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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.

Friday Jun 27, 2014

What You Didn't Learn in Medical School: Prescribing a Dose of Yourself

I sat on the edge of her bed in the nursing home and listened patiently. I would ask a question or clarify her statements occasionally, guiding her through her medical history and learning about her life to this point.

A stroke had affected J.L.'s ability to communicate. Her speech was clear enough, but she had expressive aphasia; she literally couldn't find the words.

Although she had been in this condition for some time, I could tell it was as frustrating for her as if it had started yesterday. Both the hospice nurse, who knew her well, and I would occasionally help her complete her thoughts; a sort of real-life Mad Lib. Near the end of this discourse, J.L. began to get emotional. Her lip quivered and her eyes welled up with tears, but she still had a satisfied smile on her face. I was perplexed, but the hospice nurse smiled at her, gripped her hand and said, "This is the first time someone took the time to have a conversation with you, isn’t it?"

J.L. nodded, and after a concentrated pause said, "Yes."

The day-to-day life of a physician can easily slip into a rut, especially in many of today's practices where encounters with patients are compartmentalized into 10- to 15-minute slots. The clock can be an unforgiving master as the morning or afternoon dwindles away. We start to feel the strain of every extra minute spent in a room, realizing we will pay for it by working through lunch, suffering the irritated glare of the next waiting patient or staying late to finish documentation.

I have found myself making the diagnosis shortly after entering the room, and the rest of the visit becomes a rushed formality.

It is easy to forget that although the process of diagnosing and treating a simple condition may seem straightforward to us, to our patients, it can remain an enigma. I have found that it is possible to prescribe the appropriate treatment and still have a sick patient. Other times, I might make the wrong diagnosis, but the patient feels better anyway. For most patients, it is the unknown or the feeling of isolation that makes the condition unbearable more than the symptoms themselves.

So what's the cure for that? The answer is deceptively simple: It's you. In my earlier training as an occupational therapist (in a former life), we called this "therapeutic use of self," and it is the most important skill I didn't learn in medical school.

For some, this talent seems virtually innate, but fear not; it can be learned, or rather, remembered. I would be willing to bet that for most of us it was a reason why we started on this road in the first place. Before we understood the pathophysiology of cystic fibrosis or the risks indicated by specific genetic markers in breast cancer, we only knew that we wanted to, and could, help people.

Then medical school came along and taught us that the best way to help the patient was to make the right diagnosis -- most times by ordering a slew of tests that often entail discomfort, at the very least -- and start treatment as expeditiously as possible.

I agree wholeheartedly that this approach can help the patient, but what about the person? To make the person well, we need to give of ourselves. Sit at the edge of the patient's bed in the hospital. Let her tell her story. Make eye contact and use open body language. Ask him something about his life that has nothing to do with his diagnosis but may have everything to do with who he is as a person. Don't be afraid to touch her knee, squeeze her hand, or even give her a hug.

Reassure the patient that if he has a question or a problem, you will be there for him. And finally, it is OK to cry in front of your patients.

Therapeutic use of self moves us from influencing the condition from the outside to becoming more involved. When you partner with the patient in the process, rather than acting merely as a consultant, that person realizes that you are willing to listen and to try to understand. This alleviates the patient's fear and anxiety and reduces his or her isolation. It also will build a more rewarding and fruitful partnership between you and your patient, and in some instances, our humanity will begin to heal what science could not.

The clock will always tick away sternly, and I still try to be as efficient as I can. But my efficiency has a purpose: It allows me to spend those few precious moments with my patients when what they really need can't be scribbled on a piece of paper.

G.B. was pregnant and well into her second trimester. She developed a right-sided abdominal and flank pain. She was in significant discomfort and worried about her baby. She went to the local ER and was transferred to the obstetrical unit in a tertiary care center.

Everything with the baby looked fine, and they could not find an explanation for her pain. She was discharged and followed up with me the following day in clinic. I sat with her and her mother and reviewed the hospital lab work and notes, going over them with her and listening to her history. I completed a thorough and careful physical exam.

When I had finished synthesizing all the information, I had a few theories but no firm diagnosis. I reassured her that although her problem was painful, I was sure it posed no acute threat to her infant's health or her own. She saw her obstetrician the next day, and I called her to follow up after that visit. Although she was still in significant discomfort, the pain and fear had disappeared from her voice.

"You know what's strange about the whole thing?" she asked. "Through all that, you were the only one who examined me."

The secret lies in remembering that our patients are people, not diagnoses, and sometimes the best medicine is not a medicine at all.

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 Jun 20, 2014

Up in the Air: Responding to Medical Emergencies at 30,000 Feet

I was recently sitting on an airplane when I noticed some commotion a few rows ahead of me. Flight attendants with worried looks on their faces were congregating around a passenger, while others briskly headed to the front and back of the plane.

I signaled to the crew that I was a physician, and after speaking with the embarrassed gentleman who had drawn all the attention and his concerned wife, I quickly determined that the situation was relatively benign. Having started his vacation with a few drinks before boarding and another after take-off, he had passed out briefly, frightening his wife. 

Given that he was a middle-aged and otherwise healthy male who was not on any medications, there was little to be concerned about. He was fine for the remainder of the flight, with his wife watching over his consumption of several cups of water. As a thank you gesture, one of the flight attendants offered me a $100 flight voucher.

Luckily, syncope and presyncope are the most common problems encountered on flights, followed by respiratory symptoms and gastrointestinal complaints.

A colleague of mine, however, was not as fortunate and encountered a much more serious condition -- urosepsis -- on a flight to London. A passenger who had been vacationing in the United States had put off seeking treatment for her urinary symptoms for a few days with the hope of avoiding our health care system. As my family medicine colleague (who was a resident at the time) and another physician (who happened to be an ICU attending) did all they could to care for this woman with the minimal equipment available, they eventually made the decision that the plane needed to be diverted for an early landing. My colleague missed her connecting flight, as did many passengers, and the other physician had to accompany the patient to the local ER because the emergency medical service worker did not want to be held liable for the IV line the ICU physician had inserted before the plane landed.

If you haven’t already encountered a request for medical assistance while flying, it is likely only a matter of time. A recent New England Journal of Medicine study found that the likelihood of having a medical emergency during a flight is about one in 604. Just like anything in medicine, it’s good to be prepared with a basic knowledge of what resources are available and what the expectations are before the situation arises.

First, consider carrying a copy of your license or some form of physician identification. The head flight attendant on my plane took down my information to “call it in,” stating that she would need to confirm that I was, in fact, a physician before I would be allowed to administer any medications, if needed. In most states, you can apply for a professional photo identification card, which will include your name, photo, license number in that state and the expiration date of your license.

