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Wednesday Apr 22, 2015

Balancing Act: There Is More to My Life Than Just Medicine

We are so much more than the sum of our parts. As family physicians, we treat patients who have an amazing variety of problems. There are virtually as many chief complaints in our ledgers as there are patients to go with them. We see headaches and allergies and chest pain and gastroesophageal reflux disease and hypertension and lacerations. And the list goes on.

And much like the variety in our patient populations, we need variety in our lives. Much has been written -- including on this blog -- about physician burnout and work-life balance. Sadly, little is written about the things we do outside the office or hospital. 

Who we are as people was cemented long before we finished residency. Often, our innate love of conversation, creativity, learning or some other skill or interest is what drove us to medical school in the first place. Out of some misbegotten fear of being selfish, we often forgo that one day a week, or even one day a month, during which we take time to do something just for ourselves.

Here I am preparing for the Warrior Dash in Mountain City, Ga. Physicians should follow our own advice more often and make time to take care of ourselves.

I frequently care for patients with anxiety and depression. One of the first questions I ask is, "What do you do for fun?" When I asked a patient that question recently, it dawned on me that rarely do I see that question asked of physicians in articles concerning physician burnout. With all the publicity this topic has garnered -- and so many lives on the line -- no one seems to ask one of the fundamental questions that helps gauge our mental well-being. I fear we don't ask it enough of ourselves, either.

Although concerns about patient care and the business of medicine fill our workday, and family obligations account for much of our time away from work, we still have to make time for our passions.

I enjoy writing. I also enjoy creating many types of art. From movies to paintings to sculpture to woodworking, I like using my hands to create. In some cosmic, karmic balance, it seems to offset so much of the destruction I see both in the clinic and in the world around us. I have friends whose passion drives them to scale tall rock structures and others who find peace in riding a bicycle for miles. You may enjoy knitting or flying or sitting quietly on a rock. The important part is not the activity, but the feeling the activity inspires.

It may sound trite, but we each need to be reminded why we go to work each day. We need to be reminded why we fight to save lives. We need to be reminded to live our own lives. Just as our brains cannot function without glucose, we cannot function properly without fun. Our bodies need to recharge. That's why we eat. Our brains require the same, which is why we sleep. Our spirits, if you will, require the same level of maintenance. Activities that bring us joy serve the same purpose as food or sleep. They allow us to constructively deal with the complex emotions tied to caring for the chronically ill. Pursuing an activity because you want to -- not because you have to -- rekindles the passion and fire we so desperately need when caring for our patients.

The body is more than an eye or a foot. So, too, are we more than physicians. No one is only one thing. Being a doctor is fundamental to who I am, but it is also only one part. I diminish myself when I ignore the other parts. I'm a father. I love spending time with my three daughters. I'm a husband. Spending time with my beautiful, patient wife brings me joy like nothing else. I'm a writer. In both this blog and others, I write about the things I love. I'm a tech geek. Every new gadget purchased brings a sense of wonder that I've felt since I was 5 and used my first computer mouse. I'm a doctor. I thrive on seeing lives changed by improving the health of my community.

Fitting all of these activities into my day-to-day life requires careful time management and purposeful scheduling. Unfortunately, there are only 24 hours in each day, and I need to sleep for a few of those, so I'm limited in the number of things I can do per day. Fortunately for me, there are lots of days each week and even more when looked at in terms of months. It takes a conscious effort to incorporate these small breaks into my life, but they don't lose their flavor through lack of spontaneity. I still enjoy writing or painting just as much when I've planned the time a month in advance as when I get to do it spontaneously. Much as I do with other aspects of my life, I set realistic expectations. That way, when I get extra time to put together a video or play a game with my family, that activity far exceeds my expectations.

No one-size-fits-all method to combat burnout exists. We each have to figure out the balance our life requires and how to get there. For me, were I to remove any one of the things I enjoy, my life would not cease to progress. I wouldn't just lie down and die. But neither would I feel completely whole.

