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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.

Tuesday Aug 05, 2014

Skin in the Game: Shared Decision-making May Boost Patient Buy-in to Care Plan

My patient had been on a statin, but he stopped taking it because it caused muscle aches. However, he also had hypertension, and many of his immediate family members -- including both parents -- had died at young ages from heart attack or stroke.  

He was usually a gregarious and care-free individual, but on this day, I could detect concern in his voice. His older sister had recently been diagnosed with congestive heart failure, and this had him thinking about his own health. His blood pressure, usually well controlled, had been higher lately. Although he typically did not like taking medication, he was open to discussing it now.

I explained to him the utility of a clinical decision aid I like to use while I plugged in his demographics and recent cholesterol numbers. I watched the smile return to his face as we changed parameters to show how improving his blood pressure control would reduce his 10-year risk for cardiovascular events and more of the 100 dots on the screen that represented his risk turned from yellow to green. The statin had made little difference so perhaps he wouldn't need it after all.  

He seemed his old self again as he laughed and walked down the hallway out of the clinic.  

As physicians, we make many decisions every day. Some of these decisions are simple, such as starting a hypertensive patient on blood pressure medication. Other decisions can be complex and life-altering, such as discussing how aggressively to treat a patient with newly diagnosed advanced cancer. In much of the practice of medicine, there are many options for treatment, and often, there are potential benefits and risks to each treatment so there is no clear winner.

Shared decision-making has gained traction in the past several years as a useful way to approach these kinds of situations with patients. The Center for Shared Decision Making at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., defines it as "the collaboration between patients and caregivers to come to an agreement about a health care decision."

Shared decision-making stands in stark contrast to the age-old paternalistic approach to medical care where the patient comes to the physician, who is seen as the expert, and the physician tells the patient what to do.

With shared decision-making, the idea is to involve the patient and caregivers in the decision-making process and arrive at a decision that makes sense for the patient given his or her values and circumstances. Intuitively, it makes sense that patients may be more inclined to adhere to a plan they feel they had a part in creating. However, I have found that the tricky part of shared decision-making is educating patients about their options and the associated potential benefits and risks in a way they can understand. 

This is where patient decision aids come in. There are many resources out there, but they're not always easy to locate. You can find several on the Mayo Clinic's website, as well as the Agency for Healthcare Research and Quality website. If all else fails, ask Dr. Google. 

Section 3506 of the Patient Protection and Affordable Care Act requires HHS to establish a program to create patient decision aids, so these should become more readily available -- and be tailored to different patient populations -- in the future.

However, the old adage "All that glitters is not gold" still applies. Barriers to and questions about implementing these decision aids in practice remain. Most physicians have never received training to use them and may not feel comfortable integrating them into patient visits. And using such an aid takes up precious time during the visit. There may be cultural barriers to using these aids in practice, and it may require extra insight into a patient's learning style. Would he or she respond better to written information, numbers or pictures? Concern also exists about bias in clinical decision tools. Who developed the tool, and would the developer stand to benefit from one decision over another? Some even argue there are situations in which biasing the tool toward a certain outcome, or patient "nudging," could be appropriate.

Finally, although it sounds like a logical and patient-friendly approach, there is little research to determine what benefits or harms the practice of using a decision aid may yield. Does it actually improve patient adherence? Does it help contain rising health care costs? What impact does it have on patient satisfaction and health? These are all questions that need to be addressed moving forward. 

Some of my favorite opportunities to apply a shared decision-making approach include discussions regarding prostate-specific antigen (PSA) testing, osteoporosis treatment, and use of aspirin or statins for cardiovascular event prevention. Interestingly, I have found that many men who come to my office requesting a PSA assay decide not to be tested after reviewing the risks and benefits. I have also found my female patients to be more apt to take vitamin supplements and start weight-bearing exercise to improve their bone density rather than rely on medication.

Now, you would think that patients would be ecstatic about this after all those years we have apparently just been bossing them around. Au contraire! Some of my patients are frustrated by this approach. "Isn't this why I came to you? Won't you just make the decision for me?" Although most of my patients have embraced the concept, there are those who require a bit more hand-holding. To be fair, the same could be said of us as physicians. I personally view one of my most important roles as a community physician to be that of educator, and shared decision-making fits that role perfectly. 

