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Wednesday Nov 19, 2014

Don't Wait: Advance Planning Helps Both Patients and Their Caregivers

Not long ago, while overseeing residents in the hospital, we admitted an elderly woman who was bed-bound and oriented only to herself. In the past, she had clearly indicated to her paid health care proxy (she had no close relatives or friends) that, in the event of an emergency, she would "want everything done" for her, including cardiopulmonary resuscitation (CPR). However, she had also gone to great lengths to have home care 24 hours a day, seven days a week to avoid ending up in a long-term care facility. Her wish was to pass away at home.

On one hand, the team was grateful that she had delineated her wishes regarding resuscitation. With an underlying heart problem and an infection of unknown source, it was reassuring to know what to do medically if her heart stopped. However, her strong desire to pass away at home and not be consigned to months of lying in an unknown bed in a strange environment presented us with a dilemma. We knew that if resuscitation was needed -- and if it was successful -- the likelihood of her spending the rest of her life on a ventilator in an ICU bed was high. How could we reconcile what seemed like two disparate wishes for this woman, given that she was no longer able to have a meaningful discussion about her preferences or give us consent?

Without a doubt, the ideal is to have conversations about end-of-life care in the outpatient setting, before a serious illness -- accompanied by heightened emotions -- demands it be done in the hospital. As family physicians, we are particularly well poised to lead these discussions. Not only do we have a holistic view of our patients' medical conditions, we often know a great deal about their social history. Furthermore, we frequently care for multiple members of a patient's family. Despite not knowing exactly what might lead our patients to need a resuscitation decision, we do know that for many of our elderly patients, they (or their families) will be faced with this decision at some point.

What can we do to facilitate this decision-making process? Ultimately, we want our patients to be able to make informed decisions about their care, including those that occur at the end of life. However, this is not a light subject, and the conversation is typically not one that can be had in a few minutes. Although some patients have done a good deal of research about health care proxies, advanced directives, do not resuscitate (DNR) orders, etc., most have not.

In fact, a survey of U.S. adults published earlier this year found that nearly three-fourths of respondents did not have an advance directive, and lack of awareness was the most common reason.

Broaching the subject during a routine visit can be helpful. I begin by saying that I know this can be a difficult topic, but, as their family physician, I like to have documentation on file regarding how they would like to be cared for in the event of an emergency. (Of note, our electronic medical record has a place to document information about health care proxies and advanced directives.) I ask my patients if they have ever thought about this issue. And then I ask them if we could set up an appointment specifically to discuss this in more detail. I reassure them that I am not bringing this up because I foresee any emergencies in the near future, but expressly because I believe it is better to discuss end-of-life care before we arrive at that point. I encourage them to bring a spouse or family member to the appointment.

When discussing these topics, it is important to create a space where patients feel they can safely consider their options. But it's also essential to be forthright with patients about the pros and cons of those options. Most patients' idea of what occurs during and after resuscitation is the Hollywood portrayal. Conversely, an overwhelming amount of physicians, who have a more realistic understanding of CPR and its aftermath, choose to fill out DNR forms for themselves.

I try to give a clear idea of what resuscitation can and cannot do for a patient in simple language, and I focus, in particular, on what happens after the resuscitation effort. I explain that often, when the heart stops, if the medical team can make it start again, whatever caused it to stop will still be there. Sometimes, depending on the patient and if it feels appropriate, I tell them that ribs can be broken. I let them know that patients generally go to the ICU afterwards with machines and tubes helping them breathe and maintain their heart function, and that it is not unusual for the medical team to be barred from turning off the machines and tubes after they've been put in place, and patients may be dependent on these going forward. Even if the medical team is able to remove the additional support, I explain that patients rarely return to the same quality of life they experienced before the event.

I find it helpful to frame the discussion with patients in terms of "allowing natural death" rather than "do not resuscitate." And I stay away from asking if patients would "want everything done" in the event of an emergency, because to answer "no" to that question feels as though you are saying you want nothing done, and that is a scary (and inaccurate) option. I reassure patients that a DNR order is not a "do not treat" order, and we discuss all the options they would have for being treated for infections, pain or discomfort, and so on.

In terms of the practical details of scheduling appointments to have these discussions, the 2015 CPT code set will include two codes for advance care planning, They are

  • 99497 -- Advance care planning that includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional for the first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate; and
  • 99498 -- Advance care planning that includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional for each additional 30 minutes (list separately in addition to code for primary procedure).

Currently, the 2015 Medicare physician fee schedule will not reimburse for these codes. They are not valid for Medicare purposes, and CMS indicates that Medicare uses another code for the reporting and payment of these services. CMS does plan to review and consider payments in the future. Until then, physicians can bill for the visits using regular evaluation and management codes and code based on time spent in counseling and coordination of care.

It's worth noting that the AAFP has a comprehensive policy regarding advance planning for end-of-life care, and offers related resources for patients. In addition, American Family Physician has compiled a collection of journal articles that deal with issues related to this topic, including advance directives, pain management and hospice.

Ultimately, our elderly patient in the hospital stabilized and returned to her baseline after we identified the source of her infection and started the correct antibiotics. At that point, the resident and I were able to have a rational discussion with her health care proxy, who was one of her main caretakers. We met in the patient's room to allow the proxy to ask the patient questions throughout. Although she was unable to repeat back risks and benefits of and alternatives to various treatments or discuss her wishes directly, she was able to answer "yes" and "no" to basic questions about CPR, life support and, importantly, whether she would want to be in a hospital for an extended period of time.

Although the patient didn't have the capacity to understand what CPR would be like for her, she was able to indicate she wanted to be at home and she did not want to have her life extended on machines. This gave the proxy and others who cared for her the opportunity to consider what they thought would be best in line with what the patient would choose for herself if she had capacity. And, as physicians, that's what we hope to accomplish for all of our patients in these situations -- knowing how to care for someone at the end of their life in a way that is truly consistent with their wishes.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

Wednesday Nov 12, 2014

Home Grown: South Carolina Schools Work Together to Address Primary Care Shortage

As a new physician, I sometimes reflect on whether or not primary care was the right choice for me. Over and over, the answer always is yes. Unlike many of my peers, I was a "late bloomer" in choosing family medicine. I started medical school with plans to be an OB/Gyn, and it wasn't until my fourth year that those plans changed.  

That year, I worked in Ecuador for six months, and that's where I finalized my decision to pursue family medicine. I worked on labor and delivery while I was there, but I also taught rural high-school students about sexually transmitted infections and nutrition. And I worked with a rural physician who saw men, women and children in a remote mountainous area called Cacha. Through that experience, I realized that I enjoy caring for all types of people -- from newborns to the elderly -- and that being able to influence mothers meant influencing the entire family.  

Courtesy University of South Carolina School of Medicine

Students at the University of South Carolina School of Medicine listen to a lecture. The school is collaborating with another medical school, a nursing school, and a physician assistant training program to expand the state's primary care workforce.

