Cloudy With a Chance of Misdiagnosis
"As an adolescent, I aspired to lasting fame, I craved factual certainty and I thirsted for a meaningful vision of human life -- so I became a scientist. This is like becoming an archbishop so you can meet girls."
-- Matt Cartmill, Ph.D.
"Seventy-five Reasons to Become a Scientist,"
American Scientist (Sep/Oct 1988)
"Predictions show a steady low.
You're feeling just the same.
But seasons come and seasons go.
I'll make you smile again.
If you don't believe me,
Take me by the hand.
Can't you feel you're warming up?
Yeah, I'm your weatherman."
-- Delbert McClinton, "Weatherman"
As the sum of our knowledge grows, it becomes more apparent how much more there is to learn. What we think of as fact can be easily and rapidly overturned by new observations and understanding. During the past month, I've heard more than one person discuss the "old days" of medicine, often lamenting that their doctor now gives them choices in their care.
"I miss when they would just tell me what was wrong and give me a medicine to fix it," I heard one person say. My first instinct was to defend the rights of the patient and to expound on the greatness of patient autonomy. I queued up long discussions of the antiquated paternalistic model of medicine and why the informative and deliberative models are far superior. My internal anarchist railed against blindly following those who have confidence and who assume they know what is best.
But then I stopped and looked at the situation from the perspective of these patients. What would someone -- raised among the miracles of technology, without any training in pathology or diagnostics -- see from the outside in the paternalistic model? The doctor listens, examines, and then pronounces with absolute certainty a diagnosis and treatment plan. It’s the magical black box. Information goes in and apparent cure comes out. As physicians, we know the truth. The reality is far more mundane and far less certain.
This fundamental misunderstanding of the actual amount of knowledge we as physicians possess and how we apply it leads to a mismatch in expectations and reality. Most patients don’t understand that a large proportion of what we do is based on statistical probability. The informative and deliberative models of medicine we were taught in medical school encourage us to share the thought processes and basic science behind our differential, but the process underlying our diagnostics is fundamentally no different from the paternalistic model. We observe, collect data, calculate probability and choose the most likely etiology.
It strikes me, as I contemplate this process, how closely we resemble another group of scientists -- meteorologists. We deal with complex systems. Both climate and human pathology involve hundreds, if not thousands, of variables. We collect data and select the most pertinent facts for inclusion in our models. We move from the general to the specific and make predictions based on collected data. We choose the models with the highest probability and share those with our constituents. As time passes, we collect more data, which often improves the probability analysis. We compile a differential diagnosis or a forecast. And, unfortunately, hindsight often makes fools of us all.
The more pertinent information we collect, the better our predictive models will be. Whether a function of more time or better tests, higher volumes of data improve predictions. To that end, both medicine and meteorology now outsource data collection for stronger models. Not only do we use measurements from inside the clinic, but patient-collected data from health trackers and fitness tools expand the pool of available data. We also use stronger computing tools to crunch the higher volumes of numbers. Advanced computing solutions such as IBM’s Watson can assess facts and context and ultimately output predictive models on par with those of many physicians and meteorologists. And with the growth of precision medicine and molecular genetics, we now have more specific data about the molecular underpinnings of our biology.
Although there are many facets of medicine -- and meteorology -- that carry high levels of certainty, few outcomes approach 100 percent probability. There is always a chance we are wrong. We describe most diagnostics in terms of sensitivity and specificity, or what’s the probability that a positive test result is truly positive or that a negative test result is truly negative. If there are too many false-positives or false-negatives, the test doesn’t help us with accurate prediction.
Which brings us back to the initial discussion of patient perception. Under the paternalistic model of medicine, the process was the same, but the internal mathematics remained hidden from the patient. This gave the mistaken appearance that progression from simple discussion to diagnosis followed an absolute and direct causal pathway. Tell the doctor the symptoms, and the doctor tells you what caused them. No mention of process. No peeks behind the curtain. From the lay perspective, it looked like magic. Multiple generations of patients grew up thinking many diseases and disorders were easily and rapidly cured with the magic prescription pad. The trouble with that belief isn't just that it fed skewed understanding of causality and correlation, but more that if the disease wasn't immediately cured or the problem resolved completely, the patient assumed the treatment was inadequate or incorrect and the doctor incompetent, even if both treatment and physician were medically correct.
Much like incorrect forecasts have left us skeptical of the abilities of meteorologists, incorrect or incomplete diagnoses do little to endear us to our patients. If we wish to combat this phenomenon, further explanation and discussion of the probabilities and process involved in differential diagnosis will go a long way toward improving patient compliance.
Perhaps the focus should not be on misdiagnosis, but rather the process of diagnosis as a whole and how we can improve it over time.
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.
Questions About DPC? FMX Sessions Offer Answers
I recently received an email from a physician who was just out of residency and contemplating his future career options.
"Even as a resident, I was incredibly frustrated by the limitations placed on my primary care practice by billing and documentation demands and disillusioned by the lack of support for caring for patients beyond the four walls of the clinic," he wrote as he explored the possibility of starting a direct primary care (DPC) practice.