Shared decision-making is also a two-way street, and there is much I can learn about my patients' values and beliefs as we decide together how to best manage their health. 

I urge you to visit the links above, check out the decision tools and then try to incorporate them into a patient visit or provide them as resources for your patient before a visit to stimulate discussion. I would also be interested to hear in the comments field if you have particular decision aids you like or have had interesting experiences using this approach with your patients. Have you had any negative experiences or pitfalls from which we all could learn?

Peter Rippey, M.D., is a board-certified family physician who maintains a private practice in rural Missouri. He enjoys a full-spectrum practice with a focus on community and collegiate athletic coverage.

Friday Jul 25, 2014

Oh, Baby! What Happens When a Family Physician's Family Expands?

“She bought us a minivan, ladies and gentlemen. That is the biggest goober-mobile you could ever own in your life. There is no way to be cool in a minivan." - Comedian Bill Engvall

Close to a month from now, my wife and I will welcome our second daughter into the world.

And our third.

There's a lot to do to get ready for the arrival of twins. Fortunately, my daughter, Rosella, helped put together this baby bed.


Overnight, our family of three will become a family of five. I’ve assembled a second baby bed. We bought a dual stroller and two new car seats. I bought a vertical deep freeze for storing milk. We’ve even moved our 20-month-old into her new room, complete with a big-girl bed and a fresh coat of under-the-sea paint.

We also bought a minivan. It’s cool. I promise.

On the surface, we are as ready as we’ll ever be. Below the surface, I’m still dealing with the implications of having three daughters younger than 3 years old. Don’t misunderstand. I’m not complaining. I’ve been blessed beyond measure, not only with the children, but also with my wife, my job and our family.

From a work/life perspective, the changes for me will be subtle. I’m blessed with a job that affords me nights and weekends essentially clear of clinical duties. My employer has been supportive, and during the immediate postpartum period, I’ll likely have a locum tenens physician covering my daily clinic. I know many physicians aren’t as fortunate, so I plan to make good use of my time off, acclimating to the changes that come with multiples.

My wife, a clinical Pharm.D., works 36 hours a week, including every other weekend. We live comfortably, even with our student loan payments, so it was an easy decision to scale back her hours in exchange for more time at home.

The implications to which I referred fall more in the realm of the psychological. How do we navigate rearing a 2-year-old while welcoming and investing deeply in two newborns? How do I avoid favoritism? What if I feed one twin twice and the other one goes hungry? Is the full-featured minivan really cool, or am I just lying to myself?

Some good questions, some irrational, but all running through my mind as I go about my daily clinic schedule. My work hasn’t suffered appreciably, and I certainly don't want it to. I know that I will survive, just like many other physicians before me. I depend on the support and advice I’ve gleaned from physician friends and colleagues who have navigated these waters successfully (or not), and who have seen fit to share their wisdom. I hope to be able to share my own wisdom with others in the future. Right now, though, I don’t feel wise. Maybe ask me again in six months.

As an intern, I joked with my wife that I was preparing for the sleep deprivation associated with a newborn. When our first daughter was born, I was proven right in some ways and woefully wrong in others. There are few experiences akin to parenthood. Pets are great, and they can be like children in some ways, but they will never be more than a companion who can’t speak. Patients can sometimes seem to be like children, no matter how strongly we try to avoid the paternalistic model of medicine, but they go home eventually.

Children carry all the promise that is part of becoming entirely autonomous human beings, with their own thoughts and feelings but no ability to provide for themselves or survive for any length of time apart from an adult. Others have spoken and written volumes about the responsibility and the process of child-rearing, so I won’t belabor the point. Suffice it to say, being a parent -- that is, helping to shape a human life that is entirely dependent on you for EVERYTHING -- can be significantly more stressful than being a doctor, because in this case, the person will be under your care for years, not just days or weeks. But being a family doctor has prepared me in one very big way to handle parenthood: No matter what happens, I can deal with it with skill and grace, and when doubts arise, I can refer to someone with a higher skill level than my own.