There are students who are in medical school right now, or even pre-med students still in college, who also might choose family medicine if they had the right experience or exposure to our specialty. How do we reach those students? And how do we keep the interest of those who decided early that primary care was right for them?

According to research by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, the United State is expected to need an additional 52,000 primary care physicians by the year 2025 to care for an aging and growing population, as well as for the rapidly expanding number of patients with health insurance. The situation is particularly grim in my home state of South Carolina, which ranked 40th in the number of primary care physicians per 100,000 people in 2012, according to the Association of American Medical Colleges.

The South Carolina Area Health Education Consortium has responded to this shortcoming by developing the Institute for Primary Care Education and Practice through a grant from the Duke Endowment. The institute is an interprofessional collaboration between two medical schools, a nursing school, and a physician assistant training program designed to increase the number of health professionals practicing primary care in South Carolina.  

The institute recruits first- and second-year medical students, nurse practitioner students, and physician assistant students to become fellows. These health professions students participate in monthly seminars focused on pertinent topics in primary care and an annual retreat with keynote speakers, and they have the opportunity for longitudinal precepting opportunities with primary care physicians, nurse practitioners and physician assistants. The seminars are held via video conference so that students at all the campuses -- which are more than 100 miles apart -- can interact with each other and the seminar speakers.

The institute is in its third year of funding and has experienced success in recruiting dozens of interested students into the fellowship. Many of the nurse practitioner and physician assistant graduates have remained dedicated to primary care as their career choice. This will be the first year of the program that fellows graduate from medical school, so we will have Match data available in the spring to help us gauge our progress.  

It has been an exciting time participating in the institute as a core faculty member and being able to influence so many young health professionals.  

I encourage family physicians to look for ways to foster the next generation of primary care physicians, regardless of whether your primary job function is as an educator. Students need the opportunity to see what we do in our practices across multiple settings, beyond the walls of an academic health center. You may not have a grant to support a project exactly like ours, but you can precept and show the joys we experience in practice as family physicians.

At medical schools, family medicine interest groups can collaborate in a manner similar to the way our South Carolina program works with multiple campus locations, extending limited resources and forming alliances across the state. The AAFP's FMIG Network can help with the tools to build those connections and support your work.

Meshia Waleh, M.D., is an assistant professor of family and preventive medicine at the University of South Carolina School of Medicine in Columbia.

Wednesday Nov 05, 2014

Labor of Love: Maternity Care Offers Unique Chance to Partner With Patients

Many of us who graduate from medical school and residency in this country are trained in maternity care in a similar way. Typically, that training represents a rather "medicalized" form of labor and delivery.  

Patients come to the hospital, get hooked up to monitors, see their doctor for occasional checks throughout the day (or night) and then see us again just as they are about to deliver. For some physicians, contact with the patient -- and her child -- ends there. Unless it is one of our continuity deliveries that we follow throughout pregnancy and delivery, we rarely see the mother or baby after they leave the hospital. Equally frustrating is caring for a laboring patient throughout the day but having to leave before she delivers because our shift is over.  

Patient Tawny Ashbaugh and I listen to her baby's heart beat.

Patients may bring a birth plan to the hospital, but this is sometimes not even seen by the resident scheduled to deliver the infant. And anything too out of the norm might be seen as a patient being difficult or eccentric. I trained at a hospital with high maternity volume during residency, and this was how I functioned.

However, once I moved to a rural community and began my own practice, I began to develop a much different relationship with my maternity patients. I now see it as my responsibility to educate and help them throughout their pregnancy, guide them through their labors, and provide to the best of my ability the deliveries that they envision.  

I admit that when first going into practice, I didn't have a lot of skill or experience in dealing with special labor requests. Three years later, I've accommodated a wide range of requests: essential oil diffusers, dark environment, limited checks, meditation, working with a doula, delayed cord clamping, delaying vaccinations until an hour or so after birth, etc.

During my residency, my position on such requests was that they were nice thoughts, but they often were an annoyance because I thought patients were trying to direct what I was supposed to do. I was the doctor with medical training, and my feelings on birth plans were not generally positive.  

Today, I have a different perspective. My growth in this regard began when I started my practice and began seeing women I would be with from their first visit onward. Not only would I be caring for them at every prenatal visit and through delivery, but I also would be seeing them and their child for years to come.

I began to plan hourlong visits for all of my new maternity patients to allow us to discuss everything: their questions, their medical history, what to expect from me during their pregnancy, and what they envision for their pregnancy and delivery. In this way, we become partners in the process.  

I was taken aback the first few times a patient came to interview me at her first visit, to see if I was the right fit for her. I now appreciate this and understand why choosing the right health care professional for the journey is so important.

During the past year, I had the opportunity to supervise a nurse midwife. She had an enormous impact on my practice and taught me many things about how to facilitate the childbirth process each patient desires. I am now much more skilled at recommending position changes to help the mother progress, suggesting alternative pushing positions, and allowing the patient to tell me what feels right for her. I have delivered women in kneeling, standing, squatting and side-lying positions, and although this would have felt foreign and bizarre to me on graduating residency, it is now normal to try several things until we find a position that works best for each patient.

Another change we have brought to our hospital is water birth. Our facility is the only hospital in Kansas that offers this option. We have had women travel as far as four hours to be able to have a water birth. Implementing this option in our facility required training for all relevant staff, as well as research into policies and procedures, but it has been a wonderful addition to our program.  

There is good evidence that these practices -- patient involvement in care decisions, mobility during labor, and labor support -- reduce cesarean section rates, decrease need for pain medication and improve patient satisfaction.  

I am proud of what we can offer to our mothers and families, and yet I am humbled every time I get to be part of a birth. There are three physicians in our facility who provide birth care, and two additional physicians who do cesarean sections. We have an 8 percent primary C-section rate, and we have built a reputation for patience with the labor process. After having an unplanned C-section myself, I fully understand the desire of patients to ensure they will be in a facility where it is considered something to be done only in case of medical need and not because their physician is tired of waiting.

I'm grateful that my own birth experience has made me a much more understanding physician. I will continue to strive to provide the best care I can for my patients, keep our facility up-to-date on guidelines and best practices, and accommodate my patients' vision for their births in any way I can.

What unusual requests or alternative birthing processes have you experienced with your patients?

Beth Loney Oller, M.D., practices full-scope family medicine in Stockton, Kan.

Wednesday Oct 29, 2014

Moving On: Why My First Job Won't Be My Last

I never imagined that my first job after residency wouldn't work out.

As a medical student, my focus was to get through medical school and match with a good residency. During residency, I focused on learning the practice of medicine and honing my skills. It seemed a given that I would finish residency, find a private practice and live happily ever after. It didn't work out that way.

I felt that I conducted a thorough job search and did due diligence on the offer I eventually accepted. But here I am, preparing to change jobs.

