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Thursday Jul 30, 2015

Self-Evaluation: How Many Stars Do I Rate?

As a physician, how do I know when I'm doing a good job? Is it when my patients all say they love me and come to visit even when they aren't in need of medical attention?

Is it when my diabetic patients' hemoglobin A1c readings are all less than 7.5 percent and my hypertensive patients all achieve 130/90 mmHg?

Am I doing a good job when all of the ratings web sites and physician evaluation tools say I have five stars for patient care?

Or if I can go home at night and sleep soundly knowing I did my best, does that mean I'm a good doctor?

Metrics are important to medicine in general for quality improvement and payment issues, but how do I measure myself?

Obviously, no easy answer for these questions exists. Far from a yes or no answer, the ability to quantify physician performance stymies the best statisticians and government bureaucrats. Not only do these measures affect patient recruitment and retention, they frequently determine reimbursement. And CMS is attempting to inform consumers by publicly reporting physician and group quality and patient experience data via Physician Compare.

As the health care environment is rapidly shifting to value-based payment and public reporting, it is imperative that metrics accurately reflect a physician''s quality and performance. No single metric has yet captured the essence of physician performance and perhaps no single metric ever will. Medicine and the physician-patient relationship are too complex to represent as a single number.

The advent of the patient satisfaction score has led to subjective quantization of physician performance. Instead of evidence-based measures of clinical success, satisfaction scores derive from measures of a patient's emotional state. Less a reflection of any measurable quantity, these numbers show patient feelings of contentment and satisfaction with care delivery. So what, exactly, are these ratings worth? Research indicates that patients who are most satisfied with their doctors have higher health care costs and increased mortality.

Aside from being entirely subjective, these measures are also highly susceptible to statistical biases. Most often, reporting bias, or the tendency to report only observations of a certain kind, interferes with accurate assessment. Hospitals and doctors' offices may not randomize their surveys, but instead send them only to patients they know will report high satisfaction. Conversely, even if randomized, there are statistical data to show a higher return on negative results.

This may be because patients with a negative experience are more likely to leave feedback or because patients with a positive experience don't complete surveys. Whatever the reason, these measures by themselves lack necessary mathematical significance to provide consistent and useful physician performance metrics.

In the internet age, anonymity and open access allow anyone to say whatever they please, ensuring that third-party, online reporting tools --- such as Healthgrades or Yelp -- fall prey to similar bias. Although many of these sites use metrics that do not solely rely on patient satisfaction scores, the core of these online ratings is subjective reporting. Good and bad experiences are distilled into a numerical report card, highlighted by commentary that may or may not be helpful. Inherent bias aside, allowing commentary does improve the usefulness and potential applicability of these metrics, but they are still inadequate to convey the breadth of physician competence and capability.

Most evidence-based physician outcomes derive from meeting evidence-based goals, such as the hemoglobin A1c goal above. Performance metrics cover objective data like quantifiable minimum standards of care, but that process is also fraught with problems. Culling usable data from an electronic health records system is a full-time job, meaning significant labor costs. Analyzing these data takes even more time and money. Most of these metrics rely on chart audit as well, meaning any mischarted or unrecorded data points change the overall results. Measures like post-operative infections and surgical complications also involve some level of luck, or at the very least, variables over which the physician has limited control.

There's also the question of how much the performance scores accurately reflect the ability of the physician. Given that the medical relationship requires both physician and patient contributions, patient outcomes may not be solely a measure of the competence or ability of the physician. Rather, some argue that specific patient targets more closely represent patient compliance, while only loosely approximating physician proficiency. To truly reflect physician performance, metrics should acknowledge the shared responsibility between the physician and the patient.

One may even ask if using outcome-based metrics may be detrimental in the long run. While a hemoglobin A1c of 7.5 percent may be acceptable for performance metrics -- a passing grade, if you will -- most diabetics benefit from a target closer to 6 percent. The same is true for measures like blood pressure, cholesterol and weight. If we let "good enough" be our only goal, we may miss the opportunity to help patients improve further.

Recently, the website ProPublica -- self-described as "an independent, non-profit newsroom that produces investigative journalism in the public interest," -- published what it called a Surgeon Scorecard. Based on publicly available data for elective surgeries covered by Medicare, this metric analyzed the complication and mortality rates for several surgeons and hospitals across the country. Upon publication, both patients and surgeons questioned the validity and utility of this scoring system because several major hospitals are missing. The data set came from elective procedures and was limited to hospitals that performed a specific number of the procedures in question. The number of procedures for each hospital varies, so the data -- like most other metrics -- tell an incomplete story. Given that there is no standard for comparison, further study of these data is needed before they can be presumed accurate.

So, if none of these measures accurately reflect physician performance, how then shall we rate ourselves? How do we aggregate objective and subjective data into a useful approximation of physician performance? I honestly don't know what works best. If I did, I'd have shared it long before now. If any of you have ideas, sound off in the comments. In the meantime, I'll content myself with remembering the pleasure I derive from seeing patients making healthy choices.

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.

Thursday Jul 23, 2015

FPs Can Help Curb Spending on Services Patients Don't Need

Recently, I was treating a woman in her 70s who was due for a repeat upper endoscopy due to her chronic Barrett’s esophagus.

“Can we help you schedule it at the local hospital with Dr. X?” I asked.

“No, thanks," she said. "I always get this done at the Costco hospital. It’s just more convenient for me.”

“Costco hospital?” I asked, feeling somewhat confused.

“Yeah, the hospital with the Costco in the parking lot,” she replied, as if what she was referring to should be as clear as day.

There is a good, large hospital nearby that does, indeed, have a Costco in its parking lot. Just as Costco offers nearly everything a consumer might want in a retail store, that hospital offers nearly any diagnostic procedure or treatment imaginable.

The problem for many of us when shopping at Costco is that we invariably spend more money than we intended for things that we don’t necessarily need, thus leading to a lot of waste. Unfortunately, the same problem -- spending too much on things we don't need -- persists in our health care system.

I have never actually worked in my patient's hospital of choice, but a friend of mine was admitted there a couple of weeks ago. When I went to visit her, I could not find the front door because of the sheer size of the hospital. I found the emergency department, outpatient clinics, surgical entrance, etc., but could not figure out how to get to the inpatient wards. I eventually got to her room by trudging through the ED and receiving directions from multiple people.

I can’t imagine how people find their way in such a massive facility.

And yet that has become the norm in health care. Large hospital system conglomerates often disrupt small, independent practices, buying out physicians, even in rural areas. From a global standpoint, this can either be good (consolidating services in one location with increased ease of coordination) or really bad (raising costs through large influence on third-party payer rates without the benefits of consolidation). These large systems often dance around the bad to avoid antitrust litigation (although they do have better protection if they qualify as an accountable care organization) tightening their grip on health care.

Hospital systems also tend to dramatically fuel subspecialty care to maximize revenue and, thus, tend to view primary care physicians as little more than a source of referrals to the better-reimbursed service lines.

So what controls the impact these "integrated" systems have on patients and physicians? Payers certainly have a lot to do with this; nowhere is this more evident than by looking at how CMS chooses to pay physicians. Recent efforts to move from fee-for-service payment to value-based models will undoubtedly lead to a shift from the subspecialty-centric model to primary care physicians becoming the foundation of value-based medicine. Payers in general are starting to see family medicine as the solution, as evidenced by a recent survey showing that family physician income has increased by a percentage higher than that for the majority of other specialties in the past year. But payment itself does not ensure an efficacious system for patients.

Local efforts by family physician leaders can make the biggest difference in ensuring that our hospital systems do not get too big for their britches. Filling leadership roles at all levels of the organization, including participating on hospital boards -- whether employed by the hospital system or not -- can go a long way to driving local policy. Participating in local politics also provides valuable input locally and regionally. Even more important, these venues provide a prominent voice to ensure that patients do not receive unneeded care in a nonpatient-centered environment.  

The Health is Primary campaign is a more national expression of the same desire. Family medicine is spreading awareness of the role and importance of primary care to overcome these exact issues. The health of the patient needs to be directed by the patient in conjunction with his or her primary care physician to make the best choices. Although many hospital systems support this framework, way too many don’t.