For others who have experienced being a new physician and welcoming multiple babies into your family, how did you meet the needs of your practice while also finding time to be a good partner and parent? Are there any insights or warnings you'd care to share? Sound off in the comments below or on Twitter to @DrTolbert.

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.

Monday Jul 21, 2014

Surviving Malpractice: Don't Lose Your Passion for Helping People

During my training, I was told numerous times to expect to be sued for malpractice at least once during my career. It was always said with an attitude of "This is the way it is, so just get used to it."

In fact, more than 60 percent of physicians 55 and older have been sued at least once, according to the AMA. But what happens when that dreaded letter arrives early in your career? And how do you keep it from derailing your passion for medicine?

Unfortunately, I found out about a year into my practice that I was being sued for malpractice, along with a number of my colleagues. For obvious legal reasons, I cannot divulge details of the case. But I would like to share much of the advice that was given to me and how this has affected me as a physician and as a person.

I found out about the lawsuit when a letter arrived at my clinic, stating that I was being sued for malpractice due to neglect of a patient I had seen a few months before.

My heart sank when I read that letter. For some reason, because it came in the form of a letter, it added to the cold and impersonal nature of the process. I wasn't sure whom I should call or what I should do. I spoke with my colleagues who had been named in the suit. Our emotions ran the gamut from anger and fear to stunned disbelief.

One of my senior colleagues had been through this process before and offered some simple advice: "This is going to take a long time, and it's going to be frustrating. Just try not to let it change you. We are all still good physicians."

I found great comfort in knowing that a physician I respected had been through the process and could help guide me along.

Being fairly new to practice, this suit shattered my self-confidence for a few months. I second-guessed everything I did, even fairly simple things. I seemed to see the plaintiff in the face of every other patient I saw. I spent lots of time looking up things that I already knew "just to make sure." I likely referred more people to subspecialists than I needed to for diagnostic confirmation.

One of the perks of being employed by a health care system is that we have a risk management department to help us. When we shared the information with them, I received this second piece of advice: "This is going to be very stressful, but make sure you don't bottle this up inside. I strongly encourage you to talk with a therapist about this process."

In some ways, this was difficult. I was not allowed to discuss the case with anyone who was not involved in it. I could speak with my named colleagues, our medical director and division chief, risk management and our law firm. That meant that those closest to me -- namely, my family and friends -- couldn't know anything about it. I could tell them that I was being sued, but I could not discuss any specifics.

Although I could share my experience in a limited sense professionally, I had to bear the burden alone in my personal life. This underscores the absolute necessity of having a therapist with whom to share your emotions and experiences.

We next met with our legal counsel, who offered yet more sage advice: Participate in the process as much as you can. Provide medical evidence for your choices as much as possible. Be in frequent contact with your attorney.

This process began nearly a year ago, and I have yet to be deposed. Part of the delay has been because of legal posturing, and part of it has been due to cancellations and rescheduling. But mostly, it has been because of the fact that the legal system moves slowly.

Yet despite this, I am feeling much better about things. Understanding the process and having others I can rely on for professional and emotional support has been a huge help. The existential medical crisis I went through has waned, although I am more conscious of wanting to have a specific reason for everything I do clinically that I can use to justify my actions to myself, at least, if to no one else. This puts my mind more at ease for potential future lawsuits, and I don't think about the current case all the time any more.

I was initially worried that my passion for medicine had been stolen from me. Thankfully, due in part to the advice I've received, it hasn't. And the reason people seek our help and opinions remains the same -- it's based in hope. We should never let our ability to assist perish because of our own circumstances.

Family Practice Management has compiled a collection of journal articles on malpractice -- covering everything from malpractice insurance to depositions -- for those who don't know what to expect. But for those of you who have been through this, what advice do you have for your fellow physicians?

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.

Friday Jul 11, 2014

Acting on Our Convictions: Court Ruling Shows Need to Stand Up for Evidence-based Care

I recently had an office visit with a patient who was in need of contraception. She is 19 years old, going to school part time and working. With an ever-changing schedule, no plans to start a family and a history of migraines with aura and somewhat heavy menses, we discussed the evidence-based options of progestin-only methods versus nonhormonal methods.

