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Tuesday Feb 24, 2015

Overcoming the Slings and Arrows: How Humor Can Save Us

The stress of medical education and -- later -- day-to-day practice can be crushing, sometimes manifesting as anxiety or depression, or both. The expectation that as time goes by, we will be required to handle more and more arduous tasks -- such as paperwork, telephone calls, etc. -- without adequate reimbursement can be extremely frustrating.

I believe that one of the most important things we can do when we feel our stress level overloading is to focus on positive memories, particularly those that made us laugh. Not only is it good to remember these moments for ourselves, but sharing them with others can be helpful, as well.

Fortunately, I have a wealth of such encounters to draw from. One in particular that I recall continues to remind me that it's important for us to be able to laugh at ourselves.

It was when I was an intern, and I had been up all night admitting patients. I was exhausted, but the day team needed the sign-out on the new patients, and it was my job to give it to them.

"Mr. Smith is a 64-year-old gentleman whose wife called 911 after she was unable to arouse him," I began.

Everyone immediately burst into laughter. What had I said? I was so tired I couldn't figure out what was so funny.

"We're calling EMS for that now?" someone asked. "We're going to have a huge influx of patients to the emergency department!"

It finally dawned on me that "arouse" was not the word that I was looking for, but being so tired, I couldn't figure out what the right word should have been. After waiting for everyone to calm down, I was barely able to finish the report coherently. I was utterly embarrassed, but I still laughed the whole way home.

The second story I'll share spotlights my current practice setting, a clinic with a patient population made up exclusively of individuals with developmental disabilities. It's a challenging environment, as you might imagine, but it also can be extremely rewarding. For me, one of those rewards has been the gentle humor I've found in recognizing and celebrating the innocence of some of my patients.

Sarah is one of them.

Sarah is in her mid-50s and struggles with both intellectual disabilities and bipolar disorder, among other issues. Because of worsening incontinence related to behavioral issues, she began wearing Depends some time ago. Typically, she would become anxious when I tried to explain things to her, such as the reasons behind her symptoms and the plan to address them. (Fortunately, her supported-living staff was always there to assist.)

One day, at the end of what seemed like a particularly stressful visit for her, Sarah's countenance abruptly softened, and she developed a sweet tone.

"Dr. Jones, you're a very good doctor -- all things considered," she told me.

I wasn't quite sure what she meant by the backhanded compliment, but I said, "Thank you," anyway.

She followed that up with, "So, when are we going to get married?"

Hmm. Although flattered, I knew I needed to figure out how to answer this delicately so as not to upset her but also to not allow any hope. But despite this realization, my eventual blunt and not-too-delicate reply was, "We're not."

"OK," she said.

 Phew! I dodged a bullet there, I thought, as she went on to the next topic.

"Now, Dr. Jones, you know that I like to be fancy, and I like to wear lingerie and beautiful women's underwear. Would it be OK if I wore fancy underwear over my Depends sometimes?"

I could tell that the answer to this question was far more important to her than my response to her marriage proposal had been, and I rose to the occasion.

"I think that would be just fine."

She smiled, satisfied with our unusual conversation.

It's our willingness to get to know our patients on an emotionally intimate level that gives us the chance to have memorable experiences like my interaction with Sarah. That and our ability to laugh at ourselves allow us to survive our often challenging profession. So, when you find yourself being overwhelmed by the daily grind, remember those times, and be sure to share them with others.

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

Tuesday Feb 17, 2015

At a Loss: If Educating Parents About Vaccines Won't Work, What Will?

Fifteen years ago, the CDC declared measles had been eradicated in the United States. But last year, there were more than 600 cases reported in 27 states. As of Feb. 6, there were 121 cases reported in 17 states this year.

The vast majority of recent cases were linked to an outbreak that originated at Disneyland. The high number of cases and the high-profile location has sparked some interesting and controversial debates ranging from discussions about a federal vaccine mandate for the collective good to parents' right to choose for their children. And in certain circles on the Web, I’ve noticed some are rehashing the demonization of vaccinations sparked by faulty evidence.

© 2014 David Mitchell/AAFP

A 1-year-old girl receives the measles, mumps and rubella vaccine. More than 120 cases of measles have been reported to the CDC already this year.

However -- and I can’t believe I’m writing this -- on this subject I agree with Hillary Clinton. The former senator (and a presumed candidate for the Democratic presidential nomination in 2016) recently responded to a pair of Republican presidential hopefuls who had spoken in favor of parental choice with a tweet that said, "The earth is round, the sky is blue, and vaccines work. Let's protect all our kids."

Although the debates continue, this outbreak has presented only one question for me as a family physician: How can I convince parents who refuse to vaccinate their children to change their minds? The measles, mumps and rubella (MMR) vaccine is a poster child for immunizations. More than 95 percent of people who receive a single dose develop immunity to all three viruses. Measles, on the other hand, is a poster child for contagion, causing infection in 90 percent of unvaccinated individuals who come in contact with an infected person.  

The decision to vaccinate would seem simple enough to me even though I've never even seen a case of measles. After all, it was declared eradicated before I started medical school.

But maybe that's part of the problem. Before the vaccine was introduced in the 1960s, measles was nearly as common as death and taxes. Parents had good reason to fear it. There were 3 million to 4 million cases annually in the United States. People were familiar with the illness and the problems it could cause, including hospitalization, pneumonia, blindness, brain damage and death. Most moms likely could have made the diagnosis at home even without the Internet.

But now I wonder if I could make the diagnosis. Seriously, before this highly publicized outbreak, how many of us were closely examining a child with fever and runny nose for Koplik's spots? I think younger generations of parents have no idea of the devastation this disease can wreak, and without that fear, not vaccinating seems like a viable alternative to some parents.

Keeping that in mind, education had been my approach to vaccine-hesitant parents in the past. Surely if I could impress upon them the risks of the disease -- not only to their own children but to others', as well -- and then illuminate the infinitesimal risk posed by vaccines, they would be overwhelmed by the logic of it all. When I think back on this, I realize I had limited success, and those battles were hard won.  

In fact, there is good evidence to support that this approach is likely folly. An interesting article published last year in Pediatrics looked at this issue and determined that this approach is not effective. In fact, in some instances it makes parents less likely to vaccinate their children.

So I do not admit this often, but I am at a loss. I need your help. This is a pressing issue in our practices at a time when isolated measles outbreaks are on the rise, fueled by pockets of unvaccinated children. The tool I had always considered my most powerful -- educating parents and partnering with them in decision-making -- appears to be broken.

On a personal note, I have good friends with four children who subscribe to a "natural" approach with their children, who are not vaccinated. Although we agree on some health care issues, such as avoiding overuse of antibiotics and over-processed foods, we don't agree on this subject. The mother recently posted a link on Facebook to a site that discourages vaccinations. Although I know immunizations are important, and I worry for these children, I am struggling with how to approach these situations without alienating this family, as well as parents in my practice who have similar beliefs.  

Although the evidence has indicated what does not work, there are no studies that I have found that tell us what will work. It is in these instances when the family of family medicine is the most important. If anyone has an approach that has worked well, please share it in the comments below.

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

Tuesday Feb 10, 2015

President's Focus on Precision Medicine Could Be Catalyst for Change

In his recent State of the Union address, President Obama outlined plans for encouraging a shift toward precision medicine, specifically citing the need for further research into personalized treatment of cancer.

