AFP: American Family Physician Podcast

Episode 239 – October 2025, Part 1
Date: October 15, 2025
Hosts: Dr. Steve Brown (B), Dr. Rachel Dunn (C), Dr. Emily Eisenberg (D)
Contributing Editor: Dr. Steven Brown

Overview

In this engaging episode, the hosts break down key clinical reviews and discussions from the October 2025 issue of American Family Physician (AFP). Major topics include practical approaches to uterine fibroids, the state of community-based residency training, updated evidence on GLP-1 medications, nuanced management of heart failure with preserved ejection fraction (HFpEF), the comparative effectiveness of intravenous vs. oral iron in pregnancy and postpartum, and the evidence behind nicotine e-cigarettes for smoking cessation. The hosts round out the episode with lighthearted discussion on real versus fake health trends for “Spooky Season.”

Key Discussion Points & Insights

1. Uterine Fibroids: Rapid Evidence Review

Drs. Keating Jones & Hansel, Wake Forest University
(01:23–06:45)

• Primary Care Management:
  • Fibroids often found incidentally; initial workup and treatment usually within scope of primary care.
  • Quote (D, 01:48): “This rapid review really helped sharpen my approach to managing fibroids or leiomyomas…this is definitely something we can manage in primary care.”
• Diagnosis:
  • No recommendation to screen asymptomatic women.
  • Risk factors: obesity, hypertension, nulliparity, vitamin D deficiency (B, 02:21).
  • Commonly identified during abnormal uterine bleeding workups (D, 02:40).
  • Fibroid symptoms correlate with location (classification 0–8), affecting bleeding or causing bulk symptoms (C, 03:04).
  • Imaging: Start with transvaginal + transabdominal ultrasound with Doppler; MRI or saline sonohistography may be needed (B, 03:23).
  • Labs: CBC, TSH, UA, vitamin D (treating deficiency may reduce size) (D, 03:44).
  • Quote (D, 03:44): “Treating deficiency may reduce fibroid size and halt tumor progression, which is something I had no idea about until reading this article.”
  • Rule out malignancy with endometrial biopsy in high-risk cases; imaging doesn’t distinguish fibroids from leiomyosarcoma (C, 04:04).
• Treatment:
  • Familiar first-line options: oral contraceptives, NSAIDs, levonorgestrel IUD.
  • GnRH agonists/antagonists: effective but short-term, expensive, with side effects (B, 04:41).
  • CME tidbit (D, 05:11): “GnRH antagonists are the most effective for halting bleeding.”
  • Tranexamic acid: indicated, but be cautious in patients with increased clotting risk (C, 05:20).
  • Alternative therapies: vitamin D, green tea extract (C, 05:20).
  • Surgical options: Hysterectomy (definitive), myomectomy (fertility-sparing), uterine artery embolization, radiofrequency ablation, MR-guided focused ultrasound – choice depends on future fertility desires and local resources (D, 05:48).
• Primary Care Takeaway:
  • Fibroid care is nuanced and well within family medicine’s scope (C, 06:26).
  • Quote (C, 06:26): “This review reinforces that they’re well within the scope of Family Med. With the right approach, we can manage most of these ourselves and guide patients through both diagnosis and treatment.”

2. Community-Based Residency Training Policy Brief

Drs. Manfredonia & Hofstetler, Graham Center
(06:45–09:08)