Since I presented at the Direct Primary Care Summit in July, I have talked with a wide range of physicians with nearly identical sentiments. Some are seeking tangible advice on starting a DPC practice, some are just venting, and others have given me words of encouragement.
Given the variations and rapid growth of DPC, it's difficult to pinpoint an exact number of direct-practice physicians. However, at least 500 DPC practices are now operating, and the vast majority of them opened in the past 12 to 18 months.
It's clear from my email inbox that there are thousands more physicians considering making the switch to DPC and many of them have questions.
This week, the AAFP Family Medicine Experience (FMX) in Denver will give physicians more opportunities to learn about DPC, including a dedicated track. "Delivering Patient Care, Not Paperwork" is scheduled for 8-11:30 a.m. on Oct.1 in Room 201. The session repeats at the same time on Oct. 2 in Mile High Ballroom 4D.
I will be joined by Josh Umbehr, M.D. and Doug Nunamaker, M.D., who practice in Wichita, Kan. Together with attorney Michael Campbell, we plan to cover a wide range of DPC topics. A key distinction between a DPC practice and a traditional, insurance-based practice is the relative simplicity of operating the business. However, there are many unique considerations when owning and operating a DPC practice. The questions I have fielded have been numerous, but here are a few of the common ones we will address:
- Should I go fully direct or keep some insurance contracts?
- How should I notify my patients if I switch to the model?
- What can I do with Medicare patients?
On a broader front, the DPC track will cover three main areas, including
- reviewing the unique features of DPC and relationships with other models;
- practical steps in starting a new DPC practice; and
- legal aspects of DPC practice, including Medicare issues.
On Oct. 3, there will be a meeting of the DPC member interest group (MIG) -- which is now the largest of the Academy's 11 MIGs -- from 8-10 a.m. The meeting will feature an open discussion of DPC-related topics, and leaders will give a legislative update and conduct elections of new officers for the group.
The flexibility of DPC allows it to fit a group of patients and a community and is one of its greatest strengths. Doctors can creatively tailor their practice to meet those needs, but we hope to first set the stage by sharing the framework and common traits of a successful DPC practice. I'm hoping the upcoming events at FMX will help further explain how DPC can be a viable option for family physicians and the health care system.
If you're not able to join us in Denver, be sure to keep an eye out for future opportunities to learn more about DPC practice. Upcoming AAFP-hosted DPC events include an Oct. 24 workshop in Dallas and an April 2 workshop in Detroit next year.
Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.
Eye on the Ball: Overreliance on EHRs Can Bring Disaster
My elementary school had computers, and we used them to learn arithmetic. (Anybody remember Number Munchers?) In middle school we were typing our reports on Macs that seemed great at the time but probably would be mocked by today’s teens because of their large floppy disc drives. (OK, you caught me; they were called Apples back then.) By high school we were creating PowerPoint presentations.
My generation grew up with computer technology, so to me it only seems natural to incorporate that technology into practice. I used paper charts for only one year in residency before that institution adopted electronic health records (EHRs).
I found paper charts to be cumbersome, inefficient and often illegible and incomplete. However, I would be one of the first to say that our current EHR options, although they continue to improve, are far from perfect. Entering information into these systems can be taxing, and the resulting documentation often has little clinical value. We can all easily read a physical exam in an EHR record, but with overuse of copy and paste and lackadaisical template modification, I’m not sure it’s of any more use than an illegible paper version.
It's especially troubling to read the recent findings of an expert panel that concluded that use of a hospital-based EHR was partially to blame for the initial misdiagnosis of Thomas Duncan -- the first person in the United States to be diagnosed with Ebola. Information regarding his travel history was entered into the EHR during triage but was not relayed verbally to the physician.
The patient was diagnosed with sinusitis and abdominal pain and was sent home. He returned to the hospital four days later and was correctly diagnosed but died eight days later.
Apparently, the expert panel was surprised that an alert regarding the patient’s travel history was not programmed into the EHR. Triggering such an alert could have cued care providers to actually review the information that was entered.
And finally, it was not clear in the EHR whether the physician reviewed the patient’s symptoms. I do some ER work on the side, and although I’m no Dr. Mark Greene (played so aptly by actor Anthony Edwards on the TV series ER), I would find it decidedly difficult to care for a patient in the emergency setting without discussing that patient's symptoms with him or her.
What troubles me about these findings is not just the weakness in the EHR but also the implied reliance on the system while caring for patients. Although many of us are comfortable with computer technology, perhaps we are all getting a little too comfortable.
While EHRs are becoming more useful in clinical practice, we should not rely on them or expect them to do our work for us. It is our responsibility to review the information contained in the chart -- be it paper or pixels -- whether or not an alert is triggered.
We also must keep in mind that just because something is in the EHR does not make it gospel. I was reviewing the chart of a female patient that noted a prostatectomy under her surgical history. We must always confirm information with the patient and take a history for ourselves. Although the headline of a recent news story on the report would have us believe that somehow the EHR was to blame, this is akin to watching a major league baseball player strike out and then look incredulously at his bat.