Precision medicine is loosely defined as using the maximum amount of information about a patient and his or her disease process to create the best possible treatment regimen. More precisely, it involves studying genetics, proteomics, metabolomics, epigenetics and other molecular-level analyses to quantify and characterize a disease process as thoroughly as possible and using that information to formulate targeted treatments. This means not only sequencing the genome for each patient, but looking at the environment in which those genes are transcribed and translated and how that contributes to the physiology of disease. How does activation of gene A in the presence of excess protein B affect the growth of tumor cell Z? Does that change if the patient was exposed to chemical C while in utero? Will these interactions facilitate or inhibit response to medication D?

To help in boosting our understanding of how these factors interact, the president's initiative calls for $130 million to study the biomedical data of at least 1 million volunteers; $70 million to identify genomic drivers in cancer; $10 million to build a regulatory structure for precision medicine; and $5 million so information technology systems can exchange data securely. If successful, we will be able to characterize disease in new and specific ways and avoid harmful or unnecessary therapies.

The ability to practice precision medicine will fundamentally change the diagnosis and management of chronic and acute disease seen in the primary care setting. No longer will we make educated diagnostic guesses or label diseases based solely on symptoms. Precision medicine offers the potential to diagnose disease on a molecular level, allowing for targeted treatment with significantly lower chance for failure. Genetic screens already help us determine which patients will respond favorably to drugs such as warfarin or clopidogrel. Molecular analysis of cancer cells can lead to drugs that target only cancerous cells and spare healthy tissue.

In the future, medications and other treatments will no longer be one-size-fits-all. Rather, each patient will know which drugs will interact favorably with his or her personal biology and which can lead to life-threatening side effects. Although entirely new classes of medications may arise, we won't necessarily need them for tailored treatment. Instead, we will know when existing medicines can provide the most benefit. Patients with hypertension refractory to treatment with ACE inhibitors will be differentiated from those receptive to calcium channel blockade, speeding up the time to effective disease management and avoiding untoward side effects.

During this transitional period, primary care physicians will likely be called on to parse both subjective and molecular data into something manageable. We will provide molecular screening, much like we currently screen on a macro level for colorectal or cervical cancers. Bedside or serum tests for genetic markers or certain proteins could become as quick and easy to administer as a rapid group A strep test is today. Patients will have access to information about which foods and medications may interact with their personal biology -- both favorably and poorly. Family physicians, many of whom are already focused on preventive care, will have the tools to help prevent chronic diseases on an individual basis, long before pathology arises.

Unfortunately, there are hurdles. Not only is the president's plan far from a done deal, the required molecular analysis comes at a steep price. Although rudimentary genome sequencing may cost as little as $300, analysis of this information is only the beginning. Activity such as post-translational modification of proteins can vary significantly between individuals, and the techniques used to assess this information can cost thousands of dollars. Of course, this comes at a time when roughly one-fifth of Americans younger than age 65 already spend more than 10 percent of their income on health care or insurance, according to AARP.

Savings may be realized by a more targeted approach to treatment, but the front-end cost will be substantial. Not only is analysis expensive, but reams of data will be generated about each patient. Sequencing for a single individual will create thousands of data points covering multiple pathologic disciplines. These data have to be analyzed and classified to be useful. Scientists and researchers are still developing the framework for interpreting this glut of information.

Access will also be an issue in the early stages of our transition to personalized care. Most practices and labs don't currently own or use the equipment required; procuring that equipment will add significantly to costs. Finally, unlike traditional epidemiology, molecular pathology focuses on individuals or similar groups, and results aren't meant to be generalized to large swaths of the population. Identical populations, even identical twins, may have vastly different requirements and responses to treatment. For example, not all colon cancers are created equal, even in the same individual across his or her lifetime. Each cancer will require the full spectrum of analyses and individualized treatment.

Although these hindrances are extensive, they are far from insurmountable. As the testing becomes cheaper and more ubiquitous, our understanding of how each of the pieces fits together will evolve and change. We still have a long way to go before personalized medicine is the norm, but the president's plan serves as a catalyst, encouraging scientists to accelerate the rate of knowledge-gathering and incentivizing new and cheaper technologies and testing.

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 Feb 03, 2015

Over the Long Haul, Family Physicians Are Life Savers

As a resident, I began taking care of a man I’ll call Jim. He was a trucker in his early 50s and loved being on the road. Jim never married and did not have children, so his fellow truckers and other friends became like family. He used to talk about making long journeys across multiple states in a single day, meeting many wonderful people in diners and truck stops across the country. He often had to get out of jams, such as his truck breaking down when he needed to make a timely delivery. I loved seeing him and hearing his stories.

Jim's body suffered from many of the pitfalls that often occur with truckers: He was morbidly obese, had significant hypertension and hyperlipidemia, and he smoked like a chimney.

“I can’t survive without my two packs in a day," he would say. "It helps pass the time.”

Jim first started seeing me, he said, because “they’re gonna fire me if I don’t get this blood pressure thing under control.” His blood pressure was in the 160/100s range. In the past, his physician visits had been limited to physical exams for his commercial driver’s license. His Framingham risk score was 30, meaning that he had a 30 percent chance of having a heart attack in the next 10 years.

Clearly, he was tempting fate, but over time, I was able to help Jim make choices that gave him a chance at a longer life.

Family medicine isn't viewed as a "sexy" specialty. Many subspecialists, such as surgeons, cardiologists and intensivists, receive accolades for saving multiple lives in a dramatic fashion. Their work is tremendous, and the praise they receive is certainly warranted. Many medical students choose these specialties so they can feel that rush of taking a failing body and reviving it. What many don't realize, though, is that family physicians often do this, as well, especially those who practice obstetrics or emergency medicine, but you're not likely to see that on Grey's Anatomy.

By and large, family medicine is perceived as bland. Few dramatic, life-saving gestures are associated with our primarily outpatient practices. But when considering the long-term picture, family physicians save just as many lives, if not more, as other specialists. And an added bonus is that we get to experience closer relationships with patients than most other specialists enjoy.

Coronary artery disease (CAD) kills more people in this country than any other illness or injury. According to one widely cited report published in the Journal of the American Medical Association in 2012, at least half of Americans will have CAD at some point in their lives. Thus, as family physicians, working with patients to prevent diabetes, hypertension, hyperlipidemia, and quit smoking -- the main risk factors for CAD -- and then to treat them once they occur, is a huge part of what we do. If we are able to make a dent in this disease by effectively preventing and treating risk factors, we will save lives.

I made some conservative estimates using numbers needed to treat (NNT) for impact on hyperlipidemia and hypertension, as well as nationally representative primary care practice figures to determine how many lives family physicians save during the course of their careers. I'm no statistician, so my estimates are rough and necessarily make some assumptions. That said, if a family physician practices for about 35 years, with a patient panel of 2,500, he or she will save about 1,000 lives just from addressing hypertension and hyperlipidemia. That equates to about 29 people per year, or a little more than two per month.

This does not even count other services we provide, such as smoking cessation, early cancer detection or injury prevention, among countless others. All added together, family physicians save just as many lives as many other “sexier” specialties.

The main difference is that we get to do this through the relationships and trust we build with our patients over time, which for many is the most rewarding part of our jobs.