I think Ferris Bueller said it best: "Life moves pretty fast. If you don't stop and look around once in a while, you could miss 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 Apr 15, 2015

Respect, Support Moms' Breastfeeding Decisions

I nursed my daughter until she was 2 1/2 years old, and we had a wonderful experience. I never had painful nipples, never had issues with supply and never had mastitis. She latched well, nursed easily and switched back and forth from breast to bottled breast milk without trouble. 

Translation: I was extremely fortunate. 

A young mother receives help with breastfeeding her baby. Nearly 80 percent of babies born in the United States are breastfed to some extent, but less than half are still breastfeeding at age 6 months.

The ideal situation I described is not what many mothers experience. And even with the ease I encountered, nursing, pumping, cleaning parts, storing milk, freezing milk, etc., took hours each week. Before experiencing it myself -- and having conversations with friends and patients that I wouldn't have had before breastfeeding my daughter -- I likely would have simply said, "Breast is best," and left it at that. 

I still stand by that sentiment, but I have come to understand that's not all there is to it. There is a lot of undeserved shame that sometimes comes with parenting in general, and motherhood in particular. On parenting blogs and websites, you will find surveys on this topic, with the most common listed causes of shame and guilt being method of delivery (C-section or vaginal delivery? Epidural or no analgesia?), working or staying home, breastfeeding or formula, and even disposable or cloth diapers.

For whatever it's worth, I had to have a C-section, I work full time, I breastfed my daughter, and I used cloth diapers. It doesn't make me better or worse than anyone else; it’s just my family's story. Guilt has no place in bonding and parenting, and as a physician I want to do as much as I can to alleviate guilt or shame for my patients. 

Many well-child visits often include the question, "Do you breast- or bottle-feed?" and not much of a discussion past that. I try to delve deeper, and with patients I see for prenatal care, I start the discussion during pregnancy. Most of my pregnant patients say they plan to breastfeed, but statistics show that less than half of American babies are breastfed at age 6 months, and the number falls to 26 percent by 1 year. This shortfall is usually not because mothers changed their minds about the benefits and importance of breastfeeding, but because something didn't work the way they planned. 

For example, a friend of mine had a month-old baby who was hospitalized with pneumonia. The child didn't have the strength to nurse while ill, and after she recovered, she no longer would take a breast despite extensive work with lactation consultants, nipple shields and a supplemental nursing system. This meant exclusive pumping, which was definitely not what the mother had planned. But she accepted that this was what was going to work for her family.

One problem I see in my practice is lack of supply. Some patients have driven themselves to exhaustion pumping -- every hour or two during the day and every two to three hours at night -- to try to keep up with their infants' demands. Although I applaud the dedication, there comes a breaking point for some mothers where this routine isn't sustainable.

Any breast milk is beneficial, and if what works for a mother and her infant is a mix of breast milk and formula, that is better than no breast milk at all. When nursing becomes stressful for a mother and her infant, that is rarely going to be what is best for either of them.

Breastfeeding (or not) is a choice. It's up to us to make sure that choice is an informed one. Research tells us that breastfeeding is beneficial for both mother and child, lowering both patients' risks for numerous adverse health conditions.

Still, the list of reasons that breastfeeding -- or exclusive breastfeeding -- may not be an option for some mothers is lengthy: poor latch, low supply, lack of support, work issues, depression, maternal medical problem, infant medical issues, etc. We need to provide support to women through these challenges so that those who wish to continue to breastfeed will succeed. But we also need to take care to support those who ultimately do not.

In my rural community, I helped start a breastfeeding support group, worked with the health department to get a peer breastfeeding educator in our county, donated (along with one of my colleagues) a breast pump for our hospital, and worked to ensure we had a lactation consultant available through the hospital. I do everything possible to support breastfeeding in my community and for my patients, but I have heard too many times from patients, friends and colleagues that they feel shame, guilt and fear of judgment when it doesn't work for them.

Although in many cases this kind of judgment is coming from society (and not our practices), physicians -- especially those who have not done it themselves -- need to understand the toll this takes on our patients. Patients have said they were afraid to tell me they had stopped breastfeeding, or started supplementing, because they had received such negative feedback from others.