A Costco-like health system, full of waste and overutilization of health care services, is bad for everyone but administrators and subspecialty physicians. That means we as family physicians are the ones most capable of overcoming this all-too-common trap. With our help and guidance, patients and physicians will indeed be able to find the front door of our system and make that system work for all of us.

Kyle Jones, M.D., is an assistant professor 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.

Thursday Jul 16, 2015

Direct Primary Care Model Poised for Rapid Growth

Direct primary care (DPC) physicians have been connecting with each other in recent years, usually sharing tips on what we’ve learned, but also offering words of encouragement and venting frustrations. These conversations often occur on Twitter, via email or by phone, but we’ve also had a few chances to connect in small groups at family medicine events.

In the past year, a few organizations -- including the AAFP -- have hosted DPC workshops or networking events for physicians in the planning stages of starting a DPC practice, but gathering a large number of early adopters was a rare feat. That's what happened this past weekend at the Direct Primary Care Summit in Kansas City, Mo.

© 2015 Sheri Porter/AAFP

Attendees listen to a speaker at the July 10-12 Direct Primary Care Summit in Kansas City, Mo. The event drew more than 300 physicians from 45 states.


In the first few years of my DPC practice, I could easily keep tabs on the new DPC practices opening around the country, speaking to most of them at some point. The passion and vision of these physicians have been refreshing and truly inspiring. Thanks to the hard work of many people at the AAFP, the American College of Osteopathic Family Physicians and the Family Medicine Education Consortium, I knew the DPC Summit was going to be well organized and well attended.

According to the final tally, there were 317 attendees from 45 states, including 54 physicians who already were established in a DPC model and 107 who are in the early or planning stages of building a DPC practice. About half of the attendees were exploring whether DPC was a viable option for them. About 10 percent were residents.

Despite the diversity of the groups, one thing was clear from the opening night’s events: These doctors and associated DPC organizations were passionate about how to better care for patients. The energy of the entire summit was electric. A number of DPC physicians’ stories allowed attendees to see what it’s really like to be a DPC physician in its various forms. Topic-specific presentations covered the nuts and bolts of operating or joining a DPC practice. A resident led a group discussion of how DPC education can be incorporated in the education curriculum. Attorneys and policy wonks covered the legal and advocacy efforts surrounding DPC issues.

The highlight of the weekend for me was my own patient, Blaine, who shared his story about experiencing DPC in my practice. As I’ve learned from attending patient advocacy conferences, nothing is more powerful than a patient’s story. He perfectly embodied why our model can be a game changer -- and possibly kick-started his career as a stand-up comedian in the process. “That A1c is going to snitch you out,” was the single best line of the event.

How quickly will the DPC model grow? It’s difficult for me to predict any numbers with confidence, but if the summit was any indication, the model is poised for rapid growth.

One of the things the summit demonstrated to me was the adaptability of direct practice doctors/clinics based on community needs, something missing in the micromanaged status quo. Some of the DPC practices were helping large employers or unions in urban areas tackle escalating health costs, while others based in rural towns were working with a large number of uninsured patients. The creativity of DPC physicians is truly awesome.

The AAFP has upcoming events that will provide more opportunities to learn about DPC, including my presentation about starting and running a DPC practice July 30 at the National Conference of Family Medicine Residents and Medical Students. Another Kansas-based DPC doc -- Joshua Umbehr, M.D., of Wichita -- will present an even more in-depth look at DPC during two sessions Oct. 1 and Oct. 2 during the 2015 Family Medicine Experience (FMX) in Denver.

The Academy's DPC member interest group will meet Oct. 3 during FMX, providing yet another opportunity to network and learn more.

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

Thursday Jul 09, 2015

Reflections on Surviving a Malpractice Case

I was sitting in the middle of the living room in the now-empty house, the last boxes having been loaded onto a truck. It had been a busy few weeks, with graduation from residency and moving into a new home in a new community to start a new practice. We were studying for our board exams and preparing to leave on our wedding cruise to Alaska.  

The mailman knocked on the door and handed me a certified letter. I didn’t think much of it and told him that if he had been 10 minutes later, he would have missed me. When I opened the outer envelope I saw the inner envelope had a law firm as the return address, and my heart sank. I opened it, and what I had feared was confirmed. I was named as part of a malpractice suit. 

I sat back down on the floor and called to my fiancé to tell him the news. I didn’t know what the process would look like, but I knew that it was going to be long and painful.

Many physicians are pulled into lawsuits regarding cases that their colleagues aren't familiar with, but not so in my case. The case in question involved a prolonged hospital course with consults from multiple services and an outcome that no one wanted. At least 10 of my fellow residents were associated with the case during the weeks the patient was hospitalized because they were rotating on various services.  

The hospital had had everyone who was intimately involved with the initial incident come together for a debriefing and a careful evaluation of process, but that had been almost two years before this letter arrived. The hospital's legal counsel told me the case likely would go to court, but I had put it mostly out of my mind as time marched on. No legal notice had come. The statute of limitations was a few days from being up, but here was the letter.  

I felt blessed in an important way, however. I had been through the case inside and out by myself, with my attending physicians and with hospital risk management staff, and I knew that the outcome could not have been prevented. I knew I had done absolutely everything I could, and that the patient had the best specialist and intensivist team anyone could ask for. This knowledge would make the years of the process to come easier.

I wasn’t prepared for how slowly everything moved, and how time-consuming the process could be. The monthly updates and discussions with my lawyer, depositions to prep for and give (five weeks after delivering my daughter, no less), expert testimony to review and mediation to attend.

Reading what the opposing side’s expert witnesses write about you is heartbreaking. You know you were doing the best you could and feel confident in your medical decisions, but here is someone listing your alleged incompetence. Prepping for mediation is grueling, and having someone ask the same questions in a slightly different way over several hours -- to see if you will stumble and answer in a way favorable to the plaintiff -- is mentally and physically exhausting (even without a 5-week-old infant across the hall that you have to breastfeed every few hours).

I understood that the outcome was extremely painful for the patient’s family, and it was painful for the providers, too. I just couldn’t wrap my mind around how that unpreventable outcome meant that I, two other physicians and the hospital should be sued as if we had neglected our duty.

And through it all, life went on. Aside from close family and friends, no one knew what I was going through. Patients still needed to be cared for, and I still went to work. There was still much to enjoy, but the shadow of the case loomed. It made me question myself more than usual, and it was an unwelcome specter in the first years of our practice. Being a new physician on your own for the first time already is challenging, but carrying the weight of a lawsuit with you makes it even more difficult.  

The case involved obstetrics, and it made me question whether I wanted to integrate OB into my practice, but the joy of that part of my job always won out when doubt tried to creep in. I was blessed to have supporting physicians around me, wonderful family and friends, and most of all, an amazing husband who was my rock.

Our situation was different from many other malpractice suits because my husband was one of my fellow residents. He was also not just my partner in life, but in our practice. Reading the words of the expert witnesses was difficult for me, but almost impossible for him. My husband really loved delivering babies, but since my lawsuit, he has allowed that part of his training to fade.

I think those around us often are overlooked when dealing with lawsuits. It doesn’t affect just us, but those around us as well. So I asked him to share some of his thoughts.

"I always knew lawsuits were possible," Michael said. "It’s practically the first lecture in medical school. What the lecture didn’t tell me is how to prepare for the onslaught of harmful statements from medical experts."

As my husband read each of the plaintiff's medical expert testimonies, he was naturally defensive, but a much deeper emotion that emerged was a sort of hollow fortitude.

"I have been evaluated by my peers, and I have evaluated my peers," he said, "and even when standards of care have not been met, there has always been an objectivity to the process that is overlooked in malpractice suits because no one cares about true improvement. The opposing side only cares about winning. As promised, life has gone on. We are now almost two years on the other side and, for the most part, unscathed."    

Together, we learned the importance of finding people to talk to when a physician faces something this difficult. Find a therapist, a partner who has been through it or your lawyer, and talk about what you are going through.  

Internalizing the struggle in an attempt to be strong and spare others will drown you, and little by little erode your love of what you do. Know that you are not alone and that many have walked this path before you, and many will come behind. Know that at the end you will come out a stronger person, though carrying some scars you didn’t have before. And know that you are still a good physician, spouse, friend and person.

Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.

Tuesday Jul 07, 2015

Dealing With Death: Why Helping Patients' Families Helps Me

I remember more details about my first patient who died than I do about the movie I saw last week.  

The death of a patient has an effect on me regardless of how the person dies, whether it is unexpected or anticipated. The first time it happened, I was a third-year medical student. I admitted a patient in the afternoon, explained the results of her echocardiogram and lab work to her mother and husband, and then I went home for the night.

I walked to her hospital room the next morning, but a different patient was in it. I went to the nurses' station, but no one seemed to know who I was talking about. It didn't occur to me that she had passed away. These were the days of paper charts, so I couldn’t log in and search by her name. Eventually, I found one of the residents who carried around nifty patient census lists, and I asked him what room my patient was in (because clearly she had just changed rooms).  

The next thing that happened is what I am still grateful for. He stopped writing notes, actually put down his pen and sat down to tell me that the patient had died during the night. Most important was how he said it: "Oh, I’m sorry, but she passed away." He easily could have just kept working and -- without eye contact or compassion -- simply said, "She died, so go find a new patient to present in rounds." But he didn’t.

The resident then explained what happened -- that despite aggressive diuresis, she went into decompensated heart failure. He had personally been called to run the first code, then talked to the patient's family after the second and final code, which occurred in the ICU. I remember the patient's name, her age, her family’s faces, even her pajamas. And I remember learning a lot about right-sided heart failure after that because I think that was all I read about for the next two days.  

Even though I wasn’t involved in running the codes or having the difficult conversations with her family, I learned so much about dealing with death through this patient. I needed the news to be broken to me gently, and that resident knew that. After that experience, it was months before I was involved in the care of anyone else who passed away. But when it did happen, I immediately recalled the respect and compassion that stressed, post-call resident had shown for that patient. In fact, I have remembered it each time since.  

Given that residency has a lot of hospital-based training, we are exposed to extremely sick patients, ICU care where the mortality rates are the highest and, therefore, death. In medical school and residency, we learn about delivering bad news. We even practice it as students with standardized patients. But we don’t learn how to handle our own grief and emotions associated with losing a patient. I know it's probably in the curriculum somewhere, but it's likely theoretical and is presented early on, before you are really immersed in clinical care. I did a literature search for doctors dealing with the death of patients and found nothing. I wanted a book or something to tell me how I was supposed to process these experiences. How do you tell a family their loved one just died and then go home to your own family and act like nothing out of the ordinary happened that day? What I came to realize is, you don’t.

We are human beings, and we went into medicine -- especially those of us in family medicine -- because we value relationships. We thrive on getting to know patients; their families; and their priorities, goals and weaknesses. There aren’t any resources that I found helpful, personally, because I had unique connections with each patient I have lost, and their deaths had different effects on me.  

The only constant I have found in each of these experiences is that the degree of comfort I am able to provide the family seems to make the patient’s death less traumatic for me as their physician. So that is what I share with residents and students -- that they will be changed by these experiences. But the more we commit ourselves to the process and the more compassion we are able to show everyone involved, the less wounded we feel.

I have not always embodied this. I do recall telling an intern -- who lost a patient she had just admitted (and met) a couple of hours before -- that, "Really, this is nothing, wait until you have taken care of them for years and know their entire family. Now that's a loss that hurts." But the reality is that they all hurt because patients are why we do what we do. I may have been the one to deliver the terrible news to that patient’s son, but the intern was the one who had looked into her eyes and made a connection. And in my office now, I am often the first to find out if a patient dies, and everyone in the office is affected by that news and the way I deliver it.

As physicians, I think we hear "thank you" more often than people working in a lot of other professions. And sometimes they are huge, heavy thank yous from patients or families who genuinely feel we saved a life or changed the quality of a life. But for me, the ultimate thank you was being mentioned in one patient's obituary. I wasn’t there when that patient died, but I had spent hours on the phone, in the hospital room, and in support of the patient and his family throughout his battle with leukemia.

That patient didn’t pronounce my name correctly, but everyone knew he was my patient. A colleague let me know within minutes of his passing, and I cried as if I’d lost a best friend. I wish I could have been there for the family and patient at the end, but I also realized that the work I did to prepare them was just as valuable and that they knew I cared.  

We gain trust as family physicians in many ways, especially in rural areas where we see generations of relatives. One patient’s experience with me can extend rather far. Comforting a patient and respecting  that patient's wishes as he or she transitions to end-of-life care is just as important as treating one of the family’s new babies.

I have a lot of homebound patients, some of them healthy but with limited mobility, others terminal with no plan to leave their homes again -- especially not for the hospital. One of the most powerful things we can do as physicians is to respect those patients and reassure worried family members that they are actually doing the right thing by not forcing the patient to go to the ER every time he or she has a complaint. It's worth the extra effort -- arranging for mobile imaging, home health care or home visits, or even calling home hospice -- to make sure the patient’s wishes are honored in a way that helps the family feel secure and supported by their physician. Family members need reassurance at the end of life just as they do when you are simply explaining supportive treatment for a viral upper respiratory infection.

Everything will be OK, even if it means losing someone because sometimes, letting that person go is the right thing to do.   

Kimberly Becher, M.D., graduated from Marshall University's family medicine residency in 2014 and practices at a rural federally qualified health center in Clay County, W.Va

Tuesday Jun 30, 2015

Change Isn't Optional, but Making Progress Is

Change is hard. Whether on a personal, local or national scale, transformation requires effort and patience. This truth plays out in the world around us each day.

Last week, the Supreme Court upheld the right of all people to marry whom they please. Earlier this month, discussions about race relations nationwide were fueled by a racially motivated shooting that resulted in the deaths of nine people in Charleston, S.C. Meanwhile, the overweight diabetic patient I saw this morning struggles daily with appetite control and making healthy eating choices. Life is all about change. It rarely is easy, but the results often more than offset the difficulty.

In medicine, change is constant. New scientific inquiry leads to better understanding of basic principles. Understanding, in turn, leads to better implementation of care strategies. We get better at prevention and treatment, and at the same time, we learn which questions need further investigation. It’s a never-ending cycle.

In the mid-1800s, English physician John Snow (not to be confused with the George R.R. Martin character Jon Snow) explored the link between a cholera outbreak and local water usage patterns, and recommended removing a few water pump handles from contaminated wells. The resulting changes in sanitation practices eventually created a revolution in public health. But changes based on evolving understanding aren’t limited to history. Changes in how we understand the world around us, and how we do our jobs, affect us every day.

Take, for example, the debates about prostate and breast cancer screening. No matter what your personal feelings are about the screening intervals -- or about whether to screen for prostate cancer at all in low-risk groups -- changes to the U.S. Preventive Services Task Force recommendations for screening continue to spark debate years later.

The changes we face as new physicians aren't limited to science. In my previous post, I wrote of the changes in medical records and the associated headaches and benefits. In most health care circles, the transition to ICD-10 continues to provoke heated debate, even with the increased specificity in diagnosis reporting it promises. Still, ready or not, implementation of ICD-10 codes is set for Oct. 1.

Every facet of our lives and medical careers is subject to change. Maintenance of certification, reviled by many as unnecessarily complicated, is undergoing significant changes for many specialties -- ours among them. Debate still rages over the changing scope of practice in family medicine and primary care. And practice models and payment methodologies are in flux as we adjust to a health care system that doesn't involve the Medicare sustainable growth rate.

We're told that change is inevitable but progress is optional. As new physicians, we will face numerous changes both at work and at home. How we face those change will determine who we are and how we practice. We get to choose which changes we embrace -- where we will progress, regress or stay the same. But we must choose.

My encouragement at this stage is simple. Gather information. Readily admit when you don’t know something. Learn as much about as many things as you can. Make informed decisions.

Accept that there are still scientific truths to be found. Go out and help find them.

Change is hard, but even small changes can make a huge impact. Don't fear change, but don't change merely for the sake of change. Make the changes that make you better, healthier and more well-rounded, and help your patients do the same.