• Historical Context & Problem:
  • Since Flexner Report (1910), most residency training is hospital/academic-based (C, 07:00).
  • Only 11.7% of graduating residents in 2016–2021 entered outpatient primary care (D, 07:04).
  • Contrasted with 34% of practicing physicians in outpatient primary care (D, 07:13).
  • Most primary care delivered in community, not hospital settings (C, 07:26).
• Community Training Stats:
  • Community-based tracks remain rare, though increasing (C, 07:49).
  • Uptick from 2.2% (2013) to 4.6% (2021) (D, 07:55).
  • In Wyoming & Montana, >50% of residents get community-based training (B, 08:07).
• Funding & Policy Solutions:
  • Teaching health centers established in 2011 (C, 08:14).
  • $174 million in 2022 for teaching health centers vs $16 billion for hospital programs (D, 08:25).
  • Shift Medicaid and other funds to expand community training (B, 08:32).
  • Impact: Improves prevention, chronic disease management, health outcomes (C, 08:47).
• Call to Action:
  • Despite positive trends, greater investment needed to address primary care crisis (D, 08:53).
  • Quote (D, 08:53): “We definitely need substantial public and private investing in primary care training outside of academic medical centers to sustain the workforce and improve overall population health.”

3. Medicine by the Numbers: GLP-1 Receptor Agonists in CKD + Diabetes

Drs. Elliot & Frasca
(09:08–12:10)

• Updated Guidelines:
  • GLP-1 agonists advised as initial therapy (± metformin) for type 2 diabetes with cardiovascular, heart failure, or CKD risk (D, 09:25).
  • New Cochrane review (2025): 42 RCTs, ~48,000 adults (C, 09:51).
• Efficacy:
  • NNT for all-cause death = 77 over 26 weeks (C, 09:51).
  • NNT = 15 for broader cardiovascular composite (D, 10:20).
  • NNT = 48 for narrowed composite (death, MI, stroke) (D, 10:40).
• Kidney Outcomes:
  • Little/no difference in slowing progression to kidney failure (C, 10:48).
• Limitations:
  • No direct comparison to standard care or non-GLP-1 medications; limited harm data.
  • GLP-1’s adverse effects: nausea, vomiting, early satiety (D, 11:01).
  • Humorous quote (B, 11:15): “When GLP-1s first came out, I thought they only worked because they caused nausea and vomiting.”
• Practice & Outlook:
  • Assigned a “yellow” rating: promising, but need head-to-head trials and better safety data (C, 11:30).
  • Use is rising; hope for fewer coverage barriers as adoption grows (D, 11:48).

4. Heart Failure with Preserved Ejection Fraction (HFpEF): Clinical Update

Drs. Barzin, Barnhouse & Cain, UNC
(12:34–15:46)

• Definition:
  • HFpEF = preserved ejection fraction but impaired relaxation/diastolic dysfunction (C, 12:45).
  • Symptoms similar to HFrEF: dyspnea, edema, exercise intolerance (C, 12:45).
• Management Strategy:
  • Focus on symptom relief, comorbidities, lifestyle (B, 13:04).
• Pharmacologic:
  • Loop diuretics: first-line for volume overload (C, 13:17).
  • SGLT2 inhibitors: for diabetes and non-diabetics, reduce hospitalizations (NNT = 28), possible mortality benefit (C, 13:17).
  • ACEi/ARB/ARNI/MRA: for blood pressure (B, 13:44).
• Non-Pharmacologic:
  • Weight loss (pharmacologic and lifestyle): improves quality of life — semaglutide and bariatric surgery show promise (C, 14:01).
  • Exercise (aerobic/resistance): improves capacity (C, 14:01).
  • CPAP for OSA; blood pressure management (C, 14:22).
• Atrial Fibrillation:
  • AFib in ~50% of HFpEF patients (C, 14:31).
  • Prioritize lifestyle (weight loss, alcohol reduction), standard rate/rhythm control, SGLT2 inhibitors may slow AFib (C, 14:31/D, 14:51).
  • Ablation considered, but evidence evolving (B, 14:51).
• Bottom Line:
  • No single therapy; combine meds with lifestyle (C, 15:03).
  • Quote (D, 15:31): “Core principle is tailoring therapies to comorbidities while also addressing quality of life.”