I see my role as being a cheerleader and support person for breastfeeding, and I do anything I can to make it work as long as it is what is desired and what is best for my patients. I also acknowledge that there are times when, despite our efforts, breastfeeding may not be what is best for some families. When that happens, I assure those moms that they need not feel guilty for making a decision that was best for them or their child.

I have become much less judgmental since becoming a parent myself. Although I would have supported a woman's right to practice extended breastfeeding before my own experience, I might have looked at them a little bit funny … that is, until my daughter showed no sign of being ready to wean at 18 months -- or even 24 months.

So, do I think every mom should do as I did? Sure, if it's right for them. Every mother/baby dyad is unique, and their needs are vastly different. As physicians, we need to remember that one size rarely fits all, and we must make sure we are an accessible and supportive resource for our patients on this important journey.

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

Tuesday Apr 07, 2015

Step by Step: Proper Planning Essential for Quality Improvement

All medical residents are now required by the Accreditation Council for Graduate Medical Education (ACGME) to undergo training in continuous quality improvement (CQI). Many of us were taught this, to varying degrees, at some point in our medical education. And although many of us work on improving processes and methods of care delivery in our practices, we shortchange ourselves and our patients if we cut corners.

Fortunately, my training in CQI methods as a resident was excellent. Each third-year resident led a full clinical team in a project that covered the entire academic year. We had time each month dedicated to meeting with our team to work through the FOCUS-PDSA cycle, with didactics before each meeting to prepare us for the next steps.

The project I selected was designed to improve immunization rates in children younger than age 3 years. The process was not without difficulties, but our intervention was fairly simple. We determined that there were many missed opportunities for immunization during acute-care visits, and so we needed to remind our physicians and physician assistants to bring this up during those visits. Based on alarm fatigue associated with our electronic health record (EHR) system, we decided against an electronic reminder. Instead, we printed immunization records from the state database (which, unfortunately, does not communicate with our EHR) and had the medical assistant discuss it with the physician or physician assistant during the pre-session huddle.

By the end of the project, we were able to show a statistically significant improvement, with the rate of recommended vaccinations in this age group increasing from 66 percent to 91 percent for our population. I encountered the same issue with immunization rates when I entered practice, and I implemented a similar intervention. This time, rates for the recommended vaccines being given to adults and children in our practice improved from 55 percent to 87 percent.

My next project involved improving our process for processing requested medication refills, which also showed some success but not as much as I had hoped. Why hadn't it, I wondered? What were we missing?

I quickly realized that we had skipped some steps in the CQI process. We had not done a full analysis of the existing process, and because of this, I had a harder time getting buy-in from the medical assistants, who had the biggest role to play in the intervention. I had failed to follow what I had learned, which resulted in time wasted and only modest improvements.

More recently, in a follow-up to our immunization project, I realized our rates were starting to slip again. What was happening here? In this case, we failed to follow possibly the most important part of CQI: continuous. Any process requires ongoing follow-up to ensure that problems or kinks can be addressed. Realizing the errors in both of these projects, we were able to provide solutions that really worked and provided some improvement for our staff and patients.

CQI can be a bit onerous, particularly because it takes time and the efforts of many staff members. It can be frustrating, as I experienced, to miss some steps and realize that you have to start over. But based on estimates of vaccination benefits, we saved millions of dollars in direct and indirect medical costs to society and avoided multiple hospitalizations of the children who received immunizations -- and those they could have otherwise infected -- over their lifetimes.

We also saved time by providing refills more efficiently through medical assistant support of increasing refills during visits, making our patients happier at the same time. The time and effort were well worth it.

Following the proper steps, remembering what we have already learned and experienced in quality improvement, and addressing pressing needs in our practices provides big dividends, both in quality of care and, potentially, cost. These are essential steps, whether on a small scale in our practices or on larger population-based scales, to making our health care system the high-performing entity we know it can be.