The types of mishaps that occurred in this case have been around for ages: lack of communication between health care professionals and incomplete history review. The twist is that these errors occurred in this day and age because we have come to expect the EHR to fill in the blanks for us. Although the EHR is a powerful tool to aid in patient care, it is just that, a tool. And like most tools, without a skilled operator who knows the tool's capabilities and limitations the end result can be pretty shabby.
Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.
Medicine, Media and the Need for a Physician's Perspective
"I don’t like taking medicine unless I really have to."
That is the most common complaint I hear from my patient Sandra whenever I talk with her about why she should be taking a statin or why it's important to get an annual flu vaccination. Unfortunately, she bristles at discussions about quality of life and mortality.
But a conversation I had with her at this time last year was different. Sandra was eager to learn more about an immunization and medication she thought she really needed. This patient, who had rejected recommended preventive care that could protect her from far more prevalent diseases, was worried about Ebola.
My visit with Sandra was during the peak of the Ebola scare. After the first case was reported in the United States last fall, parents pulled their children from schools, politicians called for a ban on travelers from West African nations, and health experts had to put down fears that Ebola would become airborne.
Although more than 28,000 cases resulting in more than 11,000 deaths have been reported in Guinea, Liberia and Sierra Leone, Ebola has not made much of an impact on public health in the United States. According to the CDC there were four cases and one death in this country last year.
In stark comparison, heart disease is the No. 1 cause of death in the United States, claiming more than 600,000 lives each year. But, no, Sandra won't take a statin. And although more than one-third of Americans are obese, many patients don't want to talk about diet and exercise. Diabetes, by the way, kills more than 75,000 Americans per year.
Influenza and pneumonia (nearly 57,000 annual deaths) pose much bigger, immediate threats to U.S. public health than Ebola, yet some Americans were panicked by the incessant news coverage generated by a handful of Ebola cases being treated in the United States. Sandra had heard about an experimental Ebola vaccine on the news, but she didn’t understand its indications or the fact that it was still in trials.
The intersection of medicine and the media is a peculiar place. What the media considers newsworthy -- interesting, impactful, timely or novel -- often has little or nothing to do with scientific validity and reliability.
Mainstream news outlets frequently tout new treatment modalities and new drugs long before we know their true potential. News outlets also love stories (and ratings) related to "looming" health threats, even if the threat isn't particularly great. The urgency of Ebola was easier to convey than the long-term, more significant threat of heart disease. And news about a pill being developed to prevent Alzheimer’s (someday) or a cutting-edge therapy for cancer will always beat out common-sense recommendations about exercising to prevent obesity.
In reality, newer medical treatments and technologies do not necessarily translate to better medical care or health outcomes. In fact, they are often ineffective or come with higher costs. What is new should not trump what is true. Yet the health information disseminated to the public isn't always helpful.
Medical statistics and information can easily be misunderstood by the average person. Ideally, health care news should be dominated by systematic reviews of multiple high-quality randomized controlled trials; however, this is limited by a number of factors, including a paucity of resources to execute these trials. Consequently, media outlets often cover the results of observational studies or presentations from academic meetings, although many of these abstracts will never be published in a peer-reviewed medical journal. It's no surprise such cursory information can be misinterpreted.
The good news is more media outlets are starting to rely on physicians to convey health news. Physicians are consistently rated favorably by the public in surveys regarding honesty and ethical standards. As members of a profession that has earned the public trust, physicians can work with the media to deliver important health messages. Family physicians, in particular, are in a unique position: We have both the most intimate and the most global perspectives when it comes to the health of our patients. We are able to interpret research without distorting its impact and articulate this information to the general public. Finally, given the broad scope of our capabilities, we can comment on topics ranging from antibiotic overuse to sleep hygiene.
Social media is another venue that allows physicians to potentially reach an audience that extends far beyond the exam room. Physicians can recommend evidence-based guidelines, provide commentary on journal articles and dispel misinformation.
Of course, the best way to combat medical misinformation is to have a trusting relationship with your patients. I explained to Sandra what I knew about Ebola and eased her fears about transmission. I also engaged her in a goal-oriented discussion about statins and the influenza vaccine. Although she didn’t change her mind that time, I took comfort in the fact that she always comes back to see me. And she’s no longer worried about Ebola.
Natasha Bhuyan, M.D., is a family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.
Information Overload: New Gadgets Provide More Data, What Else?
Eko Devices Inc. recently achieved FDA approval for Eko Core, which is a digital attachment for an analog stethoscope. Although it's not the first digital stethoscope on the market, it is the first to connect with a smartphone app, and it joins several hundred other devices used to collect data from patient encounters.
Essentially, Eko's device captures audio waveforms from direct auscultation and transmits them to a phone, tablet or computer. Software compliant with the Health Insurance Portability and Accountability Act allows for recording and storage of the collected waveforms, even depositing them directly into a patient's electronic health record.
© Eko Devices Inc.The Eko Core stethoscope attachment allows physicians to stream heart sounds to a HIPAA compliant smartphone app and deposit them directly into a patient's electronic health record.