Jim and I worked together to decrease his risk factors for CAD. We were able to control his blood pressure, got him on a statin medication, and he made some changes to lose weight. He wasn’t able to kick that smoking habit, however. Still, together, we cut his 10-year risk for a heart attack to 17 percent. This is still much higher than ideal, but it represents a drop of nearly one-half of his baseline risk.

Jim eventually moved elsewhere, and I haven’t seen him in years. Since risk scores and NNTs are based on population models and, thus, make predictions in individuals inexact, I don’t know whether the decrease in Jim’s risk score actually kept him from having a heart attack or prolonged his life. But on a whole, we can all rest assured that we are saving and improving lives, albeit in a less dramatic way than you'll see on reruns of ER.

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

Wednesday Jan 28, 2015

House Calls Improve Care, Lower Costs

Although demand for the service is building, the number of family physicians making house calls is shrinking. In a 2010 AAFP survey, 19 percent of Academy members said they made at least one house call a week. By 2013, the number had fallen to 13 percent, and only 3 percent of respondents reported making more than two house calls a week.

With a rapidly growing elderly population, will that trend ever reverse to meet demand? By 2030, the number of Americans age 65 and older will account for 20 percent of the U.S. population. And by 2038, the nation's elderly population is expected to double to 72 million -- or roughly the current population of California, Florida and Illinois combined. Two-thirds of the people in this age group have multiple chronic conditions and likely would need regular health care visits, which they may have difficulty accessing.

The number of house calls to Medicare beneficiaries more than doubled from 2000 and 2006, despite the fact that the number of physicians making house calls declined during the same period.

In my rural community, there are few resources for assisted living, so house calls could be the difference between an elderly or disabled patient staying in his or her home or moving to a nursing home. A 30-minute house call also can save a patient's spouse or adult children from taking half a day off work to get a patient to my office.

Although it is coded differently than a traditional house call, I also visit my patients who are in nursing homes so they don't have to be loaded into a van, transported across town, unloaded and reloaded. Coming to the patient, in these instances, is easier for everyone.

And it isn't just an age issue. I've made house calls on patients recovering from major surgeries, car wrecks and other issues -- including terminal illness -- that would make it challenging for them to come to me.

Interestingly, as reimbursement for house calls has improved, the number of patients treated at home has increased dramatically even though the number of physicians making house calls has declined. Part of the explanation for this phenomenon is practices that specialize in house calls.

It's an intriguing business model with lower overhead. It also holds potential to lower health care costs by catching relatively small problems before they become crises and keeping patients with chronic conditions and mobility issues out of the ER. A pilot program created by the Patient Protection and Affordable Care Act is documenting how providing house calls can lower Medicare costs, and Medicare will share savings with participating practices.

A study published last year in The Journal of the American Geriatrics Society compared the Medicare costs and outcomes of more than 700 patients enrolled in a house call program to a control group of more than 2,100 Medicare patients. Patients in the house call group had 17 percent lower health care costs during a two-year period. They also had 9 percent fewer hospitalizations, 20 percent fewer emergency department visits, 23 percent fewer visits to subspecialists and 27 percent fewer stays in skilled nursing facilities.

Obviously, house calls are a service that not all family practices can provide. But for those who can, it is a way to improve care and outcomes and potentially increase revenue. It's also worth noting that if primary care physicians won't make house calls, other health care professionals are willing to fill that void.

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

Tuesday Jan 20, 2015

Need for Infection Control Not Going Away Anytime Soon

The holidays may be past, but 'tis still the season … for rampant viral upper respiratory infection, that is. Let's take a look at some numbers:

It's clear from these statistics that infectious disease is everywhere. From the air we breathe, to the food we eat, to the surface of our skin and mucous membranes, microorganisms outnumber us by multiple powers of 10. And although only a fraction of those organisms are infectious, infection is still a leading cause of morbidity and mortality.

Employers who require workers to obtain doctor's notes for sick days are using a tactic that runs contrary to the idea that isolation is critical to infection control. Such policies leave employees with the choice of going to work when ill or going to a doctor's office for a condition -- such as a common cold -- that may not require treatment.

Thanks to scientists such as Koch and Semmelweis, we've known for many years that the microorganisms that cause these diseases propagate in numerous ways, but they can be stopped, or at least contained, by good infection control measures. Isolation. Sterilization. Simply keeping away from other individuals when we are ill is often enough to prevent a potential epidemic.

As primary care physicians, we live on the front lines of the infection control war. From encouraging patients to cover their coughs to disinfecting our offices and washing our hands, family doctors set the example for preventing transmission of bacteria and viruses. Encouraging appropriate and timely vaccination ensures that the most susceptible among us (the very young and the very old) will be protected should an outbreak occur. Our offices need to accommodate the separation of sick and well patients, preventing the spread of airborne pathogens to otherwise healthy patients. Some offices even have isolated negative-pressure areas for those with upper respiratory infection, although a quick literature search yielded no data on efficacy.

With limited time and resources to spend with each patient, it's imperative to make the education component of our visits count. In my practice, I use a practiced, five-minute dialogue during which I review the anatomy and physiology involved in most head colds (from nose to pharynx to larynx to trachea) and discuss why symptoms occur. I also draw stick drawings of the anatomy for patients as I go and allow time for questions. I occasionally use Google image searches to pull up more artistic or even real anatomical images. However, you accomplish it, the key is giving the patient information that makes sense and gives insight to the disease process. Even from patients who are just there for a "sick note," I can't count the number of times I've heard something like, "I learned more in that 15 minutes than I ever have during a sick visit."

And speaking of sick notes, this is one of the most common requests in my office -- and, I'd wager, in many of yours -- because many employers require proof of a doctor visit to account for any missed work days due to illness. Aside from the fact that this practice begs a study to look at how many unnecessary appointments it generates each year, this requirement runs counter to the ideas above -- that relative isolation is a key to infection control. Patients go to work sick, thus endangering their co-workers, for fear of being punished for missing work.

There may be no easy answer, and without data, we'll never begin to change policy. However, one Canadian practice has implemented a novel protocol that may curb the demand for sick notes in its community: charging employers a per-note fee.

One final note: I'd honestly like to meet the person who came up with the idea that early intervention would prevent a head cold and discuss the ramifications of this falsehood. What I've found is that providing patients with tips for managing the initial symptoms of most infections helps prevent the mad dash to the office on day two of what appears to be a viral upper respiratory infection. I created a handout with a few OTC medications like ibuprofen, benzocaine lozenges and nasal saline, as well as some simple tips to control symptoms. I encourage patients to hang it in their medicine cabinet or bathroom at home and use those interventions for the first three to four days, with the caveat that they can always come see me anytime they feel the need.

Empowering autonomy with a safety net of care seems to pervade the literature on patient-physician relationships, and this approach offers patients some degree of control over an otherwise uncontrollable situation. At the same time, it decreases the number of sick patients -- typically at the height of transmissibility -- sitting in the waiting room alongside young children and elderly patients.

Lets' face it: Until we find a cure for the common cold -- which is neither common nor a single entity, so good luck -- infection control will remain a big part of our job all year round. As new physicians, we need to overcome the mistakes of the past, educate our patients on the evidence, and seek to study and learn as much as we can about adequate infection control and treatment.