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 Mar 31, 2015

High Deductibles: Out-of-Pocket Shouldn't Mean Empty Pockets

Hearing patients ask, "How much is that going to cost me, Doc?" makes many physicians cringe. But with rising insurance deductibles, it is a question that is being asked more frequently.

Primary care physicians are busy; we're formulating differential diagnoses, satisfying meaningful use criteria, motivating patients to check their sugars and completing seemingly endless paperwork. Given the general lack of knowledge in this arena and time constraints, it might seem impossible to also help patients navigate the murkiness of out-of-pocket costs. Wanting to pass the buck is understandable, but doing so likely will impact patients' clinical outcomes. No matter how medically appropriate, many of our orders and recommendations go unfulfilled because of financial considerations.

Patients are not capable of answering the question, "Is the newest blockbuster drug really superior to older, generic options?" And even if they were, they also would need to know, "Is the benefit worth the increased cost?" Nobody is better equipped to answer these questions than their physicians.

Practicing in a safety-net clinic in residency -- and now in a direct primary care solo practice -- I have learned to navigate the "How much?" question with more comfort.

One of the most important lessons I've learned is that having an insurance card in your pocket does NOT necessarily lead to lower prices, particularly on labs, radiology and meds. In fact, often the opposite is true. Just making sure a facility or provider is in-network is not a strategy to insure fair pricing. Regardless of a patient's insurance arrangements (or lack thereof), the most important thing is to be open and proactive about financial discussions.

When prescribing or reviewing medications, ask patients if they have difficulty paying for them. We should not always assume insured patients have $10 copays for meds. Pharmacy pricing can vary dramatically, and without obvious patterns among retail chains. We frequently reference to price-check meds before sending prescriptions to pharmacies. This doesn't factor in insurance coverage, but using coupons is often cheaper than going with insurance copays (if they exist). Spending three minutes looking can often result in saving a patient hundreds of dollars per year on a single medication.  

Medical practices can legally dispense and sell prescription meds in most states, and we have found it simpler -- and better for patients -- to provide in-house dispensing of many generics. Being fully membership-fee supported -- without a need to profit off any ancillary services -- we are able to offer patients meds at wholesale prices without markup. We can often sell meds for 50 percent to 90 percent less than most pharmacies, which is a huge plus to being members of our practice. Even with a small markup and profit, on-site dispensing can be a big help to patients versus navigating the pharmacy world.

When ordering diagnostic tests, we encourage patients to ask for total costs before proceeding. Although it can take some work to get a price, it's much better than getting stuck with a bill that could've been hundreds or even thousands of dollars cheaper elsewhere. If billing an insurance plan, the insurance-based fee (ironically often called "discount" price on explanation of benefit forms) has already been set in contract with the facility, so that is not negotiable. But, insurance-based prices can be determined ahead of time to avoid surprise bills later.

When shopping for a price for a test, finding a baseline fair or average price for the service is a good start. A few resources we've found helpful are, and

To bypass the need for our patients to go shopping, we have contracted out many ancillary services, including labs. As with medications, we can charge our members our negotiated rate without markup. In fact, we purchase basic labs (lipids, hemoglobin A1c, thyroid-stimulating hormone, metabolic panel, blood counts) so cheaply we decided to provide them at ZERO cost to our members. We price other labs at a small markup (no more than $5 dollars each) to offset the no-cost labs so we break even overall.

We have found we can offer patients an average of 50 percent to 70 percent savings versus insurance-based prices and 80 percent to 95 percent versus self-pay prices. As with medications, subcontracting lab services could be easier and cheaper for patients than dealing with insurance hassles and profitable for practices with even small markups.

For radiology services, we have developed a local network of facilities with cash-friendly prices. It may seem unreasonable for patients to pay cash for things like CTs and MRIs, but we have found steep discounts when paying cash upfront (i.e., $450 for MRI). Cash discount price is often less than 20 percent of what co-insurance (after meeting the deductible) would be at other facilities. We subcontract X-ray technical service with a local orthopedic group ($25 to $35 per series), and I don't charge patients for my interpretation -- not bad, considering our local hospitals charge $100 to $300 for X-rays.