More than just a gadget, however, this device is another example of the increasingly complex data collection that's becoming ubiquitous for physicians and patients. From exercise tracking to lab values to genome sequencing, we add more complex measurements and data points every day. We measure our inputs and outputs. We track height and weight and body fat percentage. Many patients monitor glucose or INR levels at home. Add to that the reams of data we collect in physician offices and hospitals each day, like laboratory measurements of renal and hepatic function, cholesterol, and EKG data. Terabytes of storage are consumed by imaging data alone.
This glut of data is only going to increase as we develop newer, more specific technologies for tracking our biological processes. We can measure specific disease markers far more efficiently. A little more than a decade ago researchers sequenced the first human genome. Today, you can have your genome sequenced in a few hours for about $1,000.
In 2005, the CDC estimated that 7 billion to 10 billion lab tests are performed each year in the United States. A safe estimate with no inflation in the number of performed tests still amounts to at least 70 billion new data points in the last 10 years. On top of clinical data, consumer technology allows recording of what were once considered medical data. Glucose monitoring has become commonplace. Pulse oximeters are available at most big box stores. Most of us carry in our pocket enough computing power and storage to track every nuance of our daily lives.
As advanced as our data gathering methods have become, however, we still don't have direct application for most of the mountain of data we collect about each patient. Although the stethoscope attachment mentioned above provides quantifiable, measurable data about the function of a patient’s heart, it still requires context for it to mean anything.
That’s not to say that there is no benefit from recording heart sounds and waveforms. We simply don’t know yet how useful it will be. Will recording data about the heart sounds of this patient allow me to eventually detect changes during future visits? Will those changes have clinical significance? Will these measurements allow extrapolation of conclusions for other patients? These are the questions we should be -- and are -- asking, not just recording for the sake of one more piece of information in the EHR.
This also assumes the stethoscope is a medical device in the hands of a trained clinician. Not all data we collect are recorded by trained scientists. Large proportions of data now come from smartphones and exercise trackers. How significant are the data points collected by patients with home monitoring equipment? How accurate are these data? What, if any, is the context for these data points? Is there a point to all this collection? What do we do with all these datasets?
The answer is simple, but far more complex in execution. We study them. We record all the points we can, with all the context we can obtain, and we analyze them for patterns and correlations. Those correlations are not the end, but just the beginning, giving direction for further study. The real benefit from this mountain of data is a course heading for further randomized-controlled research. Rather than jumping to conclusions based on limited and often context-poor data, we can now make educated decisions about resource allocation for research using the tools at our disposal. Computer systems like Watson comb through millions of data points looking for algorithms that may improve our diagnostics and clinical decision-making.
As primary care physicians, we will be on the front lines for data collection, but we will also reap the benefit of more focused research. In this early phase, that often means information overload. We will be recording data points that may not make sense or have direct application at the moment. If used correctly, however, these measurements will eventually allow for more targeted treatment and better patient care.
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.
Key to Boosting Access Is Expanding the Pipeline
The University of California, Los Angeles’ softball team scored a verbal commitment last winter from a talented pitcher and power hitter. Recruiting success isn't anything out of the ordinary for such an elite program, but this particular story made national news because the athlete in question won't be joining the Bruins until 2019.
Why? She’s 13.
Aggressive and early recruiting is a growing phenomenon in college sports. The motives are multifactorial, but result in students who receive mentoring and generous scholarship offers to competitive colleges. That children need resources early in their lives to succeed is no surprise. Yet the level of zeal seen in athletics is missing when it comes to encouraging children to pursue an academic field.
© Errol Dunlap/Tour for Diversity in MedicineFamily physician Kameron Matthews, M.D., talks to students about careers in medicine during a Tour for Diversity in Medicine event. The initiative promotes medicine and dentistry to undergraduate students from racial and ethnic groups that are underrepresented in health care.
The Physician Shortage
Medicine, in particular, is facing a crushing doctor shortage that is expected to total as many as 90,000 physicians by 2025, according to the Association of American Medical Colleges. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care estimates that by that time, there will be a shortage of 52,000 primary care physicians. The implications of this shortage pose a real health risk to patients who can’t get timely care, but it also threatens to drive up already astronomical health care costs as hospitals absorb patients who don’t have a primary care physician.
The overall dearth of physicians must be addressed, but it's also true that there are compelling reasons for the physician workforce to grow in diversity as well as overall size. Minority physicians are more likely to become primary care physicians who practice in rural and underserved areas, where physicians are desperately needed. Closing care gaps for underserved groups is a key to reducing prevalent health disparities. Infant mortality among black infants is still twice as high as among white infants. Hispanics are three time more likely to die from asthma than any other demographic group. Lesbian, gay, bisexual and transgender Americans have disproportionately higher rates of later-stage cancer diagnoses. Access to care is a factor in these health disparities -- as are implicit biases. A more diverse physician workforce could help address both issues.
The Road to Becoming a Physician
For many, the journey to becoming a physician consciously begins at the college level. But the opportunities for success -- advanced-level classes, ambitious after-school programs, and a knowledgeable team of teachers, parents and guidance counselors -- start much earlier. Academically rigorous classes teach core content but also critical thinking skills, writing, problem-solving and oral communication, which are leveraged in the medical school application process. Yet according to the U.S. Department of Education, a quarter of the public high schools with the highest percentage of black and Hispanic students do not have any algebra II courses and a third are without chemistry classes.