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 Jan 14, 2015

Put the Rx Pad Down: Why Meds Aren't the First Step to Weight Loss

"Dr. Gray, I saw a TV commercial for a weight-loss medication. I just need you to prescribe it for me."

We've all heard this type of request. As family physicians, we encounter obesity and weight-related comorbidities every day. Now that the new year -- and patients' subsequent resolutions -- has arrived, I am hitting those issues with full force.

I am used to counseling patients on proper nutrition and the importance of routine exercise regardless of whether obesity is a factor. However, obesity has become an epidemic. In my home state of Nevada, the prevalence of obesity is greater than 25 percent. No state in the nation has a prevalence of less than 20 percent.

The AMA (with support from the AAFP's delegation to the AMA House of Delegates) definitely focused more attention on the issue when it classified obesity as a disease in 2013, and obesity is now more frequently a part of discussions with patients. But the diet fads that have swept through the nation -- and my office -- can pose an obstacle to counseling, and the discussions are almost comical sometimes.

"What do you mean eating only grapefruit for three weeks isn't healthy? It's fruit," was one of my favorite comments from a patient. I also get questions about the human chorionic gonadotropin (HCG) diet, Atkins and more.

Then there are diet medications. These magical, all-encompassing, easy-to-use drugs require no behavioral change from patients, or so they think. One pill or injection, apparently, will ease our epidemic and therefore the diabetes, hypertension and hyperlipidemia that comes with a poor lifestyle.

But if it were really that easy, millions of Americans wouldn't be struggling to achieve and maintain a healthy weight.

Weight loss was not something I was heavily educated about as a medical student or resident. I learned about nutrients and how our cardiovascular system benefits from good nutrition and aerobic exercise. I learned how to counsel patients about a proper diabetic diet. I did not, however, learn about all the new weight-loss medications being marketed and how to effectively advise patients on weight management. Stages of change certainly apply to this type of counseling, but let's face it: Behavioral changes are tough. That's why many patients find it so hard to quit smoking, for example. At the crux of a majority of weight issues are behaviors that must change.

I have to give patients a litany of reasons why they should make nutrition changes such as eliminating or reducing processed foods, carbohydrates and other unhealthy items. Sometimes, patients who think that change is too difficult turn the discussion to what I eat on a daily basis and how I manage to incorporate exercise into my busy schedule. But I practice what I preach, so that part of the conversation tends to end quickly.

The plethora of weight-loss medications (and the marketing efforts to promote them) has hindered my counseling, which is built on nutrition and exercise. In a society where people often expect what they want when they want it, it can be difficult to convince a patient to slow down and notice that the fine print of the medication label states, "with proper exercise and nutrition."

The FDA recently approved two new weight-loss medications -- including one this week -- so expect more questions from patients.

I offer a compromise to my patients who request medication management for weight loss. I ask them to implement proper lifestyle changes and return to my office in four to six weeks. I counsel them on appropriate food choices and portion sizes, and if I think they require more assistance, I refer them to a nutritionist. We discuss what an appropriate routine exercise regimen would be for them based on their previous exercise habits.

If they return to my office having made a consistent effort to follow my advice, the numbers don't usually lie. At that point, many of my patients can see that their behavioral changes are enough to obtain the healthy lifestyle they desire, and the thought of medication management goes out the window. Other times, some still wish for a boost to what they have achieved, and at that point -- after counseling them about the medication -- I send them on their way with a prescription.

There are many ways to assist patients with weight and nutrition goals. This method works for me in my practice, especially at the start of the new year when patients are making resolutions about their health. How do you deal with requests for weight-loss medications in your practice?

Helen Gray, M.D., is an employed family physician in Reno, Nev., working in a hospital-based setting. She also is adjunct faculty with the University of Nevada School of Medicine. You can follow her on Twitter @helengraymd.

Tuesday Jan 06, 2015

New Year Offers Opportunity to Help Patients Lose Weight

Lean in close and I will tell you a secret that Big Pharma does not want you or your patients to know. Exercise is powerful medicine.

And here is the best part: It can be practically free. Add in some dietary improvements and you have a potent combination for improving chronic conditions such as diabetes, hypertension, chronic obstructive pulmonary disease and chronic heart failure.

But how often do we start with those interventions or continue to encourage them as the cornerstone of chronic disease management? Physicians are inundated with advertisements and drug reps' spiels, as well as some professional guidelines that rely too heavily on pharmaceuticals.

Now combine a lack of specific training in exercise and diet prescription, a pinch of extra time in our already overburdened office visit and a dash of good ol' American "Can't you just give me a pill to fix this" attitude, and before you know it, the FDA is approving metformin-laced potato chips.

But it doesn't have to be this way. With a little effort and encouragement on our part -- and some patient buy-in -- amazing improvements in health can be achieved.

Take, for instance, my patient John. He is in his late 60s and moderately overweight. Shortly after seeing me as a new patient, we ordered some routine lab work and found his blood sugar to be elevated on a fasting test. I ordered a hemoglobin A1c, which came back at  10.7. I had him return to the office to review his lab results and discuss the diagnosis of diabetes. This scenario, unfortunately, plays out in family medicine practices every day.

Like many of my patients, John was not enthusiastic about having to start multiple medications. So we discussed improving his diet and starting an exercise regimen as initial treatment. Of course, I counseled him that this was no guarantee that he would not need to start medication in the future -- that would depend on how successful we were with this approach. I did start him on baby aspirin and referred him for diabetes education, mostly to reinforce what I had already told him and for more specific dietary counseling. I also made a follow-up appointment with him.

Now, it's all well and good to encourage patients to exercise, and everyone is familiar with the daily recommendations for adult activity. However, from a patient's perspective, it does no good to simply tell someone to exercise for 30 minutes a day, five days a week. That will get you a whole lot of patients who don't follow your recommendations.

If you really want to help these patients succeed, consider making your own modest investment in a resource you can use to educate them -- and yourself. The American College of Sports Medicine, for example, offers evidence-based guidelines for exercise testing and prescription. I like to give my patients options for types of exercise that may work best for them. For that reason, I did not recommend that John, with his bilateral knee arthritis, start a walking program because I knew this would set him up for failure. Instead, using a recumbent bicycle or pool aerobics were better options for him.

Also, it's important to assess the patient's current level of activity and keep that in mind. A sedentary patient should not start with 30 minutes a day, five days a week. He or she would be extremely sore and give up right off the bat or even be injured. Instead, start with 15 to 20 minutes two to three days a week and work up to five days a week over several weeks.

I also calculate a target heart rate for my patients during exercise so they have a measure to determine the appropriate intensity level. I use 40 percent to 60 percent of their heart rate (HR) reserve (maximum calculated HR minus resting HR) for moderate intensity. I will often write this information down on a script so they have something to refer to or hang on the refrigerator to remind them of their goals.

Dietary counseling is much more convoluted, in my opinion, because there are so many diets out there. However, I like to encourage my patients to make small changes initially and to try to choose healthier foods and improve portion control. The problem with so many diets is that they are just not sustainable for patients because they require radical changes that are hard to stomach -- pun intended.

A meta-analysis published recently in JAMA also found that there was little difference in weight loss with the named diets (South Beach, Atkins, Paleo, etc). My take on this is simply that many of us are subconscious eaters. We get hungry, and we eat without paying attention to what and how often we eat, our portions, and what macronutrients our food contains. To me, the true benefit of being on a certain type of diet lies not in the diet itself but in the fact that it forces us to make more conscious decisions about our food and eating habits.