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

Monday Jun 22, 2015

Help Patients Trim the Fat Out of Fad Diets

As primary care physicians, we constantly help patients battle obesity, which is a formidable adversary. I have found this experience to be one of the most rewarding journeys I regularly embark on with patients but also one of the most challenging.  

Although a weight-loss supplement or fad diet may help a patient achieve rapid and sometimes dramatic results, we often are discouraged by how quickly weight is regained. Could it be that we have missed the mark when it comes to educating our patients and assisting them in meeting their weight-loss goals?

Lest we get too discouraged, let’s look at the facts. Never before has there been such a wealth of information and resources to assist us in achieving optimal weight management. We are continually inundated with new diet fads, exercise programs and trendy new weight-loss gimmicks.

In an era of rising obesity rates across the country, it seems the general population is finally moving toward a more health-conscious attitude. As marketers attempt to capitalize on this trend, new supplements and diets seem to be popping up everywhere, creating an even greater challenge for physicians as we field frequent questions from patients about the safety and efficacy of the latest buzz that has piqued their interest.

The HCG Simeons therapy seems to be a great supplement for the patient who has lost the desire to eat. The egg wine diet may work wonders for detox lovers who care more for tannin appreciation and less about consuming essential nutrients.

The point is that it can be difficult to find the wheat in the sea of chaff of today’s trendy supplements, diets and detoxes. Fear not, however, for what matters most about analyzing a new diet or supplement is rather simple: maintenance, calories, nutrients and safety.

Many patients are frustrated with dieting because they suffer from the “yo-yo” effect: dieting to lose weight but regaining lost pounds -- and sometimes more -- after resuming a normal diet. A fundamental principle of nutrition is that "diet" is a noun referring to what you eat; it should not be something one “goes on.” When a patient asks for our advice, we must first decide if a diet can be permanently incorporated into the patient's life.

For the vast majority of patients, emphasizing a small move toward long-term health is preferable to a total diet replacement, no matter how bad their original diet seemed. A patient is much more likely to avoid the yo-yo effect if he or she is satisfied with a diet and maintains a healthy relationship with food.

A popular idea now is that not all calories are created equal. This is hard to rebut, as you may vaguely recall some relationship between glucose, insulin and the effects on metabolism from biochemistry in your preclinical years. And although this may be true, and there are certainly physiologic effects determined by hormones that respond to the food you eat, it may not really matter to most people.

But for every study touting the colossal impact of hormones on weight loss, there is another showing that when calories are restricted, the pounds come off. For example, a nutrition professor at Kansas State University proved that a diet consisting almost exclusively of junk food, when consumed under moderate caloric restriction, can not only result in weight loss but improved blood cholesterol and triglyceride levels, as well. Of course, eating an all-Twinkie diet is not something we would endorse, and lowering cholesterol is not the same as lowering a patient's risk for heart disease or other preventable health problems.

The point is not that there is no value to fine-tuning the levels of metabolic hormones; the point is that their role is less significant in most patients, and total calories should be the primary concern. But be aware that counting calories is painstaking; therefore, emphasize consumption of lots of fresh vegetables. Other than the benefits of the nutrients in vegetables, they have a low caloric density. This allows your patient to eat larger portions without overconsuming.  

Although weight-loss diets are generally restricting, it is important to consume adequate amounts of essential nutrients. Many patients forget the importance of protein as an essential nutrient, and we should emphasize the many benefits of adequate, complete protein. Examples of complete proteins include most meats or fish, dairy, soy and quinoa. Proper protein intake is essential to maintain lean body mass through weight loss, and has its greatest effect when the patient is also engaging in regular exercise.

Not only does protein intake help attenuate muscle loss, it also has been shown to increase satiety. When more protein is incorporated into the diet, patients feel fuller longer. This benefit is twofold: Patients tend to snack less, and it makes the changes easier to follow.

Another tip: Approach supplements with skepticism. The FDA generally doesn't get involved with supplements unless problems and complaints arise, so it is wise to think of them as only as safe as the brand they represent.

There are many well-respected diets out there: low-fat, no-meat, low-carb, no-carb … the list goes on. Which one is right for the patient in front of you depends on many factors. Place an emphasis on fresh foods and vegetables because it is difficult to eat enough kale to stress the stitching of your waistband. The U.S. Department of Agriculture recommends that at least half our diets consist of fruits and vegetables, which are high in essential vitamins, minerals and fiber.

Whichever maintainable diet makes it easiest for your patient to get a good serving of complete protein three to four times per day, while eating the most vegetables and fewest snacks, is probably the best diet for them.

So, here are some takeaways:  

  • Making weight management a priority in our practices is key to achieving lasting patient satisfaction and long-term health goals.
  • Remember, patients are keeping up-to-date with the latest weight-loss fads, so we must stay current and competent to help patients separate fact from fiction.
  • Don’t be afraid to learn from patients.
  • Don’t be discouraged. More resources mean you have a better chance of finding the perfect weight-loss solution for your patient.
  • Don’t practice cookie-cutter weight management. The most successful programs are the ones that are tailored to the individual patient’s needs.
  • Keep at it. Be your patient’s No. 1 cheerleader and health coach. Lifestyle modification is a longitudinal process often filled with trial and error and much persistence. Patients are looking to us to help them achieve and maintain what they have spent most of their lives chasing -- weight loss.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in Buffalo, Mo. He served as the AAFP's Resident and Fellow Section delegate in 2013 and was the alternate delegate in 2012.  

Zachary Treat is a second-year student at the University of Missouri-Columbia School of Medicine. He received his bachelor's degree in exercise science from Truman State University, where he worked with a research group to study muscle protein synthesis. His interests include nutrition and ergogenic aids for use in weight loss and athletic training.

Monday Jun 15, 2015

How Long Should It Take to Train a Family Physician?

I began medical school in the summer of 2005 during a trend among schools to get first- and second-year students more patient exposure. Many medical schools were dabbling with increased patient contact (including my school, the Medical College of Wisconsin), while others made wholesale changes to their curriculum to evenly blend the needed activities of four-year training.

As medical education continues to evolve, questions persist regarding the appropriate length and format of medical training.

Many of my colleagues and I look back fondly on our fourth year of medical school. It’s not that it was such a great training experience -- quite the opposite: It provided us a reprieve before residency. We spent a lot of time interviewing for residency, taking vacations and signing up for “cushy” rotations. Although some things were worthwhile, such as subinternships -- which function more as an audition for a specific program than for any significant educational purpose -- they were more the exception than the rule.

But although that fourth year did not add much to my education, it did add more than $50,000 to my student debt. For this very reason, a common discussion about medical education focuses on the possibility of eliminating the fourth year of medical school.

Specifically, a few schools are offering accelerated, three-year programs for students interested in primary care. Students who enter these programs have to agree to choose primary care training right from the start, but in doing so, they significantly lessen their debt burden. That's important because student debt is a common reason why medical students initially interested in primary care often end up choosing subspecialty careers instead.

Opponents of this idea point out how much there is to learn in medicine. The discussion then moves on to whether family medicine residencies should last four years rather than three, and a national pilot program is evaluating that concept. Eliminating the fourth year of medical school and lengthening the time spent in residency could make more efficient use of education time by adding more specialty-specific training that would expand our scope.

But the underlying question is: How much medical training is needed for physicians? Including undergraduate education, it now takes 11 years to become a family physician, but, as mentioned, some schools are eliminating the last year of medical school. So are three years of medical school and three years of residency enough to train a quality family physician? And are we training people the right way to meet future health care needs?

My opinion is that six years is plenty of time to adequately train a family physician without compromising the quality of care that family physician provides. However, we likely need to change how we train future physicians.

Medical training that lasts six years, seven years or even 20 years is not enough to fully understand all of the available medical knowledge, especially given its current rate of growth. I believe training should focus more on how to obtain reliable information quickly and efficiently to help patients at the point of care. Thus, training should incorporate tools that can be embedded into electronic health records, such as Watson from IBM or the Isabel diagnostic tool. Use of such tools does not lessen our experience as physicians; it adds to it.