The financial barriers to attending medical school also start well before college. All too often, it's the students who are the most underprepared for standardized tests (because of inferior schools, low socioeconomic status, etc.) and who need help the most who can’t afford costly test prep courses. The extracurricular activities that cultivate skills colleges find so appealing also come with extra costs many families can’t afford, such as sports uniforms, music lessons or theater costumes.
Financial burdens also limit students’ abilities to participate in extracurricular activities and shadowing experiences that college and medical school admissions processes prioritize and require -- especially once those students hit working age -- because they may have to contribute to their family's income rather than spending time volunteering in a lab or shadowing a physician.
In addition to educational and financial inequality, students from lower socioeconomic backgrounds face a social capital gap. They often don’t know college graduates who can give them advice about writing a personal statement. They aren’t connected to medical students who can provide interviewing tips and guidance in developing the all-important curriculum vitae. And they certainly don’t have doctors in their social circle who can share with them the joys, pitfalls and intricacies of a career in medicine. They also are less likely to have their own primary care physician.
All told, it’s no wonder that 75 percent of medical students come from families who are in the top 40 percent of U.S. incomes.
The Potential in Pipeline Programs
The path to medical school is daunting. Medical organizations have taken note; already, various pipeline programs -- ranging from the middle-school level to colleges -- encourage the pursuit of medicine. Their focus tends to be on underrepresented minorities in medicine who face the biggest hurdles in becoming physicians. Programs such as the AMA's Doctors Back to School use mentoring and role modeling as the foundation for success. The AAFP has developed its own version of this program, with a focus on primary care.
The Tour for Diversity in Medicine kicks off its round of fall tours in October. That initiative -- which is directed by a family physician and an emergency medicine physician and is supported by the AAFP -- promotes careers in medicine and dentistry to undergraduate students of racial and ethnic minorities who are underrepresented in health care.
I served as a counselor for a summer program, Phoenix Med-Start, that connects high-school students to health care professionals and university-level classes. We spent weeks in medical workshops, learned anatomy with skeleton models, participated in interactive labs and engaged in global discussions about health care ethics, disparities and systems. Three of my students from that program are now completing residency, including two in primary care.
But as ambitious as they are, few pipeline programs can offer generous scholarships or guarantee a coveted admissions spot (unlike the world of sports recruiting). Given the many barriers, the Medical Schools Council, which represents medical schools in the U.K., said children should actually learn about the medical field far earlier, at age 7, to plant the seeds of interest and start overcoming the social hurdles into medicine.
Pipeline programs are growing, becoming longitudinal and targeting children earlier, and a key component of their success is physician involvement. Although it takes years to realize the impact of pipeline programs, they are the first step to solving the physician shortage.
So what can you do? Family physicians can talk to their young patients about what they’re interested in and follow up with those interested in medicine and related topics. We can offer to let them shadow in the office, serve as a role model and encourage them in general. Physicians can also seek out opportunities to talk to kids in our communities by offering to do a presentation at a school or youth organization.
The AAFP’s Doctors Back to School program includes a PowerPoint presentation that members can use and modify. It also has tips for reaching out to schools, news release templates to promote their visit and other resources.
The qualities patients cite in a good physician -- compassion, excellent listening skills, clear communication -- aren’t gained from a linear or easy path to medicine. It’s the tangents that can’t be taught that eventually lead to a great physician. We need people in medicine who have experiences that prompt them to be better advocates for their patients. Let’s find those people and give them a good head start.
Natasha Bhuyan, M.D., is a family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.
Fresh Approach Turns Substance Abuse Challenges Into Triumphs
I practice in rural Missouri, but before I came here, I was a resident in the South Bronx. My experience in New York opened my eyes to the harsh realities of addiction and substance abuse in our inner cities.
As a resident, I became all-too-familiar with treating patients who suffered from alcohol and opiate addiction. Still, I was not entirely prepared for the extent of the substance abuse problem I now face as a small town doc. Addiction knows no geographical or social boundaries.
On a daily basis, I must decipher the complex motives of each patient who comes into my office seeking controlled substances to treat complaints of pain, anxiety and attention-deficit disorder. I also try to determine what illegal substances they may be using.
I have found it fairly easy to identify patients who have succumbed to opiate addiction, but it is not as easy to pick out those struggling with alcoholism. After months of this struggle, I realized that I needed a program that would allow me to draw these patients out of the shadows and into treatment. I knew that an ideal treatment modality would be one that could address multiple addictions collectively, and I resolved to develop a comprehensive, integrated practice-based program that would optimize healing by addressing body, mind and spirit.
Now, with support from my hospital and the assistance of a licensed clinical social worker and office staff, we are doing just that.
We launched our addiction recovery program in April. Our focus is on maintenance of opiate (and alcohol) cessation through the use of oral (Revia) and depot (Vivitrol) naltrexone, a nonhabit-forming opioid receptor antagonist. The program is available to patients who have been able to achieve sobriety for at least seven days. They may accomplish this on their own or through the assistance of physician-guided withdrawal, a detox program or inpatient rehab. Patients are expected to enter into a recovery contract, comply with random drug screens and attend routine counseling sessions with a licensed clinical therapist.
