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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.

Wednesday Aug 12, 2015

Mentoring Key to Molding Next Generation of Leaders

The AAFP Foundation recently brought together 30 brilliant young people -- 15 medical students and 15 family medicine residents -- to begin an innovative, yearlong leadership development program.

The Family Medicine Leads Emerging Leader Institute identified 30 participants through a competitive process that generated 115 applicants. The program's intent is to expand the number of future family medicine leaders and provide valuable training to help prepare them for this important role.  

Photo courtesy of AAFP Foundation
Fifteen family medicine residents and 15 medical students were selected to participate in the AAFP Foundation's Family Medicine Leads Emerging Leader Institute. The participants  met Aug. 1-2 in Leawood, Kan.

An integral component of the Family Medicine Leads Emerging Leader Institute is mentoring, and I have the great privilege of serving as a faculty member for the program. The participants and the faculty members met for the first time Aug. 1-2 at AAFP headquarters in Leawood, Kan., after the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo. Participants were divided into three tracks: Policy and Public Health Leadership, Personal and Practice Leadership, and Philanthropic and Mission-driven Leadership.

Residents and students were each assigned a mentor, who will provide guidance and support in the execution of projects the mentees will work on during the coming year. In completing their projects, mentees will demonstrate their leadership and skill development while accomplishing important work related to the chosen track.  

Listening to their project ideas was fascinating; they covered a wide range of issues, including childhood obesity, caring for the homeless, improving patient care by using technology to obtain information between office visits and supporting military families. The passion and talent around those tables was palpable. The participants helped each other flesh out their project ideas, and they looked to faculty to fill in the gaps when they had questions.

My colleagues serving as mentors are a phenomenal group of family physicians, including past AAFP presidents, Board members and other established leaders in our specialty. Mentors will not only provide guidance and support, they also will serve as role models, reflecting leadership attributes that the program is hoping to impart. The Emerging Leader Institute faculty members will also be available to help the participants throughout the year.  

The connections we made with these students and residents already are proving valuable. For example, one student in my track is interested in rural health care, but she had not met anyone who practices full-scope family medicine in that setting until she met me. I plan to help mentor her. Another student I met during the weekend is going to do a rotation at my clinic.

As a faculty member, this experience has been extremely rewarding. Helping to guide students and residents always is fulfilling because it helps to remind me why we do what we do. It also takes me back to a time during training when I was excited about all that was still to come. I felt confident and proud of those emerging leaders in that room, and I look forward to seeing the amazing work that evolves from their projects.

The early feedback from the students and residents has been overwhelmingly positive. Here's a sample:

“This has been an empowering and inspiring experience," said Tequilla Manning, a third-year medical student from the University of Kansas Medical Center. "Medical school is often draining, but the (Family Medicine Leads) Emerging Leader Institute has brought me back to my core values and vision for my future. Yay! I’m on fire again! Thank you.”

AAFP Foundation President Jason Marker, M.D., told me the foundation had been looking for a signature education program, and Family Medicine Leads was the result of those efforts. In addition to creating the Emerging Leader Institute, the foundation increased the number of scholarships it provides for National Conference to 250, up 50 from last year. Family Medicine Leads Scholarships will focus on rising second-, third- and fourth-year students, with the goal of influencing their commitment to the specialty.  

"We know that our donors have always been passionate about student and resident issues, but this initiative can push it to the next level," said Marker. "Leadership development is a philanthropic goal. Maybe you don’t have the time to mentor students or residents directly, but maybe you can contribute some dollars, so by helping us pull this off you are helping the pipeline as a donor."

The AAFP Foundation is the philanthropic arm of the AAFP. Its mission is to advance the values of family medicine by promoting humanitarian, educational and scientific initiatives that improve the health of all people.  The foundation supports more than 20 programs each year, including disaster relief, an annual Family Medicine Cares International delegation trip to Haiti, research stimulation grants, family medicine interest groups, Tar Wars programs and much more.

As a 501(c)(3) organization, the foundation is supported through donations. This means that if we don’t donate, these programs can’t succeed. Donors have the option of earmarking donations for a particular program or area, and as new physicians, I would encourage you to donate to Family Medicine Leads to help develop our future family physicians.  

If you are interested in serving as a faculty member or mentor for this program in the future, please contact the foundation. I assure you it will be well worth your time.

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

Tuesday Aug 04, 2015

Do No Harm: When Is a Physician Too Sick to Work?

A recent study published in JAMA Pediatrics found that the vast majority of physicians have gone to work sick -- even though we know we shouldn’t.

Included in the study were attending physicians, nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists and nurse midwives who work in a hospital setting, although some also worked outpatient. Ninety-five percent of respondents acknowledged that working while sick puts patients at risk, yet 83 percent reported working while sick during the past year. The study, which was initiated by a hospital's infection control staff, was done in an attempt to determine why we do this.

A physician looks at a digital thermometer. More than 80 percent of health care professionals go to work while sick -- despite the risk to patients and colleagues.

