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Monday Feb 01, 2016

Should We Reject Unvaccinated Patients?

Potential patients -- usually parents -- occasionally ask me if I am "vaccine-friendly." After having this question posed to me numerous times, I’m prepared for the conversation that follows. I’ve tried to ease into it in various ways, but none has proven universally comfortable.

The question's phrasing is telling about a person's perspective. It implies that their previous experiences with physicians were perceived as "unfriendly." Also, my defensive side infers it would be unfriendly for me to answer in any way other than a vague affirmative.

Patients who decline vaccines can be understandably frustrating. Even with our deep knowledge, experience and the best intentions, our pleas often seem ineffective. We are usually at a loss about how to improve our sales pitch when faced with vaccine refusal. As we see vaccination rates declining in some areas, the angst among physicians is understandable.

Professionally, we must consider our organization's and our own practices' policies on vaccine matters. The AAFP has a policy against immunization exemptions. However, this sort of a physician-oriented policy doesn't have much bearing in states that lack strong school requirements for vaccines and allow general parental belief exemptions.

Also, increasing numbers of U.S. kids are homeschooled; that number now stands at more than 1.7 million, according to the Department of Education. So ultimately, many patients -- children and adults -- can and will remain unvaccinated. And these unvaccinated families will be seeking primary care.

Despite an American Academy of Pediatrics policy discouraging practices from discharging patients because of parental refusal to vaccinate, a growing number of pediatric practices are doing just that. I understand why practices create such policies in an effort to protect newborns and kids with weakened immune systems. I support their right to do so, but I fear these policies will only worsen vaccination rates.

It is our duty to protect our individual patients from unnecessary harm, but how to promote the best public health in our communities is a complex issue. By barring the unvaccinated, we might be able to lower the risk of infections spread by sick patients in our waiting areas and exam rooms, but this practice fosters a false sense of security. Our patients are just as likely to come in contact with unvaccinated sick children at a park, school or library, or, as in the case of last year's measles outbreak, an amusement park. Ultimately, unvaccinated sick kids will seek care somewhere -- walk-in retail clinics, urgent care centers or ERs -- that cannot possibly proactively screen vaccine status or refuse care.

After a lot of consideration, I have elected to provide care to children and adults who decline my vaccine recommendations. My community, Lawrence, Kan., has higher rates of vaccine refusal than do most in the Midwest. Through the first few years of my practice, I have had lots of opportunities to hone my message when the "vaccine-friendly" question arises.

"I always try to be friendly," is one common response. "Regarding vaccines, I think it's understandable to be cautious of injecting or ingesting artificial substances into your or your child's body," is another comment that has proven to be disarming.

The reasons for vaccine refusal are numerous and varied, so I try not to make assumptions about a person's position or concerns. Asking, "What specific concerns do you have about vaccines?" is always a great starting point. The usual litany of disproven vaccine harms are common, but there is a wide spectrum of specificity from "I just don't like unnatural things" to "I am ethically opposed to using fetal tissue in medical treatments."

Depending on the initial responses and circumstances, I may address those concerns immediately or offer to continue the dialogue at a later time. I've realized a single conversation in the clinic -- or even a few -- is unlikely to change someone's mind on the vaccine issue. I have found an email exchange to be a wonderful method of communication for this and other contentious issues.

A 2014 article in Family Practice Management is a great guide on understanding the rationale behind vaccine refusals, and it offers tips on how to best respond. Whether in person or by email, I often start with some basic education on how our immune system works and how vaccines work to boost that process. Even a basic understanding of how something works can make it seem less scary.

The article's final section about trust rings most true to my experience. Although most of my patient encounters will not be specifically about vaccine-related issues, each episode of care allows the patient to see I am caring for them in a rational, thoughtful manner.

My practice numbers are small, but I estimate that 20 percent to 30 percent of unvaccinated kids who start with me become vaccinated within one year. I'd love to see that number above 50 percent and hope that longer relationships can achieve that. I recognize some people will not vaccinate no matter how much they trust me with their other health issues -- a frustrating paradox, for sure.

Ultimately, if we deny access, I fear vaccine skeptics' mistrust of mainstream medicine and the percentage of unvaccinated children will only grow. I think the only plausible way to convince a skeptical parent or patient is through a trusting relationship with a primary care physician.

How do you handle unvaccinated patients in your practice?

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

Monday Jan 25, 2016

In Family Medicine, Sometimes the Hoofbeats Are Zebras

How many times have you heard people say they want to work in subspecialty care because they think they might get bored if they choose a career in primary care?  

I have heard it from medical students, physician assistant students and nurse practitioners. I heard it from my classmates in medical school and from internal medicine residents during residency. I even heard it as a med student from a subspecialist who was determined to talk me out of pursuing family medicine.

Well, I’m happy to say that I haven't had a boring day yet. Even when it snows, the power is out, the phones don’t work, and I only see the few patients who brave the elements to get here, I’m not bored by family medicine. If nobody can reach my practice in rural West Virginia because of the weather, I’m still busy reading or writing appeal letters for durable medical equipment supplies or calculating weight loss plans for patients.

And I’ve always got a zebra I’m trying to figure out on the back burner. Any given family medicine office will have its share of rare disease cases -- "zebras on the commons" -- in the works, whether in conjunction with a specialist or on its own.

In medical school and residency, we are taught to rule out the common diagnoses before we move on to the rare disease workup. Common things are common. And that is all some people think family physicians and other primary care professionals do -- treat common diseases with common treatments. But we know that isn’t true.

During the past 18 months, I have found myself diagnosing and treating diseases that I thought only existed on board exams. Within my first month as a new physician, I was reading about connexin mutations because I have a patient with one. My family medicine colleague taught me about McArdle’s disease after one of her patients presented with muscle pain.

I don’t sit in my office treating hypertension with ACE inhibitors all day, or simply treating ear infections. Between seeing five patients with viral upper respiratory infections, I diagnose things -- really interesting things -- that change people’s lives forever.  

Patients with rare diagnoses typically have a long journey from symptom onset to diagnosis. They usually see multiple doctors. And patients often are upset about how long it takes to get to an accurate diagnosis. A recent KevinMD blog reminds us that basic physical exam findings shouldn't be discounted simply because they point to a less likely diagnosis.

The best part about being a family doctor is continuity. Most of us see patients over decades and have the benefit of knowing our patients well enough to recognize subtle changes. We also know when someone is truly sick, and we often know that in the context of their family history from first-hand experience. And when we can’t figure out the diagnosis, we don’t stop, we look harder, and we look for the zebras.  

I recently diagnosed a case of Behcet’s disease in a pediatric patient. It was the perfect example of a patient bouncing between subspecialists. Each physician was doing a wonderful job of assessing their own system of expertise, but they were not looking at the bigger picture. Each time my patient saw one of these physicians, I was relentless about getting each consult note, any labs or tests that were ordered, and talking to the patient's mom to get feedback. I spent hours reading this patient’s old hospital records, scouring over new labs and reading the literature about the differential diagnosis of some of his isolated complaints.

He was on my mind all the time, and every time I saw him it added another piece to his complicated puzzle. Then one day while driving to work it just clicked. I had a question on my family medicine boards that I had gone home and researched because I wasn’t sure I had gotten it right. I read about Behcet’s, and now that one board question led me to recognize this constellation of symptoms in this patient, despite him being far outside the expected age range for typical presentation.

When I got to work, I called the mom and told her to write the word Behcet’s on a piece of paper and hand it to the pediatric gastrointestinal specialist that her son was scheduled to see later that week. I also referred him to pediatric rheumatology.  

