Episode 252 | April 2026 | Part 2 American Family Physician

Summary

AFP: American Family Physician Podcast – Episode 252 | April 2026 | Part 2

Date: April 30, 2026
Hosts: Dr. Steve Brown, Dr. Justin Chediak, Dr. Kari Staus
Overview:
In this episode, the AFP Podcast resident and faculty team from the University of Arizona College of Medicine-Phoenix reviews essential clinical updates from the April 2026 issue of American Family Physician. The panel covers topics including heat-related illness, graduate medical education funding in primary care, foreign body ingestion in children, fall prevention in older adults, chronic constipation management, and comparative efficacy of oral corticosteroids for pediatric asthma exacerbations. The discussion balances clinical pearls, policy implications, and memorable anecdotes.

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Heat-Related Illnesses (02:11–05:35)

Key Insights:

• The risk of heat-related illness is rising, in part due to climate change. Each 1.8°F increase during a heatwave is associated with an 18% increase in morbidity and a 35% increase in mortality.
  • Steve Brown: "For every 1.8 degrees Fahrenheit rise... morbidity increases by 18% and mortality increases by 35%." (02:21)
• Heat illness exists on a spectrum:
  • Heat edema/rash: Self-limited; remove from heat, allow evaporative cooling.
  • Heat exhaustion: Symptoms include vomiting, shortness of breath, core temp <104°F. Treat with cooling measures (ice packs, fanning, fluids).
  • Heat stroke: Core temp >104°F, neurologic symptoms. Emergency—requires cooling in an ice water bath (36.5–50°F) within 30 minutes.
    • Kari Staus: "This we can definitely call heatstroke ... cool Justin within 30 minutes of recognition. We do this by submerging him in an ice cold water bath..." (04:33)
• Notable Quotes:
  • Justin Chediak (joking): "Those are insane numbers. Makes you think about moving to Minnesota." (02:42)
  • Steve Brown: "Polar plunge." (04:57)
• Clinical Pearl: Aspirin, NSAIDs, and dantrolene are not effective in heat stroke treatment.
  • Justin Chediak: "Aspirin, NSAIDs and dantrolene have no role in the treatment of heat stroke." (04:59)
• Risk Factors: Male sex, BMI >25, poor sleep, pregnancy, cardiovascular/respiratory disease, and medications like anticholinergics, antihistamines, beta blockers, diuretics, and stimulants.
  • Justin Chediak: "I can't modify the fact that I'm a male." (05:08)

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Graduate Medical Education (GME) Funding & Primary Care (05:43–07:47)

Key Insights:

• GME (Medicare) funding does not correlate with increased primary care physician production, and is often inversely related.
  • Steve Brown: "Total GME funding was inversely related to new primary care physicians." (06:29)
• Regional variation:
  • Northeast: High funding, low primary care output.
  • Northwest: Low funding, higher output (70.8 PCPs per 100,000, still less than Canada’s 119/100,000).
  • Kari Staus: "The northwestern states receive low GME funding but produce a relatively higher number of primary care physicians, about 70.8 per 100,000 people." (06:43)
• Only 24% of graduating physicians enter primary care.
• Policy Recommendations:
  • Mandate 30–50% of new GME-funded positions for primary care.
  • Distribute GME funds equitably based on health system need.
  • Increase accountability and reimbursement equity.
  • Kari Staus: "New funding for residencies should mandate a threshold of 30 to 50% of new positions for primary care." (07:23)
• Justin Chediak: "The GME disbursement is literally incentivizing production of subspecialists." (07:43)

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Foreign Body Ingestion in Children (07:47–11:19)

Key Insights:

• In 2023, >100,000 reported cases; most kids are asymptomatic with normal exams, making diagnosis a challenge.
  • Justin Chediak: "Most kids are asymptomatic with normal exams and can't tell you what they've swallowed." (08:14)
• Evaluation: Start with two-view radiographs of neck, chest, and abdomen.
• Object-specific notes:
  • Coins: Most common; urgency determined by age (<6), location (proximal/mid-esophagus), duration (>12 hrs), or size (quarter+). Complete obstruction is emergent.
  • Button batteries: Highly dangerous—tissue damage can start in 15 minutes. Emergent EGD if in esophagus.
    • Steve Brown: "On X ray, look for the double halo sign... But honestly, if it's unclear, treat it like a battery." (09:31)
  • Magnets: Multiple magnets risk bowel wall fistula/perforation—always urgent/emergent intervention.
    • Steve Brown: "Multiple magnets equals emergent EGD with no debate." (10:24)
  • Sharp objects: Roughly one-third perforate; if >3cm, EGD is indicated.
• Management Pearls:
  • Steve Brown: "Don't forget honey at home if the kid's older than one... and sucralfate in the ED can help." (10:01)
  • When in doubt: image early, intervene quickly.