Finally, education on reading nutrition labels is also important, because many people -- often through no fault of their own -- are "nutrition-illiterate."

So how did John do? At his three-month follow-up, he was eating less junk food and more fresh fruits and vegetables, and he had reduced his overabundance of carbs. He had purchased a gym membership, although he was not yet routinely going. But he felt committed to improving that and to exercising regularly. His repeat A1c was 7.1! I would challenge you to find a single medication (short of starting insulin) that would decrease a patient's A1c by that much in three months.

Needless to say, he was happy with these results, and so was I. It further encouraged him to go to the gym more regularly, and I would often see him there.

Many of our patients will be making New Year's resolutions to lose weight, and this presents an opportunity to provide counseling. Many of you likely are already prescribing these interventions, and I hope John's story motivates you to continue to encourage and counsel your patients throughout the year.

Making these changes is not easy for patients, and although it often feels as though our advice is ignored, I promise you that you are making a difference. When they are successful with these changes, I would encourage you not to be afraid to decrease or stop their medications. After all, with the potent new "medication" you are prescribing, they may not need the pills.

Peter Rippey, M.D., is working locums while transitioning from private practice to a hospital-employed position.

Tuesday Dec 23, 2014

'Tis the Season: For Us, Holidays Mix Sacrifice, Blessings

It's holiday time, which means it's time to set the "out of the office" email auto-response, close the laptop and turn off the office lights for two weeks. Except … that's not how our lives really work, is it?

We are family physicians, and although our practice environments differ, this fact unites us. As we take some time off to celebrate with our family and friends, we know that we don't ever entirely turn off as a physician, especially one who has chosen family medicine as a specialty.

DMW Photography

I plan to spend as much time as I can with my husband and daughter during the holidays. But I also will be doing some clinic work, and I have several maternity patients who are due soon.

It can be difficult at times to juggle all of the responsibilities in our lives: our spouses, children, extended family, friends, church, community and -- of course -- our patients. This becomes apparent to many of us during the holidays when others around us who work in different professions take their leave and turn their minds and attention more fully to the festivities.

For me, I have several maternity patients due this holiday season. I don't know if they will deliver on Dec. 24, 26 or 31, but I do know one thing: Whenever it happens, I'll be there.

This may mean that I miss Christmas Eve dinner with my family, or that we have to reschedule a planned gift exchange with relatives. It may mean spending New Year's Day bringing a new life into the world, which I did two years ago.

It has, in years past, meant needing the understanding of parents, siblings and grandparents when I was absent for part of our planned time together because I had to be there for a laboring patient or one who was admitted for a serious illness.

Sometimes it means stepping away from the table when the hospital calls regarding a patient and having the laptop out at times to check lab reports and answer messages via our patient portal.

I will be at work during the day while I have guests visiting this holiday season because my clinic will be open two days each week during that time, and I have notified my guests in advance.

I'm not going to lie; there are times when I resent the constant connection to my phone, but the hospital and my nurse have to be able to reach me. I have sighed -- heavily -- as I hugged my 2-year-old and put on my shoes to go back in to the hospital, even though I was on call the night before and hadn't seen her for more than an hour in two days. And we both cried because she didn't want me to leave.

I have reluctantly told friends we cannot meet them for a weekend away because I am covering maternity call, and my partners are out of town.

We sacrifice a lot of ourselves, of our lives and our family's lives to serve our patients. This can be an overwhelming and exhausting responsibility, but as those of us who have the privilege of our patients' trust know, it is also the greatest gift. Although I will be working during the holidays, I will also be taking time off to refresh and enjoy my family. I will have several days out of the office and away from the daily grind, but I will always have my phone nearby. I will have meals with my family interspersed with meals at the hospital and midnight snacks from the nutrition room while waiting on a baby.

And when I feel like sighing, I will remind myself that I am one of the most fortunate people I know. I have the chance to serve a community, to help bring new life into the world, to comfort my patients and to experience one of the best jobs there is. This is our gift not only this holiday season, but every day, and with this we are so incredibly blessed.

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

Wednesday Dec 17, 2014

Remember Ebola? How the 24/7 News Cycle Impacts Health Care

Do you remember what a huge news story Ebola was this fall? For a while, it seemed like the virus was the only story in the news. \

In fact, Ebola was likely a top-three -- and possibly the biggest -- news story of the year. It certainly was the biggest story in medicine.

Image courtesy NIAID

Produced by the National Institute of Allergy and Infectious Diseases (NIAID), this digitally-colorized scanning electron micrograph depicts numerous filamentous Ebola virus particles (blue) budding from a chronically-infected VERO E6 cell (yellow-green).

The coverage in cable news, print, talk radio and online media illustrated how our health care utilization is influenced by the news. Some hospitals experienced an increase in emergency department visits due to patient concerns about potential Ebola symptoms. At one point, in fact, the CDC was logging 800 calls a day about potential cases of Ebola infection.

None of those calls panned out.

The irony was not lost on physicians who tried to educate concerned patients about Ebola and the need for a vaccine to combat the virus when the same patients then refused a flu shot. For the record, there have been 10 cases of Ebola treated in the United States and two of these patients have died here this year. By comparison, the CDC reported that as of Dec. 6, more than 1,000 laboratory-confirmed influenza-associated hospitalizations and seven influenza-associated deaths among children had occurred, despite it still being early in the flu season. During the week ending Dec. 6 alone, the CDC said there were more than 3,400 influenza-positive tests reported to agency.

So how can we as physicians -- and as educators of future physicians -- deal with demand for health care that is influenced by the media?

Well, we shouldn't trust the "facts" provided in news reports as completely accurate. We've all seen stories about new medical studies or other health-related topics presented in the media in an inaccurate way. Oftentimes, the details are misunderstood, or worse, the entire point of the study is misrepresented.

Remember last year, when Katie Couric used a rare side effect of the HPV vaccine to imply that the vaccine was too dangerous and shouldn't be given? Stories like this are too common. As physicians, it is our responsibility to know the facts so we can properly educate our patients and the public, which means going to appropriate, evidence-based sources for information.

We should be able to put health care concerns into perspective for our patients. As mentioned above, some Americans were mistakenly more worried about Ebola than influenza. As physicians, we know that even though Ebola is scary and yes, dangerous, we all have a much greater likelihood of facing significant morbidity -- and even mortality -- from influenza.

It's critical that we be able to explain these facts to the patients we care for so they can make informed, proper decisions about their health. We can provide information on these topics not only during office visits, but through our local traditional and social media outlets.

If we can work with the media to inform people about real health care concerns and then use that leverage to improve health, we can squelch mass hysteria. For example, we recently learned from the CDC that this year's influenza vaccine is not as effective as we would have liked. Even though the vaccine will still provide some protection, the news reports likely have turned many people off from getting the vaccine.

Before the CDC shared information about the vaccine's shortcomings, there had been -- by comparison -- little coverage in the news about why we should be vaccinated against not only the flu but other diseases, as well. Physicians have the expertise and the clout to be able to drive these discussions instead of merely reacting to them. We should all be more involved in steering the conversation toward true health needs that will impact our patients and our communities.

