro- clear, strong, and personalized manner, urge every to-
pion has proved to be effective in the treatment bacco user to quit. Clear—“I think it is important for
of cigarette smokers. The aim is to stop smoking you to quit smoking now, and I can help you. Cutting
within 1 or 2 weeks after starting the medication, down while you are ill is not enough.” Strong—“As
with the duration of treatment between 7 and your clinician, I need you to know that quitting
12 weeks. This treatment modality helps address smoking is the most important thing you can do to
both the psychological and the physiologic aspects protect your health now and in the future. The clinic
of smoking addiction. It acts by boosting brain lev- staff and I will help you.” Personalized—Tie tobacco
els of dopamine and norepinephrine, thus mimick- use to current health/illness and/or its social and eco-
ing the effects of nicotine. Varenicline, a selective nomic costs, motivation level/readiness to quit, and/
nicotinic acetylcholine receptor agonist, can lessen or the impact of tobacco use on children and others
craving and withdrawal while competitively block- in the household.
ing nicotine. Assess—Determine willingness to make an attempt to
Second-line agents proven effective include clonidine and quit. Ask every tobacco user if he or she is willing
nortriptyline. Clonidine has proven efficacy in the relief to make an attempt to quit at this time (e.g., within
of symptoms of opiate and alcohol withdrawal. It has the next 30 days). Assess the patient’s willingness to
been shown to be superior to placebo in helping patients quit. If the patient is willing to make an attempt to
remain abstinent from smoking for periods up to 1 year. quit at this time, provide assistance. If the patient will
Mecamylamine is a nicotine receptor antagonist that is participate in an intensive treatment, deliver such a
analogous to naloxone for the treatment of opiate abuse. treatment or refer to an intensive intervention. If the
Mecamylamine may be useful as a method of smoking patient clearly states he or she is unwilling to make
cessation in the recalcitrant smoker. It has not been stud- a quit attempt at this time, provide a motivational
ied extensively in such a population. Propranolol has intervention. If the patient is a member of a special
been shown to relieve some of the physiologic changes population (e.g., adolescent, pregnant smoker, or
associated with alcohol withdrawal–induced anxiety, but racial/ethnic minority), consider providing additional
it has been shown to be ineffective in smoking cessation information.
Assist—Aid the patient in quitting. departments. Type—culturally/racially/education-

• Help the patient with a quit plan. A patient’s prepa- ally/age appropriate for the patient. Location—
ration for quitting includes the following: Setting readily available at every clinician’s workstation.
a quit date—ideally, the quit date should be within Arrange—Schedule follow-up contact. Schedule fol-
2 weeks. Telling family, friends, and co-workers low-up contact either in person or via telephone.
about quitting and request understanding and Timing—follow-up contact should occur soon after
support. Anticipating challenges to the planned the quit date, preferably during the first week. A
quit attempt, particularly during the critical first second follow-up contact is recommended within the
few weeks. These include nicotine withdrawal first month. Schedule further follow-up contacts as in-
symptoms. Removing tobacco products from the dicated. Actions during follow-up contact—congratulate
patient’s environment. Before quitting, the patient success. If tobacco use has occurred, review circum-
should avoid smoking in places where he or she stances and elicit recommitment to total abstinence.
spends a lot of time (e.g., work, home, and car). Remind the patient that a lapse can be used as a learning
• Provide practical counseling (problem solving/train- experience. Identify problems already encountered,
ing). Assisting patients in quitting smoking can be and anticipate challenges in the immediate future.
done as part of a brief treatment or as part of an Assess pharmacotherapy use and problems. Consider
intensive treatment program. Evidence demon- use or referral to more intensive treatment.
strates that the more intense and longer lasting
the intervention, the more likely the patient is to 8. d. Arranging follow-up appointments for the patient
remain smoke-free; even an intervention lasting is extremely important. This, in effect, prepares the
fewer than 3 minutes is effective. patient for the support and surveillance of the physi-
• Inform them that abstinence is essential. “Not even a cian. At the follow-up visits, there is an opportunity
single puff after the quit date.” Past quit experi- to review concerns, to review continuing plans, and to
ence (if any)—review past quit attempts, includ- discuss relapses. This last issue is extremely import-
ing identification of what helped during the quit ant because lapses occur in 85% of those who quit,
attempt and what factors contributed to relapse. and most relapses occur within the first 3 months of
Anticipate triggers or challenges in upcoming quitting. The reaction and counseling of the physi-
attempt—discuss challenges/triggers and how the cian after a lapse are crucial and should be framed
patient will overcome them successfully. Limit in the context of a positive learning experience. One
alcohol use—because alcohol can cause relapse, the of the key points that needs to be reinforced by the
patient should consider limiting/abstaining from physician is that learning to live without cigarettes
alcohol while quitting. Talk to other smokers in is similar to learning any new skill—you learn from
the household—quitting is more difficult when mistakes until your action becomes a new habitual
there is another smoker in the household. Patients behavior. Most patients require a few trials before
should encourage housemates to quit with them or they quit completely.
not smoke in their presence.
• Provide intratreatment social support. Provide a sup- 9. c. Cigarette smoking continues to be the most prev-
portive clinical environment while encouraging the alent modifiable risk factor for increased morbidity
patient in his or her quit attempt. “My office staff and mortality in the United States. Not only does
and I are available to assist you.” the smoker incur medical risks attributable to ciga-
• Help the patient obtain social support outside of treat- rette smoking but also passive smokers and society
ment. Help the patient develop social support for bear the ill effects and the increased economic costs
his or her quit attempt in his or her environments attributable to the smoker’s habit.
outside of treatment. “Ask your spouse/partner,
friends, and co-workers to support you in your 10. f. Nicotine replacement is especially important
quit attempt.” for the following types of smokers: (1) smokers who
• Recommend the use of approved pharmacotherapy, smoke more than 20 cigarettes a day, (2) smokers
except in special circumstances. Recommend the who smoke within 30 minutes of waking up, and (3)
use of pharmacotherapies found to be effective. smokers who experience withdrawal symptoms.
Explain how these medications increase smoking Smokers who smoke when they are exposed to extremely
cessation success and reduce withdrawal symp- stressful work situations should be managed mainly by
toms. The first-line pharmacotherapy medications behavior modification techniques, although bupropion
include varenicline, bupropion SR, nicotine gum, may be a consideration for therapy.
nicotine inhaler, nicotine nasal spray, and nicotine
patch. 11. e. The individual smoker and society in general
• Provide supplementary materials. Sources—federal incur enormous economic costs as a result of smok-
agencies, nonprofit agencies, or local/state health ing. Here are some facts from the Centers for Disease
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eternity with blood-stained hands.... I implore you, my lord, order my
chains to be broken before your death-hour comes,—permit yourself
to be moved by the most humble prayer of a man who has ever been
a loyal subject to the king.”
This letter bore date of December 1st; on December 4th, the
cardinal died. It is not known whether he ever saw it. After his death,
it came into the hands of those on whom the power now devolved,
and Dessault, far from gaining his release, was kept in the Bastille till
the year of 1692, after being a prisoner for sixty-one years. Such
remnant of life as may have remained to him, is one too forlorn and
dreary to contemplate.
And to this piteous appeal were added the sobs and frenzied
reproaches of Marion Delorme, who found access to the death-
chamber, just as the cardinal was about to receive the Viaticum.
A gentleman named de Saucourt was a slave to Ninon’s charms at
this time, causing a vast amount of envy among her friends. He was
a man of refinement and brilliant wit, so raved about by the ladies,
that Benserade composed this quatrain upon him—
“Contre se fier demon voyez vous aujourd’hui
Femme qui tienne?
Et toutes cependant sont contentes de lui,
Jusqu’ à la sienne.”
Ninon, however, was then suffering great distress of mind at the