Notable Quotes:

• Steve Brown: "Don't underestimate the toddler with suspicious silence." (11:06)

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Fall Prevention in Older Adults in Care Facilities (11:46–13:26)

Key Insights:

• Tailored, staff-involved interventions "reduce fall rate over 6 to 12 months and reduce fall risk after 10 to 12 months." (Steve Brown, 12:10)
• Non-tailored interventions: Little to no effect.
• Effective interventions:
  • Exercise (works during intervention, but effect fades after discontinuation).
  • Vitamin D (most helpful if baseline deficiency).
  • Dietitian-guided dairy increase may reduce fractures.
  • Kari Staus: "The CDC has an initiative...Steady for short...provides free training and tools to help integrate fall prevention..." (13:10)

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Management of Chronic Constipation (Practice Guideline) (13:26–15:27)

Key Recommendations:

• Initial Workup: Focused history/physical, assessment of frequency, quality, and red flags.
• Address modifiable factors (diet, meds, immobility).
• First-line treatment: Increase water and fiber (85% of cases improve).
  • Steve Brown: "First line treatment is increasing water and fiber consumption." (14:22)
• If fiber insufficient: Move to osmotic laxatives (polyethylene glycol > lactulose).
• Stimulants for rescue/second line.
• Evaluate for outlet dysfunction or slow colonic transit if not responsive.
• Refer to surgery for anatomic abnormalities.
• Panel Commentary:
  • Justin Chediak: "Miralax tastes like nothing—again, I heard from a friend." (15:03)

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Oral Corticosteroids in Pediatric Acute Asthma Exacerbations (15:27–16:53)

Key Insights:

• Meta-analysis found no significant difference in prevention of relapse between dexamethasone and prednisolone regimens.
  • Kari Staus: "Nobody really outperformed anybody else. So your choice can be more about convenience, tolerance, and getting the kid to actually take it." (16:17)
• Main outcome: Did child revisit ED or clinic within 14 days?
• Limitations: No assessment of harm, no placebo groups, moderate to high risk of bias in included studies.

Take-home message:
Justin Chediak: "For now, just pick the steroid your patient will actually take and don't overthink it." (16:53)

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Memorable Moments & Quotes

• Justin Chediak (facetiously): "Why did you run a half marathon?" (03:41)
• Steve Brown: "We’re facing increased human-induced climate change." (02:21)
• Steve Brown: "Escalate quickly, and don't underestimate the toddler with suspicious silence." (11:06)
• Classic sign-off after constipation segment:
  • Steve Brown: "Now everyone knows I'm constipated and don't like to run." (17:59)
  • Kari Staus: "Maybe you're constipated because you're immobile." (18:08)

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Timestamps for Key Segments

| Topic | Start Time | |-------------------------------------------|------------| | Heat-related illness | 02:11 | | Graduate medical education & primary care | 05:43 | | Foreign body ingestion in children | 07:47 | | Fall prevention in older adults | 11:46 | | Chronic constipation management | 13:26 | | Oral steroids for pediatric asthma | 15:27 |

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Summary

This episode delivers actionable clinical pearls and engaging policy discussion across major ambulatory care topics. Listeners gain stepwise approaches to heat emergencies, evidence-based fall prevention, and a pragmatic review of constipation and asthma care, all with the interplay and humor characteristic of the AFP Podcast team. The recurring theme: focus on practical, patient-centered solutions while pushing for systemic improvements in public health and healthcare education.

Transcript

[Justin Chediak]

The AFP Podcast is brought to you by the American Academy of Family Physicians and by the AFP's free on demand CME activity addiction treatment and care CME for family physicians Presenting the latest in managing Substance use disorders. [e-mail] sudcme.