Second, understand that the medical equipment on a plane is going to be limited. All flights are required to have an automated external defibrillator and emergency medical kits (EMK) that contain a stethoscope, sphygmomanometer (manual), CPR masks, IV kit with 500 cc's of saline solution, dextrose, syringes, aspirin, antihistamines, epinephrine and nitroglycerin.

Additional medications, such as lorazepam or diazepam (seizures account for about 6 percent of in-flight emergencies), may be available in “enhanced” EMKs, especially on longer flights. One important resource to know about that is often underutilized is what's known as ground consult. You can -- and probably should for any significant medical concern -- request that the pilot alert the airline’s medical team on the ground. Consider making this request earlier rather than later (as is often the case with medical consults) so medical staff on the ground can be apprised of the situation. Whether you will be able to speak to them directly (in the cockpit) or through the flight attendants and pilots relaying the information seems to be flight-/pilot-dependent.

Unfortunately, liability is a very real concern, particularly in scenarios when you're not practicing in your regular clinical setting. Generally, physicians are covered by the Aviation Medical Assistance Act of 1998, which protects physicians who provide in-flight emergency medical assistance in the same way that state Good Samaritan laws do. It goes without saying that you do not have to volunteer if you do not feel comfortable with the situation or are concerned for your own safety. If you have had a few drinks or have taken sedating medications, you need to use your judgment about whether to respond.

Since you are volunteering and not technically on duty, under the 1998 law, you are covered as long as you don't engage in any willful misconduct or commit gross negligence. You should make yourself aware of the law's limitations. Many physicians feel a moral obligation to help in a medical emergency, and, thus, we can find ourselves in these situations.

The New England Journal of Medicine tracked in-flight medical emergency calls reported by five domestic and international airlines from Jan. 1, 2008, through October 2010. During that time, there were nearly 12,000 in-flight medical emergencies. Physician passengers provided medical assistance nearly half the time.

As family physicians who are trained to manage a diverse array of medical conditions across patients' entire lifetimes, we are in a unique position and likely better prepared than subspecialists to address many of the medical needs that can arise on a flight. Still, it is important to practice within your comfort level and to be honest when you feel a case is beyond your skill level. In such cases, using the ground consult option can be helpful. But also remember that if you are the only physician on board, some medical care is better than no medical care.

As for compensation, under most, if not all, state Good Samaritan laws, you are no longer protected from liability if you accept payment for the care you provide during an in-flight emergency. However, it appears that accepting a thank you from the airline, such as an upgrade or flight voucher, does not necessarily prevent you from being covered under Good Samaritan laws. But given that the Aviation Medical Assistance Act is silent regarding payments or gifts from an airline, if you want to completely avoid the issue, you probably shouldn’t accept any reward from the airline.

Lastly, be sure to document the encounter in some way. Get the information you feel you need (you can always ask a flight attendant to record vital signs or other pertinent information during the encounter, if needed) and document it in your medical records or some other way when you return home.

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.

Friday Jun 13, 2014

Sticking Point: How Do We Educate Vaccine-resistant Parents Without Driving Them Away?

As of June 6, nearly 400 cases of measles had been reported in the United States this year. That is by far the highest total since public health officials declared the disease eradicated in this country in 2000. The 16 separate outbreaks in 20 states have led me to think a lot about the spread of vaccine-preventable illness and what I want my clinic policy to be regarding the care of unvaccinated patients.

The highest numbers of cases have been reported from California, Ohio and New York City. Back in April when California had "only" 58 reported cases (close to the yearly national average), the CDC reported that at least 11 people had been infected in doctors’ offices, hospitals or other health care settings. There also have been outbreaks of mumps, pertussis and varicella in various parts of the country in the past year, making the chances of encountering one or another of these vaccine-preventable illnesses in our practices much more likely than in prior years.

The combination of recent disease outbreaks and parents who decline vaccinations has raised concerns about protecting infants too young to be immunized and patients who are immunocompromised when they visit our practices.

Since starting my practice, I have wrestled with how to best provide a safe and protective environment for patients while respecting the choices they make, even when I do not agree with those choices. I fear the possibility of disease transmission from an unvaccinated patient to an infant too young to be immunized or an immunocompromised patient who could also be in my waiting room. That is a distinct possibility because measles spreads easily through the air, and infectious droplets can linger for as long as two hours after a sick person leaves.

If an unvaccinated person comes into contact with measles, there is a 90 percent chance that person will contract the disease, and for every 1,000 children with measles, one or two will die. A recent commentary in the Annals of Internal Medicine stated, "We must ensure that our facilities do not become centers for secondary measles transmission." I have had the argument put to me that people could come in contact with these diseases at the grocery store or the library, and this is true. However, I have no control over those environments, and I haven’t encouraged my patients to go to those places like I have encouraged them to come and see me.

There are physicians who have chosen to stop seeing patients who are unvaccinated. Although I can understand that position, this is not the direction I have chosen to take because I want to have every opportunity possible to educate parents and encourage vaccination. The American Academy of Pediatrics policy on this issue states that physicians "should avoid discharging patients from their practices solely because a parent refuses to immunize his or her child." Should the physician decide to pursue this course of action, however, he or she should not proceed without giving sufficient notice to allow the patient to secure another health care professional.

Moreover, the policy states, "Such decisions should be unusual and generally made only after attempts have been made to work with the family. Furthermore, a continuing relationship allows additional opportunity to discuss the issue of immunization over time."

I was recently listening to an expert at a Kansas AFP meeting who said that an average child is exposed to 2,000 to 6,000 antigens in a typical day at daycare or preschool, and the total antigen exposure for all vaccines up to age 2 is 315. I hope to use information like this to help parents make the right decision about vaccination.

The irony of the extreme success of vaccination programs is that most people -- including many physicians -- have never seen the devastating effects of vaccine-preventable illness, thus making it difficult for them to fully appreciate the benefits of vaccination. I think one of the most important things we can do is to not minimize parents’ concern. Vaccines are safe, but they are not risk-free. We should assist them in comparing the risks of the vaccine with the risks of not being immunized (for example, the risk of encephalopathy related to the measles vaccine is one in 1 million; the risk of encephalopathy associated with the disease itself is 1,000 times greater). We should give them a chance to voice their concerns and review vaccines and their risks one by one if this is what they need. And we should be prepared to address this choice each time we see them.

So you’ve educated all you can, and a parent still refuses immunizations for his or her child. What do you do? You may want to consider having parents sign a refusal waiver, stating that they understand the risks of this choice. An excellent template for this can be found on the Immunization Action Coalition website. It spells out for parents that their unvaccinated child may pose a health risk to others, that their unvaccinated child may be excluded from school, daycare and other activities in the event of an outbreak and it hammers home the potentially severe health consequences (amputation, brain damage, deafness, hospitaliza­tion, meningitis, paralysis, pneumonia, seizures and death) that could result from forgoing vaccination.