Although I feel now as though I failed, in retrospect, it seems silly that I did not consider this possibility. Many physicians do not stay in their first position out of residency. In fact, job turnover among physicians in general was at a seven-year high of 6.8 percent in 2012.

There are many reasons physicians may change jobs, including compensation, moving closer to (or further away from) family, poor job fit, and even changing careers entirely. For me, it was a combination of factors that included compensation, location, issues related to raising my family and the changing health care landscape.

Compensation among family physicians is always a sticking point because no one wants to pay us what we're worth. For the past few years, average incomes for family physicians have been on the rise, according to Medical Group Management Association data. But in an individual practice, this means little. Many residents are poorly equipped to evaluate a practice's financial statements to determine their degree of solvency. Having a salary guarantee is nice, but it pays to try to look down the road to what will happen when the guarantee runs out.

Choosing a location, especially one where you have not lived before, also can be challenging. My wife and I thought we knew what we were getting into when we moved back to our home state. However, we moved to an area neither of us had lived in before. There were many complications, such as lack of available housing and a poor real estate market, along with lack of local services and goods that we frequently required. For instance, my wife makes and sells crafts online, and with no fabric shops in town, she frequently had to drive several hours to get supplies.

We also ran into problems when considering long-term plans for our children. The schools in the area had poor ratings, raising concerns for us about the education our children would receive. About a year after we moved to the area, a bond issue on the ballot to raise money for local schools failed miserably. This raised another red flag for us that the community was not vested in improving education in the area.

Finally, it seems I have fallen victim to the tumultuous health care landscape. In short, I could not make a living as a physician under current circumstances. Although I routinely saw 20 or more patients a day, I made less money in practice than I had in fellowship. This feeds back into evaluating a practice carefully beforehand, including closely examining overhead, practice management and collection rates, as well as the practice's vision for the future and adaptability.

So looking back, what did I learn from this experience? It taught me a lot about the business of medicine -- even if I learned most of it by doing things the wrong way.

It also brings to mind my high-school Latin -- temet nosce, or "know thyself." It quickly became apparent that I had not prioritized aspects of the move appropriately. Even if the job had worked out well, I do not think we would have stayed given that we felt our children's education would suffer. Had I dug a little deeper, I would have found that the last four physicians in my position also stayed only a short time.

The fact remains that we cannot have all the information before making a decision. As a mentor once told me, there is no perfect job." We must decide what aspects of our lives, both professional and personal, are most important and be flexible with the rest. Even through a bad decision, I have learned and grown professionally, and I hope to translate that experience to a better fit for me and my family in our next adventure.

If you find yourself in a similar situation, the AAFP has online resources related to helping family physicians plan their careers and succeed in landing the right jobs.

Peter Rippey, M.D., is working locums while transitioning from private practice to a hospital-employed position.

Wednesday Oct 22, 2014

Want Change? Get Involved in Your Academy

Peter Sundwall, M.D., wasn't totally satisfied with his AAFP membership a few years ago. Specifically, he thought the Congress of Delegates -- the Academy’s policy-making body -- was spending too much time on certain issues at the expense of others that were more important to him.

A conversation with (then) AAFP President Jeff Cain, M.D., encouraged Sundwall to do something about it, so the Alpine, Utah, family physician got involved with the Utah state chapter and became a delegate to the Congress. This week, he is back at the Congress for the second time, working to ensure that the AAFP's policies address the issues he sees in his practice and those of his fellow chapter members. That's important, because he now is president-elect of the Utah AFP.

 Here I am testifying during the Reference Committee on Practice Enhancement at the Congress of Delegates.

I share Peter's desire to improve the care we provide to our patients, and being involved in developing Academy policy can help achieve that goal on a broad scale. Although I am still a new physician, I served two years as an alternate delegate for the Utah AFP and am now experiencing my first year as a full-fledged delegate.

Unlike Peter, my path to the Congress was not sparked by one specific issue, but by a general desire to improve the state of health care. And many positive changes can come from this meeting.  This week, the Congress considered dozens of issues. Here are just a few examples of topics that were debated that could directly impact our patients' health:

  • simplifying the preauthorization process;
  • studying and regulating electronic cigarettes and second-hand vapor; and
  • reforming the DEA's ruling on electronic prescribing of controlled substances to ease the regulatory burden.

Resolutions such as these inform the AAFP's Board of Directors and Academy staff about members' priorities for the coming year. That, in turn, allows the Board and staff to best direct the Academy's action on various issues, which could involve work by one of the AAFP's commissions, the Board and/or staff. The result could conceivably be the development of a program or resource or advocacy with the appropriate regulatory agencies or Congress.

This experience is giving me the ability to help my patients outside the clinic. Many of us chose family medicine, in part, so we could make a difference, and participating in the Congress of Delegates provides avenues to accomplish this. I submitted my first resolution this week, and I enjoyed the process of testifying to the reference committee and working with others to get it passed.

Even outside of the formal parliamentary procedure, those who participate in the Congress can seek out and interact with others with similar interests -- a process that often leads to other positive outcomes. For example, I met a colleague at a previous Congress, and together we developed and submitted a research proposal to the Council of Academic Family Medicine's Educational Research Alliance. We should find out in the next month or two if our idea is accepted.

It's worth noting that the Congress coincides with the AAFP Assembly, so thousands of family physicians are already traveling to the same city for the Assembly experience. That means members interested in sharing the Congress experience can simply add a couple of days on the front end of their trip to catch all the action. Although only delegates may vote during the Congress business sessions, any AAFP member present may give testimony during reference committee hearings.

I also have the privilege of working on the Commission on Governmental Affairs, one of seven AAFP commissions that provide feedback to the Board and assist in its efforts to implement resolutions the Congress adopts. That opportunity has offered me significant insight into the behind-the-scenes work required to improve our Academy and, consequently, our practices and the health of our patients.

Not only has participating in the Congress and on the commission fulfilled my desire to work for my patients and practice on a broader scale, it has also been a lot of fun. I would encourage anyone who would like to get involved this way to talk with your chapter leaders about potential roles in the Congress or commissions.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Tuesday Oct 14, 2014

Latest Study of Resident Work Restrictions Doesn't Settle Debate

A recent study published in Health Affairs reported on data collected from 2003 to 2009 that showed no evidence of a decline in mortality for patients under the care of physicians who trained with the 80-hour workweek restrictions promulgated by the Accreditation Council for Graduate Medical Education (ACGME). On the surface, this may indicate that there is little or no difference between the training received before and after the duty hour restrictions were imposed, but the limitations of data collection and the nature of the study make this conclusion an impossible one to proclaim with any certainty.

This particular study's findings notwithstanding, the issues surrounding duty-hour restrictions carry a high emotional charge. Opinions are numerous, but most folks settle into one of two camps, either for or against the restrictions. Proponents point to the dangers of sleep deprivation and its effects on concentration and focus. Opponents point to the missed opportunities for learning and the problems inherent in frequent patient handoffs. The answer, as in most cases, probably lies somewhere firmly in the middle, but collecting empirical data on these issues is difficult, at best. 