For the foreseeable future, being a comprehensive patient advocate will involve financial considerations of care and discussions with patients. Thankfully, many organizations are starting to push for transparency in health costs and provider education to help make this part of our job easier. If you'd like to learn more, you can follow the #hcpt hashtag on Twitter, or check out and the Choosing Wisely campaign.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare. He will be speaking at the Direct Primary Care Summit in July in Kansas City, Mo.

Tuesday Mar 24, 2015

House Calls: What to Do When Your Patients Are Snowed In

Medical schools and residency programs tend to be in larger cities, in part to provide inpatient training and to ensure there is enough volume to train physicians appropriately. Fortunately, there are programs that focus on rural outpatient education and place students and residents in rural settings for rotations or for continuity throughout their training, but even these learning opportunities are still within proximity of an academic center.

My nurse, Crissy Dean, L.P.N., (right) hikes through the snow with me to reach a homebound patient. Heavy snows in February and March made it impossible for some of my patients to come to me this winter.

Thus, many of us never practice in isolated rural settings during our training. This is my first year out of residency and my first in a truly rural setting -- Appalachia in Clay County, W.Va. I expected patients to have transportation challenges, I anticipated there would be socioeconomic barriers to care, and -- as is the case in many locations -- I was sure I would see fluctuations in the volume of patients coming in for treatment because of adverse weather.

What I didn’t expect was to not see many of my patients for two consecutive months -- regardless of how sick they were -- because they could not leave their homes in the winter.

Some of my elderly patients told me months ago that they need 90-day supplies of their medications during the winter, but they prefer 30-day supplies (which are easier on their budgets) during the rest of the year. That should have clued me in that they were not coming to town, much less to see me, during the winter.

I assumed they didn’t like to come out in the cold, didn’t want to risk falling in an icy parking lot, would rather stay home and were planning ahead. What I didn’t realize until about two weeks ago was that these people were not just being cautious; they knew they were going to be stuck at home from the first snow until spring.

We had significant snow fall from Feb. 15 (President’s Day) until two weeks ago when it started to rain and eventually stayed above freezing for a few days. Within two days of the weather turning warmer, I was the busiest I’ve been since starting my new job. I also recall being rather busy the week before Thanksgiving, in part because these conscientious patients were planning ahead and making their appointments as late in the fall as they felt comfortable doing. Now, here they all were again after the first thaw.

And some were quite sick. I saw patients with heart failure, subacute strokes, heart attacks, diabetic complications, skin infections, depression and pregnancies. They knew they needed to see a doctor; they just hadn’t been able to get out. Quite a few of my patients have to travel an hour or more to get to my office. Some live in the mountains and couldn’t get down the road safely, and others live in areas with flooded roads. Some don’t drive and depend on family who live far away to drive them, so there were multiple layers of bad weather limitations.

I was snowed in at my house only one day. Sometimes I was late, but I managed to get to work. Some days I didn’t see many patients and wondered if it had been worth driving through such terrible conditions to see so few patients. But each day that the weather was horrible I sent at least one person to the hospital. And there also were those determined patients who put the chains on their Jeeps and made it to their routine visit, so I wanted to be there for them, too.

The most important job I had on those snowy days was taking care of patients over the phone. Wives and daughters calling with concerning reports about loved ones who I would attempt to triage and decide who could wait and who could not. And those who could not I often decided to go to myself. My volume in the office was low, so I would put on my boots and head out to some hollow hoping to find the right house. I don’t have good cell phone service outside of town, so I depend on old-school pen and paper directions.

Reaching people's homes often involved a fair amount of hiking because if they couldn’t get out, I couldn’t drive all the way to them either. But at least I’m healthy enough to walk, and my nurse is in good shape and was willing to go along to get bloodwork, give intramuscular medications, etc. Home health is a huge help in these rural areas, but home health workers are often travelling from neighboring cities and cancel if the roads are bad, so some of these patients had no health care for weeks.