[Steve Brown]

Welcome to the American Family Physician podcast for part two of the April 2026 issue. I'm Steve.

[Justin Chediak]

I'm Justin.

[Kari Staus]

I'm Kari.

[Steve Brown]

We are residents and faculty, mostly residents from the University of Arizona College of Medicine, Phoenix Family Medicine Residency. Today on the podcast we're going to talk about heat related illness, graduate medical education funding and primary care, foreign body ingestion in children, fall prevention, chronic constipation and oral corticosteroids in children.

[Kari Staus]

The opinions expressed in the podcast are our own and do not represent the opinions of the American Academy of Family Physicians. The editor of American Family Physician or Banner Health do not use this podcast for medical advice. Instead, see your own family doctor for medical care. We're on a mission Delivering the Best

[Steve Brown]

from American Family Physician Automation Delivering the

[Kari Staus]

Best Strong American Family Physician

[Steve Brown]

before we start this episode, we'd like to clarify something on a topic related to the MMR and varicella vaccines from our last episode. The American Academy of Family Physicians recommends separate vaccines, not the combined MMRV for the first dose in children ages 12 to 47 months. They may be administered together as the combined MMRV if parents or caregivers express a preference. Now on to the episode. Let's start with heat related illnesses from Drs. Gower McNutt and Brian from Fort Bragg in North Carolina.

[Kari Staus]

All right, so it's April in Phoenix, so it feels appropriate to talk about heat related illness as we have reached record breaking heat this past month, especially

[Steve Brown]

now that we're facing increased human induced climate change. There was a review that found that for every 1.8 degrees Fahrenheit rise in hot temperatures or during heat waves, the risk of heat related illness morbidity increases by 18% and mortality increases by 35%.

[Justin Chediak]

Those are insane numbers. Makes you think about moving to Minnesota.

[Kari Staus]

Yeah, okay, but seriously, we're all at risk. Heat related illness is a spectrum with things like heat edema or rash at the mild end and heat stroke at the severe end. The general approach is to cool and hydrate the patient, but this looks different depending on the severity.

[Justin Chediak]

Okay, so say I go out and run five miles tomorrow, which I will never do and I have some swelling of my hands and my shoes are now tight.

[Kari Staus]

Well Justin, you probably have heat edema. This is A result of cutaneous vasodilation and accumulation of interstitial fluid. You may even have a heat rash and heat cramps associated. I'd recommend removing you from these high temps and allow evaporative cooling to do its thing.

[Steve Brown]

Okay, so let's say Justin instead decided to run a half marathon.

[Justin Chediak]

Ridiculous.

[Steve Brown]

And he comes to us and he's vomiting and short of breath and his core temperature is 102Fahrenheit.

[Justin Chediak]

More likely.

[Kari Staus]

Justin, why did you run a half marathon?

[Steve Brown]

Maybe you weren't prepared.

[Kari Staus]

Okay. He probably has heat exhaustion. This can be associated with hypovolemia and sodium depletion as well, and is usually associated with temps less than 104 degrees Fahrenheit.

[Justin Chediak]

So from my understanding, we treat heat exhaustion by removal from heat and with simple cooling. So things like ice packs, fanning, cold towels and ivy or oral fluids.

[Kari Staus]

Right, and it can even get confusing sometimes when there is some irritability, anxiety and disorientation. Because heat exhaustion can actually overlap a little with heat stroke. So when in doubt, start immediate cooling measures.

[Steve Brown]

Okay, so Justin now decides to hike the Grand Canyon rim to rim. And he comes back to the emergency department, and now he has a core body temperature of 104.4 Fahrenheit with agitation.

[Kari Staus]

Oh, gosh. Okay, so this we can definitely call heatstroke, which is usually associated with neurologic manifestations and temps greater than 104Fahrenheit. It is an emergency and we need to cool Justin within 30 minutes of recognition. We do this by submerging him in an ice cold water bath at 36.5 to 50 Fahrenheit to avoid long term neurologic sequelae such as seizures or coma.

[Steve Brown]

Yes, polar plunge.