The other ingredients essential to a training program are learning how to manage practice transformation and cultivating the ability to cope with change in our medical environment. Any physician who has practiced for more than 10 years has seen multiple changes in practice models, reimbursement trends, regulation and, consequently, the physician-patient relationship. Most of these changes can cause frustration, although many end up benefiting both the physician and the patient. Greater understanding and training on how to not only navigate these changes, but to lead them, is crucial to the success of our health care system.

Much change abides in our health care system and medical education, so that many schools today look nothing like the experience I had when I started 10 years ago. No doubt, this trend will continue to evolve. The main lesson for all of us is to ensure that we prepare our future physicians in the most efficient and effective ways possible to fortify our future system needs.

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 Jun 09, 2015

The EHR Conundrum: How We Got Here, How to Change It

In 1966, Lockheed and others introduced what came to be known as clinical information systems. Throughout the intervening years, the concept of the electronic health record (EHR) has evolved and shifted focus,ostensibly to meet the needs of physicians and patients. Transitioning from paper charting and ordering systems to computerized electronic records seemed like a logical step.

Why? Paper charts are heavy, fragile and difficult to correct. Searching through them requires large investments in time, money and personnel. Storage costs alone make large volume data management untenable. Most other industries instituted the paperless model decades before health care did.

Here I am entering data in my electronic health records (EHR) system. Physicians could help improve on the woeful state of the current EHR morass.

Obviously, a data-intense profession like medicine could benefit from a well-designed, properly functioning EHR. From allergies to surgeries and everything in between, we collect volumes of information on our patients. In theory, the EHR serves as searchable, well-organized storage for the information we collect about those patients and their health.

Unfortunately, reality often falls short of theory.

Although it would be easy to blame any one entity or system, the EHR problems many of us encounter daily resulted from many small failures spread across decades. The result, what is probably better termed an electronic billing system, incites almost daily discussion among clinicians across the country.

"This EHR takes too long."

"The extra garbage in this chart makes it unreadable."

"This record was entirely cut and pasted from previous notes."

Not only do the problems lead to errors in communication, they create potential harm to patients. Similar issues existed with paper charts. As a clerical worker in a medical office, I was once tasked with retrieving 40 paper charts for one of the clinicians. She was in danger of losing her hospital privileges if the old charts weren’t completed and returned, so I dutifully loaded the files into the back of my Jeep and ferried them back and forth. Fortunately or unfortunately, without social media and the Internet, we as clinicians weren’t discussing the problems on such a large scale or in such a public forum.

As with many things in the public sector, money caused most of the problems inherent in the EHR morass. For decades, the billing systems we use in medicine consisted of a database of names, addresses and identifying demographics. These existed long before the medical records systems and were often separate pieces of software designed for speed and return on investment. Sadly, most EHR software is built around those same ideas. In contrast, paper charting, while often reviewed for billing purposes, focused more on communication: what problems, medications and long-standing issues existed for each patient. Much of the content was historical and factual information designed to jog the physician's memory on repeat visits or communicate with other physicians.

In the 1970s, Medicare began using the chart as an audit tool for appropriate billing, and the landscape of charting never recovered. In the face of required numbers of questions and physical exam components, the medical chart became a series of checklists with the occasional reminder scribbled at the end. In both the inpatient and outpatient setting, medical records began the slow devolution into a billing document.

Rather than succinct and pertinent information about chronic problems or surgical history, EHRs cobble together long lists of material. Look at most medical records summaries in an EHR, and you’re likely to find redundant and often immaterial information hiding what actually matters. This is partly due to the fact that the information a specialist or a billing and coding program needs varies from information recorded for physician or health care provider benefit. Although the ICD-9 codes support appropriate billing, the descriptions attached to those codes are inadequate to describe actual pathology.

For example, if my patient sprains the anterior talofibular ligament of his or her right ankle, the code descriptor that most EHR programs attach to the appropriate billing code (845.09) is “other sprains and strains of ankle.” Although ICD-10 improves on this specificity, the communication still suffers because I cannot glance at this information and quickly assess the pertinence to my patient. This, in turn, encourages physician requests for more information, which clogs the narrative even further. Careful charting and records maintenance can alleviate some of these issues, but it’s still time-consuming and expensive.

In the hospital setting, this can be even more frustrating because patients see multiple physicians from multiple specialties, each of whom records information according to their own preferences. Template systems, though useful for personal preference and ease of use, often muddy the record further because the displayed information takes different formats from template to template. Dictation improves the narrative form of notes but is often not searchable, decreasing the efficacy of the medical record as a whole. In essence, we have cobbled together several disparate systems to accommodate preferences and costs, but we have sacrificed the overall narrative of the medical record and ease of use.

We check the boxes. We get paid. And, unfortunately, that return on a sizable investment is limited by the utility we receive in addition to billing. Most offices spend tens of thousands of dollars for EHR systems that produce unreadable records and incoherent communication, but they persist in using them because receipts increase once everyone gets on board with the system.

Hospitals attempt to help by subsidizing the system, but expensive components of the EHR are deemed ancillary and not purchased. Communication between EHR software requires costly translation components, and already narrow margins necessitate avoidance. No one entity is at fault, but the snowball keeps rolling and collecting more debris along the way.

Now that I’ve painted such a bleak picture, the question is obvious. How do we fix it?

The answer isn't simple. We need changes in infrastructure from the top down and the bottom up. It’s not going to be cheap. Neither will it be easy. The EHR systems in place are a stopgap to a better system.

Hospitals will need improved communication with vendors, physicians and other health care providers, focusing on accurate and appropriate record-keeping without sacrificing the billing aspects. Emphasis should be placed on enhancing outputs, both electronic and paper, such that records generated for review are not only accurate and complete, but legible and with minimal unnecessary internal markup. Thought must be given to long-term outcomes, not just immediate loss or return of investment. These systems, if correctly designed and implemented, should evolve with changing needs. Thus, a sizable initial investment would provide a viable product for decades, not just a few years.

Physicians, especially those of us in primary care, must contribute design ideas, while respecting the limitations of computer systems. In other words, ask for output, but don’t demand that it be created in a specific way. Too often, the overcrowding we experience in EHR interfaces is due to physician requests. If we limit ourselves to asking for what we need, the conversation becomes more comprehensible for the information technologists. These conversations will require tech-savvy graduates to translate much of the technology used daily by Generation X and beyond. In essence, we need physicians who speak the language of technology to translate the breadth and variability of medicine for the often laser-focused technology world.

All easier said than done. I realize that money, time and resources are finite. I simply posit that we could be using those finite resources more constructively. As new physicians -- most of whom grew up in a world that always contained computers -- we have a unique opportunity to step in and make changes for the better. Volunteer for EHR committees at your hospital. Seek jobs with medical records vendors, even as a consultant. Write notes that you would want to read. Take the time to learn the systems you use most effectively. In the long run, we will be better for it.

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

Wednesday Jun 03, 2015

Give Residents Tools to Turn Tide on Physician Burnout

It wasn't that long ago, during my college days, that I thought burnout referred to a certain lifestyle rather than a severe form of career (and life) dysfunction. Today, however, tales of physician burnout are hard to miss.

In fact, the Academy developed a position paper on the topic last year. And this year, the AAFP posted a blog  about  burnout, as well as an even more sobering editorial about physician suicide.  Burnout also was addressed by Dike Drummond, M.D., in his keynote speech last year during the AAFP's annual meeting, and a closely related topic -- managing stress -- will be the general session topic presented by author Kelly McGonigal, Ph.D., Oct. 1 during the Family Medicine Experience (formerly AAFP Assembly) in Denver. It’s safe to say we all know this is a huge problem.

I think perhaps one of the most fascinating concepts related to burnout is prevention. Many researchers have highlighted the idea that devoting a time to something you are passionate about (research, teaching, etc.) -- really anything that is outside of the daily grind -- can be enough to help prevent burnout. One of the reasons it has taken us so long to come to terms with the fact that we, as physicians, can (and do) get burned out is that most of us went into medicine because it was something we were passionate about. We think of medicine as a calling; therefore, how could we get burned out?

The reality, unfortunately, is that we do. During Drummond's Assembly session last year, he asked each of us in the audience to raise our hand if we, or someone we knew, had experienced symptoms of burnout (loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment). Nearly everyone in the ballroom -- hundreds of family physicians -- raised a hand.