These home visits were the most rewarding work I have done thus far in my short career. By going out, I was able to keep most people home -- which is where they all want to be -- when some of them were close to needing to be hospitalized. The patients who didn’t call for help and waited until the weather broke didn’t fare as well, and one is still in the hospital.

Next time, I’ll be much more prepared when winter hits. I may even develop a list of high-risk patients to call and check on, offer home visits to, or whatever is needed. I have never viewed my job as a physician as one limited to a brick-and-mortar structure with exam rooms. It is more than that. But patients aren’t used to doctors doing home visits, and most would never think to even ask.

My goal during the next year is to change that perception within my patient population. I want to be their doctor, not just "the doctor in town." My goals are their goals: to have better quality of life and not go to the hospital because of a lack of access to care for any reason.

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.V.

Wednesday Mar 18, 2015

Is Your Stethoscope Making Patients Sick?

An interesting conversation on an AAFP message board recently was sparked by a tale of a physician who was cited during a nursing home inspection for not cleaning a stethoscope between patients. It raises an intriguing question: How many of us are actually taking that step to prevent the transmission of disease?

In a 2012 study published in the American Journal of Infection Control, less than one-fourth of the 1,400 health care workers surveyed at a pediatric hospital said they cleaned their stethoscopes after each use. Lack of time and access to disinfectant were cited as barriers, but are either of those excuses reasonable?

As clinicians, we come in contact with multiple pathogenic organisms every day, increasing the potential for spread of disease. We often think of our hands or our mucus as doing the dirty work of transmission, but a study published last year in Mayo Clinic Proceedings pointed out stethoscopes are another possible source of contamination.In the study, three physicians performed exams on 83 patients using stethoscopes in a standardized manner. Several iterations were performed, including a gloved versus ungloved comparison, and all participants disinfected their hands before the exams. The physicians conducted routine head-to-toe exams on hospitalized patients, including heart and lung exams, so this should have been fairly representative of the routine contact we have with patients in a hospital setting.

After completing the regimen of exams, the physicians’ gloves, hands and stethoscopes were all swabbed for culture. Results were mostly as expected. In a nutshell, the stethoscopes, especially near the bell, were contaminated at a level similar to the hands or gloves.

Most contamination was found near the fingertips, but the diaphragm of the stethoscope held on to bacteria nearly as well. This finding, while not conclusive of infection transmission by stethoscope, definitely casts doubts on how well hand-washing alone can cover all of the myriad pathogens we encounter at the bedside.

With the number of devices used in medical applications growing, we need more research into methods and best practices for disinfecting the environment as well as our skin.

Anecdotally, the hospital where I trained disallowed white coats in the ICUs as an infection control measure. The reason? Many clinicians don’t routinely disinfect white coats, if they even wash them at all.

Last year, the Society for Healthcare Epidemiology of America (SHEA) suggested that clinicians consider a "bare below the elbows" approach, meaning short sleeves, no watches and no jewelry. For facilities that do encourage (or require) clinicians to wear white coats, SHEA recommended that physicians should own more than one white coat and have access to an on-site laundry. It also was recommended that facilities provide a place for physicians to hang their coats before patient contact.

The same SHEA guidance pointed out that neckties, which also have recently been eschewed by many organizations, also are a problem. In fact, multiple studies have shown that up to 70 percent of physicians admitted to not cleaning their ties -- ever.

The core issue -- and what the authors allude to in the discussion of the stethoscope article -- is transmission of pathogens. Is contamination of clothing or instruments significantly affecting the transmission of infectious agents to other individuals? We need more studies to look at the absolute risk of transmission from fomites in order to better gauge the level of appropriate concern.

Disinfecting every object would be extremely expensive. Proving that those surfaces are truly germ-free would be even more so. Once the risk is established, then it becomes much more cost-effective to look at decontamination strategies for nearly all of the equipment we use, from our stethoscopes and otoscopes to ink pens and computers.

Meanwhile, judicious use of standard precautions and alcohol swabs and hand washes likely will keep contamination to a minimum. Most stethoscopes can be washed with soap and water or alcohol-based cleaners. I tend to keep a few alcohol swabs in my pocket just for the stethoscope and otoscope. Computer keyboards are trickier, but it’s a simple matter to wash your hands before touching the keyboard or mouse. Wipe down phones, reflex hammers, calipers, etc., after any possible contamination.