[Justin Chediak]

Also important to note, aspirin, NSAIDs and dantrolene have no role in the treatment of heat stroke.

[Kari Staus]

Let's wrap up by discussing risk factors.

[Justin Chediak]

Well, I can't modify the fact that I'm a male.

[Steve Brown]

Yeah.

[Justin Chediak]

Which increases my risk. But improving acclimatization or progressively increasing exercise intensity and duration is very important. Other general risk factors include BMI greater than 25, poor sleep, pregnancy, several diseases, including cardiovascular and respiratory diseases, and some medications, including, but not limited to alcohol, anticholinergics, antihistamines, beta blockers, diuretics and stimulants.

[Kari Staus]

Stay safe out there, everybody. Especially you, Justin.

[Justin Chediak]

Never.

[Steve Brown]

Next, Graham center policy. One pager. Graduate medical education funding does not flow to primary care physician production. This is from Drs. Fenster Park, Hofstetter and Topmiller from Duke. And the Robert Graham center in Washington, D.C. i just love it when the title tells you the whole story.

[Justin Chediak]

Yeah, what's the. What's the TLDR here?

[Steve Brown]

Yeah. So the authors used several databases to find the association between Medicare, graduate medical education or GME funding distributed to each state and the percentage of new physician workforce entering primary care after five years.

[Kari Staus]

Primary care was defined as graduates of any of the family medicine, pediatrics, geriatrics or internal medicine. Hospitalists were excluded.

[Justin Chediak]

You all will be thrilled to know total GME funding was inversely related to new primary care physicians.

[Steve Brown]

Oh, geez.

[Justin Chediak]

There's a color coded map which shows the northeastern states receive high levels of GME funding but produce low levels of primary care.

[Kari Staus]

The northwestern states receive low GME funding but produce a relatively higher number of primary care physicians, about 70.8 per 100,000 people.

[Steve Brown]

This is still low compared to Canada, which produces 119 primary care physicians per 100,000 people.

[Kari Staus]

These estimates may be inflated because only 9.4% of internal medicine graduates practice primary care after Residency, and only 54% of pediatric residents remain in primary care.

[Justin Chediak]

So overall, only 24% of all physicians enter primary care.

[Steve Brown]

Okay, so what can we do to direct GME dollars to primary care?

[Kari Staus]

New funding for residencies should mandate a threshold of 30 to 50% of new positions for primary care.

[Justin Chediak]

GME funding should be distributed equitably to meet needs of the health care system.

[Steve Brown]

We need publicly available accountability measures to track GME fund.

[Kari Staus]

More equitable reimbursement policies are needed right now.

[Justin Chediak]

The GME disbursement is literally incentivizing production of subspecialists.

[Steve Brown]

Oh, boy. Now it's time for foreign body ingestion in children from doctors Valerio and Williamson from Uniformed Services and Travis Air Force Base.

[Justin Chediak]

All right, team, let's talk about the FBI.

[Kari Staus]

Excuse me. What?

[Justin Chediak]

Foreign body ingestion?

[Steve Brown]

No, that's not a real medical abbreviation.

[Justin Chediak]

You know, no one ever lets me have fun around here. Nope. So I guess I'll just have to swallow my pride. I can't take credit for that one. That's from Dr. Richards at the UT Knoxville Family Medicine Residency. Anyways, in 2023, there were over 100,000 reported cases. And the tricky part? Most kids are asymptomatic with normal exams and can't tell you what they've swallowed.

[Kari Staus]

So you're basically playing detective with zero clues.

[Steve Brown]

Yeah, exactly. First step is two view plane radiographs of the neck, chest and abdomen. These have high sensitivity for things like coins. They're cheap and they have less Radiation. If you don't see anything but suspicion is high, then you might need to

[Justin Chediak]

move to CT. Thankfully, most objects over 60% pass on their own. But there are choke points in the GI tract, so some do need intervention.

[Kari Staus]

Let's start with coins, the MVP of things kids swallow red flags for needing urgent EGD. Here are age under 6, located in the proximal or mid esophagus. Stuck longer than 12 hours or big, like quarter sized or bigger.

[Steve Brown]

And if they have complete obstruction symptoms, that's now emergent.