terrible fate of Cinq-Mars, reproaching herself not a little for the light,
thoughtless way in which she had half encouraged Marion Delorme,
half warned her off from accepting the young man’s rash proposition
to make her his wife; for Marion had seriously consulted her in the
matter. It came to light after Cinq-Mars’ death that it was Gaston
d’Orléans himself who had in his possession the original of the treaty
with Olivarez, and he had had the baseness to hand this to
Laffemas, the infamous procureur-general and chief tool of
Richelieu, when the cardinal was bent on a man’s destruction.
Laffemas earned the distinction of being called the cardinal’s
hangman-in-chief. No one stretched out a finger to help the
Chevalier de Jars, whom Richelieu kept in the Bastille for two years,
on the charge of being in the secrets of Anne of Austria’s
connections with Spain. It was in vain that de Jars produced
absolute proof of his innocence, and Laffemas added insults and
threats to the interrogatory he subjected him to. Under a strong
guard, de Jars one Sunday obtained leave to attend Mass at St
Gervais, where he knew the wretched creature would be, and as he
was about to kneel at the altar to receive the communion, de Jars,
with a bound, sprang at him, seized him by his pourpoint, and
dragging him down the nave of the church, flung him outside the
door. “Away with thee!—away from here, cowardly hypocrite!” he
cried. “Do not soil this holy place with thy foul presence,” and the
poisonous reptile crawled away, while de Jars, turning to the
officiating priest, said—“And you, my father, did you not know to
whom you were about to give the Body of our Lord? To an iniquitous
judge—another Judas—an abomination!”
Finally de Jars obtained his release, and spent his later life in
peace and happiness, but not before he had been made to mount
the scaffold itself. As he was about to lay his head upon the block,
calmly defiant, Laffemas, who had got up the scene to terrify de Jars
into a confession, approached and besought him, in consideration of
the pardon he had brought him, to disclose all he knew; but he
received scant satisfaction on the point, since de Jars, according to
some authorities, persisted in his refusal and defiance of the
monster. According to another account, the suffering and tension of
mind he had endured temporarily deprived him of consciousness,
and for some days he lay in a state of exhaustion, from which he
only gradually recovered.
And those were but instances of the cardinal’s tyranny, and there
was so little his red robe had not covered, sufficiently at all events for
him to die in his bed. And the magnificent tomb, joint work of two
great artists, that covers the spot where he was laid in the church of
the Sorbonne, bears the recumbent statue of the cardinal, sustained
by Religion and weeping angels.
Whether Louis, the king, shed any tears, is not specially recorded.
They could hardly, in any case, have been more than of the crocodile
kind; since he was so very visibly seen to smile more than once
during the passing away of his great minister. In the days when Vitry
relieved him of Concini by assassination, Louis thanked him warmly
for the service. “Now I am king, Vitry,” he said. But it had not been for
long, except in name; for he had only been free to become the slave
of Richelieu, and now his own life was ebbing fast away, not,
apparently, to his very great regret. Those last days were sorely
troubled at the thought of his mother, who had died in exile at
Cologne. He put the blame of this on Richelieu, and made all the
reparation now possible, by ordering prayers throughout the kingdom
for the repose of her soul. This seemed to bring him some
tranquillity, of mind. He loved music, and he composed for himself a
De Profundis to be chanted when his last hour should arrive. Seated
one day at the window of the Château of St Germains, he pointed
out the route which was best for the funeral cortège to follow, to
reach St Denis, and reminded of a turn of the road which was
awkward to pass, bidding care be taken to keep the hearse well in
hand.
The death of Richelieu in no way softened the strained relations
and conjugal coldness between the king and queen. On the day of
the child’s birth, Louis was about to leave the queen without
bestowing the embrace customary on such occasions, until he was
reminded of his omission, which only a stretch of courtesy might call
forgetfulness.
The little Louis, who was in his fifth year at the time of the king’s
death, does not seem greatly to have interested him or afforded him
any satisfaction; while the child rather shrank from him, notably when
he saw him in his night-cap. Then he broke into piercing screams of
terror. This the king laid, with all her other misdeeds, at the queen’s
door. He declared that she prompted the little boy to his objections.
It was a pitiable ending to a melancholy existence—inexpressibly
lonely, for in those last months, Anne left him entirely to himself.
Less desolate than the king, finding distraction for ennui in the
society of her ladies, and the gentlemen of her own little Court,
among whom Monsignor Giulio Mazarini figured ever more and more
prominently.
Previously to Richelieu’s death, the handsome, fascinating
Mazarin had been a constant frequenter of Ninon’s réunions; but
from these he soon withdrew almost entirely, in favour of the
dazzling metal to be found in the Louvre, for there it rang of
ambitions, which there was every chance of finding fully satisfied.
His first master-stroke was to set aside the late king’s will—which
constituted a counsel of regency, himself being chief of the counsel,
which he had himself recommended to Louis—making Anne regent,
with himself for prime-minister. The king was dead, Louis XIV. but a
small child, and for Mazarin it was “Long live the Queen!” while
Ninon found ample consolation in the devotion of her splendid hero,
Louis de Bourbon, the great Condé, Duc d’Enghien.
Hitherto love had been a fragile toy for her, hanging about her by
the lightest of chains made to be broken. For Condé, the sentiment
lay deeper, nourished by the breath of adulation surrounding him
when he returned, victorious over the Spaniards, from the field of
Rocroi; and she was fired to flames of admiration and of delight in
his distinguished presence. Handsome, amiable, gallant, to Ninon
and to France he was as a demigod.
CHAPTER VIII
“Loving like a Madman”—A Great Transformation—The Unjust Tax—Parted