Fortunately, her insurance covers all forms of contraception, and we were able to schedule her for a progestin intrauterine device (IUD) insertion. If her insurance had not covered IUDs, my patient would not have been able to afford the birth control method that is medically most appropriate for her.

The U.S. Supreme Court’s June 30 decision in Burwell v. Hobby Lobby Stores Inc., and Conestoga Wood v. Burwell has set off a flood of press coverage and commentary about what the ruling means. A major concern for many physicians is that the ruling could affect how we practice medicine.

“The Supreme Court’s decision allowing companies to deny coverage for important health services sets a precedent that threatens the nation’s health," said AAFP President Reid Blackwelder, M.D., in a statement. "With this decision, the court has moved health care decisions out of the exam room where patients can consult with their physicians -- and where such decisions should be made -- and put them into the hands of business owners who base decisions on personal beliefs rather than medical science.”

The American Congress of Obstetricians and Gynecologists (ACOG) and the American Public Health Association (APHA) issued similar statements.

Since the ruling, bills has been introduced in the House and Senate that would countermand the court's decision by preventing for-profit companies from using religious beliefs to deny employees coverage of health services -- including contraception -- required by federal law.

Laws that interfere with our ability as physicians to care for our patients using what we, in concert with our patients, determine to be the best, evidenced-based approach are problematic. In medical school and residency, we are taught to listen attentively to a patient’s history, perform a focused and careful physical exam, and obtain any additional resources we may need (laboratory values, images, etc.) to develop our assessment and plan.

As family physicians, we are attuned to considering additional factors when determining our plan, such as a patient’s social history, insurance status, access to follow-up and mental health. What is not usually part of our training, however, is learning how to navigate a health care system in which judges and legislators can create barriers -- that are not grounded in evidence-based medicine -- to our patients’ ability to access the care that will best serve their health needs.

As new physicians, we are often focused on ensuring that the day-to-day care we provide for our patients is appropriate and consistent with what we learned during all our years of training. As this new blog's posts have accurately portrayed, there is a lot to grapple with during these first few years out of residency; feeling confident in our diagnoses, asking for assistance when needed and figuring out how to balance our new careers with our life outside of work are just a few examples. I would add to this list finding a way to advocate for our patients on a larger scale, outside of our offices and clinics.

Physicians do not yet have a loud enough voice in the legal decisions and debates that have been politicizing medicine in recent years. But our voices are incredibly important and can affect our patients’ lives.

Making our voices heard may seem like a daunting task to add to our already busy lives, but there are simple ways to start advocating against any and all interference with the physician-patient relationship. If you hear about proposed legislation that is not evidence-based and would negatively affect your patients, call or write your lawmakers to let them know where you stand. Better yet, make a face-to-face appointment to explain your concerns as a physician.

If you see an editorial or article in your local newspaper about a legal decision or law that would interfere with physicians’ medical practice, write a letter to the editor to lay out your concerns.

You can also get involved with advocacy organizations (such as your state chapter) that can keep you informed about new developments and laws that may affect your medical practice and patients and will help you make your voice heard.

As physicians and patient advocates, we have a responsibility to speak up in the face of court rulings and laws that threaten our patients’ ability to access the health care they need. How will you fulfill that responsibility?

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.

Thursday Jul 03, 2014

Help Wanted: Swelling Med School Enrollments Boost Need for Preceptors

Although everyone's medical school experience is unique, there are some things that most of our educational years had in common. Most of us trained at large academic medical centers with every subspecialty close at hand. This specialty-focused approach can result in an environment in which medical students -- who often are still pondering their specialty choice -- see deliveries that are done mostly by OBs, pediatric care that is almost exclusively provided by the pediatrics department and, meanwhile, family medicine is relegated to routine, in-office care.

Although there are institutions where this is not the case, what I hear from colleagues and medical students across the country is that in many locations, one or more of these scenarios presents a real problem. Barriers like these make it difficult for medical students to see the true scope and nature  of family medicine and to appreciate the opportunities the specialty has to offer.

The Hippocratic Oath includes a pledge to teach medicine to the next generation. Here I am reviewing results from a fetal monitor with University of Kansas medical student Jessica Parrish at my practice in Stockton, Kan.