"I also found an excellent CDC handout that clearly lays out for parents the risks their unvaccinated child poses to others. The handout states, "With the decision to delay or reject vaccines comes an important responsibility that could save your child’s life, or the life of someone else." It then asks parents to "Notify the doctor’s office, urgent care facility, ambulance personnel, or emergency room staff that your child has not been fully vaccinated before medical staff has contact with your child or your family members." I plan to begin giving this to parents in my practice who are considering either refusal or delay of vaccinations.

Another worthwhile resource is the AAFP's free mobile applet for immunizations, which includes vaccination schedules, coding information and other vaccine resources.

You may want to institute a policy stating that any ill child who is unvaccinated should be taken immediately to an exam room or asked to use a back entrance to avoid contact with other patients, especially if the child has symptoms suspicious for vaccine-preventable illness, such as rash. You may want to ensure an alert is placed on the chart of any unvaccinated patient, and let staff know to notify you if these patients call in for an acute appointment so you can plan accordingly.

Perhaps the single most important thing we can do is to have a candid conversation with the parents regarding how their decision may affect their experience in your clinic, while limiting access to care as little as possible. I don’t think that there is a perfect solution, but I think that having that conversation and instituting a policy within our clinics are important and will help guide our future care of patients. I also think that respect and education can go a long way in helping parents make decisions that are in the best interests of their children, and there are no medical specialists better poised to do this than family physicians.

How do you handle unvaccinated children in your practice?

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

Thursday Jun 05, 2014

Practicing Workplace Medicine at the Point of 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 sixth post in an occasional series of blogs that will look at the different roles family physicians can play.

Traditionally, a family doctor would set up shop, and patients would come in to the office for most of their care, with the physician stepping out for hospital visits and house calls as needed. For better or worse, that paradigm slowly shifted over time to clinic-based care, and now a large proportion of family physicians practice exclusively in outpatient clinics.

As a medical student, I dreamed of returning to my rural home, opening a solo practice and doing it all, like "Marcus Welby, M.D.," or "Doc Hollywood." From delivering babies to holding the hands of elderly patients breathing their last, I wanted to be the quintessential Family Doctor, capital “F,” capital “D." The modern health care system -- with long waits for patients and mounting paperwork hassles for physicians -- didn’t (and still doesn’t) appeal to me.

Here I am talking with a patient at my on-site primary care clinic, which provides care for local government employees and their family members.

I tried initially to circumvent those problems by opening a direct primary care (DPC) practice. My father and I had moderate success, but the area where we chose to practice couldn’t really support two physicians.

Thus, I jumped at a chance to work as the family doctor for local government employees and their families. I took a job with a corporate primary care group serving Kenton County and the city of Covington in northern Kentucky, initially caring for about 1,500 individuals. My patient panel has since expanded to include the employees and families of a neighboring city and a large manufacturer in the area. In conjunction with another clinic, we provide broad-spectrum primary care, with a focus on employee health and wellness.

As discussion abounds about DPC, defining the framework for this approach to family medicine practice requires some outside-the-box thinking. Many of the old ideas about taking care of patients “where they are” inform the new models of practice, with some physicians opting to hold traditional office hours, and offer full-spectrum care with house calls and hospital care for a set fee. Others choose to see patients in some fixed setting other than an office, which is often more convenient to the patient.

My current practice falls into the latter category. I am an employee of a company that provides corporate primary care -- sometimes called on-site primary care -- for corporations and businesses across the country. In essence, I provide DPC at the jobsite.

Several different models of corporate primary care exist, although most consist of some combination of basic insurance and an on-site clinic staffed by family physicians to provide primary care for employees and their dependents. Our model includes a lab and an in-house dispensary, with prepackaged medications prepared at a central pharmacy. The employer pays a per-patient, per-year fee to offset visit copays, as well as the medications in the dispensary, meaning no money is handled in our clinic. Some other clinics use a traditional copay model, but often with discounts.

From an occupational medicine perspective, I spend a lot of time talking with the human resources staff of the employers I serve, helping to coordinate their plans for wellness, organizing events such as influenza vaccination days and looking for new resources we can provide or large-scale issues we can address. We also handle things like Department of Transportation physicals and workers’ compensation issues.

Patients often comment on the convenience of our clinic, both in location and the limited time spent waiting. We use open scheduling with a Web-based component, allowing patients to schedule up-to-the-minute appointments, each covering a 20-minute block. The intake process, given the lack of copay and the prearranged interface with insurance, consists of obtaining vitals and eliciting the chief complaint, leaving much of the 20-minute appointment block for the face-to-face visit between patient and physician. Many of the annoyances of the traditional doctor visit, such as copying insurance cards or collecting payment, have been eliminated.

I like the structure of this style of practice because it puts the focus of the visit back on the patient, gives more time for adequate history-taking and allows me to discuss the treatment plan in depth. I don’t walk into the room of a patient who waited for two hours to see me for just eight minutes and feels cheated out of even that meager amount of time by the hassles of registration and waiting. The scheduling system and the dispensary reduce many barriers to care, and the focus on preventive medicine encourages employees to take control of their health.

Many of the 20- to 30-year-old patients who come through the clinic for acute visits have not had a health assessment since their last visit to a pediatrician’s office, but once they realize the clinic is on-site and there’s no copay, they are eager to go over their history and health behaviors.

I spend a lot of time talking about the preventive care aspects of medicine that we all learned about as medical students but rarely have the time to emphasize in private practice. I discuss appropriate nutrition and exercise. I get to do in-person smoking-cessation counseling, and the clinic even has a smoking-cessation counselor on staff. I spend time going over medication lists, immunizations and medical histories, and patients have time to tell their stories. It’s also satisfying to know that the patients with multiple chronic diseases are leaving the clinic with medications in hand and don't have to worry about how they are going to pay to have a prescription filled.

I do miss providing hospital care for my patients, and I’m still an employed physician, but my employer practices good communication and works to ensure autonomy for clinical decision-making and patient care. I do my own prior authorizations and call-backs, and I still have to use ICD-9 (eventually ICD-10) codes.

But I get to take care of patients, coordinate their care and make sure they get plugged in to the resources they need. I’m free to take care of people, instead of worrying about the financial bottom line. It’s even freed me up to pursue other projects, like a rural outreach free clinic.

On the flip side, the employer gets guaranteed, accessible, coordinated care for employees and their families, often resulting in fewer lost hours and healthier employees. The companies using corporate primary care also end up saving money on insurance premiums, even with the DPC fees. It’s a win-win situation.