Lovers—A Gay Court, and A School for Scandal and Mazarin’s Policy—The
Regent’s Caprices—The King’s Upholsterer’s Young Son—The Théâtre
Illustre—The Company of Monsieur and Molière.
“A man of sense may love like a madman, but never like a fool.” It is
the dictum of François de la Rochefoucauld, and must have been
framed from his deep attachment to Condé’s sister, Madame de
Longueville, one of the most charming of the women of the great
world at that time, and bound by ties of close friendship with Ninon.
It was no one-sided love, no case of the one who loves, and the
one who merely consents to it; but mutual, and as passionate, as
certainly for a time the flame was pure, shining with a clear,
unflecked radiance.
Madame de Longueville, who was wedded to an old man, was
singularly fascinating, from her gentle manners and amiability. Her
face was not strictly beautiful, and bore traces of the smallpox, the
cruel scourge then of so many beautiful faces; her eyes were full of a
softened light, and she had the gift of a most sweet voice, while her
smile was gentle and irresistibly winning. The dreamy, romantic,
somewhat melancholy-natured de la Rochefoucauld’s heart was laid
at her feet in whole and undivided adoration. For their conscious
love, each strove against the temptation, she so earnestly, that she
shut herself away from all chance of so much as seeing him for a
little while. But Ninon slipped in with her philosophy. It was quite true,
she argued to Madame de Longueville, that there were grave
considerations to be respected—the indissoluble tie of marriage,
convenances to be observed—all these; but to hide herself away, to
refuse the unhappy prince the alleviation of gazing at her, of
exchanging a few fleeting words—no, it was monstrously absurd.
The very Platoniciens did not go such lengths. No, if complete
happiness could not be theirs, at least a smile, a glance, was
permitted; and Ninon’s counsel wound up with a suggestion to the
disconsolate prince, that he should try what a little note to the
woman he adored would effect, and he wrote—“Show yourself—be
beautiful, and at least let me admire you.”
And Ninon delivered the billet, and its effect was marvellous. It
conquered the young duchess’s natural timidity and retiring
disposition. She took courage; she assumed her rightful place in the
world; she appeared at the Louvre; she kept open house and gave
brilliant receptions; she took her seat on the tabouret of the
duchesses; her toilettes were magnificent; she shone brilliantly in
conversation, and began to take part in Court intrigues; ere long very
actively.
“With two lines of a man’s writing,” had said Mazarin’s great
predecessor, “I could condemn him”; and with two lines of that
magical pen of the Count de la Rochefoucauld, Madame de
Longueville became another woman. As in the matter of her warm
attachment to her lover, she was constant in her politics; while Louis
de Condé, all-conquering at Rocroi, yielded himself captive to the
charms of Ninon de L’Enclos—a veritable lion in love; not so blindly,
however, that he was insensible to the wrongs of the people, upon
whom a tax had been levied of a specially hateful kind. It was called
the Toisé, and was a revival of an old edict long fallen into
desuetude. To the Italian, d’Eméri, to whom Mazarin had entrusted
the control of public finances, was due its discovery and
resuscitation. This edict forbade the enlargement of the borders of
Paris, and as recently new buildings had been, and were being, in
course of construction far and wide, the owners of these were
threatened with confiscation of their materials, unless they
consented to pay for their newly-erected houses and other buildings,
a rate regulated by measurement of the size of them. This pressed
cruelly on the people. Loud murmurs were excited. The Parliament
expostulated, and the Toisé was withdrawn. It was the first stone
slung by the Fronde. Condé’s indignation was great; and one day, in
the rue St Antoine, he laid flat with his sword the body of some
wretched collector who had snatched away a child’s cradle from a
poor woman. His act gave great offence to the queen, who saw in it
defiance of Mazarin. Both at home and abroad, there was plenty
stirring to keep existence from stagnating; but for a few brief
delightful weeks the Duc d’Enghien sought retirement and tranquillity
in his château of Petit Chantilly, in company with Ninon, who left the
rue des Tournelles dwelling to take care of itself. It was the iniquitous
Toisé which broke in upon their content; for the queen sent for the
duke, to consult him in the emergency created by the cardinal
favourite.
After the Toisé prologue, however, the opening scenes of the
inglorious turmoil of the Fronde did not see Condé; for Austria once
more took up arms, and he lost not a moment in hastening to the
frontier. If it is indeed a fact that Ninon accompanied him thither in
the guise of a young aide-de-camp, mounted on a fiery charger, it
was but to re-enact her former exploits; and Ninon was nothing if not
daring. That her presence on the field of Nordlingen could have been
really anything but exceedingly encumbering, is more than
imaginable. At all events Condé soon begged her to return to Paris,
in order to go and console his sister, Madame de Longueville, who
had been summoned to attend his father, the Duc de Condé, in an
illness threatening to be fatal. Arrived at Paris, she found the sufferer
very much better, and writing to inform the Duc d’Enghien of this
pleasant intelligence, she begged to be allowed to return to him. The
duke, however, replied that it was hardly worth while; as he should
soon be back. To pass the tedium of his absence, Ninon resumed
her réunions, finding pleasant distraction in the society of her friends,
among which were two ladies distinguished for their birth and
undoubted talents, scarcely less than notorious, even in those days,
for their openly lax mode of life. One of these was Madame de la
Sablière, a notable member of the Hôtel de Rambouillet côtérie. A
really brilliant mathematician, she was at least equally skilful in the
science of love—so ardent a student, that one day her uncle, a grave
magistrate, scandalised out of all endurance at her ways,
remonstrated severely, reminding her that the beasts of the field
observed more order and seasonable regulation in their love-affairs.
“Ah, dear uncle,” said the gifted lady, “that is because they are
beasts.”
Madame de Chevreuse was the other specially chosen spirit of her
own sex Ninon now consorted with. After the death of Richelieu, who
had exiled her at the time of the Val de Grâce affair, she was allowed
to return to France, attended by the Abbé de Retz, Paul de Gondi,
whom Louis XIII., on his deathbed, had appointed coadjutor to the
new archbishopric of Paris. De Retz had himself aspired to the
archbishopric, and swore that he would obtain a cardinalate.
The Court was now brilliantly gay. The gloomy and sombre
atmosphere of Louis XIII. and of Richelieu’s day faded all in a
succession of balls and fêtes and every sort of festivity. Anne of
Austria enlarged the south side of the Louvre, and Grimaldi and
Romanelli adorned the chambers and galleries with their exquisite
skill. Poussin, whose friezes terminated the ends of the great gallery,
had had apartments assigned him in the Louvre, in order to carry on
his work with greater facility; but he had retired in displeasure at the
criticisms of his brother-artists, and went to Rome, where he spent
the rest of his life, leaving in Paris immortal memories of his genius,
among them the altarpiece for the chapel of St Germain en Laye,
and the mournful Arcadian Shepherd, “Et in Arcadia Ego.”
So the never-ending round of gaiety was set in motion by Mazarin,
and Anne of Austria was the regent. Anne, still handsome, and by