Many of the patients who have sought help through our program also suffer from dependence on other substances, such as benzodiazepines and methamphetamines. I have found that the medication-assisted treatment we provide, whether via placebo or through the modulation of neural pathways, along with the complementary benefits of cognitive therapy, often produces a cross-over benefit by helping our patients with their coinciding addictions.
In these early stages of the program's development, we have had some difficulties maintaining patient follow-through and compliance. Nevertheless, I have found great relief and satisfaction in knowing this resource is available to patients, and I am gratified by how easy it is to open a conversation about alcohol and opiate addiction with my patients now that I have an in-clinic treatment option.
When our addiction recovery program went live, a handful of my patients immediately enrolled, and I was pleasantly surprised by the number of referrals I received from outside my health care network.
Local law enforcement offices and family services agencies have expressed interest in working with me on a direct referral basis, which would necessitate additional credentialing for our program. This would make us eligible for state and federal funding that would cover the cost of expanding to provide a broader scope of services and to reach the uninsured. Based on the evident demand, I have taken steps toward achieving state certification. But I have done so with some hesitation because taking on such a mantle could quickly draw a greater influx of patients than we are prepared to handle.
For now, I have decided to proceed at a slow but steady pace, allowing the program to grow as a seamless part of my practice. Managing and promoting a recovery program alongside a primary care practice can quickly become a time-consuming affair, but I have managed to strike a balance that works for me, and I look forward to advancing this program as I gather resources and support.
My passion for this project builds each week through the successes I witness and the gratitude I receive from the patients it benefits. One patient in particular comes to mind. She is in her mid-30s and has suffered most of her adult life from addiction to marijuana, cocaine, opiates, alcohol, cigarettes and kleptomania. She also has a chronic pain syndrome along with a number of other comorbidities, which I have been treating for more than a year.
It was clear that this patient was a poor candidate for continued narcotic pain management, so I presented her with the option of tapering down from her controlled pain meds and trying naltrexone. I informed her that studies had shown a reduction in overall pain level and a general decrease in addictive tendencies, particularly when paired with cognitive behavioral therapy. After discussing this option at length with the assistance of some motivational interviewing and a little coaxing from a family member and friend, she enrolled in our program.
A week later, after her initial intake/counseling session with our licensed clinical social worker, she started medication-assisted therapy using Vivitrol. Two weeks later, this patient was back in my office reporting that all of her cravings for alcohol and opiates had evaporated and that she had less of an appetite for marijuana. She also reported that her pain levels were significantly reduced and she felt it was easier to control her urges to steal things. She continues to be an exemplary success, and a growing number of patients are making similar progress through the program.
Substance abuse is an age-old problem that, unfortunately, is here to stay. As clinicians, we will continue to find ourselves caught up in the delicate balance between appropriate patient treatment through the use of controlled medications and the hazy netherland of direct or indirect enablement of prescription drug abuse and diversion. As prescribers, we must always be on guard to protect our licenses from being taken advantage of by drug-seeking patients. However, it would be tragic if we let that fear keep us from seeking the best for all of our patients by providing help for those whose lives have been broken by the devastating consequences of addiction and substance abuse.
We have the skills and the tools to make a difference. The choice is ours. Let’s make a meaningful difference together.
Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.
Put the iPad Down: Find Ways to Cut Back on Screen Time
Screens are unavoidable. Even if we minimize the number of electronics in our homes, they are ubiquitous in our communities. It is becoming more common to see televisions in restaurants, large screens in retail stores and on the streets for advertising, tablets in airport terminals and even small drop-down screens in vehicles.
As a new school year starts, parents are faced with the realities of schedules, homework and extracurricular activities. How do all these screens fit in with everything else?
Unfortunately, the average American child spends seven hours a day looking at various types of screens. Seventy-five percent of teenagers own a cell phone, and more than half of adolescents access some form of social media more than once a day.
The AAFP and the American Academy of Pediatrics (AAP) recommend no screen time before 2 years of age, and no more than two hours a day for children 2 and older. This means that the time your child spends playing games on your phone while you're waiting in line or watching cartoons while you shower or cook dinner quickly add up. Before you realize it, your child's screen time can easily exceed the recommendation. The same is true for the families we care for in our practices.
Why do the AAFP and AAP make these recommendations? Too much screen time has been shown to increase problems in school, obesity rates, sleep and eating disorders, and attention problems. Violence on television and video games has been shown to increase aggression and desensitize people to violence. Additionally, adolescents are subjected to new kinds of social pressure that never existed before, such as cyberbullying and "sexting."
How powerful is the effect of media on children? It's telling that some leaders in the tech industry are stricter about their children's use of media devices -- including their own products -- than the average parent. When Apple released the iPad in 2010, co-founder Steve Jobs told a reporter with The New York Times that his young daughters had not used the device and certainly were not allowed to have their own. The same story, published last year, highlighted the fact that many industry leaders don't allow electronic media on school days or in their children's bedrooms (a practice that aligns with an AAP recommendation).