I tell this boy often that he has made me a much smarter doctor. He continues to teach me things as he starts new treatments and has new side effects. I didn’t diagnose him because I’m smart. Rather, I was able to narrow it down because I had a long time to think about it since he is my patient for the long haul.  

I have another patient who I’ve had the benefit of caring for even longer because she followed me from residency to my new office. She is the zebra of zebras. This month we thought we had finally diagnosed her with hereditary coproporphyria because all of her labs and symptoms were consistent with the diagnosis, and the hematologist even confirmed it and ordered hematin after reviewing her workup. She has had multiple surgeries, procedures, consults, imaging studies, medication trials, but even more heartbreak. She could write a book about what it feels like to have an undiagnosed rare disease if she had the energy to do so.  

But a genetic test didn’t confirm the diagnosis. There was no mutation to the coproporphyinogen oxidase gene. We were heartbroken together.

But unlike the innumerable subspecialists she has seen who have dismissed her as not having whatever disease it is that they happen to diagnose and treat, I will keep searching. Because I don’t treat diseases, I treat patients.  

And I’m definitely not bored.  

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Monday Jan 18, 2016

Doctor or Patient? Who Owns Medical Records?

Rachel (not her real name) has been a patient of mine for more than three years. She has a borderline personality disorder that makes it extremely difficult for her to create and sustain relationships and causes significant fluctuations in mood.

She suffered a serious stroke a few years ago, which further impaired her cognitive abilities. Her resultant extreme mood instability led to numerous suicide attempts. Some of them were not legitimate attempts, and she later admitted they were for attention. But there also have been times when she truly wanted to die. Her psychiatrist and I meet with her frequently to try to keep her as emotionally stable as possible.

Rachel will periodically ask to see her medical records. She has a legal right to these records, but there also is concern about how she may respond to seeing doctors' written opinions about her, particularly concerning her personality disorder.

The question of who owns medical information is a big issue. Should the physician or health system own it? Records represent our medical opinions on what is presented, and therefore are not necessarily property of the patient. But why shouldn't the individual own the records? It is completely about them and for them. The issue goes beyond medical notes. Lab work is a literal part of the patient; why should someone else own that?

Different states have different laws regarding ownership. Only one state, New Hampshire, explicitly gives ownership to patients, whereas most states have no law delineating custody of records. In Utah, where I practice, the physician and/or hospital owns the record, meaning that a patient must go through a hospital medical records department, oftentimes with considerable delay, to get their own information. Many systems provide limited access to information through Web portals such as MyChart. This grants a list of a patient's conditions that are listed in patient-friendly terms, medications, lab and imaging study results, and recommended preventive health measures. Basically, everything but reading their doctor's notes.

OpenNotes, an organization that encourages full patient access to their doctor's notes, has started a revolution in this area. More than 5 million patients from at least 20 institutions around the country have full and immediate access to their medical records. They log into a Web portal that allows them to see all of their health information, including what their doctor has written about them. The operative word here is their health information.

Many physicians have been nervous about this for various reasons. What will patients think? Will they be able to understand what is written? What about patients like Rachel? Could it truly be harmful for her to read the notes from her psychiatrist and me? A recent survey shows that two out of three physicians believe that they (i.e., the physician) should own the record.

But even many skeptical physicians have been pleasantly surprised by the results of allowing full access. In one published pilot project, the 105 primary care physicians who participated all wanted to continue its use by the end of the experiment. This pilot also showed significantly improved patient satisfaction and education, and it also was thought to contribute significantly to improved patient safety.

Despite initial concerns from many physicians, it is also believed that patient access to records will lead to fewer malpractice claims because of the increase in trust and transparency. OpenNotes represents a move away from medical paternalism and toward patient engagement.

Some are also concerned, however, that greater patient access could lead to confusion. The classic example is a physician using the acronym SOB. In medical terms it means shortness of breath, but there are other obvious interpretations that a patient may have. Physicians worry that they will have to spend more time explaining their notes to patients and less time on actual care. The pilot study mentioned above did not show that, but it's likely to take more widespread adoption before many cynics will buy in.

There is a pilot underway at Beth Israel Deaconess Medical Center in Boston allowing access to psychiatric notes. It will be interesting to see what it shows. It's possible that patients similar to Rachel will do just fine with more direct access to medical information.

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.

Monday Jan 11, 2016

Helicopter Parents Need to Know When to Land in Waiting Room

Scene: An exam room in a family physician's office.

Characters: A teenager, a parent and the physician.  

Setting: Teenager sits in the corner, engaged in his phone. Mother is likewise engaged. Physician enters the room, but the teen does not look up.

Physician, looking at teen: "I see that you are here because your knee has been hurting. Can you tell me about that?"

Teen does not make eye contact or answer, looking to his mother to answer the question.

Mother: "It started two days ago at basketball practice. He fell while doing a drill, and he immediately began complaining of pain."

Physician, again directing question at teen and addressing him by name: "Johnny, would you say that the pain is better, worse or the same since the injury?"

Teen shrugs shoulders and again looks to his mother to answer the question.

Mother: "He said that it was worse yesterday, but it feels a little better today."

We've all been here. Patient encounters with teenagers who A) don't get off the phone long enough to answer your questions, B) look to their parents to answer every question and/or C) try to answer but are interrupted or corrected by a parent.  

These are frustrating encounters, trying to develop a rapport and begin a patient/physician dialogue, but being stymied by the patient's parent. A recent study shows that beyond being irritating for us, this situation can be harmful for our teen patients.

A study conducted at the University of Michigan suggests that helicopter handling of health care by teens' parents impedes young patients from learning to care for themselves. The study showed that 89 percent of parents attended their teen's visits to the doctor, and two-thirds filled out their children's health history and other forms, either because they preferred to do so or because they thought their teens would be unable to. Only 15 percent of parents reported their teenagers independently share physical and emotional health concerns with their doctors, and the top reason parents gave for teens not being involved in discussing health problems is that they are not comfortable in that role.

But if we partner with parents, we can change that.  

Parents who control visits prevent teens from learning to take control of their own health. It also keeps them from raising important health issues, questions and concerns that their parents aren't even aware of.  

As parents, we want the best care possible for our children, and the tendency to take control stems from our desire to protect. However, if teens don't learn to talk with physicians about easy topics (upper respiratory infections, muscle strains, sprains, sports physicals, etc.), how can we expect them to feel comfortable talking to us about issues such as tobacco and alcohol use or contraception?  

We need to help our teen patients become more self-sufficient when it comes to their health care, and a 2013 study found that doing so can help lower risks for anxiety and depression and improve overall life satisfaction as they age.

I encourage parents to start giving their children some autonomy in their care during their preteen years. I try to pose all questions to the patient and wait for their answers before posing questions to the parents. If a parent starts to answer for the teen, I politely ask them if I can hear the patient's answers first, and then have them help me fill in the gaps.  

At yearly well-child or sports physical visits for kids in this age group, I begin discussing with parents that I like an opportunity during these visits to speak with the patient one-on-one. Most parents are receptive to this, and they understand there are likely questions that their child may not feel comfortable asking them that they may be willing to ask me, but only if they are comfortable speaking to me. If the idea of speaking with their doctor is intimidating because they have never asked a physician a question, they are unlikely to open up to me. On the other hand, if they have been asking questions of their physician during visits since childhood, and answering questions posed by their physician, this interaction will feel familiar.  

Setting the expectation that they will have time alone to discuss their concerns with me allows them to think about questions they may have before the appointment.  