You could argue that was a rather unscientific survey and a relatively small sample size. But there is plenty of evidence that suggests burnout is rampant in our profession. A study presented recently (free registration required) at the American Psychiatric Association's annual meeting found that 70 percent of medical residents met criteria for burnout. The numbers were lower, but still significant for family medicine, with 50 percent of our residents experiencing burnout.

I feel fortunate to work at a community-based academic residency program because we spend more time addressing this topic than the average practice would. Our program has been proactive in teaching residents and students to recognize burnout. Of course, we have the traditional Maslach Burnout Inventory that we discuss with residents, but we also have invited thought leaders on the subject to speak at our residency and to other programs within our health system. Most recently, we heard from Tait Shanafelt, M.D. director of the Mayo Clinic's Department of Medicine Program on Physician Well-being, and colleagues.

We provide residents with resources to not only recognize burnout, but to treat it when they do recognize it. Even more importantly, we try to prevent it.

Physicians have always been pressed for time, and demands in the current health care system may be worse than ever. Therefore, we try to capitalize on 15- to 20-minute segments of time by, for example, utilizing a short reading followed by a period of reflective writing or discussion. We also ask questions that orient residents' attention to challenging or rewarding encounters, such as asking them to recount a time in the past week where they felt particularly helpful (or helpless) or to describe a situation that reminded them why they became a physician. We have found that Balint groups are particularly helpful in setting the stage for these other brief, “on-the-fly” activities.

These exercises in mindfulness about the topic really seem to help accomplish our goals. We have implemented this program during the past few years, and although we have not officially published any findings, we have noted a significant shift in the recognition, and, we believe, prevention of burnout.

I’m fortunate to have variety in my job and also to be involved in research. I think these aspects of my role have buffered me from the burnout epidemic. Still, I keep the issue in the forefront of my mind and remember to enjoy my time away from work, whether it's simply reading a book quietly at home, spending time with family or on a needed vacation.

The millennials have some of this figured out. It’s really about balance, self-awareness and introspection, and as you can see, the resources and tools are not anything groundbreaking. I think we are beginning to recognize just how far-reaching this problem can be, and by empowering our youngest physicians (and really all physicians), we’ll all get there eventually.

Joshua Tessier, D.O., is a faculty physician and coordinator for research and scholarly activity at the Iowa Lutheran Family Medicine Residency and serves as regional assistant dean for Des Moines University at UnityPoint Health – Des Moines. His professional interests include research, medical student education and evidence-based medicine. He enjoys time with his family, cruises, and drum and bugle corps -- all great buffers to burnout.

Wednesday May 27, 2015

Food Desert: A Community Coping Without a Grocery Store

A couple of months ago, I heard rumors that our county grocery store might close. That’s right  -- not town, not local, not biggest, not best, but the ONLY store in the county might go out of business.  

About 500 people live in Clay, W.V., and roughly 9,000 live in the county. It seemed like one of those things that just couldn't happen because there is plenty of demand for the business. So it wasn’t until the store's sign was gone and the doors were locked that I accepted the fact that my patients no longer had access to a grocery store. A list of brittle, insulin-dependent diabetics and precariously balanced heart-failure patients flooded my mind. I worry about all of them every day. 

Since the store closed, I’ve been asking my patients where they buy their food. If they have diabetes, I ask what their sugar has been doing. My heart sinks when they say they are buying all their food at the Go-Mart. Not that it's a bad place (if you need gasoline) but the food choices are high-carb, high-salt and deep fried. (My patients also complain that it's expensive.) This isn’t just a run-of-the-mill gas station. It also offers prepared foods, and it reportedly has the best fried chicken in town. A couple of miles away are Family Dollar and Rite Aid stores, both of which have a few shelves of food as well, but, again, it is mostly processed and less than ideal.  

On May 8, the comment period ended for the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (DGAC) which is produced by the HHS Office of Disease Prevention and Health Promotion. As I read Chapter 4: Food Environment and Settings, I was surprised (and happy) to find the list of reference articles contained numerous studies regarding access to healthy food. We know what foods to avoid and what foods are better for us and our patients. But proximity to a grocery store or farmer’s market is critical to the chronic disease status of a community.

My concern as I searched through the document wasn’t how many fruit and vegetable servings we were now going to recommend, but how much social and geographical inequalities were contributing to poor health outcomes, and what was the plan for addressing it?

The CDC’s Community Health Improvement Navigator provides resources and examples of improvement strategies for various stakeholders, including physicians. It attributes 40 percent of our health outcomes to socioeconomic factors and 30 percent to health behaviors. Both far outweigh the 20 percent physicians contribute to via clinical care.

A recent study by Virginia Commonwealth's Center on Society and Health examined how life expectancies vary by ZIP code within the same communities. For example, Richmond, Va., had the starkest data with life expectancy variances of 20 years in two neighborhoods that are just 5.5 miles apart.

Understanding such health disparities is not as simple as identifying who chooses to eat fast food or smoke. It is about so much more than that. Something as simple as how a home is heated can have serious, long-term implications on patients' health. Largely due to cost, many of my patients heat their homes by burning wood or coal. Often I see a grandparent with chronic obstructive pulmonary disease raising a grandchild with asthma, and both patients suffer through the winter due to poor air quality inside their home.   

So, what does the DGAC report say about diet? Access to farmers markets and produce stands result in healthier eating habits. The data is less clear when it comes to supermarkets and grocery stores. But in the more rural, seasonal growing areas, the grocery store is the produce stand. The report readily admits that it was difficult to compare data across studies, and most were specific to one type of geography, e.g., inner city vs. rural. The report clearly found that proximity to a convenience store led to higher BMIs.

The report also studied influences and efficacy of school- and work-based interventions. In the end, the report found that multiple strategies work to improve healthy eating habits at all ages, but that a definitive, all-encompassing approach is impossible given the variability between communities. It defines areas of future research, highlighting projects that work and encouraging partnerships of all types to create thriving businesses that would improve food access as well as workplaces that promote healthy behaviors.  

A few years ago, a local health department study concluded Clay County residents lacked access to fresh produce (even with a grocery store) so the local extension service set up a farmers market. The market opens June 4, but it will only operate four hours a day, one day a week.

The growing season is just getting rolling here in West Virginia and lasts through August before dwindling in the fall. Fortunately for local families, school is running later than usual to make up for numerous snow days, so kids will get a couple of meals a day at school until June 15. After that, parents will struggle to find easily accessible food sources during what may be a trying summer break.

My hope is that someone takes over the vacant store, reopens it with the county’s needs in mind, and my patients realize how much they missed having access to healthy food while the store was closed. Perhaps that will  prompt some to make up for lost time and replace all the packaged, fried food they likely will consume in the next few months with fresh, lower-calorie meals when they have the opportunity.

A few months ago, I bought cookbooks for each of my exam rooms, and my nurse encourages patients to look through them while they are waiting for me. One patient asked to borrow one and take it home, to which I obviously said yes. But right now, no one without the means to travel 40 miles to a grocery store in an adjacent county could make even one of those recipes.

Kimberly Becher, M.D. graduated from Marshall University's family medicine residency in 2014 and practices at a rural federally qualified health center in Clay County, W.V. 

Tuesday May 19, 2015

Far From the Madding Crowd: Whole-Patient Focus Facilitates Diagnosis

Many of us have struggled with perplexing cases in which the diagnosis remains elusive. Trying to solve these seemingly insolvable cases captures the mystery and art of the practice of medicine.

However, for patients, this can quickly become their worst nightmare. One such patient suffered with symptoms that threatened to ruin her life. It took more than three years, evaluations by two dozen physicians and more than $100,000 in medical costs to find the correct diagnosis and treat her condition.

It was that patient's story that inspired Jared Heyman to found in April of 2013. The patient was his sister.

CrowdMed is an online service that uses the “wisdom of crowds,” along with a prediction market algorithm, to generate a list of possible diagnoses and treatment suggestions for patients with conditions that have not been diagnosed by more traditional medical models. A patient using the service fills out a detailed questionnaire, uploads all of his or her test results, and then the patient's case is reviewed online by what CrowdMed calls its "medical detectives."