At heart, all physicians are scientists. We formulate and test hypotheses -- collecting data, refining the question, and using the results to guide further questions and actions. That said, much like the general public, doctors often misinterpret or overestimate the ability of statistical analysis to "prove" anything. Studies like this one are great at giving us a place to begin, but they are often used to draw broader conclusions than is statistically possible, making the reporting of these data difficult and fraught with misinterpretation. To that end, I'll offer my thoughts on the interpretation that this article espouses.

First, the data came only from Florida. Although the data should be somewhat representative of the country, the diversity seen in training approaches and locations nationwide, even with ACGME standards in place, is far broader than data from a single state can encompass. This limits the generalizability of the data to any group outside that state. For example, there may have been novel programs instituted in Florida to accommodate the new duty-hour restrictions, giving residents trained in Florida a completely different experience than those trained in Colorado or Maine or Nevada.

This possibility is not as far-fetched as it sounds. When the ACGME's 2003 duty-hour restrictions grew even tighter in 2011, my residency program in South Carolina modified schedules to include mandatory nap time, which in effect allowed interns to have overnight call without a "night float" system. Across the country, the night float has become a standard program to compensate for the 16-hour contiguous work restriction on interns, but the modified system we had was far different than any other solution I've seen since. Novel programs such as this were not accounted for directly in this study.

Second, the study has so many possible confounders that being able to accurately conclude anything other than similar mortality before and after the changes is highly improbable. The study authors themselves admit that there were many innovations in medicine during that time, not to mention the increasingly ubiquitous use of health information technology, from electronic health records to Epocrates and Up-to-Date. There is no statistically sound model that can accurately take those use case scenarios into account.

Simply put, any mortality rate change attributable to duty-hour restrictions may have been masked by other changes that could have independently shifted mortality up or down. Isolating the change in mortality due solely to the duty-hour restrictions requires far deeper analysis of the other factors influencing resident performance and patient mortality than were analyzed in this study.

Third, although patient death is an easily measured outcome, it may not be the best indicator of change. Quality of care, patient morbidity, readmission rates, and errors in patient handoffs and communication could all be added to outcomes measures to better understand the impact of duty-hour restrictions, but most of these markers are difficult to measure, link to a specific physician, and parse accurately in a retrospective fashion. However, they may provide a better picture of the overall impact of the duty-hour restrictions. For example, if patient handoffs necessitated by the duty-hour restrictions created more medical errors resulting in morbidity but not mortality, that needs to be depicted as part of the overall impact.

There's little doubt that the debate about duty-hour restrictions and their impact on physicians and patients will continue for now. Coupled with the emotional biases tied to our educational strategies, the idea that "we do it this way because that's the way it's always been done" leads to a highly charged issue.

The good news is that ACGME has acknowledged the limitations of available research on this issue, and more data are coming -- eventually. ACGME announced in March that multicenter trials designed to investigate the effect of resident duty-hour restrictions are underway. Analyses of those studies, which are focused on surgery and internal medicine residencies, are expected to be completed in 2016 and 2019, respectively.

Hopefully, those controlled trials will shed more light on what effect, if any, the restrictions have, moving us past conjecture and assumption to a place of better empirical understanding.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Wednesday Oct 08, 2014

Culture Shock: Practice Transitions Impact Our Loved Ones

We all know how difficult residency and the transition to practice can be for physicians. But what often gets overlooked is that this also can be a tough time for our loved ones -- spouses, children, significant others, friends and other family members.

Nearly half of U.S. marriages end in divorce, and the divorce rate is even higher among physicians than it is in the general population. But does it have to be that way?

My wife and I have three children. Because of my packed schedule as a student and a resident, my wife struggled with the feeling that she was "doing it alone" when it came to raising our family. Now that my schedule is more flexible and I am more available, she and I are adapting to changing roles. Not only did residency and entering practice change me as a person, but it changed my family as well, and sometimes it's hard to go back to "normal," or even to define what that is now for us.

Open communication has been the key to ensuring our relationship has stayed healthy. My wife says it has been difficult for her to know how to provide emotional support as I have advanced in my career. Although I am grateful for her support, I know she is sometimes unsure how to help me deal with experiences such as taking on new leadership roles, becoming increasingly accountable to my patients and medical decision-making, and going through a malpractice case.

And she certainly isn't the only one who has found the transition disorienting. As we start practice and get established in our profession, many of us move to a new area. Many take on the added responsibility of buying a house. While we struggle with professional responsibilities, our families often struggle with transitioning to a new place and trying to find a new support network. This can also include new jobs for our loved ones, which can be just as stressful for them as our own transition is for us.

Children, meanwhile, sometimes struggle with attending new schools and trying to make new friends and can feel neglected during this experience if we fail to show them special attention.

Perhaps somewhat counterintuitively, the sudden increase in income that comes with transitioning to practice also can cause significant stress on families. Many of us who traversed the difficult financial times of medical school and residency act as if heavy shackles have been removed and we can now live the lifestyle that we expect physicians to live. But the realities of loan repayment; the need for life, disability, and malpractice insurance plans; the desire to build up a prudent amount of savings; and the need to begin looking toward the financial health of our retirement can put a large dent in those financial expectations. This stress can be alleviated somewhat by open communication about expectations, budgeting and proactively managing finances instead of incurring further debt to change our lifestyle.

The increase in free time that often accompanies this transition can also be problematic. My family expects more of my time now, but I'm also interested in hobbies that I had to put aside during medical training. Devoting ample time to my family and friends is crucial to them and to me, although it can oftentimes mean my other interests have to take a back seat.

My family means everything to me. But I realize that as I have gone through the difficulties and changes inherent in medical training, I have sometimes failed to take into account how these stresses affect them. In my case, healthy communication and appropriate expectations have been the keys to managing these tensions, and I would just offer this advice: As we go through our unique experiences in becoming physicians and establishing our careers, it is crucial that we not neglect those who mean the most to us.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Wednesday Oct 01, 2014

Make It Easy: Convenient Communication Can Boost Patient Adherence

We've all experienced the frustration of caring for a patient who doesn't do what's best for his or her health.

"Why won't he (or she) just take his (or her) medications?!" we frequently vent behind closed doors (and on blogs). As family physicians, we want the best for our patients, even when they seemingly don't want the same for themselves.

© 2014 Tara Higgins/Fosse Photography

My mentors taught me to be a good listener and to speak in layman's terms, saying it was the best way to "connect" with patients. These skills are essential, but sometimes they're not enough to move our patients to take sustained action. As a resident, I believed that if I just explained things well enough, my stubborn patients would finally start taking my advice. But often my honed pitch and elegant napkin diagrams were forgotten within a few days.

I would ask my patients, "Why didn't you call us when your blood sugars were above 300 every day for the past three months?" The conclusions of their responses varied, but the beginnings were usually along the lines of, "It was just too hard because … "

These excuses angered me. I was trying my hardest; why couldn't they? At the end of a long clinic day, I felt like Lloyd Christmas from the movie Dumb and Dumber (except it was my patient's feet falling off instead of a parakeet's head).

