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Tuesday Sep 09, 2014

The Value of Family Medicine: Stating the Obvious to the Oblivious

I recently participated in a state-level meeting with Medicaid administrators that also included a number of subspecialists. The discussion revolved around the appropriate dosing of proton pump inhibitors for acid reflux, with some Medicaid representatives opining that these medications were being over-prescribed by "general physicians." Some, in fact, called for implementing a stricter prior authorization process if drugs in this class are to be prescribed by primary care physicians.

Both the administrators and the subspecialists offered misguided statements, such as

  • "Family physicians can't follow treatment guidelines because of the complexity and ever-changing nature of those guidelines."
  • "Treating acid reflux should be left strictly to subspecialists."
  • "Primary care physicians don't actually think about what they do but reflexively prescribe medications that they don't fully understand."

As the lone family physician in the room, I defended our specialty. However, thoughts like these remain prevalent among some payers and subspecialists who fail to understand the value we bring to the health care system.

I know I am not the only one facing these gross misperceptions, so I want to refresh everyone's memory about why family medicine is the foundation of health care and, thus, one of the most important areas of medicine in any health care system.

We Care for the Whole Patient
Probably the biggest reason family physicians are best suited to caring for patients is our broad training and how we apply it to patient care. For example, a patient's depression impacts his or her diabetes, which, in turn, can affect his or her chronic obstructive pulmonary disease and heart failure. Medication side effects often worsen another disease process. And a patient's social context frequently provides significant insight into his or her symptoms. Understanding how to look at all of these pieces and see beyond a specific organ system to the complete person provides many of the clues to proper diagnosis and treatment. Comprehending how these issues fit into the patient's framework of values, beliefs, community and culture presents the key to healing.

We Blend the Evidence With Our Knowledge of the Patient
Providing quality care for patients is a central principle of family medicine. We use the best medical evidence to guide our diagnostic and treatment recommendations, but we also recognize when the context of a patient's illness calls for tempering that evidence-based approach. The medical decisions we make in conjunction with patients may not always look best to an administrator, but that doesn't mean they're the wrong decisions. They simply reflect the biopsychosocial model of family medicine training that uniquely positions us to respond to a wide variety of complaints and situations to better meet patients' needs.

We Provide Value to Our Patients and the Health Care System
Family physicians deliver higher quality care for a lower price than does any other specialty. This topic has been studied extensively by researchers, such as Barbara Starfield and others, who recognize the impact family medicine has on individuals, as well as systems. With the ever-increasing costs of health care, the solution to the problem is to better utilize the value that family physicians provide instead of viewing us as merely a source of referrals to subspecialty care. But reaching that solution -- providing the value that we as a specialty are truly able to deliver -- means safeguarding the time we spend with each patient from being restricted by payers.

By no means is this intended to disparage the contribution subspecialists make, because we all recognize their worth and how necessary they are in treating many of our patients. But our health care system is never going to be able to overcome its main pitfalls if more people cannot recognize the essential role of family physicians. It is our responsibility to continue to educate those around us about our role so that together, we can continue to improve the health of our individual patients and the performance of our entire health care system.

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

Wednesday Sep 03, 2014

Frequently Asked Questions -- and Answers -- About Direct Primary Care

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

"Is that actually working for you?"

© 2014 Michael Laff/AAFP

I recently participated in a panel discussion at the AAFP's National Conference of Family Medicine Residents and Medical Students along with Abbas Hyderi, M.D., M.P.H., left, and Lilia Cardenas, M.D., center. Students and residents had a lot of questions about my direct primary care practice.

"What if a patient gets hit by a bus?"

"What about patients who are publicly insured?"

Whenever I discuss my direct primary care practice, I expect a barrage of questions. After opening my DPC practice more than two years ago, I think I've heard them all.

When I participated in a panel discussion recently at the AAFP National Conference of Family Medicine Residents and Medical Students, I was ready for all comers. The panel covered a range of family medicine topics, so I only briefly spoke to questions regarding DPC. But afterward, a sizable group of curious students and residents approached me. Several had already thoroughly researched DPC, but most had just recently been introduced to the idea.

A few themes -- and perhaps misperceptions -- emerged. I will try to address a few of them here.

Q: How do your patients get labs, meds, specialists or surgery?

A: My chief concern is my patients' care when I am sitting in the room with them. Family physicians can provide comprehensive care to 80 percent to 90 percent of people at most times in their lives. Enhancing our services should be our main focus. How can we provide the best primary care in an efficient and affordable manner? The better we do our job, the fewer hospitalizations, consults and coronary stents patients will need.