[Justin Chediak]

Coins in the stomach or small bowel can usually be watched for up to two weeks if they're low risk.

[Kari Staus]

Now, button batteries way scarier. They can cause tissue damage fast.

[Steve Brown]

On X ray, look for the double halo sign on AP or step off sign on lateral to distinguish from coin. But honestly, if it's unclear, treat it like a battery.

[Justin Chediak]

Yep, battery in the esophagus. Emergent EGD tissue damage can start in 15 minutes.

[Kari Staus]

And if it's past the stomach, management depends on risk. Multiple batteries, magnets, age under 6 or size greater than 14 millimeters. That determines EGD surgery or close outpatient monitoring.

[Steve Brown]

And don't forget honey at home if the kid's older than 1 and doesn't have swallowing issues. And sucralfate in the ED can help limit injury while you're getting them scoped.

[Justin Chediak]

All right, next up, magnets, AKA nightmare fuel.

[Steve Brown]

Oh, my.

[Kari Staus]

Multiple magnets can attract across bowel walls, leading to fistulas, perforation, sepsis, and even death.

[Steve Brown]

Multiple magnets equals emergent egd with no debate.

[Justin Chediak]

Single magnet in the esophagus. Urgent EGD on less symptomatic than emergent.

[Kari Staus]

If it's beyond the stomach loop in GI or surgery, symptomatic patients may need admission and intervention. Asymptomatic patients can sometimes go home with close imaging. Follow up.

[Steve Brown]

Last category is sharp objects. About one third of these cause perforation,

[Justin Chediak]

so if it's wider than 3 cm, it likely won't pass the esophagus. So EGD.

[Kari Staus]

And if in the stomach, urgency depends on symptoms and size.

[Steve Brown]

Beyond the duodenum, talk to surgery. The ileocecal region is the most common perforation site.

[Justin Chediak]

All right, so bottom line here, most pass, but the dangerous ones move fast. When in doubt, image early, escalate quickly, and don't underestimate the toddler with suspicious silence.

[Steve Brown]

We'll be right back.

[Justin Chediak]

The AFP podcast is brought to you by the American Academy of Family Physicians and by Chartnote Tired of pajama time, more physicians are turning to AI to simplify documentation. ChartNote is a HIPAA compliant platform designed for physicians. Its ambient AI Scribe listens during patient visits and drafts notes using custom templates that match your style. See how it [e-mail]

[Steve Brown]

now we have Cochrane for clinicians Fall Prevention Interventions for Older Adults in care facilities from Dr. Jean and Q from Penn State the

[Kari Staus]

clinical question this Cochrane seeks to answer is what interventions reduce falls among older adults living in care facilities.

[Justin Chediak]

And we care about this because residents of care facilities face significantly higher risk of falling compared to their community counterparts.

[Steve Brown]

The short answer here is that tailored interventions implemented with staff engagement reduce fall rate over 6 to 12 months and reduce fall risk after 10 to 12 months.

[Kari Staus]

And if interventions are not tailored to individual needs, there is probably little to no effect on fall rate at 6 to 12 months.

[Justin Chediak]

So what types of interventions did this Cochran review?

[Kari Staus]

Exercise as a standalone intervention does reduce the rate of falling, but after discontinuation of this intervention there was no difference observed in post intervention follow up medication

[Steve Brown]

optimization interventions did not demonstrate a difference in the rate or risk of falls,

[Justin Chediak]

but vitamin D supplementation was found to probably reduce the rate of falls among older adults. These studies that looked at vitamin D supplementation had participants with low baseline serum vitamin D levels, so this intervention is most applicable to older adults with vitamin D deficiency.

[Steve Brown]

Even increasing dairy intake through a dietitian assisted menu design may have reduced fracture risk.

[Kari Staus]

The CDC has an initiative called Stopping Elderly Accidents, Deaths and Injuries Steady for Short that aims to prevent falls by screening, assessment and intervention and provides free training and tools to help integrate fall prevention into routine clinical workflows.

[Steve Brown]

Steady for the Win Now a practice guideline Management of Chronic Constipation from the American Society of Colon and Rectal Surgeons. This is summarized by Dr. Arnold from the Naval Undersea Medical Institute in Connecticut. This guideline gets a score of 8 out of 8 on the G Trust Scorecard.