Beyond asking questions of their physician, teens need to be familiar with their own health history, as well as their family health history. One form that many parents fill out yearly is the sports physical form. There are many questions and places to write in responses. I encourage parents to sit down with their child and fill this form out together, having the child record the answers. This is a great place to start acquainting them with medical questions and wording and ensure that they understand their health history.  

I also encourage parents to have their child fill out the yearly clinic paperwork required. If parents are comfortable with it and do not have specific concerns, I encourage them to have their teens come to their sports physicals and other routine visits by themselves. It shows that their parents have trust in them to take an active role in their own care and begins the transition to adulthood.

When discussing things such as testing, it helps to make the teen an active participant in the explanation and decision-making process. Encourage the teen to ask questions about any decisions being made so that he or she feels treatment is being done for -- not to -- him or her.

Developing relationships with my teen patients as individuals has enabled me to have a more effective and rewarding relationship with them. I have maintained relationships with many patients as they headed off to college, seeing them when they are back in town on breaks and keeping in email contact with them on issues related to health, but also answering their questions about college and careers.  

As family physicians, we have a unique opportunity to help our teen patients grow into independent adults. The most important tool we can use to achieve this is simple self-awareness in our patient encounters -- addressing patients directly, encouraging them to answer questions and ask their own, and making speaking to teens alone a normal part of office visits. Although a bit more time-consuming, these changes can expand our impact on our teen patients' health and development in a way that will serve them well in the future.

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

Tuesday Jan 05, 2016

Looking for a Hero: Kids Need Medical Role Models

One of my community's elementary schools invites local professionals in every Friday to speak about their jobs and answer kids' questions. Although the program is designed primarily to introduce children to varied professions, it also serves as an introduction to local professionals and possible mentors. Student attendance is voluntary, so those who participate show interest, even if they don't all ask questions.

The school recently invited me to speak to a group of fourth- and fifth-grade students about being a physician. There were the typical questions about salary and education. They asked about other specialties and allied health professions such as physical therapy. But many questions focused on specific diseases or disorders. Multiple students asked about problems facing their families and friends. They asked about pneumonia and other infections. They even asked about medical anomalies they themselves faced. 

Although health professionals are concerned about the Health Insurance Portability and Accountability Act and privacy rights, these kids weren't worried about who knew their problems. The students just wanted to know as much as possible about the challenges they face.

As I discussed health issues such as abscesses and broken limbs, I realized how little education some of these students had received about even the basic functioning of the body. Although they all seemed to grasp the answers I gave, each question led to many more, and we had to limit ourselves somewhat because of the time we had available.

And then it dawned on me. They -- just like their parents -- are victims of the same time constraints placed on primary care physicians. Likely, these children have never had the opportunity to ask their questions in a comfortable setting. Much like the five-minute office visits that have become all too common, there had been no time for these young minds to be curious without an agenda. We fill up our days with curriculum and planning, both in and out of the classroom. We've sacrificed the time to be curious.

We as physicians serve a hugely important role as educators. This knowledge we gained is not to be hoarded, but shared. Inherent in our job description is arming patients with appropriate knowledge and preparation. Too often we can choose the easy path of "do it because I said so," whether because of time constraints or our own limited understanding, but we owe it to our patients to equip them to deal with their maladies.

In multiple languages, the word for doctor and the word for teacher derive from the same root. Traditionally, medical knowledge was passed from one teacher to only a single or select few apprentices. The traditional Hippocratic Oath even begins with the following passage:

"I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary for his support, and will consider his sons as brothers. I will teach them my art without reward or agreement; and I will impart all my acquirement, instructions, and whatever I know, to my master's children, as to my own; and likewise to all my pupils, who shall bind and tie themselves by a professional oath, but to none else."

Teaching persists as an integral part of medical education and practice. From our first days as medical students, we are indoctrinated with the directive "See one, do one, teach one." Inherent in this phrase is the message that teaching someone a skill ranks equally in importance with the ability to perform the skill ourselves. Teaching the details, preparing for questions, and cultivating the ability to adequately communicate the intricacies of even the simplest procedures or concepts requires a high level of understanding. This includes the education of not only students and residents, but of our patients, as well.

Much like the students with whom I conversed, many patients are innately curious about their disease processes. We must take care not to stifle that curiosity but devise innovative ways for teaching and fostering education within the bounds of the current system. Although time constraints and economic concerns dictate parts of our practice, we must keep looking forward to better systems that will eventually replace the broken pieces. Whether through social media, group classes or some fledgling technology such as augmented reality, we need new tools for education and sharing information.

Education researchers in the 1950s demonstrated a correlation between increased curiosity and improved learning and retention. Think about the things you recall even after decades have passed. Nearly all of them relate to things that piqued your interest. I grew up watching scientists like Mr. Wizard and Bill Nye the Science Guy conduct experiments on television. I had teachers and physicians who taught me about the world around me and inside me. Without access to those individuals, I may have chosen another career path entirely.

One oft-proposed solution for physician shortages centers on starting recruitment and increasing student interest early in the education process. With the growing interest in science, technology, engineering, art and mathematics (STEAM) education, there has never been a better time to begin introducing medicine, especially the concept of whole-patient primary care -- family medicine -- to the next generation. Why not strike when naturally curious students are looking for answers? We need science heroes like the athletes and media personalities that our children often idolize.

We have thousands of well-qualified, intelligent physicians in communities across the country who appear ready and willing to lead that charge. AAFP President Wanda Filer, M.D., M.B.A., for example, has appeared on The Dr. Oz Show twice in the past nine months, discussing the importance of primary care and the dangers of prescription drug abuse. Regardless of what you think of that particular venue, there's no denying the fact that the platform allowed her to reach millions of viewers with those key messages.

We can talk to our young patients about their career goals and interests, but we also can look for broader opportunities in our local schools and through groups like the YMCA, Boys and Girls Clubs, etc. Physicians are in a unique position to be an inspiration for not only the young people we see, but also for patients of all ages. We can encourage their curiosity and give them tools they need to succeed and lead healthy lives.

Do you have suggestions or stories about how you've included education inside or outside your practice? Sound off in the comments 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.

Tuesday Dec 22, 2015

Family Physicians Can Help When Holidays Aren't Merry

Happy holidays?

My clinic, like many, is festively decorated for the holidays. At the end of a visit, my patients often wish me a Merry Christmas. In general, this time of year is known for its holiday cheer and all that comes with it -- good food, fun parties, time off and being with the people you love.

But it's not a happy holiday for everyone. This time of year can be extremely stressful. For some patients, the holidays trigger anxiety and worsen depression. Financial concerns (Can I afford all these gifts?), relationship issues (Can I avoid family conflicts?) and work pressures (Will I meet all those end-of-the-year deadlines?) can have a cumulative effect.

Many people are remembering the loved ones they've lost, while others aren't able to travel to be with their families. Even for patients who don't have an underlying mental health condition -- but particularly for those who do -- the holidays can bring an overwhelming flurry of activity and demands on their time and emotions. All the commercials, songs and decorations are constant reminders and possible triggers.

For patients with chronic medical conditions such as diabetes, hypertension or obesity, the onslaught of unhealthy foods can add an extra challenge to making it through the season.

And let us not forget that there are patients who do not celebrate anything that "Happy Holidays" encompasses.

So how do we as physicians avoid contributing to the stressors our patients might be experiencing? Moreover, what can we do to screen, monitor and support our patients who are struggling this time of year?

We can start with cultivating awareness during each encounter and among our staff. Make an effort to ensure your routine screening for depression is, in fact, happening appropriately. (The AAFP recommends screening provided that support services are available.) In your encounter, take a moment to ask an open-ended question such as, "Do you have any plans for this holiday season?"

