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Monday May 02, 2016

Insurance Hurdles Add Challenge to Treating Pain

If you are an opiate prescriber or are dependent on opiate prescriptions, you are likely well aware of the CDC's new guideline for prescribing opioids for chronic pain.

At some point in your life, the quality of the pain management you deliver or receive is likely to be impacted by how the medical community responds to these guidelines. They likely also will impact insurance coverage of certain medications and will undoubtedly influence further regulations.

You could say that the time had come, and perhaps was even overdue, for CDC's guidelines, and I am cautiously optimistic about what their ultimate effect will be. I have been painfully aware of the need for more guidance and oversight of pain management in the primary care setting, especially as new abuse-deterrent medications become available. I was hoping for some sort of clear pain management algorithm that would pressure insurance companies to provide blanket coverage for physical therapy and abuse-deterrent medications, while withdrawing support for the use of the frequently abused prescription narcotics.

It took me a couple of reads through the guidelines and a few reviews of the commentary from my peers before I began to see that this might be exactly the impetus we need.

I think the solutions to the opioid issue lie not in the guidelines themselves but in the larger conversation they generate and the medical community's response as a whole. To that end, let me present a glimpse into the difficult reality I and many other physicians face on a day-to-day basis. I am continuously confronted with the challenge of treating the subjective complaint of pain, sometimes called the fifth vital sign, while maintaining safe medical practice and achieving the often coveted, and now mandated, secondary goal of patient satisfaction.

One thing is clear; patients rarely come to the clinic or the ER complaining of pain with the expectation that they are going to get a sticky note saying, "Go pick up some Tylenol or Motrin at your local convenience store."

When you start with this understanding and the premise that you are a medical service provider who is being rated on the quality of your service, things get really tricky. For example, what do you do when the patient who you already have seen five times for back pain says, "Doc, I've done all the exercises and tried all the medications you prescribed me, but none of it is working?"At that moment, you review the chart and see that, indeed, patient X has failed every nonsteroidal anti-inflammatory drug (NSAID) known to man and jumped (or limped) through all the hoops you set. Or you look at the allergy list and you see "NSAIDS, acetaminophen, codeine and tramadol" while your patient looks you square in the eye and says, "That's right, Doc, the only pain medications I can take are hydros or oxys, and if I'm going to be honest with you, Percocet works the best for me."

Then there is the fibromyalgia patient who has failed pregabalin (marketed as Lyrica), and the insurance won't pay for milnacipran (Savella) or duloxetine (Cymbalta), which leaves the higher risk medication amitriptyline (Elavil).

How about the osteoarthritis patient who can't afford celecoxib (Celebrex)? You write a script for the diclofenac patch (Flector), but it is only covered for acute arthritis pain and is not affordable with Medicaid or Medicare.

For your lumbar radiculopathy and sciatica patient, you think, "Wouldn't it be great if I could write a script for a lidocaine patch (Lidoderm)?" But you know you can't because it is only covered for post-herpetic neuralgia. But no worries because of course there is gabapentin (Neurontin, Gralise and Horizant) which is really only indicated for restless leg syndrome, partial seizures and post-herpetic neuralgia, but thankfully is covered by all insurances.

If you are really trying to reduce the number of prescription narcotic pills floating around your neighborhood, you might get inspired when a pharm rep stops by to talk to you about the new options in abuse-deterrent pain management. So in your patient encounters, you start talking up abuse-deterrent variations of buprenorphine (Butrans and Belbuca), hydrocodone (Hysingla and Zohydro), morphine (e.g. Embeda), and oxycodone (Xtampza), but later you find out that these drugs are unaffordable, require a step edit, or need a prior authorization that says something like, "patient must first fail Opana, MS Contin, or Nucynta."

You likely have similar stories of your own. My point is that we, as medical professionals, are all deeply invested in the welfare and satisfaction of our patients. We are also adaptable and extremely adept at achieving good outcomes using whatever tools we have.

So, speaking for myself, I can say that I am longing for the day when insurance companies no longer dictate how I practice, and I am looking forward with tempered expectations to see if the CDC's opioid prescribing guidelines will lead to real solutions. Whatever the outcome, I am certain that I and many physicians like me will keep plugging along, doing the best job we can for our patients within the parameters that are set for us.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.

Tuesday Apr 26, 2016

FPs Are 'Soldiers in Field' Against Outbreaks

I recently was hired as the medical director of our local health department, and my new role started in the midst of one of the worst pertussis outbreaks on record in my state.