nature frivolous under her somewhat cold Spanish demeanour—
surely a born coquette, delighting in show and magnificence, none
the less that she had so long lived under repression. The queen,
apparently, was the reigning power; but it was the crafty prime-
minister who pulled the strings, and set the puppets dancing and
fiddling, and amorously intriguing, so that they should leave him to
carry on his politics, and mount to the heights of his ambition and
power in his own unhindered way. Unlike his great predecessor, he
was handsome, and good-natured in manner, and therefore an
ornament in those brilliant assemblies. Wrote St Evrémond—
“J’ai vu le temps de la bonne régence,
Temps où régnait une heureuse abondance,
Temps où la ville aussi bien que la cour
Ne respirait que les jeux et l’amour.
Une politique indulgente
De notre nature innocente
Favorisait tous les désirs
Tout dégoût semblait légitime;
La douce erreur ne s’appélait point crime,
Les vices délicats se nommait des plaisirs.”
Very pleasant and entertaining the world of society was then; and
seasoned as it was with even unusual spice of malice and spite,
scandal was rife. Among others, the stepmother of Madame de
Chevreuse, Madame de Montbazon, who was married to the old Duc
de Rohan, was a past-mistress in the gentle art of making mischief;
and where the material was insufficient, she manufactured it without
scruple. In this way she nearly succeeded in bringing a rift into the
love-harmonies of Henri de la Rochefoucauld and his adored
Madame de Longueville, by means of sheer, brazen lying, alleging
that certain letters of Madame de Longueville, which had been
found, had dropped from the pocket of Coligny. It was a pitiful
fabrication, and Madame de Montbazon—of whom de Retz, in his
Memoirs, says “I never saw any person showing in her vices less
respect for virtue”—did not come out of it with very flying colours, for
all her best efforts at effrontery, and she received an order from
Mazarin to retire to Tours. The letters, in effect, proved to be not
those of Madame de Longueville at all; and the pocket they dropped
out of, was not Coligny’s. It was altogether an affair of another pair of
lovers.
The embellishments of the Louvre were still not completed, before
the queen decided not to reside in it. She began to recall, rather
tardily it would seem, all the lugubrious memories of her past life
connected with the palace; and she established herself in the
magnificent Palais Royal—originally the Palais Cardinal.
In all those festivities, Ninon took prominent part. Ever
philosophical, she thus consoled herself for the prolonged absence
of the Duc d’Enghien, an absence which had, moreover, not
intensified the sentiments of adoration she at first conceived for him.
It was but Ninon’s way. She had begun to see small defects in the
case-armour of the perfection of her Mars. Her acquaintance with the
dead languages supplied her with the Latin proverb, “vir pilosus, aut
libidinum aut fortis.” “Now Esau was a hairy man,” and the Duc
d’Enghien was also vir pilosus, and Ninon taxed him with being a
greater warrior than an ardent wooer, and the passion cooled rapidly;
but the friendship and mutual liking ever remained.
Ninon employed Poquelin, upholsterer to the king, in the furnishing
of her elegant suite of apartments. His shop was in the rue St
Honoré, and there was born his son, Jean Baptiste, an intelligent,
rather delicate-looking little boy, whom he duly educated and trained
for his own trade. Young Jean Baptiste, however, fairly submissive
and obedient, was also very fond of reading and writing, the only two
acquirements his father thought necessary for assisting the chair and
table-making the boy’s future was destined for. Fortunately he had a
very kind grandfather who loved the drama, and sometimes he
would take little Jean Baptiste with him to see the performances at
The Hôtel Bourgogne. Poquelin père looked with distrust on these
excursions, thinking that he saw in the lad, as undoubtedly he did,
growing aversion to the upholstery vocation, and a fast developing
passion for tragedy and comedy—comedy very markedly—and the
boy’s delight in study and books generally, created a disturbance in
the good upholsterer’s mind, which culminated in distress, when it
became certain beyond all question, that young Jean’s liking was as
small for cabinet-making as it was unconquerable for literature. He
was at that time about fourteen years old, and he carried about with
him a small comedy he had composed called l’Amour Médecin,
which Ninon one day, when he came to assist his father at her
house, detected, rolled up under his arm. Won by her kind smiles,
young Poquelin was induced to allow her to look at it, and she, no
mean critic, saw such promise in it, that she showed it to Corneille—
who was then staying with her, pending the representation of The
Cid. Corneille warmly seconded her estimate of the boy’s promise of
unusual dramatic gifts; and after great demur, Poquelin yielded to the
good grandfather’s persuasions to send him to college. Several
helping hands, Ninon among them, contributed to the necessary
funds for this new career, and Jean Baptiste became a pupil of the
Jesuits at Clermont. There he studied for five years, in the same
class with Armand de Bourbon, Prince de Conti, the youngest
brother of Madame de Longueville, who promised Ninon the special
protection and friendship of Armand, and of the college preceptors, a
promise that was ever faithfully held by; and the celebrated teacher
Gassendi took him under his special care, with two other gifted lads
confided to him.
At the end of the five years, Jean Baptiste was forced to resume
his old occupation, on account of his father’s increasing infirmities.
But it was not for long. Richelieu’s love of letters, and of the drama
especially, brought him knowledge of young Poquelin’s talent, and
made the difficult way of literature easier for him; for the theatre was
beginning to flourish. There was no regular company of actors in
Paris until the coming of Corneille. Only a few of the “rogue and
vagabond” wearers of the sock and buskin came and went, selling
their plays, when they could find buyers, for some ten crowns
apiece. The comedies of Corneille caused the establishment of a
dramatic troupe in the city, and then it was that young Poquelin,
leaving the upholstery to the dogs, established a small company of
young men—“stage-struck” as the mockers were pleased to say, in
this instance guided however by the sterling judgment of Jean
Baptiste, truly dramatically gifted, in the Faubourg St Germain. They
called it the Illustrious Theatre—(l’Illustre Théâtre). So through the
years of the ignoble strife of the Fronde, when times were arid for
real literary talent, Poquelin acted and composed little comedies,
mainly for the provinces. Travelling with his company to Languedoc,
where the Prince de Conti happened to be staying on his estates,
Poquelin produced before him several of his pieces, afterwards
finding their world-wide renown, l’Étourdi, le Dépit Amoureux, and
others. The Prince de Conti introduced him to Monsieur, the only
brother of Louis XIV.; and in a short time there came a day of days
when the command of their Majesties reached the actor-manager, to
give a representation in the chamber of the Guards in the old Louvre.
After the performance of this long five-act piece, Poquelin—who had
followed the custom of the actors of his time, had taken another
name, and selected Molière—stepped to the front, and begged His
Majesty’s permission to play a short one-act piece. It was le Docteur
Amoureux. This is possibly the origin of the custom, still so
frequently observed, of the “Curtain-raiser.”
POQUELIN DE MOLIERE
Coypel pinc. Ficquet Sculp.
To face page 100.
Now established at Paris, Molière’s company, which he styled the