For patients who are struggling with their weight, diabetes or high blood pressure, help them develop a plan for eating some of the foods they love and that they think make the holidays more special, but in a way that doesn't derail their overall health goals. Emphasize that eating well (and getting exercise) during stressful times can help them feel better.

Offer ways to manage stress with simple breathing techniques or meditation or by listening to calming music or going for a walk. YouTube (for patients who have access to the Internet) is a great free resource for finding meditation, yoga and mindfulness techniques that can be tailored to whatever time restrictions your patients have. Give your patients a prescription -- virtual or paper -- to take at least five minutes a day for themselves.

For patients who mention feeling lonely or withdrawing from events because they find them too overwhelming, find out if they have friends or family they can reach out to who might be willing to get together on a smaller scale. Connecting with people one-on-one or in a less intimidating setting can help them feel less alone.

If a patient is worried about the financial stress of buying presents, you might suggest giving gifts of time or experiences, such as "gift certificates" that can be redeemed for spending a day together or taking routine walks together. Remind them that homemade gifts are often more heartfelt and appreciated.

A common misconception that is perpetuated in many articles is that suicide rates increase during this time of year. In fact, the opposite is true. According to the CDC, suicide rates are lowest during the holidays. So remember to ask the appropriate questions and follow up if someone does have suicidal thoughts or a plan, but know that the time of year does not necessarily put your patients at increased risk.

Ultimately, we all want to take advantage of all the good things the season can bring. Being sensitive to our patients' potential conditions and offering our support will, hopefully, help keep as many people as possible in good spirits.

So on that note, take a few deep breaths and think about the things that bring you joy this time of year. And may you all have the happiest of holidays, however you choose to celebrate!

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.

Tuesday Dec 15, 2015

Can Physicians Save Patients From Violent Deaths?

"Do you have a family history of sudden death?"

In medical school, I learned to ask my patients this standard prompt during sports physicals, in search of possible hypertrophic cardiomyopathy. Their answers often surprised me.

Many of my patients do have relatives who suffered a "sudden, unexplained death," often the result of a murder or suicide. Which feels, in a way, utterly unexplainable.

Violence certainly isn't unique to any particular country or demographic, although some communities are at higher risk than others. Gun violence, in particular, has commanded recent headlines. Our culture is peppered with violence in many forms: intimate partner violence, bullying, hate crimes, gang violence, sexual assault, elder and child abuse, and others.

The impact of violence, including deliberate self-harm, is overwhelming: According to the CDC, almost 60,000 Americans die each year as the result of homicides or suicides.

There are nonfatal consequences of violence, as well. In addition to the emotional impact on victims of violence and their families, the CDC estimates medical and productivity costs associated with violence exceed $70 billion annually.

It is difficult to get through a day without seeing another fatal beating, another shooting, another self-inflicted fatality on the news. But are these deaths preventable?

Advocacy Efforts Decrease Accidental Deaths
In public health terms, deaths from violence technically fall under the broader category of injuries. "Accidental" injuries that result in death include car accidents, burns, poisonings, drowning, falls and so on. There are only two types of "intentional" injuries that result in death: suicides and homicides.

Physicians have historically been leaders in the campaigns and public policy changes that reduce accidental injuries. In 1984, New York was the first state to pass a law requiring drivers and front-seat passengers to wear seat belts, an effort led by physicians and public health advocacy groups. Since then, the other 49 states followed suit, and seat belt use jumped from 11 percent in 1981 to 85 percent in 2010. Seat belts have saved an estimated 255,000 lives since 1975.

Although it seems like common sense now, the battle over mandating seat belts was initially contentious in the face of arguments about personal autonomy, coupled with the high cost to car manufactures to meet certain safety standards. However, diverse groups came together -- including auto insurance companies -- to provide research and education on the societal impact of seat belts.

An array of grassroots groups also came together to tackle deaths from fires, including parents, fire chiefs, physicians and politicians. Fire-prevention efforts, including nearly 400 local ordinances requiring residential sprinklers, smoke alarm legislation and fire education, have resulted in a 26.5 percent decrease in fire-related fatalities in a 10-year period.

Similarly, drowning deaths have dropped significantly since 1985 thanks to greater use of pool fencing, water-entry alarms, pool covers, lifeguards and CPR training -- to say nothing of more adult supervision -- according to a the American Academy of Pediatrics.

These public health successes resulted from careful data collection and research into pilot interventions. The evidence led to advocacy and policy changes.

Investing in Mental Health
More than 500,000 Americans call in sick -- or are impaired on the job -- every day because of depression, according to the Harvard Business Review, which recently called for employers to offer free and anonymous screenings.

There is an overwhelming body of evidence that supports screening for depression in adolescents and adults, including pregnant and postpartum women. New York City's public hospital system recently announced it is making depression screening universal for pregnant women and new moms. Such screenings can lead to early disease detection and interventions such as counseling and medication. But patients diagnosed with depression need a continued collaborative approach to their care. Roughly 45 percent of people who commit suicide visit their primary care doctor in the month before their death. It is prudent for physicians to always ask their patients about thoughts of hopelessness, self-harm and death when screening for depression.

Moving beyond what an individual physician can do to prevent suicide, evidence shows that system-wide changes can be extremely successful. The U.S. Air Force implemented a comprehensive approach to suicide prevention that included education, rapid intervention teams and a buddy system. Followup analysis showed a significant reduction in suicide rates in that branch of the military.

Unfortunately, however, suicide rates are increasing in the general population, and suicide is the 10th leading cause of death in the United States, according to the latest figures. Physician groups should advocate that more research be conducted on prevention strategies, and the country needs to invest more in mental health, because access to these resources is often key to prevention.

Approaching Homicide as a Public Health Problem
Homicides are even more complicated. These deaths often involve interpersonal violence among individuals -- whether known or unknown to the victim -- such as community violence, child/elder abuse, intimate partner violence, bullying and sexual assault. Homicides can also involve collective violence -- which may be social, political or economic in nature -- such as hate crimes, terrorism, gang behavior, war and human trafficking.

Changing the trajectory of intentional causes of deaths is a daunting challenge, but it's not impossible. The responsibility can't simply fall on politicians, religious leaders, physicians or any other group of individuals. To achieve success, society as a whole must tackle this problem.

And just like every other public health issue addressed above, reducing homicides starts with collecting data and studying pilot interventions.

The World Health Organization already has a multifaceted strategy to reduce violence globally that includes fostering healthy relationships between parents and children; helping youth develop life skills; reducing access to alcohol, guns, knives, poisons and other lethal means; promoting gender equality to prevent violence against women; changing cultural norms that support violence; and increasing social support programs.

As family physicians, we can have a powerful impact on childhood development. We can ask parents about spanking and have an open conversation with them about discipline. We can promote comprehensive sex education that emphasizes healthy relationships between partners. And in the vast majority of cases, we can inquire about safety and offer support or resources to those in need.

Although the evidence on screening every single patient for violence and abuse is limited, certain populations should be asked.

And, of course, we can continue to be leaders in the community by launching or joining grassroots efforts that are seeking solutions to violence.

Although there isn't any single solution to this issue, violence is a learned behavior and can be changed. We have seen success when we define and truly understand the challenges we are facing.

Mostly importantly, I hope Americans continue to ask themselves, "What else can we do?" And then work to make it happen.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.

Tuesday Dec 08, 2015

A Food Desert Reveals Much About Health -- and Community

When the only grocery store in my county closed earlier this year, many of my patients resorted to eating food purchased from gas stations and dollar stores. Morale was pretty low, and so was the nutritional quality of available food.