If you have questions about corporate primary care or want to debate the merits of cash-pay systems, drop me a line on Twitter or respond using the comments feature below.

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.

Friday May 30, 2014

Family Medicine: Make It What You Want

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

One of the factors that attracts many of us to family medicine is the diversity of practice settings. This can manifest as having the freedom to choose a particular practice location or a certain practice model, but it can also mean choosing to focus on a patient population that shares a common background or set of diagnoses. Yet even though I knew about these variations, I never anticipated being in the type of practice I’m in.

I have learned more about psychiatry and neurology on the job because caring for patients with developmental disabilities required it.

I work at the Neurobehavior Healthy Outcomes, Medical Excellence (HOME) Program in Salt Lake City. It is a novel patient-centered medical home (PCMH) that provides care for individuals with developmental disabilities (DD). We provide primary care, case management and full-spectrum mental health services (psychiatry, therapy and behavioral interventions) for people of all ages who have developmental disabilities. We are an official Utah Medicaid HMO, meaning that individuals have to be accepted into the program, and we receive a per-member per-month capitated payment for each of the nearly 900 individuals who are enrolled. We spend one hour with each patient to allow us the time to address their many needs and to better coordinate with other members of the care team.

I always envisioned myself working with an underserved population, but I never would have guessed that I would be working with this particular group of patients. I did not have any specific training that covered the unique health care problems individuals with developmental disabilities face. In fact, I have had to learn on the job the past couple of years to properly care for them. I applied for the job after it was suggested to me by a residency faculty member who saw an interest and ability that I was unaware I had. He recognized that the way I interacted with patients and the way I thought about medicine in general would be a good fit with this population.

At first, I was more curious about the model of care then the population itself. I had wanted to work in a PCMH so I would have the proper team in place to care for patients, so the idea of working with psychiatrists, therapists, case managers and others strongly appealed to me. But now that I have been working for some time in this setting with oftentimes challenging but always interesting and rewarding patients, I have grown to love it and wouldn’t trade it for any other practice.

My story is not unique in family medicine. Many of us end up in a niche practice based on a specific population need or personal interest. It is obviously a challenge to be an expert in all areas of family medicine, so many of us naturally gravitate to a certain area. And this change often comes about a little more organically than deliberately. But that’s the great part of family medicine -- you make of it what you want.

In some ways, a practice like this narrows my skills. I do not practice obstetrics because that is not a common issue faced by my patients. I do fewer procedures than I was trained to do because many of my patients require sedation in the operating room. I have decided that this is an appropriate trade-off because working with this population has increased my knowledge and skills in other areas. There are few physicians around the country who have a deep understanding of the health care needs of individuals with developmental disabilities. I likely have learned more about psychiatry and neurology than the average family physician because caring for my patients required it. These added skills are an asset I use to teach residents, students and others. If I end up in a different practice setting in the future, these skills can be used to supplement those of others in the practice. I can also retrain in specific areas at a future time if I choose to do so.

There is often some anxiety that accompanies a decision to narrow one’s practice after having received such broad training, but we should not be afraid to tailor our practice to our needs or interests. This is one of the great beauties of family medicine – you’re free to make it what you want.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program. 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.

Thursday May 22, 2014

Physician's Killing Prompts Changes, Reflection

You wouldn't even notice the new safety precautions at my practice, and you probably don't know about the bad things that happened in my medical community that necessitated them. But I know those new safety measures are there, and the recent additions make me feel a little bit safer than I did a few months ago.

There are new locks on the doors between the waiting room and the area that leads to our exam rooms, and other changes are under consideration.

Here I'm reviewing electronic health records with medical assistant Jessica Martinez. Events in our community have made me think about what my practice can do to keep staff and patients safe.

I always thought of my practice as a safe place where people could come for help, and where I, in turn, would "do no harm." But it turns out that violence can happen anywhere. And sometimes it comes to us, as it did for my community back in December.

After the dust had settled, we found out that a disgruntled patient had entered a local urology clinic and told everyone in the waiting area to get out. The man, who blamed a vasectomy for his failing health, then walked through an unlocked door between the waiting room and the exam rooms and opened fire with a 12-gauge shotgun. When it was over, one physician was dead and another was seriously injured. A relative of a patient visiting the clinic also was injured before the shooter took his own life.

When we discovered who had been killed and who had been injured, we were shocked and speechless. These were not only colleagues, they were friends and mentors.

The incident affected our community far beyond the walls of the medical building where the shootings took place. For example, the wife of the physician who died is an obstetrician who works downstairs in my building. She has two teenage children.

In the aftermath, patients were wary of coming to appointments at the urology clinic. Some patients couldn't even go into the building where the shootings had happened.

Both my brother- and sister-in-law are police officers here in Reno, Nev., and they often point out that things like this can happen anytime, anywhere. They get up in the morning, put on their bulletproof vests and are pretty much prepared for anything.

Me? I put on scrubs and a stethoscope and prepare to help people who need it. Never would I have previously gone to work thinking that my patients or I would be at risk for such a tragedy. How do we feel safe -- and make our patients feel safe -- in an increasingly violent society?

A few weeks before the shooting at the urology clinic, a 12-year-old boy brought his parents' gun to school in a neighboring town and killed a teacher and wounded two students before killing himself.

A month after the shooting at the urology clinic, an elderly man entered a hospital in Carson City -- our state capital -- and shot and killed his wife in what was planned as a murder-suicide. His gun jammed.

Violence seems to lead to more violence. After the attacks on the local urologists, other physicians in our community received threats from patients. One man who was denied narcotics by a physician at my practice took it way too far. First, he called in threats. When that didn't get the response he wanted, he made more threats in person. The police were called, and he was arrested.

Incidents like these make me realize that we physicians deal with issues of safety and mortality in more ways than one. It also made me step back and evaluate how experiences shape the way we practice. Are there physicians who now are more lenient in their prescribing practices because of threatening patients? Are there physicians who have changed the way they perform surgery?

Was something lacking in the communication between the disgruntled patient and his physicians? Now I make even more of an effort to listen to both the spoken and unspoken concerns of my patients. I have tried, along with my colleagues, to rebuild the sense of security within my office and our medical community that was shattered this past winter. The physical changes to our clinic are just a small change that helped me and my staff go back to our normal everyday lives.

What is your practice doing to keep its physicians, staff and patients safe?

Helen Gray, M.D., is an employed family physician in Reno, Nev., working in a hospital-based setting. She also is adjunct faculty with the University of Nevada School of Medicine. You can follow her on Twitter @helengraymd.

Thursday May 15, 2014

Overcoming the Stigma of Mental Illness in Physicians: My Story

Pamela Wible, M.D., a family physician who is an expert in physician suicide prevention, recently asked other physicians why so many in the profession kill themselves. The answers were plentiful, tragic and not at all surprising.