I do have a good portion of patients who have ongoing needs for chronic conditions. A membership-based direct model has allowed me to do innovative things to assist in those areas. We provide labs, meds and procedures at huge discounts. We subcontract lab services and provide members most routine labs (lipids, A1c and many more) for no charge and others with minimal fees. Selling wholesale medications directly to patients often results in hundreds of dollars in savings per month for individual patients. Most procedures are $10-$20 to cover the cost of supplies.

Q: What about insurance?

A: Direct primary care is not anti-insurance. Sometimes, although rarely, people really do get "hit by a bus." Insurance is absolutely necessary for certain types of care. Some events and conditions are inherently expensive. I encourage all my patients to have an insurance plan in case of such an event.

However, hypertension management and radiation treatment for brain cancer are radically different things. Why should we pay for them in the exact same manner? For better or worse, the move toward higher deductible insurance plans has created a demand for transparency among patients. Direct primary care can help fill that void. For many of my patients, combining a high-deductible health plan (a "bronze" level plan on insurance exchanges) with a DPC practice membership with us is a significant savings versus a Cadillac, low copay plan ("gold" or "silver").

Despite my recommendations, many of my patients are uninsured. This is not ideal, but they will
continue to get stellar, continuous care with us in the meantime.

Q: What about someone who cannot afford the DPC membership?

A: The main reason many people cannot afford health care is because it's too dang expensive. Most of my patients found us because they could not afford insurance premiums and/or out-of-pocket expenses under the current system. They could not afford to be without direct primary care.

Although "affordable" is a relative term, I recognize some people have trouble paying even modest DPC membership fees out-of-pocket. There are many ways we could assist people in obtaining care outside of the status quo.

When DPC physicians advocate that insurance be removed from the primary care picture, many people jump to the conclusion that we are therefore calling to end all public assistance. But this is not the case.

There are a variety of alternative funding mechanisms -- outside of subsidized managed care -- that could assist people in getting better primary care. Some progressive health insurance plans and DPC practices, such as Qliance (Washington) and Turntable Health (Nevada), have partnered and are available on state-based exchanges, which is allowed for in the Patient Protection and Affordable Care Act. Also, permitting a portion of public assistance funds to be controlled by patients directly -- via health spending accounts -- could help pay for DPC practice membership fees.

Q: Is DPC really a viable option for me and my patients?

A: There are a number of factors that should be considered before switching to this model of practice -- both personally and from a business standpoint. Despite some stereotypes, DPC practices are not monolithic. Many docs have succeeded with varying models and in a wide variety of communities and populations. However, growing a practice is not easy or without risk. Research and a solid business plan are required.

An increasing number of resources are available to help doctors start and manage a DPC practice. The AAFP recently created a member interest group for DPC, and the Academy also is offering a series of DPC workshops, starting in November.

Even without systemic changes, patient demand for high-quality, affordable primary care will grow. I hope more family physicians will join in meeting that demand.

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

Tuesday Aug 26, 2014

Small Investment, Big Payoff: Grants Offer Opportunity to Improve Community Health

Have you ever had an idea that you knew would address a significant problem affecting many of the people in your community? I know there isn't a global answer for all of our patients' problems, but there are some things that can be improved with a little help. Here's one example.

The neighborhood adjacent to the clinic where I work has the highest number of amputees in the country relative to population size. Seriously, the highest in the nation.

Perhaps not surprisingly, a large number of our patients have the big three -- type 2 diabetes, hypertension and hyperlipidemia -- in addition to obesity. Many of these patients have poor diets. This is due, in part, to limited access to healthy, affordable foods combined with easy access to cheap but nutrient-poor, highly processed foods. The neighborhood has roughly a dozen fast food restaurants and only one or two grocery stores.

I knew I could help change those patients' lives for the better; I just needed the funding to do it. But where would the money come from?

I applied for, and received, a grant to help address childhood obesity. Through this project, we built raised-bed gardens at the high school and, with students helping to plant and maintain the gardens, produced quite a yield of fresh produce.

We hoped to boost the availability of nutrient-dense foods and, perhaps, replace some of those nutrient-poor foods. Some of the crops did well; others did not. But teachers and students were able to freely take from the garden when it was time to harvest. Overall, the gardens have been a success, and we are planning to double the size of the gardens this school year to have enough to hold a community-wide event with cooking demonstrations, movement classes and teaching about emotional health.  

Another encouraging development is that students are asking for healthier food -- specifically, a salad bar -- at their school, and teachers are getting used to fresh foods.  