The leading reason given for working while ill was not wanting to let colleagues down (98 percent) followed by not wanting to let patients down (92 percent) and the need for continuity of care (69 percent).

System-level challenges were found to be at fault, as well.

There also were complaints about sick leave policies -- either the lack thereof or the inability to utilize sick leave because of logistical difficulties or because no other providers were available for coverage. Overall, study participants generally noted that it was simply easier to work while sick than to overcome these barriers.

We have created a culture where working while ill -- despite our better judgment -- is not only accepted but expected.

The study's conclusion noted that more research is needed regarding what specific illnesses constitute danger to patients. In other words, when are we too sick to work?

We all can probably think of times when we or a colleague should have stayed home, with some situations being more reckless than others. However, we rarely make our sick colleagues leave, and sometimes I think that would be the only way one of us would admit to being too sick to work.

Resident presenteeism has been studied, and the results aren't pretty. The Accreditation Council for Graduate Medical Education mandates that programs have sick leave policies, and some programs have a back-up call schedule, someone who is on call to be on call, so the difficulty of finding a person to cover is eliminated. But personally, even when I have been in such a situation, I didn’t use the back-up resident; I kept working.  

Intern year I was sitting at a computer typing an H&P when I felt I’d been shot in the neck. I had just finished rounding, the attending was sitting beside me and for a few minutes I tried to keep typing as if nothing had happened. But then he asked me a question, and I had to turn my whole body to look at him. I realized this was not just a little neck pain. This was going to stick around awhile. I thought it was probably just because I was tired. I had flown back from an AAFP meeting less than 24 hours before that call shift, my last one on this service for the month. I took some ibuprofen, which prompted the attending to ask if I felt OK. Of course, I replied with something to the effect of, "Yeah, I'm good."

He left for the night, and a few hours later I found myself walking through the hospital with my eyes barely open because the light made my intense headache much worse. I was walking as if I was trying to sneak up on someone so as not to jar my head with each footstep. I met up with my senior resident for the night to discuss an admission, and he asked, "Are you having meningitis right now?" My answer, "I hope not."  

A couple of hours later I was at home with a fever and vomiting, realizing that regardless of what I had hoped, this was likely viral meningitis. I had been exposed to multiple patients with a few different types of viral meningitis, and mine resembled enterovirus. I still have hearing loss and a new respect for people with chronic migraines.  

We collect these stories like they are something to brag about, but we should be embarrassed. I worked under residents who told stories of starting IVs in the call room on each other because they had been vomiting for so long that they were more dehydrated than most of the patients we were admitting. One of my ER attendings finished a shift with appendicitis before signing himself in for treatment. These were my role models, people I respected and wanted to respect me.  

But just as the JAMA Pediatrics article concluded, there needs to be a threshold we do not cross. There is a point at which the risk to the patient is too great for us to go to work just because we can manage to put one foot in front of the other and walk through the door. Unfortunately, this behavioral pattern we display as physicians goes beyond being sick. It runs throughout every part of our training and later our obligation to function as essential employees who drive through the snow, go to work when there is no power, and treat patients in disaster settings. We go to work when people need us because it's what we do.  

More well-constructed studies about disease transmission from physician to patient would be great. But at the same time, we are doctors, and we know what is contagious. We know when to tell patients not to go to school or work, despite sitting there working in the exam room with the same diagnosis as the patient.  

I am motivated to work when sick if patients would otherwise not be seen. That is a deal breaker for me. But I expect my nurse to stay home if she is sick. During a flu epidemic this past winter, I had her swab herself three different times in one day hoping one would turn positive because I suspected she was too sick to work. I didn’t think I could convince her to go home otherwise.  

Flu is a good example of a success regarding medical sick leave. Everywhere I have worked there has been a policy that if you test positive for the flu, you are off work for five days -- no exceptions. That is evidence that we can make sick doctors go home when the risk is too great to the patients and staff.  

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

Thursday Jul 30, 2015

Self-Evaluation: How Many Stars Do I Rate?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thursday Jul 23, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thursday Jul 16, 2015

Direct Primary Care Model Poised for Rapid Growth

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

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

© 2015 Sheri Porter/AAFP

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

 

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

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

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

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

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

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

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

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

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

Thursday Jul 09, 2015

Reflections on Surviving a Malpractice Case

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Jul 07, 2015

Dealing With Death: Why Helping Patients' Families Helps Me

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Jun 30, 2015

Change Isn't Optional, but Making Progress Is

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

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

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

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

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

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

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

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

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

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

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

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

Monday Jun 22, 2015

Help Patients Trim the Fat Out of Fad Diets

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So, here are some takeaways:  

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

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

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

Monday Jun 15, 2015

How Long Should It Take to Train a Family Physician?

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Jun 09, 2015

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

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

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

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

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

Unfortunately, reality often falls short of theory.

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

"This EHR takes too long."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Jun 03, 2015

Give Residents Tools to Turn Tide on Physician Burnout

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

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

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

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

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

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

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

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

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

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

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

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

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