One physician confessed to having posttraumatic stress disorder after medical school. Another cited constant sleep deprivation. Yet another mentioned the combination of a crushing workload, a difficult boss and payers who are more worried about the bottom line than patient outcomes. That’s just a sample.

When physicians seek assistance for mental health issues like anxiety and depression, it not only helps us, it helps our families, friends and patients.

More than 300 physicians commit suicide every year; that's a higher rate than the national average. Burnout and mental illness have garnered attention both in the mainstream media and medical journals and threaten to exacerbate a growing primary care physician shortage. But despite widespread recognition of this very real problem, a stigma remains among physicians. Thus, many physicians remain reluctant to seek needed care because they think they should be impervious to perceived weakness. However, we cannot properly care for our patients if we have problems that impede our ability to do so.

This is my story of mental illness, and I hope it can help others with similar health issues.

I began having problems with anxiety when I was in high school. It mostly involved social interactions, and I would get nauseated and sometimes have diarrhea. It usually only lasted a short time, and I could overcome it well enough to function. I didn’t recognize any depression during this time, but the anxiety -- combined with the natural angst of adolescence -- may have covered up some signs of illness.

At age 19, I served as part of a church-based mission to Ukraine. My GI symptoms worsened during this time, but I didn’t recognize it as anxiety or depression. I was convinced I had parasites or another infectious process (neither of which is uncommon among Westerners living or traveling in the former Soviet republics). I struggled through it without much medical intervention until I returned home two years later.

My symptoms persisted, especially as I began my premedical studies. I saw an internist about my complaints, and he was convinced that I had giardiasis. I had several negative stool tests, however, and eventually I was told I would just have to learn to live with it.

After getting married and dealing with the increasing financial struggles of a young couple going to school, I ended up having a full-blown panic attack while I was working a night shift at a group home for the mentally ill. This experience, combined with the growing understanding of mental illness I gained while working in that setting, helped me to recognize my problem for what it was: I had generalized anxiety disorder.

I was nervous all the time -- about life, about money, about getting into medical school. I couldn’t control it. I lost sleep sometimes and significantly overslept at other times. I didn’t eat much. My GI symptoms persisted, and I began to realize them as irritable bowel syndrome secondary to my anxiety.

I saw the student wellness physician, who started me on Prozac. The first month was terrible because of the side effects, but I stuck with it, and the medication began to help. I was more productive and felt better than I had in years.

After being accepted into medical school, I thought my anxieties were behind me, so I tapered off of the medication. That was a mistake.

My symptoms returned, and I tried to fight through them. Despite the staunch independence that prevails throughout the medical culture, I eventually realized I couldn’t deal with this on my own. Psychiatric services were provided to medical students, so I started seeing a psychiatrist, who put me on Lexapro.

It didn’t work quite as well as Prozac, but the side effects were less significant, so I stuck with it. For a short time, I also was on clonazepam, but I found that depressed me too much. I started seeing a counselor. I had seen one during my undergrad years but had found it dissatisfying because I didn’t think my problems were legitimized by the therapist. I had a slightly better experience this time around, but still found it difficult to connect with the therapist and believe that she really understood what I was going through.

I am still on Lexapro today, and it works fairly well. I go through peaks and valleys with my symptoms, and I have had some depression in the years since I started residency. I have tried another therapist but still find it hard to connect and let that person in fully.

Thankfully, I can talk about my issues with my wife. As physicians, we have a higher divorce rate than the national average and a higher rate of unhappy relationships, even if we don't divorce. This underscores the importance of being able to share our feelings with someone we trust, no matter who it is, and of seeking counseling when needed. Now I am giving therapy another shot to help me better manage my symptoms.

Fortunately, I have never considered suicide, or even leaving the medical profession. Despite my illness, I still find hope and value in working with my patients and focusing on their needs.

Being a physician is hard. We all know the pitfalls and frustrations of the profession. The harsh reality is that physicians commit suicide more often and have more problems with substance abuse than the rest of the population.

Physicians avoid seeking help for many reasons, not least of which is concern about losing their job or practice. But it's critically important to recognize the problems when they exist and seek help. We are much more likely to cause harm to others and ourselves when we avoid getting help.

The stigma is sometimes difficult to overcome, but seeking proper services not only helps us, it helps our families, our friends and our patients.

I know I'm repeating myself, but I can't say it enough: Please don’t hesitate to seek assistance when you need it.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program. 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 May 09, 2014

Looking for Inspiration, Rejuvenation? NCSC Could Be the Answer

Since graduating from medical school, I've made an effort to return to my alma mater for Match Day and hooding ceremonies every year. There's something about the energy that buzzes through the room at these events. So when frustrations like my electronic health records system or reimbursement issues weigh me down, spending a few hours among bright-eyed, future physicians reminds me of why I went to medical school in the first place.

When I was a student and, later, a resident, I attended the AAFP’s National Conference of Family Medicine Residents and Medical Students. I enjoyed the opportunities to learn, lead and connect with my peers. But as I began my new practice, I shifted away from conferences and focused on being a good family physician. I also had my own growing family to think about.

I testified on behalf of the women’s constituency during the Reference Committee on Advocacy at the National Conference of Special Constituencies in Kansas City, Mo.

Little did I realize how important these conferences, and the opportunities they present, can be when it comes to enjoying what we do. It’s easy to become entrenched in the negatives in the day-to-day grind of practice. More than once, I found myself in conversations at my office about the need to change policies that hinder my ability to do what I love.

Fortunately, one of our state chapter leaders asked if I would be one of our chapter delegates at the Academy’s National Conference of Special Constituencies. I was unaware of this conference, but he explained that it is the Academy’s leadership and policy development event for women, minorities, new physicians, international medical graduates, and physicians who self-identify as gay, lesbian, bisexual or transgender (GLBT) or who support GLBT issues.

Not only would I be able to discuss group-specific issues, it is a forum for change. I would have the ability to participate and learn about policy development and leadership. It sounded like a great opportunity, and I agreed to go as Nevada’s delegate for the women’s constituency.

When we arrived last week in Kansas City, Mo., my initial thoughts were that I would "get my feet wet" and just observe and take things in, but the event had a huge impact on me. I attended a workshop for first-time attendees and learned that I wouldn't be sitting in meeting after meeting or lecture after lecture. I would be participating in sessions where we would brainstorm policies, write resolutions and participate in our own caucus, elections and a business session.

After the opening session and plenary, I went to my constituency meeting. I admit I was intimidated by the fact that I did not know anyone in the room or what to expect. I was awed by the passion the delegates showed when we discussed the many health issues women face.