According to CrowdMed's website, these are people from all walks of life, although 57 percent of them work in, or are studying for careers in, medical professions. Sixty-nine percent reside in the United States, but 19 countries are represented.

Interestingly, the average age of a medical detective is 36 -- not exactly the gray-haired authority one would envision working on such difficult cases. The medical detectives brainstorm and come up with a list of possible diagnoses that are then ranked in order of most to least probable by the algorithm. The patient then takes the list back to his or her physicians, and, hopefully, a diagnosis is confirmed.

According to CrowdMed, the service comes up with an accurate diagnosis 80 percent of the time.

Of course, there are some legitimate concerns from the medical profession at large, including the ethics of such an arrangement and issues regarding liability. Patients must sign a waiver agreeing that CrowdMed is in no way liable for anything. (Don’t you wish you had that option in your own practice?) Also, although CrowdMed's privacy statement says it will not sell any information that identifies patients, the company reserves the right to sell any nonidentifying information.

CrowdMed also states it is not bound by the Health Insurance Portability and Accountability Act, so it is up to patients to safeguard their identity in anything they upload. Also, buried in the fine print on the site is the disclaimer that if CrowdMed is acquired by another company, it cannot guarantee that a new owner won't sell patients' private information.

Among other concerns about this service is that it may undermine the physician-patient relationship. Patients may start to mistrust their physician or question that physician's qualifications. And who hasn’t had to spend extra time educating a patient who came into the office with a list of diagnoses he or she dug up on Wikipedia?

As I looked at the CrowdMed website -- which has several vignettes of patients who were helped by their service -- I was struck by two things. The first is that many of the vignettes have a common thread: patients who complain they were seen by specialist after specialist without a diagnosis. I wonder, where was the primary care physician during all these subspecialist visits? Perhaps the reason the diagnosis remains elusive in some of these cases is that care is too fragmented and specialty-driven, and we simply cannot see the forest for the trees.

A family physician should be the key person compiling the results of tests and procedures, looking at the patient as a whole, and coordinating that patient's care. Of course, doing so will likely require a significant amount of collaboration, and this can be difficult in our current medical system. Time is limited, and getting multiple physicians to discuss a single case at the same time can be like herding cats.

The second thing that struck me as I read the vignettes was that I often knew the correct diagnosis after the first paragraph. This has nothing to do with my clinical acumen and everything to do with taking a proper history and correctly organizing information. Have we forgotten how to take an adequate patient history?

Our current system sets us up for failure because too often we are pressed for time and put too much emphasis -- and reliance -- on test results. We sometimes forget that no test is infallible, and the results need to be interpreted in the context of the case as a whole.

In some ways, the demand for a service like CrowdMed points out how our medical system can fail patients, and as practitioners, we should do our best to avoid these shortcomings.

Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.

Wednesday May 13, 2015

Here's Why New Physicians Should Care About Global Health

For generations, the United States has proudly labeled itself a melting pot of cultures from around the globe. Not only has the influx of people continued -- it has accelerated. According to population projections released by the Census Bureau last year, 43.3 million documented and undocumented immigrants live in our country. Immigrants account for more than 13 percent of the U.S. population, the highest percentage in nearly a century.

With our patient populations becoming ever more culturally and ethnically diverse, it is important for us to be aware of how this cultural interplay affects our clinical encounters, treatment options and medical outcomes. Understanding and learning about my patients' cultures has improved clinical rapport, patient compliance and satisfaction. Hand-in-hand with this has come a boost in follow-up rates.

Here I am discussing international exchange opportunities available through Polaris. I spoke recently at Iberoamerican Congress of Family and Community Medicine in Montevideo, Uruguay.

As our world becomes more interconnected, both the interest in and need for global health has risen. Not surprisingly, those who have completed an international clinical rotation tend to report an improved ability to recognize disease presentations in addition to more comprehensive physical exam skills with less reliance on expensive radiographic imaging. This is important because the United States has one of the most expensive health care systems in the world, yet our outcomes lag behind those of other developed nations.

Global health initiatives allow us to interact with our international peers to learn about their medical systems, share best practices and strengthen our cultural intelligence. These opportunities are not only valuable for medical students and residents, but also for new physicians who are still solidifying their specific style and preferences for medical practice. With experiences through exchange programs such as FM360 (as described by family physician Aaron George, D.O.), who would not want to participate?

The majority of our newest physicians have grown up as part of Generation Y -- a.k.a., millennials -- and share a unique set of experiences and characteristics. Our entire lives have been inundated with modern technology, including cell phones, computers and the Internet. Notably, we are also more likely to speak a foreign language, engaging with both our local and global communities through face-to-face clinical encounters, online messaging and social media.

Although time and money can be limitations, physicians and medical students still may participate in the global health community through one of many organizations, including the AAFP or Polaris (our North American New and Future Family Doctor Movement) or via initiatives like our Balint 2.0 group and the Polaris international journal club, the AAFP Center for Global Health Initiatives, the #1WordforFamilyMedicine social media project, the FM Changemakers group and many more. Most of these novel approaches are discussed in the following section, and you can learn more by following @WoncaPolaris on Twitter or joining the Wonca Polaris group on Facebook.

Recent Events
Maria del C Colon-Gonzalez, M.D., and I recently represented the Wonca Polaris group in Montevideo, Uruguay, at both the Iberoamerican Congress of Family and Community Medicine and the Young Doctors' Movement (YDM) preconference. We served on the preconference organizing committee and as speakers and moderators for small-group discussions that took place during the preconference. Later, at the congress, we participated in the rural medical education panel, made four oral presentations, including one regarding improving research methods for residents and new physicians and presented two posters. The presentations resulted from collaboration with family doctors from countries around the region, including Peru, Uruguay, Colombia, the Dominican Republic, Portugal and Spain.

Undoubtedly, evidence of Polaris' positive effect in the Latin American region went far beyond posters and presentations. One such example was a Polaris initiative -- the Balint 2.0 Ambassadors -- which has united all seven Wonca YDMs in the first-ever multi-international online Balint group. Of the 14 international participants, five were present in Montevideo.  

Additionally, the social media project #1WordforFamilyMedicine, which launched eight months ago during the AAFP Global Health Workshop, has gone viral in Iberoamerica. The project asks family physicians and residents to describe their favorite part of our profession in a single word on Facebook or Twitter. Responses are then collected and the lists are turned into "word cloud" images that represent the specific participating region/country. Of the 50 countries that have participated, almost half are in the Iberoamerican region.

Evidence of the project was abundant during the conference in the form of T-shirts, photos, mugs, posters and more. This ongoing project has helped unite young family physicians from different parts of the world and has improved our specialty's image around the world.  

World Family Doctor Day
May 19th marks a special day for family physicians: World Family Doctor Day. The AAFP and family medicine organizations around the world will be celebrating in different ways. Family physicians are asked to display the #1WordforFamilyMedicine image on our social media profiles. An online interactive map shows the countries that have provided images to date. Go to the map, and click on the image over your country. Right click, save and display on your profile.

Also on May 19, I will be speaking with medical students about the intersection of family medicine and global health through the live social media series Family Medicine On Air hosted by the AAFP's Family Medicine Interest Group Network.

Lastly, the Polaris-led ASPIRE Global Leader Program will launch on World Family Doctor Day. We welcome medical students, residents and new physicians who want solidify their leadership skills and become more involved in global health to participate.

Looking Ahead
Polaris is focusing its efforts on organizing Wonca North America's first international preconference, which will take place on Oct. 1 in Denver before the AAFP Global Health Workshop. Both of those events are being held in conjunction with the AAFP's 2015 Family Medicine Experience (formerly Assembly).

In addition to our Canadian and Caribbean colleagues, the preconference's organizing committee is delighted to have assistance from other regions' YDMs. The preconference and the Global Health Workshop will give medical students, residents and new physicians opportunities to develop in the areas of research and scholarly activities, as well as in leadership and mentorship.

Kyle Hoedebecke, M.D. is a 2013 graduate of the Womack Family Medicine Residency in Fort Bragg, N.C.  He is a clinician in the U.S. Army, an assistant professor at the Uniformed Services University and serves as the chair of Polaris. Speaking Spanish, Portuguese and Guarani, his passions include global health, traveling and spending time with his family.