The experience has made realize just how important community physicians are in reporting and controlling an infectious disease outbreak. We are the soldiers in the field, not only caring for the patients affected by the disease, but also collecting information and reporting it to state, local and national health agencies.

Family physicians see patients from every age range and socioeconomic background. It's imperative -- especially during a disease outbreak -- that we keep our eyes and ears open, know how to contact our state and local health departments and report what we see. This means that community physicians need to have a low threshold for testing for specific diseases when an active outbreak occurs.

It's also important to know the rules for reporting infectious diseases at the local, state, and national level. The CDC has a list of reportable diseases, and most local health departments will have a list of diseases reportable in your state.

Although the pertussis outbreak is waning locally and flu season is winding down nationally, a new potential threat is looming. Anthony Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases, recently said local outbreaks of the Zika virus are likely this summer in the United States.

If you've read any recent news, you've likely seen reports about the Zika virus and its now-confirmed links with microcephaly in infants. You may have been bombarded with questions from patients or email from public health groups about preparing for the Zika outbreak.

Whenever an outbreak hits, physicians and patients alike need good quality information to make good health care decisions. As primary care physicians, we translate and disseminate critical information to our patients. They trust us to keep them safe, but who do we trust to help us build that knowledge base?

Much like what happened with Ebola, or happens with any other highly publicized disease, lots of information -- and misinformation -- about Zika floods the airwaves and the Internet. Fortunately, the AAFP maintains accurate, up-to-date reference materials concerning Zika.

State and local health departments also are an excellent source of information. Most health departments have one or more epidemiologists who track and report on communicable diseases. They work with a team of medical professionals and communications specialists who collect and collate data, and then create resources for better patient education and disease prevention. Most state health departments work closely with local agencies to devote more personnel and resources to the task.

Once those resources have been developed, they are shipped out to patients and community physicians via multiple channels. We must use this information to help our patients sort the facts from the morass of misinformation that flood the public consciousness.

Zika, a flavivirus similar in structure to the viruses that cause dengue and yellow fever, is most often transmitted to humans by the Aedes mosquito. Recent studies have concluded that the virus can also be transmitted from mother to child, through sexual contact, or by blood transfusions.

Symptoms include fever, skin rash, eye irritation and redness, muscle and joint pain, malaise and headache. Obviously, these symptoms can overlap with many other illnesses, so accurate assessment requires not only a visit with a health care professional but also a full accounting of recent travel or other possible exposures. Currently, no vaccine for Zika exists, and there is no treatment to eradicate the disease once contracted. The best we can do for patients is treat the symptoms and control spread to others.

Preventing the spread of infectious disease depends on community physicians being able to detect and report cases early. Conversely, it's the job of the state and local health departments to communicate to community physicians when an active outbreak is in progress. Community physicians can then report cases to improve surveillance. We can all work together to ensure the safety of our individual patients and the public as a whole.

Have you had good experiences with your state or local health department? Any words of wisdom or best practices for timely communication? Sound off in the comments below or contact me on Twitter @DrTolbert.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology.

Tuesday Apr 19, 2016

Ah, Nuts: Is Kellogg's Putting Consumers at Risk by Adding Allergen to Food?

Editor's Note: This blog post was updated after Kellogg's announced that one of the eight products it had planned to add peanut flour to will be peanut-free again in September.

Kellogg's Co. recently made big waves in the allergy community when the manufacturer announced plans to add peanut flour to several varieties of Austin and Keebler brand crackers. The products affected previously had been considered safe for consumers with peanut allergies.

The change largely went unnoticed by the mainstream media, and I'll admit that my initial reaction was not extreme concern. No one in my family has food allergies, and neither do any of my close friends. But then my instincts as a doctor and a mother kicked in. As a physician, I know food allergies are a major public health concern. As a mother, I understand that they are a life-or-death matter for a parent of a child affected by food allergies.

But how wide-scale is the problem of food allergies? I didn't know, so I went looking.

Eight percent of U.S. children have a food allergy, and allergies to peanuts and tree nuts are the leading causes of fatal allergic reactions. Peanut allergies tripled from 1997 to 2008, and 3 million Americans have peanut and tree nut allergies.  

Eight foods are responsible for 90 percent of serious allergic reactions: milk, eggs, peanuts, tree nuts, soy, wheat, fish and shellfish. Even trace amounts of these products can cause a reaction. Milk, eggs and peanuts are the top three allergens, and although milk and egg allergies often are outgrown by school age, roughly 80 percent of peanut allergies remain.  