I watched as delegates volunteered to participate in the research and writing of resolutions that would be debated the next day in reference committee hearings. I felt the desire to make a difference and volunteered to help with a couple of resolutions after listening to the discussion amongst the delegates. The respectful banter in the room was refreshing.

In the afternoon, we had the opportunity to work with the other constituency delegates in writing resolutions. I worked with delegates from the new physician constituency and my own. At one point, I was struck by the fact that I was amongst physicians from a variety of different practice models who had come together from all over the nation to create a better environment not only for ourselves as physicians, but for our patients and communities, as well. At the end of the session, I proudly handed in our resolution feeling satisfied.

During this first day, I learned of opportunities to volunteer for committees and run for leadership positions. I wanted to learn more about the process, so I applied to volunteer and was selected for the teller's committee. With only a few hours of exposure to this conference, I was already feeling rejuvenated and hopeful.

We did more than debate Academy policy. Our keynote speaker, Paula Braveman, M.D., M.P.H., gave an eye-opening presentation on health care disparities. Breakout sessions taught me how to speak with legislators as well as strategies on how to overcome challenges in leadership. Other sessions covered a variety of topics, including the legislative process, social media, giving a keynote speech and the challenges facing new physicians.

Here's another bonus: NCSC runs concurrently with the AAFP's Annual Leadership Forum, which offered even more opportunities to learn.

One of my favorite aspects of these events was the connections I made. The networking opportunities were amazing. I had the pleasure of meeting like-minded but diverse individuals. Some were completely new encounters, and there were also those I previously had interacted with only on social media. An added benefit was the chance to meet AAFP directors and officers, who attended the discussion groups, business and breakout sessions, caucuses and committee hearings.

Another interesting aspect was having a chance to interact with Academy staff, who I found to be organized and efficient. I have never seen a conference run so smoothly.

On day two, the constituencies elected new leaders, and I fulfilled my duties as a teller. Listening to the candidates’ speeches inspired me to take part in the change (rather than standing around discussing it in my office back home). I testified in a reference committee on behalf of my constituency on a resolution that I co-authored. At the end of the day, I felt accomplished and had a sense of purpose -- to improve family medicine and the quality of care in our communities.

The third and final day featured the business session. The process and format are similar to those used at National Conference and, ultimately, the Congress of Delegates, which is the Academy’s policy-making body. Discussion on the various resolutions brought forth left me feeling empowered with new knowledge and a voice to share these ideas.

As I sat on the plane heading back to my family and practice, I felt a sense of renewal. It wasn’t only a feeling that I did indeed choose the right specialty but an inspiration to improve our specialty for future students who choose to practice family medicine.

I'm grateful for a forum where groups with specific concerns have a voice that can be brought to our Academy. I cherish the relationships I made during these past few days. I excitedly look forward to the 25th anniversary of this conference next year when it returns as the rebranded National Conference of Constituency Leaders. It is sure to be another inspiring few days. I hope to see you there.

Helen Gray, M.D., is an employed family physician in Reno, Nev., working in a hospital-based setting. She also is adjunct faculty with the University of Nevada School of Medicine. You can follow her on Twitter @helengraymd.

Thursday May 01, 2014

Global Health Offers Unparalleled Opportunity to Learn While Helping Patients

"It will be another adventure," I thought as we prepared for our journey.

I was just a few months shy of graduating from residency, and my mind was racing. What could I cram into my sparse free time to help me be prepared for anything and everything? Of course, with the demands of residency, there wasn't enough time to prepare for much.

As August approached, we were as ready as we could be to move to another country for a year. We were headed for Santa Lucia, Honduras, a little more than a month after I had graduated. I could only imagine what awaited us there.

Working for 11 months in Honduras allowed me to put all of my training into practice and help people who really needed it.

We were going because we wanted to serve people and give back a portion of what we had been given by so many others -- compassion and care. Edwin, my husband, was going to be the information technology manager at a clinic there, and I would be a staff physician.

We lived in Honduras for 11 months. Now we are often asked, "How was it there?" I reply, "It was good." But it's not the travel, the food or the scenery that stands out in my memory. The "good" is when I realized that my character as a physician, a person and a citizen of the United States had been challenged during our time there, and I am better for the experience.

Many of our days in Honduras were hard. Some were fun beyond measure. Whether the days were good or bad, there was always something to learn. I saw malnourished children and a horrible shoulder dystocia. I traveled down a mountain into El Salvador with an 11-year-old girl -- who was in status epilepticus -- in my lap, trying to make sure her airway was protected. She ended up having neurocysticercosis.

We routinely had to think about both time and distance when we were managing a laboring patient because the nearest hospital was at least 2 1/2 hours away. More specifically, it was 2 1/2 hours away during the day, in the dry season and with a skilled driver. Otherwise, it could take a minimum of four hours to get to the nearest hospital with a surgeon.

There were many days I rode down the mountain with a woman in active labor, trying to ascertain her progress and determine whether her pain was due to contractions or from the combination of contractions and going bumpety-bump on the glorified path through the woods we called a road.

Good roads are just one of the things we take for granted in the United States that were lacking in Honduras. More importantly, access to clean drinking water was a problem, and I was struck by the number of children who needed oral rehydration solution.

With limited resources, I learned how to take and develop my own radiographs. I also learned how to set an IV drip rate without an electronic monitor. The nurses at our clinic counted the number of drips per minute and adjusted the flow of the IV fluid accordingly. I had never done this or seen it done before.

Although we worked hard in Honduras, we made time to play, as well. We traveled to the Copan Ruins and Guatemala. We saw waterfalls and breathtaking views of the mountainous countryside. We ate wonderful food (but also had occasional bouts of traveler's diarrhea).

Overall, international medicine can be quite an adventure for a family physician. You not only get the opportunity to put all of your training into practice, you also are extremely useful to those you serve. You become the physician for anyone you encounter.

Global health provides both a great learning opportunity and a chance to help in places where there is great need. Perhaps that's why interest in these opportunities is growing. Two-thirds of family medicine residency programs now offer international rotations or electives, and more than 30 percent of medical students completed a global health rotation in each of the past four years. These days, medical schools and residencies that have faculty with knowledge and experience in global health have a competitive edge over those that do not.

The AAFP responded to this growing interest by creating a Global Health Workshop in 2003. The annual event is scheduled for Sept. 11-13 in San Diego.

The Academy also has developed a new global health strategy with four key objectives for the AAFP:

  • Be a leader in promoting family medicine and population-based, patient-centered primary health care on a global scale.
  • Provide support to members through development of comprehensive, member-focused global health resources, information and networking avenues.
  • Educate and engage members in global health through development of educational products specific to needs and interests of AAFP membership groups.
  • Become a clearinghouse of international family medicine opportunities to foster collaborations between members and domestic and international agencies, foundations, educational institutions, training programs, and businesses relevant to AAFP content expertise.