The systemic effects of nonadherence have been recognized for many years. Organizations and policymakers have promoted a myriad of remedies in the hope they would prove effective, but they often seem incompatible with our daily clinic grind. In fact, many of these "fixes" become a source of frustration themselves and further distance us from patients.

Thankfully, we have started to move away from the paternalistic approach that has long dominated our interaction with patients. "Patient engagement" is the new catchphrase, but what does that look like in action? How do we truly partner with patients? How can we get difficult patients to take responsibility and stop making unhealthy decisions? Is it even possible in our dysfunctional, rushed system with its 10-minute office visits?

I started a direct primary care practice nearly three years ago, and it gave me an opportunity to think about delivering care without the usual constraints. My membership-based pricing allowed for creativity in many things, including patient communications.

One of my primary goals was to make care less of a hassle. Communicating by any reasonable channel, including email and text message, was one of our selling points. (And yes, this is allowed under the Health Insurance Portability and Accountability Act given permission and appropriate safeguards.) Of course, there was business incentive to offer such access, but the clinical effect became evident early on.

One of my first patients, who I'll call John, joined my new practice at the behest of his wife a few days after being discharged from the hospital for transient ischemic attacks and hypertensive urgency. He had been inconsistent in taking his meds since being diagnosed, despite having regular contact with primary care and cardiology, as well as a personal escort (his wife) to all visits. Being a typical middle-aged man, he wasn't a fan of doctors and let me know that upfront.

Our first visit lasted nearly an hour. The risk of stroke and disability were clearly understood, but scare tactics had failed in the past. He said that medications were "fine" with him, but busy days running a small business caused him to miss doses occasionally and also had led him to delay picking up refills for prolonged periods.

I explained I'd like an update on his home blood pressure readings within one or two weeks and that he could email or text us anytime with numbers or concerns. Although he was agreeable, his wife and I were both skeptical he'd stick with the plan.

Much to my surprise, he emailed about a week after that initial visit. His BPs were nearly at goal, but he reported some "bedroom performance issues." He suspected his meds were to blame. He failed to mention this problem to any of his physicians previously but had gotten some "Mexican Viagra" from a friend in the past.

His beta-blocker, metoprolol, could likely be contributing to the problem. I suggested trying an alternative antihypertensive in his regimen. He texted me about two weeks later reporting he felt like he was 25 again, his blood pressure was at target and he needed prescription refills. Was I a genius for recognizing that a common beta-blocker adverse drug reaction prevented adherence? No. In fact, I failed to inquire about the common issue during an hourlong visit.

John has now had well-controlled hypertension for more than two years and no further ER visits or hospitalizations. He likely wouldn't be able to define "patient engagement" if asked, and I didn't need Jedi mind tricks to engage him. I was available and convenient; and sometimes that makes all the difference.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.

Wednesday Sep 24, 2014

Group Visits: A Patient-Centered Approach to Improving Pregnancy Outcomes

One of the things I love most about being a family physician is caring for families. Although this may seem obvious, I think it bears stating because some family physicians focus on specific areas within the field, and as such, not all of us care for patients at all stages of their lives. But for me, offering prenatal care, postpartum care and pediatric care for women and their families is one of my favorite perks of being a family doc.

CenteringPregnancy is a group visits model of prenatal care that brings together eight to 10 women whose babies are roughly the same gestational age for a checkup, interactive learning and social support.

Despite the variety inherent in practicing family medicine, we often find ourselves repeating the same recommendations over and over again, particularly when it comes to common chronic conditions such as diabetes, hypertension and obesity. Prenatal care can fall into this same pattern. Although each patient is unique, a good deal of each visit includes a standard repertoire of instructions and advice about nutrition and diet, common concerns and discomforts, what testing is offered and when, how to manage labor pains, and the importance of breastfeeding. Group visits are a great way to disseminate this information to patients in an efficient manner.

The community health clinic I work in is part of a larger family medicine organization that has chosen to provide prenatal care through a group visits model called CenteringPregnancy. Although the overall concept of providing group visits for various conditions has been gaining traction for many years, CenteringPregnancy is a specific model that was developed in the 1970s by nurse-midwife Sharon Rising, who began teaching the model in the 1990s.

Rising said in an interview with The New York Times that she developed the model because she feared that answering the same questions and providing the same advice day after day might lead to burnout.

The model has three key components: the checkup, interactive learning and social support. The basic structure is a two-hour group visit that, ideally, takes place in a large exam or conference room and involves eight to 10 women whose babies are roughly the same gestational age.

The visit begins with each patient taking her own weight and blood pressure as the first step in actively participating in her prenatal care. After a brief one-on-one visit with the clinician in one area of the room to measure fetal heart tones, review any private questions, etc., the women sit in a circle. Often, their partners or support people are with them, and healthy snacks are available.

There is a standard curriculum for each monthly visit (and, later, biweekly visits) that covers all that would be addressed in a typical prenatal visit and more. The idea is to allow the patients to direct the discussion. Clinical staff members are there only to confirm the medical accuracy of clinical issues raised, if needed. By running the show themselves, these women, many of whom are from low-income backgrounds with significant socioeconomic hardships, build a support network that often continues beyond their pregnancy.

I was first introduced to CenteringPregnancy during residency. In my program, a second-year resident was paired with a third-year resident, and the two physicians would follow a group of continuity patients who were all due within a six-week period. For a second-year resident without much experience, these groups were a valuable way to learn not only about the medical aspects of prenatal care (such as what is considered appropriate weight gain and when to check for group B Streptococcus disease), but also the normal range of signs and symptoms that accompany pregnancy and the techniques and remedies that are available to manage them. As a resident, it can be particularly anxiety-inducing to care for a woman and her developing baby, but in the CenteringPregnancy environment, I was able to learn a great deal from the anecdotal experiences of my patients without feeling pressure to reassure them that I "knew enough" to deliver their babies.

Although this approach was helpful during my training and continues to be a great way to provide prenatal care, the truly inspiring and fascinating aspect of CenteringPregnancy is how these patient-centered visits improve health outcomes. At a time when the United States is seeing rising rates of maternal morbidity and mortality, the evidence to support CenteringPregnancy is heartening: decreased rates of premature deliveries and Cesarean sections and increased rates of breastfeeding. Perhaps the "icing on the cake" is the increased patient and clinician satisfaction that accompanies these visits.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

Wednesday Sep 17, 2014

Choose Well: Helping Patients Act on Their Choices Reminds Us to Do the Same

When my oldest daughter was a baby, she came to work with me almost every day for the first nine months of her life. I co-owned a fledgling private practice then, and it was cheaper and easier to bring her to work with me than to send her to daycare. I loved every moment of bonding with her, and patients actually enjoyed having her there. Once I started leaving her at home with family, patients often asked, "Where is Ella?"