Troupe de Monsieur, his patron, was accorded the Salle of the Palais
Royal, for the representation of his piece. It had been originally
constructed for the cardinal’s tragedy of Mirame, and “The chamber,”
says Voltaire, “for dramatic purposes, is as bad as the piece for
which it was built.”
Molière had a very agreeable personality. He was a little above
medium height, well-built and of noble presence. His gait was
dignified, his nose and mouth were large, and his lips full; his
complexion was dark with black, thick eyebrows, and these he could
control to giving his face all sorts of comic expressions. His manner
was gentle, pleasing and kindly. He loved to speak, and when he
read his plays to his company, he liked them to bring their children,
so that he might study their ways and actions.
Molière, having the good or the ill fortune, as it may be, to become
such a distinguished public favourite, had his fair number of enemies
among his many friends. His chief detractors were, of course, to be
found among the bad authors and the great unacted; also the “unco’
guid” tried to sting him hard, and in a measure succeeded—as when
do they not when their poison is dropped upon sensitive natures?
But the warmth of the Sun-King’s admiration and patronage greatly
shielded him. His Majesty bestowed a canonry on his son.
Molière had a physician, Mauvilain. It was rather an unfortunate
name, and one day when he was dining with the king, Louis asked
him about him. “You have a doctor,” he said; “what does he do for
you?”
“Sire,” replied Molière, “we gossip together; he prescribes me
remedies; I do not take them—and I am cured.”
That Ninon was proud of the brilliant man she had so signally
helped to befriend as a lad, may well be conceived, and whenever a
new piece was produced, she was always there to witness it, in one
of the most honoured places reserved for her.
CHAPTER IX
The Rift in the Lute—In the Vexin—The Miracle of the Gardener’s Cottage—Italian
Opera in Paris—Parted Lovers—“Ninum”—Scarron and Françoise d’Aubigné
—Treachery—A Journey to Naples—Masaniello—Renewing Acquaintances—
Mazarin’s Mandate.
Again victorious at Nordlingen, the Duc d’Enghien, now Prince de