I reviewed the data on grocery stores, access to produce, farmers markets and obesity to see what the closing would mean to the health of my community, but what I didn't anticipate was a lost sense of community -- or how easy that is to restore.

My office partner worried about kids who rely on school-based nutrition programs going without food during summer vacation, but a few weeks before school let out, flyers appeared around town promoting free snacks and lunches for school-aged children at a building downtown. The same organization that stepped up to feed the children (a nonprofit that provides in-home care) also arranged for bus transportation to grocery stores in a neighboring county. Individuals could pay $7 for a round-trip ride to the grocery store. Given the distance (about 45 miles each way), the cost per ride wasn't much more than the cost of gas.

It turns out we aren't alone. A growing number of small towns in West Virginia have lost their local grocery stores in recent years, but creative community-based efforts are trying to fill the void.

Based on the literature regarding the link between access to nutritious food and obesity reduction, I was excited to see the greenhouse just outside town post a big, hand-painted sign that said "Fresh Produce." A family-owned business built the greenhouse before the grocery store closed and had been selling things like hanging baskets and garden plants. Adding fresh produce to the greenhouse's offerings was a huge asset to the town during the summer, and most of my patients took advantage.

I ask my patients questions about food all the time: What did they eat that day? Where do they buy food? Who cooks their meals? Who in their family hunts (and for what)? Do they have a garden? Part of this is self-motivated interest in food and the culture surrounding food, but it's also a natural way to learn about my patients' health.

I worry about the functional status of many of my older patients, but some bristle at questions such as, "Can you walk two blocks without becoming short of breath?" We can still have a conversation, though, so I ask how many quarts they were able to can the last time they processed something, and when that was. If one of my elderly ladies says she had to stop canning for any reason other than arthritis, I get worried. So I ask about canning in the summer and carrying firewood in the winter to assess my patients. They are proud of how they live, and most of their sustainable ways of living weren't affected by the grocery store closing. But even those people who didn't need a ride to a far-away store felt better knowing their neighbors and friends had access to a store if they needed it.

This fall, I changed the treatment plan for one of my patients because he told me he left the woods on the opening day of deer season. People here are willing to miss Thanksgiving dinner, work, school, doctor's appointments and more for opening day, so I knew this guy was really sick. His symptoms seemed like run-of-the-mill allergic rhinitis, or maybe a cold, but for him to leave the woods without a deer, I knew he had to have an abscess in there somewhere. Hunting is in part for the trophy, but the majority of my patients -- and West Virginians in general -- hunt to fill their freezers for the year. There is no school here during the opening week of deer season because attendance would be too low.

Although food deserts remain a big problem in my state, the good news locally is that my community has a grocery store again, and it is wonderful. On the day the new store opened, I walked there at lunch and bought fresh-cut fruit and a cup of yogurt, which was probably the healthiest lunch I'd had in months. I walk to the store from my office a few times a week, and although it might seem hokey, there is a sense of excitement and community about the place, largely because I remember how we felt without it.

Before the store opened, people would go stand outside, knock on the doors and windows and ask if the people working inside could sell them anything. I doubt many went hungry, but people did long for real, healthy food.

Like anywhere else I go in our small town, I often see my patients in the new store. Last week I heard someone calling, "Dr. Becher?" down the aisle, and I answered the woman although I didn't recognize her. She had walked into the store and asked a cashier to help her pick out groceries because she had been told her cholesterol was too high. The cashier knew I was in the store and suggested the woman find me instead. First, I asked her what her LDL was. She reported it was 130 and I thought to myself, "Well, that's pretty darn good." But I proceeded to suggest some things, such as using healthier oils rather than shortening.

The electricity was out that day, so the store was quiet, and everyone in the building could hear every word the two of us said to each other. There are moments that I know I'll never forget and look back on as quintessential small-town doctor moments, and talking with that lady in the dimly lit baking aisle will always be one of them. My interaction with that woman -- and the fact that our town again has a grocery store that can help her live a longer, healthier life -- still make me smile.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Tuesday Dec 01, 2015

High Costs (and Profits) of Prescription Drugs Make Me Sick

Reggie is a spunky, 38-year-old patient of mine who makes my clinic day more enjoyable. His collection of chronic health problems -- including type 2 diabetes, near-complete hearing loss, bipolar disorder, active hepatitis C from prior IV drug use with no current liver fibrosis and chronic migraines -- certainly make life more difficult for him, making his buoyant personality all the more remarkable.

Reggie and I have been working on these conditions since I started practice a few years ago -- well, except for the hepatitis C, even though he does have a treatable strain. Because many of his other conditions would likely be significantly worsened by the standard treatment regimen of interferon and ribavirin, he has never been a good candidate for therapy.

You can imagine my excitement when many new treatment regimens with considerably fewer side effects began receiving FDA approval, beginning with sofosbuvir (Sovaldi) and simeprevir (Olysio) in 2013. I began coordinating with a hepatologist at that point to get Reggie the care he needed, but we quickly discovered that none of these regimens would be approved for him because of the exorbitant cost, reportedly more than $84,000 for a 12-week treatment course. Reggie is covered by both Medicaid and Medicare, but neither payer would cover the cost because, ironically, his disease had not yet progressed far enough.

Likely every family physician has stories like this, whether about patients with hepatitis C or other conditions requiring expensive medications. If every person in Utah afflicted with active hepatitis C disease were to receive treatment with Sovaldi, it would consume the entire Medicaid budget for my state. The average cost of medications for complicated conditions such as cancer, rheumatoid arthritis and multiple sclerosis is now higher than the median household income in the United States. So it's no surprise that rising prescription drug costs are now the biggest health care concern for the general public.

After years of ignoring the problem (and, in some cases, contributing to it), politicians and policymakers have started discussing the crisis. HHS recently hosted a summit on prescription drug prices. Presidential candidates have weighed in on the topic in their stump speeches and debates. A Senate committee recently grilled President Obama’s nominee to head the FDA on this issue. All this may or may not lead to change, but at least the issue is reaching a national level of discourse.

But what has led to exorbitant price increases in medications? Why do Americans pay so much more for the exact same medications than do patients in other countries? There are multiple likely culprits:

  • Price of innovation -- It simply costs money to come up with new, effective medications, but how much is “reasonable” for a company to spend on research and development of new drugs is a controversial question. Many think that the investment drug companies claim to make in R&D is an excuse to reap higher profits, whereas others argue it is simply the cost of doing business.
  • Direct-to-consumer advertising -- The FDA loosened regulations on advertising pharmaceutical products directly to patients in 1999. There has been a significant increase in drug prices since that time, but it is unknown if the agency's action was the cause. The AMA recently came out against this practice as have many patient advocacy groups, and the AAFP says direct-to-consumer ads should not mention prescription drugs by name.
  • Patent laws -- Many laws passed during the past two or three decades have lengthened the life of pharmaceutical patents. This keeps generic medications from coming to market until much later, allowing the developing company a larger profit on its product. And 27 percent of generic medications increased in price in 2013, including the long-time generic medications doxycycline and pravastatin. Because of this, it is unclear if changing patent laws would significantly decrease prices.
  • Changing insurance market -- The long-term trend in health insurance is leading to more out-of-pocket costs, including those for medications. Patients may be simply more aware now of the high costs of medication.
  • Medicare restrictions on price negotiations -- Medicare is prohibited from directly negotiating drug prices with pharmaceutical companies, leading to significantly higher prices compared with those of national systems in countries that do negotiate prices. Correcting this is one of the most widely discussed potential solutions, likely because it is in direct control of the federal government, and because the bulk buying power of Medicare could significantly alter drug costs in the United States. For these reasons, it is my opinion that this is the most likely first step to be taken in addressing the problem.
  • Reimportation ban -- It is illegal to reimport medications from other countries for cheaper sale. Many Americans do travel elsewhere, particularly to Canada, to buy prescription drugs, but opponents claim that raises potential safety issues. Whether that is a significant concern or not, the limited supply of medications in other countries makes reimportation an unrealistic solution on a broad scale.