Inaccurate medical information in the mass media can be difficult for patients and physicians to deal with and often causes frustration. Still, as physicians, it is our responsibility to educate and inform people about the realities of media-driven health care utilization.

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 Dec 09, 2014

Direct Primary Care Doc Sets Record Straight

Since starting a direct primary care (DPC) practice nearly three years ago, I've become accustomed to skepticism and even the occasional criticism. Given the status quo, I understand it's difficult for some to envision a model that could be better for family physicians and our patients than traditional fee-for-service practice.

Two common concerns about DPC have emerged during my conversations with fellow docs, and those concerns were reflected in the comments on a recent AAFP News article on the topic. I will try to address both issues here.

"Many Patients Cannot Afford to Participate in a DPC Practice"
Affordability should be of concern to all physicians. One of my chief motivations for starting a DPC practice was to serve patients who I saw struggling to afford care in the standard fee-for-service practice. Most DPC docs I know report the same.

Here I am examining a patient at my direct primary care practice. I opened a DPC practice in Lawrence, Kan., nearly three years ago.

It is our current mish-mash of public and private managed care -- not DPC -- that has inflated health care costs for all parties. Although employers and governments can (for now) subsidize absurdly high premiums for some individuals, having coverage doesn't automatically equate to being able to afford care. For many of those with insurance plans, meeting out-of-pocket costs remains a big burden. I routinely see patients with insurance who tell me they avoided seeking primary care -- often at their peril -- for years because of high or uncertain out-of-pocket costs. I suspect hurried physicians, shielded by their billing departments, do not always hear these concerns from patients directly. It's easy to overlook the unseen.

Some media outlets and critics of the DPC model have offered examples of docs charging higher "concierge" rates. In reality, there is a wide range of DPC "retainer" fees, with most being between $30 and $150 per member per month. Newer and quickly growing DPC practices typically charge prices at the lower end of that spectrum. My average membership fee is about $42 per member per month, and many families pay less than $30 per member per month.

Most DPC docs return that value to patients in a number of ways. Being membership-supported -- and not needing to make a profit on ancillary services -- we can offer drastic discounts on labs, diagnostic testing, medications, procedures and more. Just last week, I was able to provide nine doses of sumatriptan to a new patient for $8.12. She had previously been paying more than $100 per month through her insurance for the same amount of the drug.

I also recently managed a forearm fracture in an uninsured patient for a total cost of $45 ($10 for a splint, $25 for an X-ray, and $10 for cast a few days later). These patients certainly don't think our membership fee is unaffordable.

Many of my patients, including those with insurance, save more money on these ancillary services (versus traditional prices) than they pay for their membership each month. And they get unlimited visits with their personal physician without copays.

With improving technology, scalable models and use of physician extenders, I believe DPC membership prices can and will continue to trend even lower. What level of DPC pricing would be low enough to deem it universally affordable? I rarely hear critics give an acceptable dollar figure. I recognize some people may struggle to afford even $10 per month, but does this sad reality invalidate the entire concept of DPC?

Many critics often jump to the conclusion that direct payment models are proposing abolishment of all forms of government assistance for health care. This certainly does not need to be the case.

In the past year, there have been some creative partnerships in payment models to support DPC. Qliance in Washington is caring for members of a private Medicaid managed care plan. Iora Health is providing care to Medicare Part D members in Phoenix. Turntable Health in Las Vegas is available to all members of the exchange-subsidized Nevada Health Co-op. Many employers and unions have also opted to support quality primary care using DPC across the country.

Regardless of whether these payer partnerships represent the best way to organize things, they do show that third parties can help individuals and families secure access to DPC. Alternatively, we could also allow individuals receiving government assistance to control a portion of that money directly to purchase routine care how they see fit.

Finally, let's not forget the fact that many primary care docs are juggling too many patients and too much paperwork, which itself has profound downstream impacts on our expensive system. I realize there will not be a simple fix to our health costs, but higher-quality primary care must be a part of that solution. I haven't seen any other solution that fits that requirement better than DPC.

"The DPC Model Will Worsen Our Primary Care Workforce Shortage"
Our national shortage of primary care physicians was created by decades of perverse incentives. Despite numerous carrots and sticks, there is no significant reversal of that trend. Intuition may dictate that physicians taking on smaller patient panels in a DPC model will exacerbate this problem, but that's not the whole story.

I've heard DPC critics claim that docs taking "only 600 patients are abandoning other patients" (previous or potential). From my perspective, however, this is an odd critique, given that virtually every doctor in traditional insurance-based practice must also close his or her practice to new patients at some point.

Some primary care physicians stop taking new patients at 2,000 active patients, and others take on more than 4,000. Is the doctor with a smaller panel of 2,000 abandoning patients? In other words, what is an ethically "sufficient" panel size for a primary care physician? And who should be the arbiter of this theoretical obligation? I trust individual physicians to make that decision for themselves.

We all know that overburdened family physicians are retiring early or finding nonclinical positions. I have met a number of burned out colleagues who are considering both options, but DPC has given them some hope of continuing clinical practice. For my part, I would posit that a doctor who still actively cares for 600 to 1,000 patients per year provides more value to the health care system than one in retirement.

Regardless of how few or how many patients we each take on, ultimately, the only long-term solution is for more students to choose primary care and have long careers. Medical students contact me regularly and tell me that the promise of DPC is what is encouraging them to enter or consider family medicine. Given that choosing between primary care and subspecialty care is a zero sum game, if DPC tips the balance in our favor, I think we can all agree that patients are better off.

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

Wednesday Dec 03, 2014

Getting Engaged: Patient Input Can Spark Improvement

There is a lot of talk these days about partnering with patients -- not just during their office visit, but truly making them the center of their own care team. In fact, this is one of the main themes of the patient-centered medical home.  

When patients are engaged in their care, patient satisfaction improves, care quality and safety are enhanced, and efficiency is heightened. In a nutshell, actively involving and engaging patients in their care helps us achieve the triple aim of improving health, improving the patient experience and reducing costs.

It seems like a given that patients should be central to their own care, but in reality, care often is given to -- rather than coordinated with -- patients.  

I recently served on a panel that discussed patient engagement during the fall conference of the Patient-Centered Primary Care Collaborative (PCPCC). We heard from organizations that have included patients on a variety of levels, from serving on focus groups to helping with clinic redesign. One clinic included patients in the process of developing their care management workflows, starting with information-gathering and continuing to use patients' input for plan development and delivery.  

These examples really showed that when patients were involved, not only did patient outcomes improve, but the providers came to better understand how to deliver care. However, these were large, university-funded practices with the ability to appoint patient advocates and teams to monitor patient engagement. Many of our small practices can't afford to do those things, but that doesn't mean we can't benefit from patient feedback.

At my integrative primary care practice, the patient experience has been at the core of our mission since we opened last year. It is important to get patient input, and in the year-and-a-half that we have been open, we have used two patient satisfaction measurement tools. The first was an ongoing patient feedback form that was given to patients at check-out after every visit for several months. The second was a survey instrument that was e-mailed to all patients who had been seen in the previous six months. The survey allowed patients to comment on how we were doing both individually and collectively. They could celebrate our accomplishments and voice their concerns. We received a lot of valuable feedback that will help us as we grow and move forward.  