At first, my wife and I were somewhat concerned about possible exposures or infections she might pick up at the office, but these concerns were limited, and the advantages of having her there far outweighed the day-to-day risks. I chose to keep her with me based on multiple factors, including money, time and -- frankly -- safety. Recognizing that there are risks inherent in sending a child to daycare, my wife and I chose to live with any consequences that might arise from Ella being in the practice environment. She survived intact, and I spent several formative months with my daughter without sacrificing patient care.

Helping my patients made going back to work after a short paternity leave bearable. Here I am talking with Tracy Miller, L.P.N., about a patient on my first day back in the office.

Fast forward to today. After the recent arrival of twin girls, we now have three children younger than 2 years old. And with my current job, taking the girls to work isn't an option. That made returning after a brief five days off quite difficult.

I have a relatively straightforward schedule, though, and limited after-hours duties, so I've opted to return to work full time, which will allow my wife to return from maternity leave to her job as a pharmacist part time and give her the chance to spend more time with the girls.

My patients have been excited about the twins. Many even ask to see pictures when they come into the exam room. They've offered congratulations, and my pride swells each time I get to show off my wife and our daughters. Conversation eventually turns to the medical issues at hand, but I'm more than happy to talk about my family for as long as the patient will let me.

That simple act of sharing sets primary care, especially family medicine, apart from other specialties. We take care of multiple family members, often multiple generations, through all stages of life. In essence, we act as part of the family. We expect patients to share the most intimate details of their lives and their health with us, knowing that we must maintain the medical distance required for good judgment. I tend to allow some of my own life to bleed over into the conversation, though. Not intrusively, I hope, but as reciprocity. How can I expect a patient to tell me everything if I'm not willing to share? Building relationships requires work from all parties involved. My patient-physician relationships are stronger when we both share some of ourselves.

Working together to find the least objectionable solutions for illness is the part of the job that makes it more than just a job. I missed that when I wasn't working.

None of that makes leaving Sara at home with the girls any easier. I occasionally worry that I will miss milestones or the small moments that make life so interesting. Each of us chooses where we spend the 24 allotted hours of our day, so I'm not any different than anyone else in that regard. I just hope I'm choosing the right place to spend the time I have. So far, so good. Would I be excited and happy to be at home all day long with my wife and three little girls? Of course. There would likely be some psychiatric diagnosis attached to my personality if I wasn't. However, staying home is not an option, so I will continue with the choices I've made and live with the results.

I won't be home as much, but I am determined to work hard at being both physically and mentally present when I am. I don't turn off my phone (although I probably could), but it takes a backseat to my wife and daughters when they want my attention. It can be a struggle, but it is always worthwhile. We talk a lot about work/life balance in this blog, from what type of practice we have to how many extra activities we can fit into our lives. It can all be summed up, though, with two words -- "choose" and "act."

As physicians, we make thousands of choices each day -- some great, some small. We and the patients under our care live with the consequences of those choices. It's the small amount of control we can exert over our environment. Helping my patients make the best possible choices is, for me, one of the most rewarding parts of being a physician. I happily return to that part of my job each day. It was that part of the job that made returning to work bearable, considering what I was leaving.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Tuesday Sep 09, 2014

The Value of Family Medicine: Stating the Obvious to the Oblivious

I recently participated in a state-level meeting with Medicaid administrators that also included a number of subspecialists. The discussion revolved around the appropriate dosing of proton pump inhibitors for acid reflux, with some Medicaid representatives opining that these medications were being over-prescribed by "general physicians." Some, in fact, called for implementing a stricter prior authorization process if drugs in this class are to be prescribed by primary care physicians.

Both the administrators and the subspecialists offered misguided statements, such as

  • "Family physicians can't follow treatment guidelines because of the complexity and ever-changing nature of those guidelines."
  • "Treating acid reflux should be left strictly to subspecialists."
  • "Primary care physicians don't actually think about what they do but reflexively prescribe medications that they don't fully understand."

As the lone family physician in the room, I defended our specialty. However, thoughts like these remain prevalent among some payers and subspecialists who fail to understand the value we bring to the health care system.

I know I am not the only one facing these gross misperceptions, so I want to refresh everyone's memory about why family medicine is the foundation of health care and, thus, one of the most important areas of medicine in any health care system.

We Care for the Whole Patient
Probably the biggest reason family physicians are best suited to caring for patients is our broad training and how we apply it to patient care. For example, a patient's depression impacts his or her diabetes, which, in turn, can affect his or her chronic obstructive pulmonary disease and heart failure. Medication side effects often worsen another disease process. And a patient's social context frequently provides significant insight into his or her symptoms. Understanding how to look at all of these pieces and see beyond a specific organ system to the complete person provides many of the clues to proper diagnosis and treatment. Comprehending how these issues fit into the patient's framework of values, beliefs, community and culture presents the key to healing.

We Blend the Evidence With Our Knowledge of the Patient
Providing quality care for patients is a central principle of family medicine. We use the best medical evidence to guide our diagnostic and treatment recommendations, but we also recognize when the context of a patient's illness calls for tempering that evidence-based approach. The medical decisions we make in conjunction with patients may not always look best to an administrator, but that doesn't mean they're the wrong decisions. They simply reflect the biopsychosocial model of family medicine training that uniquely positions us to respond to a wide variety of complaints and situations to better meet patients' needs.

We Provide Value to Our Patients and the Health Care System
Family physicians deliver higher quality care for a lower price than does any other specialty. This topic has been studied extensively by researchers, such as Barbara Starfield and others, who recognize the impact family medicine has on individuals, as well as systems. With the ever-increasing costs of health care, the solution to the problem is to better utilize the value that family physicians provide instead of viewing us as merely a source of referrals to subspecialty care. But reaching that solution -- providing the value that we as a specialty are truly able to deliver -- means safeguarding the time we spend with each patient from being restricted by payers.

By no means is this intended to disparage the contribution subspecialists make, because we all recognize their worth and how necessary they are in treating many of our patients. But our health care system is never going to be able to overcome its main pitfalls if more people cannot recognize the essential role of family physicians. It is our responsibility to continue to educate those around us about our role so that together, we can continue to improve the health of our individual patients and the performance of our entire health care system.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Wednesday Sep 03, 2014

Frequently Asked Questions -- and Answers -- About Direct Primary Care

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the eighth post in an occasional series of blogs that will look at the different roles family physicians can play.

"Is that actually working for you?"

© 2014 Michael Laff/AAFP

I recently participated in a panel discussion at the AAFP's National Conference of Family Medicine Residents and Medical Students along with Abbas Hyderi, M.D., M.P.H., left, and Lilia Cardenas, M.D., center. Students and residents had a lot of questions about my direct primary care practice.

"What if a patient gets hit by a bus?"

"What about patients who are publicly insured?"

Whenever I discuss my direct primary care practice, I expect a barrage of questions. After opening my DPC practice more than two years ago, I think I've heard them all.

