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Tuesday Nov 24, 2015

Moving On: Finding the Right Job Worth the Effort

Starting over is scary.

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

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

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

And sometimes you have to follow your heart.

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Nov 18, 2015

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

Tuesday Nov 10, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Nov 04, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Oct 27, 2015

Digging Out of Medical School Debt

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Oct 20, 2015

Strength in Numbers: Teamwork Prevails in Face of Disaster

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

You'd rely on your team.

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

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

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

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

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

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

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

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

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

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

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

Wednesday Oct 14, 2015

Fewer, Not More, Vaccine Exemptions Needed

I am fortunate, compared with many of my peers, when it comes to immunizations. I have the luxury of taking care of patients in a state with a mandatory vaccination policy.

No religious, conscientious, personal preference, made-up or any other type of exemption is allowed -- only true medical contraindications. In West Virginia, we have mandated vaccination standards for children involved in public education.  

© 2015 David Mitchell/AAFP

A 1-year-old girl receives a vaccination. The AAFP recently adopted a policy against nonmedical vaccine exemptions. 

Until recently, only Mississippi shared my state’s vision for mandated vaccination, but California joined our ranks earlier this year. It likely is one of the few things West Virginia and California have in common.

Children who attend state-licensed daycares in West Virginia must be up-to-date with the vaccine schedule recommended by the AAFP, the American Academy of Pediatrics and the CDC. To enroll in pre-K, children must have received at least the first dose of all recommended vaccines. They then have eight months to obtain the additional doses recommended for their age group.

Children entering West Virginia schools for the first time from kindergarten through high school must show proof of immunization against diphtheria, pertussis, tetanus, polio, measles, mumps, rubella, varicella and hepatitis B unless they have medical exemptions. And all students in seventh and 12th grades -- regardless of whether they have been previously enrolled -- must prove they are up-to-date with tetanus, diphtheria and acellular pertussis (Tdap) and meningococcal vaccinations. Unlike the pre-K policy, there is no allowance for provisional enrollment.

These policies have provided West Virginia with some of the nation's highest immunization rates -- and correspondingly lower vaccine-preventable disease rates. In 2013-14, students entering kindergarten in public schools had coverage rates ranging from 97 percent to 98 percent for five recommended vaccines. Medical exemptions were allowed for only 0.1 percent of students.

Yet despite this public health success story, bills were introduced during our last legislative session that would have weakened our vaccine requirements by allowing nonmedical exemptions. I would like to assume that when something good for our state exists, it will stick around, so I was shocked when I heard one of these bills actually had some momentum. Why would we move backward? Why would we start putting our citizens at risk? Why wasn't every physician in the state at the capital in Charleston expressing outrage?

Fortunately, these bills -- which were debated while a measles outbreak was spreading in 24 states -- did not become law. There were plenty of physicians and other public health-minded people willing to testify in support of mandatory vaccination policies, and we kept our current standards. I fear, however, we will see similar bills introduced in the next legislative session.  

If I had been chosen to testify during the previous session, I would have referenced public health data and general information about the benefits of vaccines. Because of the success of our state's immunization policy, I have never seen a case of measles or mumps, so I can’t give first-hand testimony about infants dying of vaccine-preventable diseases. In the coming legislative session, however, I will be able to provide concrete examples I’ve seen in my adult patients who have acute hepatitis B infection.

West Virginia didn’t start to mandate hepatitis B vaccinations until 2000. Unfortunately, we have the highest rate of acute hepatitis B cases in the country, a shocking 10.5 per 100,000 persons in 2013, when the national rate was 1.0 per 100,000.

National data show most of the cases are in the 25-50 age group, which is consistent with what I see in my state. I see far too many cases of hepatitis B and C infection in my rural practice. Thankfully, I know I will see a change in this disease pattern in my lifetime because of our vaccination policies. The children I vaccinate today will grow up to be adults without hepatitis B infection.    

I have never had an adult patient refuse the hepatitis B vaccine series. They come see me for vaccination when a friend or relative is diagnosed with hepatitis B infection. I think that is in part due to the groundwork we lay with childhood vaccines. My patients see stories in the news about disease outbreaks happening in other states, and that just doesn't happen here.

The AAFP recently adopted policy that objects to immunization exemptions for any reason other than a documented allergy or medical contraindication. I hope that California adopting a mandatory vaccine policy is just the beginning and soon, that state, Mississippi and West Virginia will be part of a long list of like-minded states.  

We need to be smart about crafting these programs and learning from what already exists. Health Affairs published an article exploring disease patterns that result from state-specific exemption policies. The numbers speak for themselves, but we as family physicians must speak for our communities. No legislative conversation -- or, more importantly, vote -- about vaccination policies should occur without our input. We have to be willing to sacrifice a few hours, or even a day, of patient care to influence policy.

This issue should not be up for debate. Immunizations are a medical necessity.

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

Tuesday Oct 06, 2015

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.

Monday Sep 28, 2015

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.

Monday Sep 21, 2015

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.

Wednesday Sep 16, 2015

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.

Wednesday Sep 09, 2015

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.

Tuesday Sep 01, 2015

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 Medicine
Family 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.

Monday Aug 24, 2015

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.

Tuesday Aug 18, 2015

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.

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