As part of the project, we had residents speak with students about physical activity and even had the students participate in movement activities. We also were able to have a registered dietitian and a resident educate the students on emotional well-being and its impact on fitness.  

I learned quite a bit through this process. I learned how to think through a health problem to develop a project that realistically addresses a problem. I also learned how to think about sustainability; I did not want a project that would only be for one year. Rather, I wanted to create something that could last for many years and have a long-term impact. I learned about completing grant reports and managing a budget, including administrative support, supplies, travel, etc. Some of these are things I would not readily have thought of when considering how to improve the health of my patients.  

As for initially obtaining a grant, some grant applications are more complicated than others, but there are free online resources that can help you through the process.

Grants are a great way to start small in addressing a large, complex problem. Grants can offer you resources you otherwise would not have had and allow you to influence the problem without taking away from your clinical productivity. I hope many of you will seek out grant funds for small ideas or projects you want to implement to improve the health of your patient population. It might take some digging, but opportunities are out there.

Government agencies and health insurance company foundations are two places to consider looking. The AAFP Foundation provides grants for family medicine residents each year to support short-term research projects that address health disparities.

I've learned more than I thought I would throughout this process and will continue to use that knowledge for future endeavors to address community health.  

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

Tuesday Aug 19, 2014

Outside the Box: Integrative Medicine Might Just Expand Your Comfort Zone

Not long ago, a young woman came into my office. For years, she said, she just hadn't felt right, suffering from fatigue, joint pains, strange rashes, bloating, gastrointestinal upset, and mood and sleep issues. She had undergone many tests and imaging studies and had taken multiple medications, but nothing helped.

She wasn't seeing me for any of these issues, however. Sadly, she had resigned herself to always feeling this way. I finished her well-woman exam and made a suggestion: Stop eating gluten. She had never heard this suggestion.  

© 2014 Aaron Huniu Photography

Nearly 40 percent of U.S. adults use some form of complementary and alternative medicine, but are physicians ready to consider nonconventional therapies?

"It costs nothing, is practically risk-free, and it just may help you," I said.

A few months later, she was back and feeling normal. She had stopped eating gluten.

It is easy to find evidence both for and against a gluten-free diet. I am not interested in this evidence. For this "study," which had an N of 1, I can happily report a 100 percent success rate. To be fair, I have had plenty of other patients who did not respond to this diet change, but I have never hurt a patient by suggesting it, and I doubt I ever will.  

In an excellent article titled "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't," Robert Cowan, M.D., recently made a practice-changing point: "If the only standard we apply is evidence-based medicine, or standard-of-practice medicine, or FDA-approved medicine … we will miss clinical opportunities which could well transform how we manage disease … (and) do a disservice to our patients."

Complementary and alternative medicine, he points out, is complementary and alternative simply by convention. This convention sprung out of the Flexner Report of 1910, which marginalized any medical schools not using a European, scientifically centered form of education, much to the dismay of William Osler, M.D. Abraham Flexner was not a physician, but an educator, and his report forever marginalized the art of medicine.

Part of that art is knowing when our treatment recommendation is based on actual evidence, balancing probable benefit (number needed to treat) with possible harm (number needed to harm), and doing so in a neutral manner.

There is a treatment of which I am particularly fond that helps manage a condition that confounds many family physicians: irritable bowel syndrome. It has almost no side effects (heartburn is the main one, easily avoided by providing the medication in enteric-coated capsules) and its number needed to treat is … wait for it … TWO. Any guesses?  The treatment is peppermint oil -- enteric-coated, of course.

In contrast, the number needed to treat high cholesterol with a statin to prevent a cardiovascular event hovers in the 60s, and the number needed to harm and cause myalgia is as low as 10.

How 'bout them apples?

We spend the most formative years of our education getting steeped in Western conventional treatments, for which the evidence is rich, albeit sometimes skewed, as any statistician will tell you. Additionally, most of us, once in practice, have even less time to read all the evidence. And we ignore treatments that could very well help our patients, often with much lower risk and lower costs

I practice integrative medicine. This is a style of medicine that neither blindly accepts traditional medicine, nor blithely dismisses nonconventional medicine (often called CAM, or complementary and alternative medicine). It balances evidence of efficacy with potential for harm. It is patient-centered, not doctor-centered, and it forces me to shut down my ego, and my judgment, on a regular basis.

Whether or not you are ready to start challenging the treatments that sit squarely in your comfort zone makes little difference; I believe you have no choice. Although you may practice evidence-based medicine, your patients may not. According to a 2007 HHS survey, 38 percent of adult Americans used CAM in some form, and this same group spends more than $33 billion each year on CAM therapies and products and $9 billion on CAM services, generating 122 million office visits annually.