Condé, for his father was now dead, returned to Paris—but not to
Ninon. She had given great offence to his family by permitting de la
Rochefoucauld and Madame de Longueville to meet at her house,
and Condé sternly reproached her for the indiscretion; hence the tie
between them was broken—perhaps merely a little sooner than
otherwise; for the distinction of winning the admiration of the hero of
the hour had played for Ninon a very powerful part in the liaison. And
after all, she preferred to receive homage more than to offer it; for
though she liked to ruffle it in masculine attire, she was a very
woman; and taking her heart back again, she permitted it to be
captured by the Marquis de Villarceaux, who had sued for long past.
Villarceaux was handsome and agreeable, but he had a serious
defect in Ninon’s eyes: he was fair, and a fat man or a fair man she
ordinarily found detestable. Still he was eloquent, and she allowed
herself to be persuaded to go and rusticate with him in the Vexin, as
the guest of a friend of the Marquis, Monsieur de Vicariville. This
gentleman found great pleasure in discoursing on philosophical
themes with Ninon, while Monsieur Villarceaux went out to amuse
himself in the neighbourhood, flitting from flower to flower, as ready
to converse with the maids as with the mistress.
In the course of a few days, visitors arrived at the château. One of
them was the Chevalier Villars Orondate, afterwards ambassador to
Spain, a man full of originality and humour. During his stay, he
rendered his host a signal service by the exercise of his quaint wit
and ingenuity. Monsieur de Vicariville’s château was reached by a
long, noble avenue, whose perspective would have been
incomparable, but for the intrusion of a miserable tumbledown
cottage just about midway.
Large sums had been offered when the avenue was made, to its
owner, whose name was Jérome, to sell his small holding; but he
flatly refused. His father had built the cottage, he had been born in it,
and desired to die in it when his time came, continuing meanwhile to
follow in it his trade, which was a tailor’s; and the eyesore had to be
left.
Orondate asked his host what he would give him if he got the
cottage removed within a week’s time.
“With Jérome’s consent, of course?” laughed Vicariville.
“That would not be required.”
“I would give you a hundred louis, gladly.”
“Money? For shame! It is for glory’s sake I would go to work—or at
all events for a kiss from Mademoiselle.”
Villarceaux demurred at this; but Ninon cheerfully agreed; and
going in search of the tailor, Orondate told him he wanted a
handsome suit made for Monsieur de Villarceaux, who was going to
Court with him. Was he capable of fulfilling the order? Certainly,
Jérome was as able to do it as the grandest tailor in Paris.
“Very good. I will give you a pistole a day, if you agree to come
and work in the château, never leaving off all day, and entirely under
my supervision. Your food will be all found for you; and you will be
paid on completion of the task.”
The tailor accepted the bargain with delight, and fell to work; while
Orondate caused a scrupulously exact plan of the cottage to be
made, with precise measurements of every thing in its interior, taking
note even of the position of each piece of furniture, and the smallest
object in the place. Then he had the entire cottage taken to pieces,
the walls knocked down, and the whole load of it transported to a
spot a little outside the avenue. There the skilful workmen he had
engaged, put it all together again, and all the smallest things back in
their places, not forgetting the good man’s little soup saucepan, and
the enclosing garden hedge.
The avenue, meanwhile, was carefully swept, and cleared of all
traces of the removal. Nothing remained to be seen of either the
cottage or the garden.
The tailor’s work being now completed, he received his
honorarium from Orondate, with a couple of louis in addition. Then
going home, well satisfied, towards nightfall he passed down the
avenue. It seemed rather long, yet he arrived at the end at last,
sooner than he quite expected. Returning, he came and went, came
and went, and could find his house nowhere. The poor man spent
the night in searching for it. The day broke, and shed light on the
avenue, but there was no cottage. Had the foul fiend been at work?
Reaching the outskirts of the park, he saw, just beyond the wall, a
house resembling his own. Rushing forward, he recognised his own
sheltering trees, the garden, the grass-plot, and the honeysuckle
hedge. The door faced him, and Jérome inserted the key in its lock.
It fell open smoothly. Going in, he found everything in its proper
place—only the table, instead of being bare, bore a smoking hot leg
of mutton, flanked by two bottles of wine.
The tailor crossed himself devoutly, convinced that he was
bewitched.
The leg of mutton, however, looked appetising, and Jérome was
hungry after his long nocturnal perambulations; he approached the
joint, and contemplated it with lessening repugnance. Then, fetching
his little holy-water brush, he sprinkled the mutton to see if it
disappeared; but it smoked on. It certainly had not been cooked in
the infernal regions. Jérome took heart therefore, and sat down to
dine.
The authors of this curious transformation scene, concealed to
watch what would happen, waited till Jérome had well banqueted;
then they entered, and with bursts of laughter, asked him what he
thought of the sorcerers of the château?
Monsieur Orondate was paid the price he had asked, Monsieur
Vicariville gave Jérome the hundred louis his guest had declined,
and the tailor contented himself with pulling a grimace at the trick
which had been played him.[3]
It was Mazarin France had to thank for establishing in Paris,