Wednesday May 06, 2015

Dealing With Addiction at Home

Roughly 320 million people live in the United States. Ponder that number for a moment while considering that in 2012, U.S. health care professionals wrote 259 million prescriptions for opioid pain killers. My state, Nevada, ranked on the high end, with more than 82 pain killer prescriptions per 100 people.

So, although it is frustrating for physicians trying to help patients with legitimate pain issues, it's no surprise that state lawmakers have put additional restrictions on prescribers. Legislation our governor signed into law this week authorizes the state's medical licensing board -- and the licensing boards for all other health care professionals able to prescribe opioids -- to establish new CME requirements for doing so and requires prescribers to register with a prescription drug monitoring program.

(According to the AAFP's position paper on pain management and opioid abuse, the Academy opposes mandatory CME as a prerequisite to licensure "due to the limitations on patient access to legitimate pain management needs that may occur.")

The new law comes on the heels of research that shows that roughly one-fourth of prescription painkillers are misused, and about 10 percent of patients who take them become addicted.

Dealing with chronic pain is common for family physicians in my state, where there are too few pain specialists and patients face long waits for appointments. Although we've all dealt with chronic pain in our practices, I've wondered a lot in the past year how many of my colleagues would know what to do when addiction becomes not only a professional issue but also a personal one.

This is my family's story.

My husband -- now ex-husband -- began taking prescription painkillers while recovering from an injury. If there were red flags -- and there probably were -- I missed them while working full-time and raising four kids. So it was a shock when I learned that my husband had been discharged from a family medicine practice because he was misusing his medication.

I tried to help him, and I (and others) urged him to get help. But things actually got worse. After we separated, I was again surprised when several of my physician colleagues informed me that he had approached them with requests for prescriptions. He had been doctor-shopping our friends.

Although my husband's physician was limited in what he could say to me because of the Health Insurance Portability and Accountability Act, these other physicians had no such restrictions. Why hadn't anyone talked to me sooner?

They likely weren't sure what to do or say, and it certainly would have been an incredibly awkward conversation. But maybe an early intervention might have made a difference. When there are obvious signs that a person -- and a family -- need help, it's important to speak up. Even if the conversation is difficult, you can walk away with a clear conscience knowing you had good intent.

In retrospect, I realize that I also could have benefitted from asking for help as my family went through this difficult transition. At the time, I was embarrassed that this terrible problem that I have helped my patients with had found its way into my own home. I was concerned there would be a stigma in our health care community.

I should have known better. My colleagues have been incredibly supportive. They understand addiction.

Now, I feel like I understand it better, as well. Our life experiences can affect how we treat patients, and I think I'm more empathetic now when dealing with patients who have addictions. I better understand what it's like to be that person who has to make a difficult life choice for his or her well-being and that of his or her family.

Sadly, we likely will be hearing more stories about families like mine.

It's worth noting that American Family Physician has compiled a collection of journal articles and other Academy resources related to the treatment of chronic pain. The Web page even includes links to the Academy's CME activities on management of chronic pain.

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.

Wednesday Apr 29, 2015

Family Leave Policies Failing U.S. Families

It has been more than 20 years since President Clinton signed the Family Medical Leave Act (FMLA) into law, guaranteeing 12 weeks of unpaid leave to employees for certain family or medical reasons. That law was an important first step, but a number of restrictions on FMLA -- size of employer, length of employment and full-time vs. part-time employment -- render it useless to roughly 40 percent of U.S. workers.

Even more troubling is that since FMLA became law, little progress has been made nationally to support working parents with newborn or adopted children. President Obama, however, vowed to prioritize paid leave earlier this year in his State of the Union Address.

Here I am with my daughter at our mom-and-baby yoga class. Maternity leave not only gave me time to focus on the care of my child but also time for us to bond.

The United States lags far behind most developed countries on this issue. In fact, an International Labour Organization report published last year examined information from 185 countries and territories and found only two that did not offer some form of paid maternity leave. Sadly, the two exceptions were Papua New Guinea and the United States.

A map published last June by The Atlantic graphically illustrates how poorly we compare to the rest of the world. Only three states (California, New Jersey and Rhode Island) offer some form of paid family leave.

I recently returned to work after the birth of my daughter and am grateful for a revamped parental leave policy at my job that is more in line with those that benefit families in other advanced countries. Not only did I benefit directly from this support, I was proud that my workplace acknowledged the importance of supporting all of its staff -- and our families -- during one of our most important life events.

This is significant because we strive to be leaders in the communities where we work. For our patients, many of whom come from low-income, disadvantaged populations with poor health outcomes, we are better equipped to advocate for their rights when we are able to see first-hand the impact of such policies.

Why should we, as family physicians, be leading the charge for paid parental leave? Family leave has broad public health implications, from maternal mental health and breastfeeding to infant mortality and child development.

In my clinic, we screen for postpartum depression at every well-child check. The questions are built into our electronic health record system. Research has found that women experience a wider range of disorders now being called maternal mental illness, a term that recognizes the symptoms of postpartum depression can begin any time from before the baby is born through the first year after giving birth. A 2013 article in JAMA Psychiatry found that one in five women suffer from depression during the first postpartum year. Another study found that returning to work less than six months after childbirth increased the risk of postpartum depression.

Additional research is needed on this topic, but it is becoming more apparent that there is a correlation between maternal mental health and the kind of support -- financial as well as social -- women receive during that critical postpartum period.

The AAFP recommends that "all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first six months of life" and that breastfeeding "should continue with the addition of complementary foods throughout the second half of the first year."

Although laws now require that workplaces accommodate employees who need to pump, the reality is that it can still be difficult. I am fortunate to work in a supportive atmosphere where my pumping sessions are scheduled so that no patients are scheduled during that time, and my staff are protective of that time. A colleague of mine has almost given up pumping during the day because her clinic has done nothing to ensure that she has the time or necessary staff arrangements to make pumping an actuality.

If mothers had the option of staying home for the first six months, knowing their leave was at least partially paid and that their job was protected, perhaps the rate of breastfeeding in this country would be closer to our goals.

Child Health
It's not news that the United States doesn't lead by example when it comes to infant mortality. In 2014, the infant mortality rate was 6.1 deaths per 1,000 live births, which put our nation last on a list of 26 developed nations.

Research has shown that when maternity leave increases, infant mortality rates decrease. Years before the United States adopted FMLA, research showed that 10 weeks of maternity leave decreased infant mortality rates 1 percent to 2 percent, and 30 weeks produced a 7 percent to 9 percent reduction. Although our infant mortality rates are the result of many variables, we should not ignore the fact that they are higher than those of every other advanced country, even as our parental leave policies trail behind theirs.

Families that are struggling with an infant whose health is failing shouldn't also be faced with financial concerns and possible job loss when they need to take extra time to care for that child.

Child development is intricately linked to the maternal-child relationship and has lasting effects on the child's health.

Many of my pediatric patients in the Bronx struggle with obesity, learning disabilities and mental health disorders. I often wonder what their future will be like. Will they still be living in the Bronx, dealing with a low-paying job, struggling with the physical ailments that result from being obese their entire lives? What if their mothers had the opportunity to have a supportive maternity leave that ensured some wages and a job to return to postpartum? This is an area of health that is multifactorial, but if a multipronged approach is needed to improve the mental and physical health of the children we care for, certainly better parental leave should be one of those prongs.

It comes as no surprise that unpaid parental leave disproportionately impacts low-income, single and minority mothers and fathers. As family physicians, we are the ones who care for the patients in rural areas, the patients who are uninsured, the patients who have problems accessing medical care. We must advocate for the health of these patients on a broader scale, and helping them secure a substantial parental leave could have significant health implications for them and their families.

Finally, although much of the research on this topic evaluates maternity leave, fathers' access to a protected and paid time off after the birth of a child is also important and, not surprisingly, is yet another place where we lag behind many other countries. Research shows that paternity leave benefits women and their communities.

For the health of the families we have dedicated our careers to caring for, and for the health of the communities we work in, we, as family physicians, need to join the fight for a better parental leave policy nationwide.

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.

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