I don't eschew the medicine I spent so many years studying, but I stand in front of more than one altar. I prescribe statins. And peppermint oil. There are medical systems outside of ours, treatments we were not taught in training, that help more than they hurt. I encourage all family physicians to consider spending some CME time investigating the therapies within integrative medicine. Our patients deserve it.

Heidi Meyer, M.D., is an employed integrative family physician at Kaiser Permanente, San Diego. She enjoys yoga; dark chocolate; weekends in Vegas; bonding with her ferocious 9-pound dachshund, Bella; and plotting a drastic overthrow of the house of medicine. You can follow her on Twitter @tweetyturt.

Tuesday Aug 12, 2014

Sense of Community: CHCs Offer Way to Battle Health Disparities, Social Injustice

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

I am coming up on the two-year anniversary of starting my first clinical practice in a community health center. The joys have been great -- as have the challenges.

I've been passionate about working in a community health center (CHC) since I first learned about the opportunity as a medical student. The biopsychosocial model of care that is a hallmark of family medicine strongly resonated with me, and it made perfect sense that a CHC would be the ideal place to bring that model of health care to life given that these centers provide comprehensive primary care to medically underserved communities and vulnerable populations.

The team-based model of care used in our community health center helps me meet the complex needs of my patients. Here I am (far right) with my medical assistant, team assistant and case manager.

With a directive for half of a CHC's board of directors to hail from the local community, there is a built-in mechanism to ensure these clinics are responsive to the greater context from which their patients come. They were founded on a basic social justice mission of promoting health care equality by addressing not only medical care for individuals but also the social determinants of health within a community.

When it was time to choose a residency, I couldn't imagine training anywhere but a community health center. And as a National Health Service Corps scholarship recipient, I knew I needed to be prepared to practice in a CHC. My alma mater, the Family Medicine Residency of Idaho in Boise, is affiliated with a community health center that was designated one the of the country's first teaching health centers.

Training in a CHC, where fees are adjusted based on a patient's ability to pay, was an invaluable experience. I not only learned how to care for a panel of patients, I learned how to care for patients with no insurance or means to get certain medications or testing and patients with concurrent mental illness who lack access to higher levels of psychiatric care. And it's all amid the day-to-day battle against the social determinants of health that can foil delivering even the best evidence-based medicine.

There are times when even the most starry-eyed, optimistic types (such as me) can feel burned out. I can't always get my patients the medications or tests they really need or the subspecialist visit that might help augment their care. Mental illness is prevalent and presents a challenge for many patients in navigating their health care and the community at large. Sometimes, I'm not sure how to intervene.

But even with these daily roadblocks, I still believe in the mission of caring for anyone who walks through my office door regardless of their payer source, and I love the moments when patients say our clinic was the first place in the health care system where they felt they were treated with dignity.

I like the challenge of figuring out if I really need to order a particular lab or test -- especially if my patient might be getting the full bill. At times, I feel I am trying to live the mission of social justice and equality, and also of the triple aim (improving population health, enhancing the patient experience and reducing costs) to which our whole health care system should strive.

CHCs also are already designed to follow the patient-centered medical home model using team-based care, which at our site includes physicians, nurse practitioners, physician assistants, nurses, medical assistants, clinical pharmacists, therapists, case managers and dietitians. I could not take care of the complex needs of my patient panel without this team!

Although CHCs can be a challenging environment in which to practice, I am grateful to be a physician among those serving in our nation's community health centers. I cannot imagine another place where I could better live the values of family medicine in the biopsychosocial model of care while addressing health disparities and social injustice on a daily basis.

Amy McIntyre, M.D., M.P.H., is a family physician at the Butte Community Health Center in Butte, Mont., and her practice includes full-scope outpatient care, maternity care, and long-term care and hospice.

Tuesday Aug 05, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday Jul 25, 2014

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

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

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

And our third.

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


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

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

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

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

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

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

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

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

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

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

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

Monday Jul 21, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday Jul 11, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

Thursday Jul 03, 2014

Help Wanted: Swelling Med School Enrollments Boost Need for Preceptors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday Jun 27, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday Jun 20, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

Friday Jun 13, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How do you handle unvaccinated children in your practice?

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

Thursday Jun 05, 2014

Practicing Workplace Medicine at the Point of Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday May 30, 2014

Family Medicine: Make It What You Want

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

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

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

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

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

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

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

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

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

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

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.