musical Italian plays, in other words, Italian operas. From time to
time, since the days of Henri III., Italian dramatic singers had visited
Paris, finding no regular stage or fair opportunity for their beautiful
presentations. Mazarin, however, secured them the rights for these
at the Hôtel Bourgogne, and by one of the exercises of his wily
ingenuity, also contrived to win away from Charles II. Budeaud, the
musical leader of the Court-revels in London, as the conductor of the
Paris company.
Early in the winter, whose approach brought Ninon and everybody
back to Paris, invitations were issued for the performance of an
Italian opera on a magnificent scale, in the Palais Royal, and to
Ninon the invitation was sent by the Duc de Condé—who had
repented of his harsh estimate of her conduct—and finding his way
to her fauteuil in the course of the performance, the two made their
peace by mutual concessions. Meanwhile Condé had diplomatically
set several hundred leagues between the lovers, by pairing off
Madame de Longueville with her husband to Münster, while he
caused the Duc de la Rochefoucauld to be summoned to his duties
as governor of Poitou. Independently of the ardent but brief
attachment of Rocroi and Nordlingen days, the Duc de Condé
entertained sterling admiration and esteem for the qualities of Ninon,
and their friendship remained sincere through life.
For three years Ninon came to Paris only at intervals; she
remained in the Vexin, with the erratic Marquis de Villarceaux for her
companion. Of a furiously jealous nature in regard to the object of his
affectionate consideration, he permitted himself a wide range. The
lawful wife he owned was, not unnaturally, jealous of Ninon, and
made her a constant subject of contention between them. One day
she requested the tutor of her little son to examine him before some
company she was entertaining, upon his recent classical studies.
“Quem habuit successorum Bellus, rex Assyriorum?” (“Who
succeeded Belus, King of the Assyrians?”) inquired the tutor, who
was no less a person than the Abbé Scarron.
“Ninum,” replied the little boy.
The word, so absolutely resembling Ninon, threw Madame de
Villarceaux into a furious rage. Scarron vainly endeavoured to
explain and justify himself. She would not listen. The answer, she
said, was quite enough for her; and Scarron was dismissed. It was a
cruel accident for him, crippled as he was, so utterly as not to be
able to stir from his wheel-chair. Bodily “a wretched log,” as he called
himself, intellectually more brilliant than ever, and in a human sense,
ever the same kindly, generous epicurean philosopher as of old,
“always” as he said, “unfortunate.” On the top of all his other troubles
he had fallen in love. Alas! for the poor prisoner of that wheeled-
chair, the helpless wreck of the ex-canon! Ninon found refuge in
silence as she stood before him where he had been carried in from
his coach. It was long since they had met, and her heart was full of
pity. The object of his affection, Scarron went on to tell her, was one
Françoise d’Aubigné, a native of Niort. “Ah, d’Aubigné,” interrupted
Ninon at last. “A Protestant then?” A Calvinist by birth, went on
Scarron, and reared in that teaching by an aunt who had adopted
her on the death of her parents; but the aunt died, and then a lady,
Madame de Neuillan, a friend of the Marquise de Villarceaux, had
taken her in hand. It was a misuse of words to call it befriending. It
was in this way Scarron had seen her, a charmingly pretty girl of
about seventeen.
This Countess de Neuillan was a gorgon of virtue and principle,
and, as also a bigot of a Catholic, she had compelled Françoise to
become one. In return for all her tender care, Madame de Neuillan
imposed the most menial duties on the young girl, who was of
angelic disposition as well as beautiful. Her father had been the son
of the friend of Henri IV. More or less worthy as he might be
represented—de mortuis nil nisi bonum—he had died in prison,
guilty of no other crimes, perhaps, than being a Protestant; and so
his two children had been left cast in indigence upon the world. The
lot of Françoise in the house of Madame de Neuillan was deplorable,
and Scarron, as well as some other friends, had advised her to leave
her, and get her living by the work of her hands sooner than remain
in such dependence; and for twelve months past she had lodged in a
little street of a neighbouring faubourg, with her brother, a ne’er-do-
well; but still her brother; and her goodness to him was the only fault
Scarron had to find in the adorable Françoise. And Ninon’s generous
heart overflowed with sympathy for the young girl, and she took her
to her own home, and they were warm friends, living in the closest
ties of affection; and ere long the sweet, modest, gentle girl repaid
the kind friend’s goodness by winning her lover, Monsieur de
Villarceaux, away from her, and Ninon, who was sincerely attached
to him, felt the sting acutely. She taxed Françoise with the attempt,
which was quite successful, and refused to listen to any denial or
excuse, merely saying that they would have the field quite free to
themselves, as she was leaving on the following day for Naples. And
thither she went, taking the sea-journey from Marseilles. For
travelling companion, she had the Chevalier de Méri. This gentleman
who had been one of the guests of Monsieur Vicariville had a sister
who was married to a Spanish Grandee, to whom was promised the
viceroyalty of Naples.
Monsieur de Méri was in every way far more desirable as a
companion than the man she had left in the company of Françoise,
to whom she also entrusted the ménage in the rue des Tournelles,
only making the condition that she and Villarceaux should hold their
sweet converse exclusively in the “Yellow Chamber,” which was the