So how can family physicians who enjoy a richer, more comprehensive style of practice help? It's deceptively simple: We can show students what we do every day.

With the marked growth in the number of medical schools and med school enrollment seen in the past few years, there is a bigger need than ever for preceptors. A new report from the Association of American Medical Colleges summarized the results of an online survey designed to gain insight into the experiences of allopathic and osteopathic medical schools, as well as nurse practitioner and physician assistant programs, regarding clerkship or clinical training sites. Across all four disciplines, most respondents had experienced increasing difficulty obtaining clinical training sites, and at least 80 percent of respondents in each discipline were concerned about the modest number of training sites available to them.

For most, respondents finding a primary care training site presented the greatest challenges, and up to 60 percent of allopathic programs reported difficulty locating family medicine sites.

The result? More than half of allopathic schools and nearly 75 percent of osteopathic schools are expanding the radius of their site searches, and more than half of all respondents from allopathic schools are using clinical simulations to help fill in the gaps.

In short, this study makes it clear that more of us need to step up and help train the next generation of family physicians. I shadowed a family physician during my first year of medical school and was surprised to discover that he rounded on his own patients in the hospital, delivered babies, saw patients in the nursing home and was director of the local hospice. All this was in addition to seeing patients in the clinic.

Based on what I had seen at med school, I thought his job would consist entirely of providing in-office care for minor conditions. How wrong I was!

As I have mentioned in previous blogs, I am where I am today -- practicing rural, full-scope family medicine, because of a family physician preceptor. Although I had determined family medicine was what I wanted to do, I had never even considered the option of rural practice. If my mentor Jen Brull, M.D., hadn't been willing to take me into her practice, teach me what she did, and show me the love she had for her job I would not have realized this was what I wanted to do.

Any physician who has opened his or her practice to students knows that it is not always an easy endeavor. In fact, it can slow you down. If you allow a student to see a patient before you do, formulate a plan and then present the patient to you, it takes twice as long as it would have if you had done it yourself. However, this is how that student learns what it is like to be trusted to see a patient on his or her own, what questions should be asked and how to make a thorough differential diagnosis.

It would be faster to complete the chart documentation on your own, but students need to learn to navigate an electronic health record system. It's easier to code without needing to explain how and why a visit meets criteria for a particular level of complexity, to not take the time to walk someone through sutures or joint injections, or to not take your lunch hour to outline current treatments for diabetes. But as any of us who precept know, the time demands are far outweighed by the benefit gained by student and preceptor alike.

Most of us can tell a story of an amazing preceptor, one who changed our idea of what we would specialize in, showed us the kind of physician we wanted to be for our patients, or modeled for us what we would like our future practice to look like.

Think of where you would be without these experiences, likely somewhere different from where you are now. As preceptors, we can be that person to a medical student. We can show them the full scope of family medicine and why we love what we do every day. We can show them, as was mentioned by my colleague Peter Rippey, M.D., in a recent blog, how to "prescribe a dose of yourself."

We know what precepting gives to students, but what does it give to us? I find having students in my practice to be energizing and a great reminder of how special my job is.

Seeing what we do each day from the perspective of a student reminds us that there is nothing routine about the things we get so used to doing day in and day out. Having someone come into a room and share with you their fears and concerns, allow you to poke and prod and examine their body, and trust your judgment about something as important as their health is not anything we should take for granted. Having someone excited to put in sutures for the first time or to learn to dictate a history and physical makes a call night much less tedious. Helping a student deliver a baby and seeing the pride and wonder of the moment is priceless. And knowing that you have helped shape someone's perception of family medicine is perhaps the biggest thrill of all.

I had a medical student who was trying to decide between OB and pediatrics when she started her rotation with me. A few weeks after she left my practice, she emailed me to say that she realized that she could do both, and more, if she chose family medicine.

Granted, this is an extreme example of the influence a preceptor can have. For me, just having the opportunity to have a student experience full-spectrum family medicine is worth the time and effort I put into it. And most days, even though I am supposed to be the teacher, I learn something from my students, as well: the importance of not forgetting that I have the most amazing job in the world.

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

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