5. Cochrane for Clinicians: IV vs. Oral Iron in Pregnancy & Postpartum Anemia

Dr. Foley, Harvard Medical School
(15:46–18:13)

• Efficacy:
  • IV iron raises hemoglobin 0.5 g/dL more than oral at 3–6 weeks, reduces risk of Hgb <11 at delivery (NNT = 11) (C, 16:12/B, 16:37).
  • Even stronger effect postpartum (NNT = 4 for Hgb <11 at 4–6 weeks) (B, 16:37).
• Patient-Oriented Outcomes:
  • No difference: postpartum hemorrhage, transfusion rates, breastfeeding (D, 17:12).
  • Better adherence with IV; oral has more constipation (B, 17:17/C, 17:39).
• Limitations:
  • Data mostly from India/Africa; more studies needed on long-term, patient-important outcomes (C, 17:39).

6. FPIN Clinical Inquiry: Nicotine E-Cigarettes for Smoking Cessation

Drs. Montgomery & Beaverson, Univ. of Colorado
(18:13–20:17)

• Evidence & Effectiveness:
  • Nicotine e-cigarettes (EC) superior to NRT, non-nicotine EC, or no support (S.O.R. A) (C, 18:36).
  • Single RCT: ECs as effective as varenicline (S.O.R. B) (B, 18:51).
  • 2024 Cochrane review: 88 studies, 27,000+ patients, 47 RCTs (D, 19:01).
  • Example: 7 RCTs (2,500 pts) — EC better than NRT, RR = 1.59 (C, 19:12).
  • One RCT NNT = 5 against placebo for both varenicline and e-cigarette at 26 weeks; effect faded at 52 weeks (D, 19:28).
• Considerations:
  • Some may quit tobacco but continue using nicotine (B, 19:50).
  • Studies include cotinine/CO levels as objective measures (D, 19:59).
• Clinical Implication:
  • Nicotine ECs can be reasonable for motivated patients (C, 20:07).

Quotes & Memorable Moments

• Vitamin D and fibroid management:
  • D (03:44): “Treating deficiency may reduce fibroid size and halt tumor progression, which is something I had no idea about until reading this article.”
• Self-deprecating and relatable humor about new therapies:
  • B (11:15): “When GLP-1s first came out, I thought they only worked because they caused nausea and vomiting.”
• Call for primary care advocacy:
  • D (08:53): “We definitely need substantial public and private investing in primary care training outside of academic medical centers to sustain the workforce and improve overall population health.”
• Core management principle for chronic disease:
  • D (15:31): “There’s no single drug that fixes HFpEF. The best outcomes come from combining pharmacologic and non pharmacologic care.”

Special Segment: “Spooky Season” Real or Fake Health Trends Game

(20:17–24:25)

The hosts challenge each other to decipher real vs. AI-generated health trends, courtesy of ChatGPT—ranging from “dry scooping pre-workout powders” (real), to “digestive moon pauses” and “oxygen microdosing” (fake), with humorous commentary throughout.

• C (22:00): “I mean, I do tell my patients to eat a lot of cucumbers, so…”
• C (22:55, on ‘digestive moon pauses’): “That sounds a little AI generated to me.”
• Entire segment tone: Lighthearted, reflective of the friendly banter and approachability that define the show.

Timestamps: Important Segments

• Uterine Fibroids Rapid Review: 01:23–06:45
• Community Residency Training Brief: 06:45–09:08
• GLP-1 Agonists in CKD/Diabetes: 09:08–12:10
• Heart Failure with Preserved EF: 12:34–15:46
• IV vs. Oral Iron in Pregnancy: 15:46–18:13
• Nicotine E-Cigs for Smoking Cessation: 18:13–20:17
• Spooky Season Real vs. Fake Health Trends: 20:17–24:25

Conclusion

This episode distills critical, up-to-date evidence for frontline clinicians, emphasizes family medicine’s role in managing a wide range of conditions, and advocates for the profession’s future through system-level policy changes—all with educational depth and approachability. The "Spooky Season" segment offers levity while highlighting ongoing trends in health misinformation and the growing presence of AI in medicine.