When I participated in a panel discussion recently at the AAFP National Conference of Family Medicine Residents and Medical Students, I was ready for all comers. The panel covered a range of family medicine topics, so I only briefly spoke to questions regarding DPC. But afterward, a sizable group of curious students and residents approached me. Several had already thoroughly researched DPC, but most had just recently been introduced to the idea.

A few themes -- and perhaps misperceptions -- emerged. I will try to address a few of them here.

Q: How do your patients get labs, meds, specialists or surgery?

A: My chief concern is my patients' care when I am sitting in the room with them. Family physicians can provide comprehensive care to 80 percent to 90 percent of people at most times in their lives. Enhancing our services should be our main focus. How can we provide the best primary care in an efficient and affordable manner? The better we do our job, the fewer hospitalizations, consults and coronary stents patients will need.

I do have a good portion of patients who have ongoing needs for chronic conditions. A membership-based direct model has allowed me to do innovative things to assist in those areas. We provide labs, meds and procedures at huge discounts. We subcontract lab services and provide members most routine labs (lipids, A1c and many more) for no charge and others with minimal fees. Selling wholesale medications directly to patients often results in hundreds of dollars in savings per month for individual patients. Most procedures are $10-$20 to cover the cost of supplies.

Q: What about insurance?

A: Direct primary care is not anti-insurance. Sometimes, although rarely, people really do get "hit by a bus." Insurance is absolutely necessary for certain types of care. Some events and conditions are inherently expensive. I encourage all my patients to have an insurance plan in case of such an event.

However, hypertension management and radiation treatment for brain cancer are radically different things. Why should we pay for them in the exact same manner? For better or worse, the move toward higher deductible insurance plans has created a demand for transparency among patients. Direct primary care can help fill that void. For many of my patients, combining a high-deductible health plan (a "bronze" level plan on insurance exchanges) with a DPC practice membership with us is a significant savings versus a Cadillac, low copay plan ("gold" or "silver").

Despite my recommendations, many of my patients are uninsured. This is not ideal, but they will
continue to get stellar, continuous care with us in the meantime.

Q: What about someone who cannot afford the DPC membership?

A: The main reason many people cannot afford health care is because it's too dang expensive. Most of my patients found us because they could not afford insurance premiums and/or out-of-pocket expenses under the current system. They could not afford to be without direct primary care.

Although "affordable" is a relative term, I recognize some people have trouble paying even modest DPC membership fees out-of-pocket. There are many ways we could assist people in obtaining care outside of the status quo.

When DPC physicians advocate that insurance be removed from the primary care picture, many people jump to the conclusion that we are therefore calling to end all public assistance. But this is not the case.

There are a variety of alternative funding mechanisms -- outside of subsidized managed care -- that could assist people in getting better primary care. Some progressive health insurance plans and DPC practices, such as Qliance (Washington) and Turntable Health (Nevada), have partnered and are available on state-based exchanges, which is allowed for in the Patient Protection and Affordable Care Act. Also, permitting a portion of public assistance funds to be controlled by patients directly -- via health spending accounts -- could help pay for DPC practice membership fees.

Q: Is DPC really a viable option for me and my patients?

A: There are a number of factors that should be considered before switching to this model of practice -- both personally and from a business standpoint. Despite some stereotypes, DPC practices are not monolithic. Many docs have succeeded with varying models and in a wide variety of communities and populations. However, growing a practice is not easy or without risk. Research and a solid business plan are required.

An increasing number of resources are available to help doctors start and manage a DPC practice. The AAFP recently created a member interest group for DPC, and the Academy also is offering a series of DPC workshops, starting in November.

Even without systemic changes, patient demand for high-quality, affordable primary care will grow. I hope more family physicians will join in meeting that demand.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.

Tuesday Aug 26, 2014

Small Investment, Big Payoff: Grants Offer Opportunity to Improve Community Health

Have you ever had an idea that you knew would address a significant problem affecting many of the people in your community? I know there isn't a global answer for all of our patients' problems, but there are some things that can be improved with a little help. Here's one example.

The neighborhood adjacent to the clinic where I work has the highest number of amputees in the country relative to population size. Seriously, the highest in the nation.

Perhaps not surprisingly, a large number of our patients have the big three -- type 2 diabetes, hypertension and hyperlipidemia -- in addition to obesity. Many of these patients have poor diets. This is due, in part, to limited access to healthy, affordable foods combined with easy access to cheap but nutrient-poor, highly processed foods. The neighborhood has roughly a dozen fast food restaurants and only one or two grocery stores.

I knew I could help change those patients' lives for the better; I just needed the funding to do it. But where would the money come from?

I applied for, and received, a grant to help address childhood obesity. Through this project, we built raised-bed gardens at the high school and, with students helping to plant and maintain the gardens, produced quite a yield of fresh produce.

We hoped to boost the availability of nutrient-dense foods and, perhaps, replace some of those nutrient-poor foods. Some of the crops did well; others did not. But teachers and students were able to freely take from the garden when it was time to harvest. Overall, the gardens have been a success, and we are planning to double the size of the gardens this school year to have enough to hold a community-wide event with cooking demonstrations, movement classes and teaching about emotional health.  

Another encouraging development is that students are asking for healthier food -- specifically, a salad bar -- at their school, and teachers are getting used to fresh foods.  

As part of the project, we had residents speak with students about physical activity and even had the students participate in movement activities. We also were able to have a registered dietitian and a resident educate the students on emotional well-being and its impact on fitness.  

I learned quite a bit through this process. I learned how to think through a health problem to develop a project that realistically addresses a problem. I also learned how to think about sustainability; I did not want a project that would only be for one year. Rather, I wanted to create something that could last for many years and have a long-term impact. I learned about completing grant reports and managing a budget, including administrative support, supplies, travel, etc. Some of these are things I would not readily have thought of when considering how to improve the health of my patients.  

As for initially obtaining a grant, some grant applications are more complicated than others, but there are free online resources that can help you through the process.

Grants are a great way to start small in addressing a large, complex problem. Grants can offer you resources you otherwise would not have had and allow you to influence the problem without taking away from your clinical productivity. I hope many of you will seek out grant funds for small ideas or projects you want to implement to improve the health of your patient population. It might take some digging, but opportunities are out there.

Government agencies and health insurance company foundations are two places to consider looking. The AAFP Foundation provides grants for family medicine residents each year to support short-term research projects that address health disparities.

I've learned more than I thought I would throughout this process and will continue to use that knowledge for future endeavors to address community health.  

Meshia Waleh, M.D., is an assistant professor of family and preventive medicine at the University of South Carolina School of Medicine in Columbia.

Tuesday Aug 19, 2014

Outside the Box: Integrative Medicine Might Just Expand Your Comfort Zone

Not long ago, a young woman came into my office. For years, she said, she just hadn't felt right, suffering from fatigue, joint pains, strange rashes, bloating, gastrointestinal upset, and mood and sleep issues. She had undergone many tests and imaging studies and had taken multiple medications, but nothing helped.