So what about Reggie and treatment for his hepatitis C? I have tried multiple avenues, but there is likely no hope for getting any appropriate regimen covered for him at this time. There is a limit to what I can do for my patients. Many pharmaceutical companies offer rebate or discount programs for medications, and occasionally, direct appeals to insurance companies (beyond prior authorizations) can be successful, but there is no easy fix to this problem.

Considering the immense power of the pharmaceutical lobby, the solution may need to come from patients up, instead of from the government down.  

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

Tuesday Nov 24, 2015

Moving On: Finding the Right Job Worth the Effort

Starting over is scary.

After surviving college, medical school and residency -- and the many moves and transitions that come with those stages of our training -- the last thing we want is more upheaval. We finally have some stability, more income and something resembling a routine. We make connections with colleagues and build a patient panel.

So when things aren't ideal and payers and others are making life difficult, physicians often stick it out. We feel obligations to our communities, our practices and our patients.

But sometimes, we have to go. We have to do what is best for our careers and our families.

And sometimes you have to follow your heart.

In August, I moved from Reno, Nev., to the Seattle area, leaving behind the community where I had completed medical school, residency and then practiced for four years. I delivered babies in residency and had those families follow me into private practice. I developed relationships not only with my patients but also the medical community in my city and state. I built a reputation in the community. I knew the payers, the specialists and the layout of the community hospitals. I had a safety net and a village of medical support at my fingertips should I experience a difficult case.

In Seattle, I knew my new husband and … hardly anyone else. I knew nothing of the medical community or culture in this area. I had no local colleagues to vouch for my abilities as a physician. I now had to re-establish myself and my practice and go through the process of figuring out what type of practice would suit me.

So how do you find not only a job but the right job? I knew the change was coming, so when I attended AAFP events -- such as the Congress of Delegates or the National Conference of Constituency Leaders -- I sought out the Washington delegates, told them about the move I was pondering and asked about potential employers I should look at it. I also reached out to a few old med school and residency friends who had relocated here for advice on local groups they worked with.

That meant my job search was based on networking and informed opinions rather than random Internet searches and the biased opinions of recruiters. I visited many clinics, spoke to many employees of all ranks within those teams, and in the end I found a place that fits how I practice and has a better flow, organizational goal and payer mix than the practice I left.

Keeping an open mind helps, too. At my old practice, I had a dedicated medical assistant (MA). We had a traditional system where patients checked in at the front desk and then had a seat in the waiting room. In my new practice, the MAs rotate among the physicians, and patients are checked in directly to rooms. There were other changes to adapt to, including how we handle referrals and phone triage. But ultimately, patient flow is improved and everyone on our staff works to the highest level of their training. That's a refreshing change that allows me to spend more of my time with patients.

Starting over, of course, brings new challenges. I'm building a new patient panel and starting new relationships. I'm learning a new set of subspecialists for when my patients need care that I can't provide. I rely more on my colleagues to ensure I am performing tasks in the right flow for this clinic. I’m learning a new electronic health record (EHR) system while still having to perform meaningful use measures.

There also were numerous hoops to jump through. I had to find my transcripts from medical school and the U.S. Medical Licensing Examination to go through the Washington state medical boards to obtain my new license. I needed signatures from the residency and hospitals where I had privileges in Nevada. I needed to go through orientation again and EHR training.

There were numerous tedious steps to get through in the credentialing process, and I have to prove myself again in the privileging process.

I learned through this process that moving in general is a stressful time, but finding and establishing a new practice has its own set of stressors. Many of them are logistical -- licensing and finding a good fit for what you want in a practice. I found that using a spreadsheet to compare each practice helped me visualize what each clinic offered in terms of payers, practice type, EHR, etc. Although it was tiring at times, I was able to obtain a great amount of knowledge on the culture and relationships of each practice by approaching and talking with all members of the teams.

I also realized that I was not a physician fresh out of residency and therefore was able to negotiate compensation differently than I did four years ago.

Moving across state lines can be challenging for physicians, but it can be done. And you might just find a better life on the other side.

Helen Gray, M.D., is an employed family physician in Kirkland, Wash., working in a regional medical center.

Wednesday Nov 18, 2015

They're (Usually) Not Doctors, but They Play Them on TV

When I was an undergrad, I decided to pursue my emergency medical technician license at a nearby community college. I would get home from class each week just in time to watch ER. I joked with my roommates that I had to watch it as homework. I got excited when I started to understand what the doctors, nurses and others were talking about and could point out the show's medical inconsistencies and mistakes.

Helga Esteb/
Actor Ken Jeong, M.D., a former internist, arrives at a Hollywood premier with his wife, family physician Tran Ho, M.D. Jeong plays the title role in the new sitcom Dr. Ken.

Numerous medical programs have come and gone in the 21 years since ER began its 15-year run, but more often than not, TV still gets it wrong. Most medical dramas glorify and romanticize physicians' relationships with each other, nurses and even patients. These shows also manage to get so many things wrong about medicine that it leaves you wondering if the writers even bothered to have a medical team review their scripts.

Ironically, the only show in recent years that demonstrated any medical accuracy was Scrubs, a goofy comedy that did not take itself seriously.

There are a host of new medical shows making their debuts this fall. Will they be any more realistic?

  • Code Black takes place in the Los Angeles County Hospital ER and is based on a documentary by the same name.
  • Heartbreaker is based on the experiences of a real-life heart surgeon.
  • Chicago Med is a sister show to Chicago Fire and Chicago P.D. that is set in a trauma center.
  • Dr. Ken is the lone sitcom among the new medical shows and features physician-turned-actor Ken Jeong, M.D., probably best known for his roles in the Hangover movies.

It's worth thinking about the impact TV medical shows may have on our patients and whether physicians should be concerned about how our profession is portrayed. Everyone knows these shows are unrealistic … right? NBC, for example, gushes that the main character on Heartbreaker has "a racy personal life that's a full-time job in itself."


I'm not worried that my patients think I sneaked away to supply closets for romantic escapades during my training. But could these shows be contributing to unrealistic expectations of what medicine can actually do? Do they glorify saving lives in the ER setting? Do these shows negatively impact our attempts to educate patients about the importance of primary and preventive care?

During residency, when we admitted patients and discussed their code status preferences, I often found myself wondering how TV portrayals of CPR were affecting their decisions. As the Radiolab podcast article "The Bitter End" discusses, there is a huge discrepancy between what doctors would chose at the end of their lives versus what patients choose. And this is largely because we know realistically what CPR does and doesn't do. One study found that 75 percent of patients on TV are successfully resuscitated, and 67 percent survive long enough to be discharged from the hospital. The reality is that only about 40 percent of CPR administered in the hospital is successful, and a mere 10 percent to 20 percent of patients live to be discharged.

So when it comes to addressing what medicine can offer my patients, I often tell them that what they have seen on TV is not in line with what I have seen in real life.