As families prepare for kids to go back to school, many physician practices see an increase in demand for physicals. This offers a perfect opportunity to address screen time with our patients and their parents. How do we counsel families and limit (or restrict) our own kids' screen time, given the myriad of opportunities to engage with devices in our culture?
We start by disconnecting ourselves. As role models, our children are watching us all the time. As we all know, the "do as I say, not as I do" adage is not the most effective method of parenting. So lead by example. As a recent NYT blog suggests, reserve your screen time for parts of the day when your children aren't around or awake. Make sure that those transition times -- going to school or coming home -- are special, "electronic media-free" times so you can talk about your day together and connect on a person-to-person level. Consider deciding as a family to have "screen holidays" once a week, or with some regularity, during which time no one checks email, looks at Facebook or plays video games. This time can be used to enjoy reading actual books, playing board games or playing outside.
Another incentive to put down the electronic leashes is that they distract us from paying attention to what really matters. In the same blog, Catherine Steiner-Adair, Ed.D., attributed a 20 percent increase in accidental injuries treated in pediatric ERs to adults failing to focus on the children they were supposed to be watching.
How screens and electronic media change our brains is a commonly debated topic, and more research is needed to determine how this affects us and our children. The recommendation to limit screen time remains a worthwhile goal because it enables us to spend more time doing things we know promote good health and well-being: preparing fresh meals, riding bikes, reading books and having conversations with our children.
And so, I leave you with a challenge (and you should consider challenging your patients): Can you go one whole day without looking at a screen?
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.
Mentoring Key to Molding Next Generation of Leaders
The AAFP Foundation recently brought together 30 brilliant young people -- 15 medical students and 15 family medicine residents -- to begin an innovative, yearlong leadership development program.
The Family Medicine Leads Emerging Leader Institute identified 30 participants through a competitive process that generated 115 applicants. The program's intent is to expand the number of future family medicine leaders and provide valuable training to help prepare them for this important role.
Photo courtesy of AAFP FoundationFifteen family medicine residents and 15 medical students were selected to participate in the AAFP Foundation's Family Medicine Leads Emerging Leader Institute. The participants met Aug. 1-2 in Leawood, Kan.
An integral component of the Family Medicine Leads Emerging Leader Institute is mentoring, and I have the great privilege of serving as a faculty member for the program. The participants and the faculty members met for the first time Aug. 1-2 at AAFP headquarters in Leawood, Kan., after the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo. Participants were divided into three tracks: Policy and Public Health Leadership, Personal and Practice Leadership, and Philanthropic and Mission-driven Leadership.
Residents and students were each assigned a mentor, who will provide guidance and support in the execution of projects the mentees will work on during the coming year. In completing their projects, mentees will demonstrate their leadership and skill development while accomplishing important work related to the chosen track.
Listening to their project ideas was fascinating; they covered a wide range of issues, including childhood obesity, caring for the homeless, improving patient care by using technology to obtain information between office visits and supporting military families. The passion and talent around those tables was palpable. The participants helped each other flesh out their project ideas, and they looked to faculty to fill in the gaps when they had questions.
My colleagues serving as mentors are a phenomenal group of family physicians, including past AAFP presidents, Board members and other established leaders in our specialty. Mentors will not only provide guidance and support, they also will serve as role models, reflecting leadership attributes that the program is hoping to impart. The Emerging Leader Institute faculty members will also be available to help the participants throughout the year.
The connections we made with these students and residents already are proving valuable. For example, one student in my track is interested in rural health care, but she had not met anyone who practices full-scope family medicine in that setting until she met me. I plan to help mentor her. Another student I met during the weekend is going to do a rotation at my clinic.
As a faculty member, this experience has been extremely rewarding. Helping to guide students and residents always is fulfilling because it helps to remind me why we do what we do. It also takes me back to a time during training when I was excited about all that was still to come. I felt confident and proud of those emerging leaders in that room, and I look forward to seeing the amazing work that evolves from their projects.
The early feedback from the students and residents has been overwhelmingly positive. Here's a sample:
“This has been an empowering and inspiring experience," said Tequilla Manning, a third-year medical student from the University of Kansas Medical Center. "Medical school is often draining, but the (Family Medicine Leads) Emerging Leader Institute has brought me back to my core values and vision for my future. Yay! I’m on fire again! Thank you.”
AAFP Foundation President Jason Marker, M.D., told me the foundation had been looking for a signature education program, and Family Medicine Leads was the result of those efforts. In addition to creating the Emerging Leader Institute, the foundation increased the number of scholarships it provides for National Conference to 250, up 50 from last year. Family Medicine Leads Scholarships will focus on rising second-, third- and fourth-year students, with the goal of influencing their commitment to the specialty.
"We know that our donors have always been passionate about student and resident issues, but this initiative can push it to the next level," said Marker. "Leadership development is a philanthropic goal. Maybe you don’t have the time to mentor students or residents directly, but maybe you can contribute some dollars, so by helping us pull this off you are helping the pipeline as a donor."