For example, one of the concerns we heard was that our new patient intake and history form was too long. We revised the form, drawing on sample forms and examples of best practices. We tried to take ourselves out of our role as health care professionals and put ourselves in the patients' shoes. We developed a form that we thought balanced the information that we needed to collect with the brevity they desired.

But before we released the new form, we decided to take it one step further and actually ask our patients what they thought. We convened a diverse group of our patients and asked them to come in one evening to review the forms. They were compensated with dinner and a gift certificate for a class in our wellness center. What we learned was invaluable, and as much as we had tried to put ourselves in our patients' position, we realized we hadn't done a good job of it. With their feedback, we were able to further streamline the form, add questions that addressed their concerns, and we got additional suggestions on how to use technology to assist in the process.

The process isn't yet complete, and we are taking their suggestions forward as we implement our new electronic health records system. But what's most important is that we have established a system of patients as partners who are invested in their own care and the care of everyone else who walks through our doors. That is true patient engagement.

Kisha Davis, M.D., M.P.H., is medical director of an integrative primary care practice in Gaithersburg, Md.

Monday Nov 24, 2014

Here to Help: Launching Free Clinic Is Culmination of a Dream

One of the reasons -- probably the biggest reason -- I chose a career in medicine was to help people. I know it sounds trite because we all write about "helping people" somewhere in our medical school applications or our residency personal statements. But for many family doctors, helping people is truly a life's pursuit, a calling.

I first realized I wanted to be a doctor when I was in high school, and for a long time, I have wanted to find a way to give back to my hometown. Two years ago, I started taking steps to make that long-time dream a reality. The mayor of Falmouth, Ky., approached me about improving access to care in my home county of Pendleton, and that opened the door to discussions about free health care for the residents of the county.

Back in 1997, my junior year of high school, flooding along the Licking River submerged the city of Falmouth under several feet of water. Costs for repairs and rebuilding were in the millions, and many of the town's 2,000 residents left, never to return. The city and the surrounding county lost more than buildings and money. They lost hope.

To add insult to injury, the burden of chronic disease has increased in the area in recent years. For example, nearly 30 percent of the population smokes cigarettes. It doesn't help that according to the Health Resources and Services Administration (HRSA), there is just one doctor for every 7,349 residents in the county. Before the flood, access to care was an issue, but enticing new physicians or even hospital-related services became harder when businesses started closing down and the population declined.

As the mayor and I discussed these depressing statistics, we quickly realized that improving the health of the population would require more than just a free clinic. There's more to health than simply not having a chronic condition such as diabetes, taking the right medication, or even seeing your doctor on a regular basis. Health encompasses all aspects of our lives, from the food we eat to our ability to have a safe and restful place to sleep. The goal for the project became meeting not only the physical needs of the population, but building a sustainable culture of health by helping folks better communicate with each other and use their talents to support each other.

My vision, as I speak with representatives from groups like the health department or the Cooperative Extension Service, involves tapping the resources of individuals that utilize the clinic. Every person has something they can contribute to build community. If a middle-aged, self-employed father of three with hypertension comes to the clinic for treatment, the plan is for one of the registration staff to ask him about any special talents or skills he might possess. Let's say he's a carpenter, and he's willing to volunteer his skill and time in that area if a need arises. It's not a requirement for getting medical care, and we are taking great care to make sure patients understand they have no such obligation. But let's say he volunteers. This means that next week, when elderly Mrs. Smith, who's otherwise healthy but is virtually stuck in her home because she can't navigate her front stairs any longer, comes into the clinic for her arthritis, I would have a resource to tap to help build her a ramp.

While this is just an example, the idea of citizens helping each other forms the foundation for the project. Rather than assuming I know everything or have everything that people need, the plan is to help the members of the community discover how they can help each other. Too many times, free clinics open to provide only disease management, forgetting about health.

Like most things I tend to write about, this story doesn't have an ending yet. The group involved with the clinic has grown from two or three people to encompass multiple individuals, local organizations, and even city and county governments. We recently learned that the building we've been hoping to use as a base of operations will be ready for business in early December. As the process continues, I plan to post updates, mostly as an encouragement to others to continue giving their time and talents to help underserved populations.

Although time pressures and financial demands can make the process of providing free care daunting, multiple entities exist to help physicians -- particularly primary care physicians -- provide low-cost or no-cost care in urban and rural areas with the highest need. Via the National Health Service Corps, HRSA provides grants, loans, loan repayment, and scholarships for physicians agreeing to practice in federally designated health professional shortage areas. The federal government also extends medical malpractice coverage to free clinics via the Public Health Service Act, Section 224(o), and the Federal Tort Claims Act through an application process.

The AAFP Foundation provides assistance to no-cost clinics via the Family Medicine Cares USA program. The foundation offers grants to purchase equipment or supplies for new and existing free clinics in underserved areas. Applications for the program can be found on the Foundation's website, and the deadline for the next award cycle is March 15.

The plan for our group involves utilizing all of the above and even seeking some outside-the-box sources of funding, such as federal telemedicine grants. We're now working thanks to the generosity of private donations of time and money, but to maximize efficacy, the team is considering multiple different funding sources. We may eventually pursue creating a federally qualified health center.

My story, thank goodness, is not unique. Hundreds of doctors, medical students and allied health professionals across the country serve the needs of underserved populations. As new physicians, time and economic pressures may hinder us from helping others beyond the scope of our everyday practice, but multiple groups exist to help alleviate those stressors. I encourage you to check out the links above, whether you're already providing indigent or no-cost care or want to start. And feel free to add other resources for physicians in the comments field below.

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

Wednesday Nov 19, 2014

Don't Wait: Advance Planning Helps Both Patients and Their Caregivers

Not long ago, while overseeing residents in the hospital, we admitted an elderly woman who was bed-bound and oriented only to herself. In the past, she had clearly indicated to her paid health care proxy (she had no close relatives or friends) that, in the event of an emergency, she would "want everything done" for her, including cardiopulmonary resuscitation (CPR). However, she had also gone to great lengths to have home care 24 hours a day, seven days a week to avoid ending up in a long-term care facility. Her wish was to pass away at home.

On one hand, the team was grateful that she had delineated her wishes regarding resuscitation. With an underlying heart problem and an infection of unknown source, it was reassuring to know what to do medically if her heart stopped. However, her strong desire to pass away at home and not be consigned to months of lying in an unknown bed in a strange environment presented us with a dilemma. We knew that if resuscitation was needed -- and if it was successful -- the likelihood of her spending the rest of her life on a ventilator in an ICU bed was high. How could we reconcile what seemed like two disparate wishes for this woman, given that she was no longer able to have a meaningful discussion about her preferences or give us consent?

Without a doubt, the ideal is to have conversations about end-of-life care in the outpatient setting, before a serious illness -- accompanied by heightened emotions -- demands it be done in the hospital. As family physicians, we are particularly well poised to lead these discussions. Not only do we have a holistic view of our patients' medical conditions, we often know a great deal about their social history. Furthermore, we frequently care for multiple members of a patient's family. Despite not knowing exactly what might lead our patients to need a resuscitation decision, we do know that for many of our elderly patients, they (or their families) will be faced with this decision at some point.

What can we do to facilitate this decision-making process? Ultimately, we want our patients to be able to make informed decisions about their care, including those that occur at the end of life. However, this is not a light subject, and the conversation is typically not one that can be had in a few minutes. Although some patients have done a good deal of research about health care proxies, advanced directives, do not resuscitate (DNR) orders, etc., most have not.