As I watched a clip from Code Black, a comment about "saving someone's life" reminded me of friends who have said to me -- while discussing their own stressful days -- "Well, it isn't like I was saving lives like you, but … "

Our roles as family physicians are crucial as we strive to improve the health of our country. An ad for One Medical Group, which uses a novel approach to delivering primary care, came on while I was writing this very piece and wondering why there are no television shows about primary care. The answer, unfortunately, is because watching a patient sit in a waiting room or discussing Pap smear results doesn't make for an entertaining show.

The way that we as family physicians save lives is often not what our friends, family and patients might expect based on what they see on TV. And the tools we use to do it are not necessarily the CT scans, frequently excessive labs and involvement of several subspecialists that are the norm in TV dramas that fail to emphasize patient-centered care and clinical skills.

But there may be some hope for how medicine is portrayed on TV. The executive producer for Code Black, Ryan McGarry, M.D., is the ER physician who directed the documentary that the new show is based on. Before filming ever started, the show's cast went through a medical bootcamp, and the actors actually work 12-hour shifts to reflect conditions that one might experience as a resident physician or a nurse. So although the dramatic "saving lives in the ER" aspect is still present -- against the backdrop of one of the busiest ERs in the country -- at least there is an attempt at medical accuracy.

It's worth noting that the sitcom Dr. Ken does not take place solely in the main character's primary care clinic because the show also is about his role as a father and husband -- like so many of my colleagues' lives are. When he tries to make his job sound important, his wife -- a therapist -- angrily retorts that "it's family medicine, not the ER."

Although that snippet of dialogue was disappointing, the pilot episode demonstrated the true significance of having a family physician. Dr. Ken sends a patient for a colonoscopy and receives a letter of gratitude because the polyp that was removed could have been "fatal." Perhaps TV's Dr. Ken -- who in real-life is an internist married to a family physician -- will expose our patients to the importance of making health primary.

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.

Tuesday Nov 10, 2015

Cut the Jargon and Let Patients Hear What You're Saying

The X-ray report made sense to me. It was a hairline fracture. I hurried to tell the patient in emergency department room No. 3 the news.

"Are you sure?" he asked. "I didn't even injure my head."

I sheepishly clarified what a hairline fracture was and silently scolded myself for falling into the trap of using medical jargon.

For a seemingly straightforward profession, the language of medicine is deceivingly vibrant. We are taught an endless barrage of culinary medical metaphors in our early education: the currant jelly stool of intussusception, the port wine stain of a capillary malformation, the cottage cheese discharge of vaginal candidiasis, the strawberry tongue of Kawasaki disease.

Do your patients know that when it comes to medical tests negative results are actually positive news? This scene from "The Office" offers a reminder that people can be confused by what seems like straightforward communication.

Medical school is a paradox of changing the language we speak while at the same time struggling to enhance our cognizance of broader populations. Unfortunately, communication skills actually decline as students progress through their education. As a result, entire lectures in medical school are devoted to communication: working within interdisciplinary teams, breaking bad news, avoiding medical errors. But gaps in communication permeate every corner of our profession.

The way we communicate often makes little sense to patients. Negative test results are actually a good thing. A patient being transferred from the ICU to the "floor" may not even change floors when switching units. By now, car insurance companies probably understand what a "restrained driver in an MVA" refers to, but patients likely do not. It's all jargon sprinkled with cultural slang.

One of the most deeply ingrained metaphors in medicine is the "war" with this or that disease. When doctors diagnose and discuss treatment for cancer, it is framed as a battle. Many patients with cancer embrace this metaphor -- they describe themselves as fighters and survivors. But on their death, I cringe when others describe it as a battle lost. My patient with cancer who died shouldn't be reduced to a cliché because society is uncomfortable with direct terms.

It's not necessarily that all metaphors negatively affect our dealings with patients. In fact, one study found physicians who use metaphors had better patient ratings regarding communication. However, our imprudent use of language has the potential to influence patient decisions. This is especially obvious when it comes to end-of-life conversations.

When a physician asks if a patient wants "everything done" or "heroic efforts," it's difficult to say no. After all, don't all patients deserve heroes? Even the term "DNR" elicits inaccurate thoughts of isolation, of a journey where physicians exit and the patient drives alone -- although that is simply not true.

Rather, it is better to frame end-of-life discussions in terms of patients' values. Ask them if they would prefer to allow natural death. Explain that "life support" is actually organ support. Most importantly, listen. The role of clear communication is most critical during challenging times when even the most basic uses of our ingrained vernacular can lead to confusion.

Although physicians carry the responsibility of appropriately guiding patients, the extra effort we make in conveying a clear message will ultimately change the doctor-patient relationship into a partnership.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.

Wednesday Nov 04, 2015

30-hour Shifts? Only If It Makes Us Better Physicians

When new rules for medical residents were implemented four years ago, the Accreditation Council for Graduate Medical Education limited interns to 16-hour shifts. But at dozens of U.S. hospitals, first-year internal medicine residents are working 30-hour shifts in a study that's taking yet another look at resident work hours.

The 2011 rules were an update to guidelines set in 2003. Each revision has provided more data for accurate assessment of work hours on performance and patient safety. Today's interns -- excluding those in the study -- may work only 16 hours per shift and a total of no more than 80 hours in a week.

From the outside world, where a 40-hour week is considered the norm, this still seems like a lot, especially given that there are only 168 hours in a week. For those physicians who trained before the restrictions went into effect, however, there are significant concerns about the level of experience and education that newer trainees receive.

The original restrictions, put in place in 2003, were intended to combat mental fatigue and trainee errors. Initially, the collected data painted a picture of little or no change, but more recent trends have suggested a subtle decrease in mortality Granted, there are several possible confounders, including increasing use of electronic health records, better access to medical knowledge databases, and improved understanding of disease processes, but the overall trend in mortality for patients cared for by residents appears favorable.

That bodes well for the process, but it’s only one metric. Questions remain about the impact the duty-hour changes have on the knowledge and training of new physicians. United States Medical Licensing Examination scores have remained consistent but there are so many potentially confounding variables that this means little. Many other possible metrics, such as trainee confidence or bedside manner, are also exceedingly difficult to measure accurately.

One of the biggest concerns is the possibility that the restriction of work hours will generate more errors during patient handoffs. For most residents, the greatest chance for forgotten information comes during the transfer of care from one physician to another. We collect reams of data on each patient and order multiple tests that may not be performed until after checkout, making it imperative that we communicate as much pertinent information as possible. Even the most meticulous handoff procedure may miss some details. And more frequent handoffs, which are necessitated by work-hour restrictions, can compound these errors of omission and potentially negate the benefits gained from reducing fatigue. There are several studies looking at handoff procedures and the best way to minimize errors, but so far no one model has prevailed.

The other big concern among duty-hour restriction detractors centers on the decreased exposure to complicated pathology in the early years of training and subsequent deficiencies in education and confidence. As an intern during the initial 80-hour work week rules (2008), I personally saw more pathology on overnight call than during daytime call. I suspect this is because it is more likely that more complex patients will be evaluated and admitted by specialists during daytime hours, but a quick literature search found no specific supporting evidence. Regardless of the reason, there were far more "interesting" cases coming to our service from the ER at 2 a.m. than at 2 p.m.

The system in place at the residency where I trained facilitated the gradual introduction of personal responsibility for admissions. Each intern always had an upper-level resident and an attending faculty member overseeing the admission process. As in all things, some upper-level residents and attendings were better at it than others. The interns took responsibility as we were able, but we were never alone. I understand that this isn’t always the case, and I shudder to think of how many errors I would have made if I were solely responsible for even a simple admission as an intern.