I encourage students, residents and our more seasoned physicians to experience health care beyond your own community. During my year abroad, I learned health care administration -- although probably by default -- management skills and how to deliver care with limited resources.

I also learned that medicine in the developing world is in some ways not much different than what we practice in the United States. Of course, there may be some diseases that we only remember from an infectious disease lecture, but the overwhelming majority of disease processes are those we are quite familiar with: diabetes, hypertension and hyperlipidemia, as well as musculoskeletal complaints and dehydration.

Just like here in the states, I met patients who used a lot of resources unnecessarily as well as those who really needed them. I met worried mothers with small infants and worried children caring for elderly parents. The human aspect of medicine was exactly the same. People are people in need of compassion and care wherever you are.

A few years ago, the World Conference of the World Organization of Family Doctors (WONCA) declared May 19 World Family Doctor Day to highlight the role and contribution we play in health care around the world. If your medical school, residency or organization is planning activities to celebrate this year, we would love to hear about it in the comments field below.

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

Thursday Apr 24, 2014

Locum Tenens Work Offers Freedom, Control

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

My mom was born and reared in Vietnam, but neither of us had visited her native country in several years. So I took three weeks off from work in March to travel with her. We reconnected with family, experienced the culture and ate amazing food.

My schedule for this summer promises to be equally interesting because I’m leaving my home in Seattle to spend a month working in a small community hospital in Alaska. I’ll be practicing full-scope inpatient and outpatient family medicine, including obstetrics, while exploring the town of Kodiak and experiencing an Alaskan summer.

Working locum tenens has allowed me to set my own schedule. In March, I took a three-week vacation with my mom to Vietnam, including a visit to Ha Long Bay.

And I’m keeping nearly a month of my work schedule open in August for my wedding and honeymoon.

My point isn’t to brag about the frequent flyer miles I’m accumulating but to point out that for some physicians, working locum tenens can be a fantastic opportunity.

My fiancé is a third-year medical student who hopes to match to a pediatric residency. Given that there is only one such program in our area, relocation is a real possibility in just a little more than a year from now. For me, it didn't make sense to sign on to a full-time job if I wasn't going to stay in the area. So while many residents around the nation were searching for jobs last spring and summer, I was looking for locums positions in the Seattle area.

In fact, a large portion of my residency graduating class elected to do locums. It might seem like we’re delaying the inevitable and avoiding what brought us to primary care in the first place (care continuity), but how are we are supposed to know what kind of work environment we would like to wind up in if we don’t try different options?

Every practice is different and has its own ways of doing things. As a new-to-practice physician, how do you know what kind of clinic environment you need? Working locums provides an opportunity to see where you might fit best and what might keep you happiest.

I started my first position at a private practice, slowly, last July. I was only working one or two days a week at first, and that gradually increased to three or four days a week. The clinic needed a lot of help, and for a while it seemed like I was a regular employee, experiencing the benefits of continuity of care and having my own patients.

Eventually, the clinic's need decreased, and I started having shifts cancelled. I also realized that maybe private practice wasn’t the best fit for me, and maybe the patient population didn’t fulfill all of my needs. But soon after that realization, I started a role as a “float provider” with a health system that has more than a dozen locations in my area.

With so many physicians on staff, the clinics have vacancies, maternity and other medical leave, and vacations to cover. I’m paid an hourly rate and can plan my schedule months in advance. I fill in for a variety of internal medicine, family medicine and pediatric physicians, which makes things interesting. There are days I see only pediatric patients, some days that are all adult medicine and some days that are mixed.

The pediatric days, in particular, have been excellent for my training. I’ve solidified my ability to talk with kids, and I’m more confident in my skills after those shifts.

I work for the health system three to four days a week, which leaves me one or two days for precepting at my residency program. This flexibility allows me to work on mentoring and honing skills that I hope to use in the future in a faculty position at a residency program.

There are a few drawbacks to not being a full-time employee, most notably the lack of health insurance. But with no husband or children, I was able to find a reasonable plan for myself.

The lack of continuity of care also is a drawback, but so far, I’ve been able to see some patients on return visits because I’m working somewhat steadily at these clinics. I’ve heard that some physicians doing locums might run into a paucity of work, but I have yet to experience this.

For me, the benefits of my current career choice have far outweighed any negatives. What's the biggest perk of locums after three years of residency training?


My schedule, including vacations, had been dictated to me for my entire life, from early childhood through high school and on to college, med school and residency.

Locum tenens gives me a chance to build my own schedule. I can take a four-day weekend if I want. Or I can work seven days and take seven days off. I’m a planner, and this is all about managing my own time and having control of my professional and personal life.

Right now, I’m planning my wedding, which is like a job in its own right. When my fiancé matches, I might be ready to settle down and pick a clinic. After working in a variety of locations, I think I’ll have a better idea of what I’m looking for in an employer. And if we stay in this area, I hope the employers that have had me as a locums provider will feel confident in hiring me as a full-time employee.

One thing is certain. If I had taken a regular job last summer, I wouldn’t have been able to do many of the incredible things I’m doing now. And I wouldn’t want to miss any of it.

Jennifer Trieu, M.D., is a family physician in Seattle.

Thursday Apr 17, 2014

Benefits of Rural Practice Make Sacrifices Worthwhile

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

I grew up in a town of 40,000 people. In the region where southwest Missouri meets southeastern Kansas and northeast Oklahoma, that passes for a metropolis.

During my time at nursing school and later during my first year of medical school in Kansas City, it never occurred to me that I might wind up in a small, rural practice. I hadn't grown up in a rural area, and the possibility of moving to one wasn't on my radar.

Stockton, Kan., hadn't had its own physician for more than a decade when my husband and I opened our practice in the small, rural community.

But during my second year of med school, we had the option to experience a rural health weekend. We were paired with a rural physician and allowed to see what they do and how they do it. Fortunately for me, I was matched with family physician Jen Brull, M.D., in Plainville, Kan.

It didn't take long for her to make an impression. I met one family Jen had delivered two babies for. She also cared for the mom and dad, grandparents and even great-grandparents. The relationship she had built with that family grabbed by attention. I was definitely intrigued.

Coming from the University of Kansas Medical School in Kansas City, I knew how easy it was to get lost in a big practice. In Plainville (population 1,900) I saw what a big difference a family physician could make in a small town.

During our third year, we were required to complete a rotation in family medicine. I asked if I could do mine in a rural setting rather than in the local, metro area. Given that option, I went back to Jen's practice in Plainville. I got away from the large, academic medical center and watched this small-town physician connect with her patients and her community in a meaningful way.