The AAFP Foundation is the philanthropic arm of the AAFP. Its mission is to advance the values of family medicine by promoting humanitarian, educational and scientific initiatives that improve the health of all people. The foundation supports more than 20 programs each year, including disaster relief, an annual Family Medicine Cares International delegation trip to Haiti, research stimulation grants, family medicine interest groups, Tar Wars programs and much more.
As a 501(c)(3) organization, the foundation is supported through donations. This means that if we don’t donate, these programs can’t succeed. Donors have the option of earmarking donations for a particular program or area, and as new physicians, I would encourage you to donate to Family Medicine Leads to help develop our future family physicians.
If you are interested in serving as a faculty member or mentor for this program in the future, please contact the foundation. I assure you it will be well worth your time.
Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.
Do No Harm: When Is a Physician Too Sick to Work?
A recent study published in JAMA Pediatrics found that the vast majority of physicians have gone to work sick -- even though we know we shouldn’t.
Included in the study were attending physicians, nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists and nurse midwives who work in a hospital setting, although some also worked outpatient. Ninety-five percent of respondents acknowledged that working while sick puts patients at risk, yet 83 percent reported working while sick during the past year. The study, which was initiated by a hospital's infection control staff, was done in an attempt to determine why we do this.
|A physician looks at a digital thermometer. More than 80 percent of health care professionals go to work while sick -- despite the risk to patients and colleagues.
The leading reason given for working while ill was not wanting to let colleagues down (98 percent) followed by not wanting to let patients down (92 percent) and the need for continuity of care (69 percent).
System-level challenges were found to be at fault, as well.
There also were complaints about sick leave policies -- either the lack thereof or the inability to utilize sick leave because of logistical difficulties or because no other providers were available for coverage. Overall, study participants generally noted that it was simply easier to work while sick than to overcome these barriers.
We have created a culture where working while ill -- despite our better judgment -- is not only accepted but expected.
The study's conclusion noted that more research is needed regarding what specific illnesses constitute danger to patients. In other words, when are we too sick to work?
We all can probably think of times when we or a colleague should have stayed home, with some situations being more reckless than others. However, we rarely make our sick colleagues leave, and sometimes I think that would be the only way one of us would admit to being too sick to work.
Resident presenteeism has been studied, and the results aren't pretty. The Accreditation Council for Graduate Medical Education mandates that programs have sick leave policies, and some programs have a back-up call schedule, someone who is on call to be on call, so the difficulty of finding a person to cover is eliminated. But personally, even when I have been in such a situation, I didn’t use the back-up resident; I kept working.
Intern year I was sitting at a computer typing an H&P when I felt I’d been shot in the neck. I had just finished rounding, the attending was sitting beside me and for a few minutes I tried to keep typing as if nothing had happened. But then he asked me a question, and I had to turn my whole body to look at him. I realized this was not just a little neck pain. This was going to stick around awhile. I thought it was probably just because I was tired. I had flown back from an AAFP meeting less than 24 hours before that call shift, my last one on this service for the month. I took some ibuprofen, which prompted the attending to ask if I felt OK. Of course, I replied with something to the effect of, "Yeah, I'm good."
He left for the night, and a few hours later I found myself walking through the hospital with my eyes barely open because the light made my intense headache much worse. I was walking as if I was trying to sneak up on someone so as not to jar my head with each footstep. I met up with my senior resident for the night to discuss an admission, and he asked, "Are you having meningitis right now?" My answer, "I hope not."
A couple of hours later I was at home with a fever and vomiting, realizing that regardless of what I had hoped, this was likely viral meningitis. I had been exposed to multiple patients with a few different types of viral meningitis, and mine resembled enterovirus. I still have hearing loss and a new respect for people with chronic migraines.
We collect these stories like they are something to brag about, but we should be embarrassed. I worked under residents who told stories of starting IVs in the call room on each other because they had been vomiting for so long that they were more dehydrated than most of the patients we were admitting. One of my ER attendings finished a shift with appendicitis before signing himself in for treatment. These were my role models, people I respected and wanted to respect me.
But just as the JAMA Pediatrics article concluded, there needs to be a threshold we do not cross. There is a point at which the risk to the patient is too great for us to go to work just because we can manage to put one foot in front of the other and walk through the door. Unfortunately, this behavioral pattern we display as physicians goes beyond being sick. It runs throughout every part of our training and later our obligation to function as essential employees who drive through the snow, go to work when there is no power, and treat patients in disaster settings. We go to work when people need us because it's what we do.
More well-constructed studies about disease transmission from physician to patient would be great. But at the same time, we are doctors, and we know what is contagious. We know when to tell patients not to go to school or work, despite sitting there working in the exam room with the same diagnosis as the patient.
I am motivated to work when sick if patients would otherwise not be seen. That is a deal breaker for me. But I expect my nurse to stay home if she is sick. During a flu epidemic this past winter, I had her swab herself three different times in one day hoping one would turn positive because I suspected she was too sick to work. I didn’t think I could convince her to go home otherwise.
Flu is a good example of a success regarding medical sick leave. Everywhere I have worked there has been a policy that if you test positive for the flu, you are off work for five days -- no exceptions. That is evidence that we can make sick doctors go home when the risk is too great to the patients and staff.
Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.
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.
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.
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.
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.
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
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