But I also understand that had I not had the opportunity to fail in a controlled setting, I would not be the physician I am today. I would not know the limits of my endurance, or how to push past them to do what must be done. I wouldn’t even know I was capable of doing so. That’s not to say that I feel the restrictions don’t allow this for current trainees, but this experience needs to be incorporated into training, no matter what the duty-hours restrictions call for.

Regardless of your feelings about work hours, or even the profession of medicine as a whole, there is no denying that our job is full of stress. Good stresses and bad stresses, sure, but it's potentially one of the most stressful and demanding callings on both personal and professional levels.

Family physicians literally hold the power of life and death in our hands on a regular basis. We sacrifice time with our families with the hope that the care we provide will allow someone else to spend time with theirs. We spend hours in clinics and hospital wards helping patients learn to help themselves. We help escort new life into the world and, on the same day, hold the hand of the dying as they breathe their last.

In short, we have been given the awesome responsibility of caring for the lives of others, and with that responsibility comes a social contract that we will do so to the best of our ability. That means figuring out the best way to equip doctors in training for as many eventualities as possible, while at the same time preserving their sanity, their health and their compassion.

We must be willing to try new techniques and strategies in the pursuit of that education. Just like the researchers studying work hours at the University of Pennsylvania, we must iterate until we get it right, and be ready for further change when a better way presents itself.

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 Oct 27, 2015

Digging Out of Medical School Debt

The number of students enrolling in U.S. medical schools has reached a record high, despite the fact that the cost of becoming a physician also continues to climb. The number of first-year allopathic medical students increased to 20,630 this year, up 1.4 percent from last year's record-breaking enrollment.

Although these brilliant young students can look forward to a future of serving their communities, healing the sick and comforting the dying, many also will face a future burdened by significant debt.

It is estimated that between education costs and years of lost earning potential, it costs at least $1 million to become a physician. And medical debt burden is growing at an alarming rate. In 2006, the average medical student's educational debt was more than $120,000. Less than a decade later, that figure has grown to an average of $180,000.

But does it have to be this way? The Association of American Medical Colleges projects a shortage of as many as 90,000 physicians by 2025, so we cannot let students who are interested in careers in medicine be deterred by the high cost of training. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care estimates that the shortage of primary care physicians alone will be in excess of 33,000 by 2035.

Wayne State University in Detroit recently announced plans for an innovative way to provide medical education for students from disadvantaged backgrounds. Each year, 10 students who agree to study health disparities as part of their medical career will receive free undergraduate tuition, free housing, guaranteed acceptance into medical school and free medical school tuition. This program will be paid for through donations, and the goal is for the university to become a national hub for the study of health disparities.  

Other programs like this are slowly cropping up across the country, and there is a huge need -- not only to help physicians pay off their burdensome debts, but also to address health disparities.

But what about those of us who already made it through medical school without the benefit of a program like the one at Wayne State?

I graduated from a private medical school in 2009 with roughly $215,000 in education debt, making my load significantly higher than the national average. With my growing family, I was unable to start payments until after residency, using the forbearance option on my loans. I have been paying slightly more than the minimum payments during my three years of practice and I currently owe … $215,000. Because of high interest rates, I have not yet gained any ground.

There are, fortunately, some programs to assist physicians with their debt burden. I recently took advantage of the AAFP’s new partnership with SoFi to consolidate and refinance my remaining loans. This has provided a lower interest rate, lower monthly payments and the ability to pay off my loans faster.

There are numerous loan repayment and forgiveness programs, as well as other resources. I recently authored a resolution adopted during the AAFP’s 2015 Congress of Delegates (COD) that calls for the Academy to add to its website a page listing various national options for repayment because it is often difficult to find them all on your own. The Academy's website already features many resources about debt for medical students.

My resolution also asked for the AAFP to assist state chapters in lobbying for programs that have been effective in other states. According to the Association of American Medical Colleges, there are currently 70 state-based repayment, forgiveness or scholarship programs open to physicians, the majority of which are aimed specifically at primary care.

In Utah, we have recently had some success in recreating a loan repayment program for physicians practicing in rural areas. That program was defunded during the recession, but now we are hoping to expand it. At least three other states also passed bills this year related to physician loan repayment.

Another resolution adopted by the COD calls for the Academy to advocate for greater loan reimbursement for those in the National Health Service Corps who are not working full time. Many employers also offer some loan payback options to entice family physicians to work in areas of high need.  

I am glad I chose family medicine; I wouldn’t change my mind if I had to do it over again. But medical debt burden is a common problem facing physicians in all specialties. The best thing we can do is to share our stories, continuing to lobby both lawmakers and individual institutions to make costs more reasonable, decrease loan interest rates, provide more scholarships, and increase opportunities for loan forgiveness and repayment.

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

Tuesday Oct 20, 2015

Strength in Numbers: Teamwork Prevails in Face of Disaster

What would you do if a sewage leak closed half the patient care rooms in your clinic and a historic flood injured patients, damaged your community and created general chaos?  

You'd rely on your team.

Tech. Sgt. Jorge Intriago/U.S. Air National Guard
A levee is breached at the Columbia Riverfront Canal, Columbia, S.C., during a flood. Historic flooding in early October caused more than a dozen dams to fail, closed hundreds of roads and bridges and left thousands of the state's residents without power and electricity.

That’s what happened recently here in Columbia, S.C. Thanks to floods from what experts described as a "1,000-year rainfall," the west side of our family medicine center -- home to a residency program with about 40 practicing residents and attendings -- flooded with "gray water" that shuttered half of our exam rooms for nearly a week.

At one point, our main hospital was planning evacuation strategies for ER patients because the water supply in its Level 1 trauma center was compromised. I happened to be the ward attending when that happened and was working with week-one interns and senior-level residents.  

We could have been quite harried in this situation, but we weren't. Although we could not discharge patients home on the day of the deluge -- especially when a patient’s mother tells you she saw her house in floodwaters on the news -- our service was not overcrowded, residents were not burned out, and rounds continued.  

I did take a moment to visit the family medicine center during the downpour, but thankfully, there was no flood damage. Only the west side of the clinic was crippled by the gray water.

Although our team did fine, many resources were tapped and strained. Early Sunday afternoon, colleagues had treated two patients who had nearly drowned and another who had rhabdomyolysis from hanging on for dear life in floodwaters. Another patient, who was discharged from the ER, was later swept away by rushing water and found dead downstream. That was one of at least 19 deaths related to flooding in the state.

More than a dozen dams in the state failed, and hundreds of bridges and roads were closed. One of the main interstates in my community was closed because of concerns about the stability of a bridge that had turbulent water from the above flood-stage Congaree River flowing beneath it. And even though the closures made it challenging for my colleagues to get to and from work, some of our team members came to work that Monday and Tuesday -- even though the clinic was closed -- to relieve the inpatient service of clinical patient questions, refill requests, etc.  

To make matters worse, the canal that supplies Columbia with most of its drinking water broke and set off a boil-water advisory. Imagine what it is like to not be able to wash your hands while working in a hospital! Statewide, thousands of residents were left without water or electricity.

Recovery from what we've come to call "South Carolina's Great Flood of 2015" continues. Many of the residents of Columbia and surrounding areas have months of recovery and cleanup ahead of them. Damages are expected to run into the billions of dollars.

Still, amid great tragedy, a sense of compassion, sacrifice and community has arisen. From the amazing first responders who risked their lives -- including one who died -- to rescue hundreds of people, as well as my colleagues who were willing to work long hours to ensure patient care continued, to the hundreds of volunteers at shelters, cleanup sites and water distribution sites who gave freely of their time, labor and money, Columbia escaped despair during what were truly desperate times. Because of the team approach in our clinic and our community, we have been able to remain strong.  

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

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