She wasn't seeing me for any of these issues, however. Sadly, she had resigned herself to always feeling this way. I finished her well-woman exam and made a suggestion: Stop eating gluten. She had never heard this suggestion.  

© 2014 Aaron Huniu Photography

Nearly 40 percent of U.S. adults use some form of complementary and alternative medicine, but are physicians ready to consider nonconventional therapies?

"It costs nothing, is practically risk-free, and it just may help you," I said.

A few months later, she was back and feeling normal. She had stopped eating gluten.

It is easy to find evidence both for and against a gluten-free diet. I am not interested in this evidence. For this "study," which had an N of 1, I can happily report a 100 percent success rate. To be fair, I have had plenty of other patients who did not respond to this diet change, but I have never hurt a patient by suggesting it, and I doubt I ever will.  

In an excellent article titled "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't," Robert Cowan, M.D., recently made a practice-changing point: "If the only standard we apply is evidence-based medicine, or standard-of-practice medicine, or FDA-approved medicine … we will miss clinical opportunities which could well transform how we manage disease … (and) do a disservice to our patients."

Complementary and alternative medicine, he points out, is complementary and alternative simply by convention. This convention sprung out of the Flexner Report of 1910, which marginalized any medical schools not using a European, scientifically centered form of education, much to the dismay of William Osler, M.D. Abraham Flexner was not a physician, but an educator, and his report forever marginalized the art of medicine.

Part of that art is knowing when our treatment recommendation is based on actual evidence, balancing probable benefit (number needed to treat) with possible harm (number needed to harm), and doing so in a neutral manner.

There is a treatment of which I am particularly fond that helps manage a condition that confounds many family physicians: irritable bowel syndrome. It has almost no side effects (heartburn is the main one, easily avoided by providing the medication in enteric-coated capsules) and its number needed to treat is … wait for it … TWO. Any guesses?  The treatment is peppermint oil -- enteric-coated, of course.

In contrast, the number needed to treat high cholesterol with a statin to prevent a cardiovascular event hovers in the 60s, and the number needed to harm and cause myalgia is as low as 10.

How 'bout them apples?

We spend the most formative years of our education getting steeped in Western conventional treatments, for which the evidence is rich, albeit sometimes skewed, as any statistician will tell you. Additionally, most of us, once in practice, have even less time to read all the evidence. And we ignore treatments that could very well help our patients, often with much lower risk and lower costs

I practice integrative medicine. This is a style of medicine that neither blindly accepts traditional medicine, nor blithely dismisses nonconventional medicine (often called CAM, or complementary and alternative medicine). It balances evidence of efficacy with potential for harm. It is patient-centered, not doctor-centered, and it forces me to shut down my ego, and my judgment, on a regular basis.

Whether or not you are ready to start challenging the treatments that sit squarely in your comfort zone makes little difference; I believe you have no choice. Although you may practice evidence-based medicine, your patients may not. According to a 2007 HHS survey, 38 percent of adult Americans used CAM in some form, and this same group spends more than $33 billion each year on CAM therapies and products and $9 billion on CAM services, generating 122 million office visits annually.

I don't eschew the medicine I spent so many years studying, but I stand in front of more than one altar. I prescribe statins. And peppermint oil. There are medical systems outside of ours, treatments we were not taught in training, that help more than they hurt. I encourage all family physicians to consider spending some CME time investigating the therapies within integrative medicine. Our patients deserve it.

Heidi Meyer, M.D., is an employed integrative family physician at Kaiser Permanente, San Diego. She enjoys yoga; dark chocolate; weekends in Vegas; bonding with her ferocious 9-pound dachshund, Bella; and plotting a drastic overthrow of the house of medicine. You can follow her on Twitter @tweetyturt.

Tuesday Aug 12, 2014

Sense of Community: CHCs Offer Way to Battle Health Disparities, Social Injustice

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the seventh post in an occasional series of blogs that will look at the different roles family physicians can play.

I am coming up on the two-year anniversary of starting my first clinical practice in a community health center. The joys have been great -- as have the challenges.

I've been passionate about working in a community health center (CHC) since I first learned about the opportunity as a medical student. The biopsychosocial model of care that is a hallmark of family medicine strongly resonated with me, and it made perfect sense that a CHC would be the ideal place to bring that model of health care to life given that these centers provide comprehensive primary care to medically underserved communities and vulnerable populations.

The team-based model of care used in our community health center helps me meet the complex needs of my patients. Here I am (far right) with my medical assistant, team assistant and case manager.

With a directive for half of a CHC's board of directors to hail from the local community, there is a built-in mechanism to ensure these clinics are responsive to the greater context from which their patients come. They were founded on a basic social justice mission of promoting health care equality by addressing not only medical care for individuals but also the social determinants of health within a community.

When it was time to choose a residency, I couldn't imagine training anywhere but a community health center. And as a National Health Service Corps scholarship recipient, I knew I needed to be prepared to practice in a CHC. My alma mater, the Family Medicine Residency of Idaho in Boise, is affiliated with a community health center that was designated one the of the country's first teaching health centers.

Training in a CHC, where fees are adjusted based on a patient's ability to pay, was an invaluable experience. I not only learned how to care for a panel of patients, I learned how to care for patients with no insurance or means to get certain medications or testing and patients with concurrent mental illness who lack access to higher levels of psychiatric care. And it's all amid the day-to-day battle against the social determinants of health that can foil delivering even the best evidence-based medicine.

There are times when even the most starry-eyed, optimistic types (such as me) can feel burned out. I can't always get my patients the medications or tests they really need or the subspecialist visit that might help augment their care. Mental illness is prevalent and presents a challenge for many patients in navigating their health care and the community at large. Sometimes, I'm not sure how to intervene.

But even with these daily roadblocks, I still believe in the mission of caring for anyone who walks through my office door regardless of their payer source, and I love the moments when patients say our clinic was the first place in the health care system where they felt they were treated with dignity.

I like the challenge of figuring out if I really need to order a particular lab or test -- especially if my patient might be getting the full bill. At times, I feel I am trying to live the mission of social justice and equality, and also of the triple aim (improving population health, enhancing the patient experience and reducing costs) to which our whole health care system should strive.

CHCs also are already designed to follow the patient-centered medical home model using team-based care, which at our site includes physicians, nurse practitioners, physician assistants, nurses, medical assistants, clinical pharmacists, therapists, case managers and dietitians. I could not take care of the complex needs of my patient panel without this team!

Although CHCs can be a challenging environment in which to practice, I am grateful to be a physician among those serving in our nation's community health centers. I cannot imagine another place where I could better live the values of family medicine in the biopsychosocial model of care while addressing health disparities and social injustice on a daily basis.

Amy McIntyre, M.D., M.P.H., is a family physician at the Butte Community Health Center in Butte, Mont., and her practice includes full-scope outpatient care, maternity care, and long-term care and hospice.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.