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For technical assistance:

Alfred F. Tallia, Professor and Chair

Nancy W. ­Dickey, President Emerita, Texas A&M Health Science Center

SWANSON’S FAMILY MEDICINE REVIEW, EIGHTH EDITION ISBN: 978-0-323-35632-9

Copyright © 2017 by Elsevier, Inc. All rights reserved.

Library of Congress Cataloging-in-Publication Data

Content Strategist: Suzanne Toppy

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Lani K. Ackerman, MD Noemi C. Doohan, MD, PhD

Adity Bhattacharyya, MD, FAAFP Negin Field, MD

Michael Bogey, MD Kory Gill, DO

Anna Lichorad, MD Damoun A. Rezai, MD

Benjamin Mahdi, MD, MPH Beatrix Roemheld-Hamm, MD, PhD

SECTION ONE 22 Acute Coronary Symptoms and Stable Angina

SECTION NINE 169 

PR O C ES S F O R O BTA I N I N G C M E C R ED I T section is indicated below. (The fees shown are based on a

C L I N I CA L CA S E PR O B L E M 1 2. The most common problem related to clinical deci-

d. all of the above c. 75.0%

TA B L E 2 -5 Ten-Year Mortality Data 23. Regarding clinical epidemiology in relation to the

Prevalence = (a + c) / (a + b + c + d) Prevalence = 40, 000 cases/100, 000 = 400/1000

That is: Setting the total number equal to 1000,

10. a. Answers 10 and 11 are explained in answer 12, Thus,

11. b. See answer 12. Cell b = 400 − 320 = 80

CHAPTER 3 b. ask the patient to return to the consultant for

of care, and it makes a joke of the idea of a medical

CHAPTER 4 Results from the Medical Outcomes Study suggest

CHAPTER 5 the time to reflect on your patient care practices, to

C L I N I CA L CA S E PR O B L E M 2 7. Which of the following is not a reasonable perfor-

CHAPTER 6 4. Which of the following statements regarding a health

Good reasons to consider recommending a health

CHAPTER 7 b. a pharmacologic agent as a part of the smoking

Assist—Aid the patient in quitting. departments. Type—culturally/racially/education-

Ninon, however, was then suffering great distress of mind at the

“Loving like a Madman”—A Great Transformation—The Unjust Tax—Parted

Now established at Paris, Molière’s company, which he styled the

Again victorious at Nordlingen, the Duc d’Enghien, now Prince de

It was Mazarin France had to thank for establishing in Paris,

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Nancy W. Dickey, President Emerita, Texas A&M Health Science Center

SWANSON’S FAMILY MEDICINE REVIEW, EIGHTH EDITION ISBN: 978-0-323-35632-9

SECTION ONE 22 Acute Coronary Symptoms and Stable Angina

SECTION NINE 169

C L I N I CA L CA S E PR O B L E M 1 2. The most common problem related to clinical deci-

d. all of the above c. 75.0%

TA B L E 2 -5 Ten-Year Mortality Data 23. Regarding clinical epidemiology in relation to the

10. a. Answers 10 and 11 are explained in answer 12, Thus,

11. b. See answer 12. Cell b = 400 − 320 = 80

CHAPTER 3 b. ask the patient to return to the consultant for

C L I N I CA L CA S E PR O B L E M 2 7. Which of the following is not a reasonable perfor-

CHAPTER 6 4. Which of the following statements regarding a health

CHAPTER 7 b. a pharmacologic agent as a part of the smoking