Common sense cleaning can cut out a lot of risk.

The Mayo study doesn’t say we need to autoclave our stethoscopes. Instead, it points out that there are tens, if not hundreds, of possibly contaminated objects in physicians’ offices and hospitals that need further evaluation. We have a responsibility to our patients to provide a safe environment, especially as it pertains to infectious organisms.

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 Mar 11, 2015

Media's Focus on Dietary Cholesterol Masks Bigger News

Every five years, HHS and the Department of Agriculture update the Dietary Guidelines for Americans. Much of this work is directed by the Dietary Guidelines Advisory Committee report, which was released last month and caused a few waves.

Actually, they were more like ripples, reminding people of things they should already know, like limiting refined sweets and saturated fats and moderating alcohol intake. However, one recommendation -- or rather lack thereof -- did garner quite a bit of media attention, and that was a declaration that cholesterol is no longer a "nutrient of concern."

I guess that means cholesterol is now allowed to leave Guantanamo to live its life as a free molecule. But will this change how we counsel our patients, and should this change in the guidelines be getting as much play as it is?

For me, it won't change my counseling much. I never counseled my patients that dietary cholesterol was evil. In fact, our bodies need cholesterol. Even if we eliminated cholesterol completely from our diets, our livers would continue to produce it.

Dietary cholesterol has been a focus for many physicians and patients alike for years, and some may find this shift a little hard to swallow. The previous recommendation had been to limit dietary cholesterol to no more than 300 milligrams per day, and some patients already have asked me questions about the revision since this report was released. Although patients seemed a little surprised by the change, they also seemed to embrace it. One patient was excited to add shrimp and eggs back to her diet after avoiding them for years because of concerns about their cholesterol content.

I think most patients understand, and even expect, that as our knowledge about health and diseases advances, our recommendations will change accordingly. This report provides an opportunity for us to review with our patients what comprises a healthy diet and identify areas for improvement.

Personally -- and perhaps this shows my age -- I don’t see what all the fuss is about. The bit about cholesterol is buried on page 91 of a 571-page document, and it is not mentioned at all in the executive summary. The report includes several other recommendations that I thought were much more interesting and could have made better headlines. In fact, all the attention paid to cholesterol overshadowed these more noteworthy points:

  • Americans, in general, aren't getting enough of Vitamins A, C, D or E, and the same is true for calcium, fiber, magnesium and potassium;
  • Premenopausal females don't consume enough iron; and
  • Children ages 2 to 5 years are the only subset of kids who routinely consume the recommended daily amount of fruits and vegetables.

The report also raised eyebrows by addressing food sustainability and access issues, which some critics thought was outside the purview of the committee. However, I applaud the committee's attention to these topics. Any physician who does his or her own grocery shopping knows how challenging it is for some of the families we care for to afford the kind of diet this report recommends.

Here's the takeaway: This latest iteration of the dietary guidelines report contains some important observations, and I would hate for us to miss those because people were too focused on what was recommended in the past.

The public is invited to submit comments about the report through April 8.

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

Wednesday Mar 04, 2015

Breastfeeding: What Every FP Should Know but Didn't Learn in Med School

I've always encouraged the new moms in my practice to breastfeed their babies because a mountain of evidence suggests that the practice leads to better outcomes for both mother and child. When I go back to work at the end of this month, I'll have an even greater respect for the moms who endure the frustration, fatigue and pain (even with a good latch) associated with breastfeeding because I've been doing it myself for three months. But I also will have more empathy for the women who aren't able to do it because it has been well worth the effort.

My daughter was born around the same time that a few of my physician friends also had babies. Although we learned about breastfeeding in medical school and residency, we all agree it's been more difficult than we imagined. That admittedly small consensus made me wonder how many physicians acknowledge -- or are even aware of -- how challenging it is for some of our patients.