I loved my experience in Plainville, and I was eager to go back. So when it was time for a rural rotation during my fourth year, you probably can guess where I went.

If KU hadn't provided opportunities for us to experience rural practice, my husband (who also is an FP) and I never would have wound up in rural medicine. By the time we completed medical school and residency in 2011, we knew we wanted to settle in a rural, underserved area.

At a time when most of our peers were seeking employment, my husband and I were looking to open our own practice. Sixty percent of AAFP members are employed physicians, and AAFP surveys tell us that only 13 percent of those employed FPs have an interest in becoming practice owners. Furthermore, only 11 percent of active AAFP members practice in rural areas.

But off we went to become business owners in small-town Kansas.

And it was terrifying.

There are plenty of reasons that the trend is toward employment -- fewer headaches and greater financial security being two of the obvious factors. But it also is true that as the number of small practice owners shrink, it becomes harder and harder for medical students and residents to find mentors who have done it.

Fortunately, we found someone who is running her own small, rural practice and doing it well. In fact, Jen was one of three physicians in the area who were running their own practices and sharing overhead expenses. We joined them by opening our own practice in Stockton, which is about 15 miles north of Plainville. Our little town of 1,300 hadn't had its own physician for more than a decade.

Our decision has come with some sacrifices. We don't make as much money as our residency colleagues who are hospital or large-group employees. We're not there yet.

You don't learn how to run your own business in med school or residency, either. We realized we needed a good business manager, so we hired one. However, we still have to be more involved in tracking billing, insurance and collections than our employed colleagues.

We're also responsible for things like paying for rent, supplies, utilities, staff salaries and more. When you're employed, you know the lights are going to be on when you show up for work. As practice owners, we have to worry about all these things.

Some days, I think it would be easier if it was someone else's headache. But there also is a lot to like about being your own boss. We like having flexibility and control of our schedules. I don't have to rush my patients. When I have a new patient with multiple conditions, I give them an hour so that we can address everything they need. You can't put a price on that.

We allow our staff to bring their babies to work until the children are 6 months old. After my daughter was born, I went back to work feeling comfortable because she was with me.

And I never go home frustrated because someone was unhappy with my productivity or wouldn't allow me to practice medicine the way I want to.

We like it here, and we're happy caring for our small town.

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

Thursday Apr 10, 2014

New Gadgets Show Promise for Future of Medicine

As a physician with a technological bent, I'm constantly looking for new gadgets to add to my arsenal and enhance my practice. From hand-held, two-lead, smartphone-based electrocardiography machines to USB otoscopes, I have played with and used a number of tools in practice that hold the potential to change medicine, especially primary care, as we know it.

Even our patients, especially those who have grown up with computers, now electronically document multiple aspects of health and wellness in a movement referred to as the "quantified life." From calories counted to miles run, from photographs of each day to recordings of blood sugar and blood pressure, technology allows patients to document and analyze every moment of their lives. Physicians are getting on board, and the recent surge in interest about telemedicine has pushed hand-held and wearable medical technology into the spotlight.

Google Glass, which I'm wearing here, is one tool that makes it easy to document visual findings from a physician's perspective.

I enjoy being on the cutting edge. To that end, a few weeks ago, I was lucky enough to be selected for the Google Glass Explorer Program. Although not yet "ready for prime time," as they say, the device serves a few useful purposes. Much like smartphone cameras, Glass makes it easy to document visual findings from the physician's perspective (with patient permission and a signed release form, of course). I also can capture audio notes and search for information from multiple sources.

I haven't used Glass for telemedicine yet, but hosting a Google Hangout with Glass could easily offer an opportunity to broadcast audio and video of standardized (or actual) patient encounters, give students a new perspective on patient interviews and physical exams or provide a distant subspecialist with a personal view of patients in a remote clinic. A surgeon in India recently used Glass to broadcast a live orthopedic surgery. Several surgeons here in the States have written about using Glass to visualize imaging studies or patient vitals while performing surgery. It's an amazing gadget, and we are just beginning to see the potential for head-mounted displays and augmented reality realized.

Telemedicine tech encompasses a lot more than screens and cameras, though. Several companies make USB versions of tools that are common in the primary care arsenal, including stethoscopes, otoscopes, electrocardiography machines that attach to a cellphone, even ultrasound machines the size of a smartphone. While dismissed by some as frivolous gimmicks, the move toward using remote sensing technologies continues to evolve as a viable medical option, especially in underserved areas of the United States and abroad.

The entire patient encounter can even be conducted by a layperson with limited training and broadcast to a physician half a world away or just across town. Much of the tech hinges on high-speed broadband Internet, so there are some limitations, but transmitting either live or recorded information for later review could allow physicians to help more patients in more places. A patient could come to a clinic; give a history with video conference software; be examined using a digital otoscope, ophthalmoscope, stethoscope and visual inspection performed by a trained worker; and receive a two-lead electrocardiogram using a device attached to a cellphone, and the physician on the other end of the link could determine whether telediagnosis was appropriate or whether the patient should be referred to a hospital or clinic, all from several hundred or thousands of miles away.

Personally, I've been working on a plan to use the technology in a rural/underserved area to provide triage and care in a free clinic, even when I can't be there in person. Although still relatively expensive, the technology continues to improve and costs continue to trend down, making this an increasingly viable option. The quality of the signal, from pictures and video of the tympanic membrane to recorded heart sounds, is more than usable, even over cellular or low-speed broadband (1-2 megabits per second) connections and can be transmitted to mobile devices, laptops or desktop computers. Proof of concept is one thing, and I'm excited about the potential, but once the project is fully underway, I plan to post a follow-up with more details.

Therein lies the problem with many of these technologies: They are new. Untested. Untried. Critics often call these gadgets a solution looking for a problem. Maybe they're right about some of them, but each and every one of these gadgets can be viewed as a step in the right direction. I don't know whether anyone told René Laennec he was crazy when he rolled up a piece of paper and placed it on a patient's chest, but his invention of the stethoscope moved us from immediate auscultation (an ear on the chest) to the ability to hear with striking clarity the motions of fluids inside the heart, lungs and abdomen. Inventions and technology have entwined with medicine ever since and continue to provide new ways of caring for the sick.

Although technology can never completely replace laying a human hand of comfort on the shoulder of a suffering patient, it can offer new methods of recording patient encounters and extending skilled health care to those in remote or underserved areas. From cellphones to cameras to augmented reality, we're entering a new phase in the practice of medicine, and, as new-to-practice physicians, we'll be leading the charge.

Sound off in the comments below about any novel tech or new gadgets you're using that help make your practice better, both for you and your patients, and feel free to contact me @DrTolbert on Twitter.

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.

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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.