In fact, a survey of U.S. adults published earlier this year found that nearly three-fourths of respondents did not have an advance directive, and lack of awareness was the most common reason.

Broaching the subject during a routine visit can be helpful. I begin by saying that I know this can be a difficult topic, but, as their family physician, I like to have documentation on file regarding how they would like to be cared for in the event of an emergency. (Of note, our electronic medical record has a place to document information about health care proxies and advanced directives.) I ask my patients if they have ever thought about this issue. And then I ask them if we could set up an appointment specifically to discuss this in more detail. I reassure them that I am not bringing this up because I foresee any emergencies in the near future, but expressly because I believe it is better to discuss end-of-life care before we arrive at that point. I encourage them to bring a spouse or family member to the appointment.

When discussing these topics, it is important to create a space where patients feel they can safely consider their options. But it's also essential to be forthright with patients about the pros and cons of those options. Most patients' idea of what occurs during and after resuscitation is the Hollywood portrayal. Conversely, an overwhelming amount of physicians, who have a more realistic understanding of CPR and its aftermath, choose to fill out DNR forms for themselves.

I try to give a clear idea of what resuscitation can and cannot do for a patient in simple language, and I focus, in particular, on what happens after the resuscitation effort. I explain that often, when the heart stops, if the medical team can make it start again, whatever caused it to stop will still be there. Sometimes, depending on the patient and if it feels appropriate, I tell them that ribs can be broken. I let them know that patients generally go to the ICU afterwards with machines and tubes helping them breathe and maintain their heart function, and that it is not unusual for the medical team to be barred from turning off the machines and tubes after they've been put in place, and patients may be dependent on these going forward. Even if the medical team is able to remove the additional support, I explain that patients rarely return to the same quality of life they experienced before the event.

I find it helpful to frame the discussion with patients in terms of "allowing natural death" rather than "do not resuscitate." And I stay away from asking if patients would "want everything done" in the event of an emergency, because to answer "no" to that question feels as though you are saying you want nothing done, and that is a scary (and inaccurate) option. I reassure patients that a DNR order is not a "do not treat" order, and we discuss all the options they would have for being treated for infections, pain or discomfort, and so on.

In terms of the practical details of scheduling appointments to have these discussions, the 2015 CPT code set will include two codes for advance care planning, They are

  • 99497 -- Advance care planning that includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional for the first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate; and
  • 99498 -- Advance care planning that includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional for each additional 30 minutes (list separately in addition to code for primary procedure).

Currently, the 2015 Medicare physician fee schedule will not reimburse for these codes. They are not valid for Medicare purposes, and CMS indicates that Medicare uses another code for the reporting and payment of these services. CMS does plan to review and consider payments in the future. Until then, physicians can bill for the visits using regular evaluation and management codes and code based on time spent in counseling and coordination of care.

It's worth noting that the AAFP has a comprehensive policy regarding advance planning for end-of-life care, and offers related resources for patients. In addition, American Family Physician has compiled a collection of journal articles that deal with issues related to this topic, including advance directives, pain management and hospice.

Ultimately, our elderly patient in the hospital stabilized and returned to her baseline after we identified the source of her infection and started the correct antibiotics. At that point, the resident and I were able to have a rational discussion with her health care proxy, who was one of her main caretakers. We met in the patient's room to allow the proxy to ask the patient questions throughout. Although she was unable to repeat back risks and benefits of and alternatives to various treatments or discuss her wishes directly, she was able to answer "yes" and "no" to basic questions about CPR, life support and, importantly, whether she would want to be in a hospital for an extended period of time.

Although the patient didn't have the capacity to understand what CPR would be like for her, she was able to indicate she wanted to be at home and she did not want to have her life extended on machines. This gave the proxy and others who cared for her the opportunity to consider what they thought would be best in line with what the patient would choose for herself if she had capacity. And, as physicians, that's what we hope to accomplish for all of our patients in these situations -- knowing how to care for someone at the end of their life in a way that is truly consistent with their wishes.

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 Nov 12, 2014

Home Grown: South Carolina Schools Work Together to Address Primary Care Shortage

As a new physician, I sometimes reflect on whether or not primary care was the right choice for me. Over and over, the answer always is yes. Unlike many of my peers, I was a "late bloomer" in choosing family medicine. I started medical school with plans to be an OB/Gyn, and it wasn't until my fourth year that those plans changed.  

That year, I worked in Ecuador for six months, and that's where I finalized my decision to pursue family medicine. I worked on labor and delivery while I was there, but I also taught rural high-school students about sexually transmitted infections and nutrition. And I worked with a rural physician who saw men, women and children in a remote mountainous area called Cacha. Through that experience, I realized that I enjoy caring for all types of people -- from newborns to the elderly -- and that being able to influence mothers meant influencing the entire family.  

Courtesy University of South Carolina School of Medicine

Students at the University of South Carolina School of Medicine listen to a lecture. The school is collaborating with another medical school, a nursing school, and a physician assistant training program to expand the state's primary care workforce.

There are students who are in medical school right now, or even pre-med students still in college, who also might choose family medicine if they had the right experience or exposure to our specialty. How do we reach those students? And how do we keep the interest of those who decided early that primary care was right for them?

According to research by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, the United State is expected to need an additional 52,000 primary care physicians by the year 2025 to care for an aging and growing population, as well as for the rapidly expanding number of patients with health insurance. The situation is particularly grim in my home state of South Carolina, which ranked 40th in the number of primary care physicians per 100,000 people in 2012, according to the Association of American Medical Colleges.

The South Carolina Area Health Education Consortium has responded to this shortcoming by developing the Institute for Primary Care Education and Practice through a grant from the Duke Endowment. The institute is an interprofessional collaboration between two medical schools, a nursing school, and a physician assistant training program designed to increase the number of health professionals practicing primary care in South Carolina.  

The institute recruits first- and second-year medical students, nurse practitioner students, and physician assistant students to become fellows. These health professions students participate in monthly seminars focused on pertinent topics in primary care and an annual retreat with keynote speakers, and they have the opportunity for longitudinal precepting opportunities with primary care physicians, nurse practitioners and physician assistants. The seminars are held via video conference so that students at all the campuses -- which are more than 100 miles apart -- can interact with each other and the seminar speakers.

The institute is in its third year of funding and has experienced success in recruiting dozens of interested students into the fellowship. Many of the nurse practitioner and physician assistant graduates have remained dedicated to primary care as their career choice. This will be the first year of the program that fellows graduate from medical school, so we will have Match data available in the spring to help us gauge our progress.  

It has been an exciting time participating in the institute as a core faculty member and being able to influence so many young health professionals.  

I encourage family physicians to look for ways to foster the next generation of primary care physicians, regardless of whether your primary job function is as an educator. Students need the opportunity to see what we do in our practices across multiple settings, beyond the walls of an academic health center. You may not have a grant to support a project exactly like ours, but you can precept and show the joys we experience in practice as family physicians.

At medical schools, family medicine interest groups can collaborate in a manner similar to the way our South Carolina program works with multiple campus locations, extending limited resources and forming alliances across the state. The AAFP's FMIG Network can help with the tools to build those connections and support your work.

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

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