[Kari Staus]

It's based on a systematic review, focuses on patient oriented outcomes and the Chair and the majority of guideline panel have no conflicts of interest.

[Justin Chediak]

Why don't we go over some key recommendations? I'm asking for a friend.

[Steve Brown]

Okay. First a directed history and physical exam should be performed to rule out serious

[Kari Staus]

disease associated symptoms and stool frequency and quality can be helpful in determining the etiology.

[Justin Chediak]

We should first address modifiable behavioral factors like diet, medications and immobility.

[Steve Brown]

Talking now about management. First line treatment is increasing water and fiber consumption 85% of patients with normal transit constipation will be improved with dietary fiber.

[Justin Chediak]

Combined, soluble and insoluble fiber and oat bran are beneficial.

[Kari Staus]

Fiber is helpful in irritable bowel syndrome with constipation.

[Steve Brown]

Also, patients with slow colonic transit or outlet obstruction will likely benefit less from dietary interventions alone.

[Justin Chediak]

Use osmotic laxatives next. If dietary changes are not sufficient, a meta analysis showed polyethylene glycol is more effective than lactulose and pro tip Miralax tastes like nothing again. I heard from a friend.

[Steve Brown]

Stimulants like bisacoidal can be used for rescue therapy or second line treatment. And if those steps don't improve things, patients should be evaluated for outlet dysfunction or colonic motility concerns.

[Kari Staus]

The guideline discusses non surgical management for pelvic floor dysfunction or non relaxing puborectalis muscle.

[Justin Chediak]

And some anatomic abnormalities may benefit from surgery.

[Steve Brown]

We're going to wrap things up with a poem. Poems are patient oriented evidence that matters. All oral corticosteroids for children with acute asthma exacerbation appear to be equally effective. This is from Dr. Berry.

[Justin Chediak]

All right, Team Quick hitter today. Which oral steroid regimen is best for kids with acute egg exacerbations? Are we team dexamethasone or are we team prednisolone?

[Steve Brown]

And the answer is that it probably doesn't matter. Womp, womp.

[Kari Staus]

A network meta analysis looked at 11 RCTs with over 2000 kids in outpatient and ED settings and found no significant difference between dexamethasone and prednisolone regimens when it comes to preventing relapses.

[Justin Chediak]

Yeah, the main outcome they cared about was pretty practical. Did the kid come back within 14 days or another visit to the ED or clinic?

[Kari Staus]

Across 15 comparisons of six regimens, nobody really outperformed anybody else. So your choice can be more about convenience, tolerance and getting the kid to

[Steve Brown]

actually take it, which, let's be honest, might be the hardest endpoint of all.

[Justin Chediak]

A couple caveats though. No placebo or non steroid groups were included. So this is more of a which steroid and not a do steroids help? Type of study.

[Kari Staus]

And they didn't report harms, which, I don't know, feels like kind of important.

[Steve Brown]

Yeah. Also, the evidence quality wasn't amazing. Three studies had high risk of bias, four low and overall very low confidence in the results from the authors.

[Justin Chediak]

So, bottom line, for now, just pick the steroid your patient will actually take and don't overthink it.

[Kari Staus]

Send us your thoughts by emailing [e-mail]

[Steve Brown]

follow on Instagram fpjournal. Please subscribe and rate us wherever you get your podcasts.

[Justin Chediak]

Escucha nos en espanol a revista medica a fap.

[Kari Staus]

Our podcast team is Jake Anderson, Puneet Barro, Steve Brown, Justin Chediak, Sarah Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg, Elena Kelly, Chisum Okuwabu, and Kari Staus.

[Steve Brown]

Our sound and technical guru is Tyler Coles. Our theme song is written and recorded by family physicians Bill Dabs, Ryan Evans, and Justin Jenkins.

[Justin Chediak]

This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Program Programs.

[Kari Staus]

We'll talk to you soon for the next edition of the American Family Physician Podcast.

[Steve Brown]

Now everyone knows I'm constipated and don't like to run.

[Justin Chediak]

I'm really not paying a good immobility.

[Kari Staus]

Maybe you're constipated because you're immobile.

[Justin Chediak]

No, that's impossible.