My maternity leave, which included this trip to California, has gone by fast. Breastfeeding has helped me develop a strong bond with my daughter.

A few of my friends have struggled with low milk supply, leaving them feeling anxious and, unfortunately, inadequate at times during the already delicate postpartum period. Meanwhile, I've experienced mastitis -- complete with fever and exhaustion -- as well as oversupply issues, which came with its own host of problems.

At first, I didn't understand why my daughter was fussing, pulling away and even choking. After only a few minutes, she would fall asleep and not be interested in nursing for a few hours. It turned out she was trying to drink from the equivalent of a fire hydrant. To correct this, I pumped for a little bit each time before nursing my baby, so she could benefit from the slower, higher fat content hindmilk instead of the faster flowing foremilk that was filling her up too quickly (and making her extra gassy). Now that she's a bit bigger and my body has figured out how to correct for its overshoot mistakes, we're a much happier team.

Despite the early frustrations, there have been so many moments of absolute wonder. To personally experience the biology we all learned about was truly awe-inspiring. Oxytocin is a remarkable hormone, and nothing compares to the feeling of developing that special bond with a little human being that you created. I made a point to be mindful and present as often as I could. With all the stresses of being a new mom, it can be easy to forget to enjoy these fleeting moments.

Being a patient has been a learning experience for me, and I'm going to feel more confident in my ability to help my own patients with this issue when I go back to work. We have lactation consultants in my clinic system, but we don't have one at my specific clinic. For the moms who need immediate help or aren't able to make an extra trip to see a consultant, I'm going to be better able to troubleshoot and make suggestions.

Most women know what a baby on a breast looks like, but the correct latch is so much more complicated than many women realize. Now I have personal experience to guide me through exactly what to look for when a baby is latching -- or not -- and what signs indicate the baby is swallowing. I also know better how to instruct partners and support people about ways they can help mom and baby while they work out their intricate breastfeeding dance, from holding the baby's hands out of the way to bringing mom a tall glass of water.

And the fun doesn't end at latching. There is an entire world of breastfeeding equipment -- electric pumps, hand pumps, nursing bras, hands-free bras, nursing pads, breast compresses, nipple cream, etc. -- that I knew little about before. Knowing firsthand what the reputable brands are and what to look for in a particular product will be helpful when making recommendations to my patients.

It's important that all family physicians -- whether you provide maternity care or not -- are knowledgeable on this topic because we can help our patients who want to breastfeed be successful. If you or your practice could use some free help with breastfeeding, it's worth noting that the AAFP recently launched a new breastfeeding toolkit that includes evidence-based clinical information, coding tips, patient education materials and more.

Here in the Bronx, talking to moms about breastfeeding can be a challenge. Teenagers account for roughly 90 of every 1,000 pregnancies -- or roughly 1,800 babies -- each year. That's the highest teen pregnancy rate among New York's five boroughs.

Many of these patients are single moms still living with their own moms. They're teenagers and young adults trying to wake up every two to three hours to nurse a baby, and they are not necessarily getting a lot of support with breastfeeding at home. The majority of them don't know anyone in their community who has experience breastfeeding. Many of them also have easy access to free formula. But many are good moms trying to make good decisions.

So what am I going to do?

Despite the challenges, I still believe in the old adage, "Breast is best." It's a wonderful bonding experience for moms and babies, and the positives far outweigh any negatives. So I will continue to encourage breastfeeding as much as possible. I'll refer to lactation consultants when I need to, offer my own knowledge and experience when appropriate, and be understanding of the women who opt for formula.

I'll be back at work soon enough. One benefit of working in a family medicine clinic is that I'm surrounded by people who also believe in the benefits of breastfeeding and are dedicated to supporting the cause. Fortunately, my clinic is planning to change my schedule to help me and my family. Instead of one long lunch break, I'll get a few 15-minute breaks spread throughout the day so I can pump. I'm already practicing pumping with my hands-free bra so I will be able to chart and pump at the same time.

Every new mom should have the same type of encouragement, support and understanding.

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 evidence-based care to underserved communities.

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.

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