At a time when the number of children with food allergies and intolerance issues is skyrocketing -- and knowing that peanut allergies account for one of the most persistent and most dangerous allergies -- why would a manufacturer add a peanut ingredient to a previously peanut-free product?  

Many manufacturers are working to eliminate food allergens from their products, and indeed the market for foods free of major allergens is booming, creating a large market for food manufacturers.

In its responses to angry consumers on social media, Kellogg's positions itself as if it's trying to figure out how to expand, not shrink, that market: "We are truly sorry to disappoint you. We appreciate you sharing your concerns and understand why you're upset. We know it's not easy to find foods that people with peanut allergies can eat, and are looking at ways to make a cracker sandwich you and your family can buy."

My thought when I read that was, "You already had one, so why change it?"

Since the announcement by Kellogg's, more than 20,000 people have signed a petition on Change.org that says, in part, that peanuts are "the allergen most responsible for triggering anaphylaxis, an allergic reaction that can result in horrific consequences including death." The petition calls adding peanuts to previously peanut-free products "unethical and irresponsible."

As family physicians we need to be aware of changes that can affect the health of millions of our patients, and act as advocates when possible. The petition allows people to say why they are signing it. My comment says, "Because I am a family physician and believe that the safety of my patients is important."  

Kellogg's assured consumers that any product including allergens will be clearly labeled and later said that one of the eight affected products will again be peanut-free beginning in September. But a big concern is that all eight of these products have long been known to be safe in the allergy community. Parents, grandparents, allergy sufferers themselves, coaches and teachers who are familiar with these products would have little reason to think that an allergen would be added. Most consumers likely would not expect to find peanut ingredients in a cheese cracker, nor would they be likely to check the allergy label on a food they have known to be safe.  

As physicians, we can remind our patients with food allergies (and their parents or caregivers) that they should check product labels every time, even on familiar foods, because manufacturers may change their ingredients or manufacturing processes. We can also inform them that there are blogs and websites -- like the one at the beginning of this post -- that alert consumers with allergies to such changes. Although manufacturers might not make decisions with our patients in mind, we can help our patients make good decisions for themselves.

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

Tuesday Apr 12, 2016

Does Prevention Save Money? That's the Wrong Question

Ben Franklin's proverb that "an ounce of prevention is worth a pound of cure" makes sense to all of us, especially in medicine. Why wouldn't you want to prevent lung cancer by helping someone quit smoking?

Preventive health care is something family physicians excel at. We use evidence-based medicine to focus on how to best prevent heart attacks, to find cancer early and to prevent infectious diseases through immunization. But are we targeting the right individuals and populations in our specific preventive efforts? Are we aware of the most impactful preventive strategies?

A 6-month-old girl receives a vaccination. According to CDC estimates, vaccinations among children born from 1994 to 2013 will prevent 322 million illnesses, 21 million hospitalizations, and 732,000 deaths and save the health care system $295 billion.

Many economists say that prevention isn't cost-effective, and that focusing too much on prevention instead of treatment can actually make things worse for our health care system. So which is it, and what should family physicians do to best help our patients?

There are actually three types of prevention, a nuance that most policymakers and economists miss.

Primary prevention is preventing a disease or problem in the first place, such as exercising to avoid obesity. This tends to be a combined effort of public health and medical professionals.

Secondary prevention is typically performed in medical settings and has to do with preventing progression or impact of an existing disease, such as establishing an appropriate diet to control blood sugar for someone with diabetes mellitus.

Tertiary prevention is about "softening" the impact a disease may have on a person's life, such as routine eye exams for people with diabetes mellitus to detect and treat early diabetic retinopathy.

Misunderstanding or misidentifying the differences between these types often causes confusion. Assessments of the costs and benefits of preventive efforts typically look at the cost for primary prevention of a disease vs. the cost of treating the disease, which sometimes includes secondary and tertiary preventive measures. If it's a bigger effort and cost to prevent the disease than treat it, is it worth our time and resources?

Many studies have found that the majority of primary and secondary preventive efforts don't save our health care system money. However, almost 40 percent of deaths in the United States could be averted through better primary prevention, such as by decreasing tobacco use. Relatively simple public health interventions, such as including seat belts in cars and immunizing infants and toddlers, can save thousands of lives at minimal cost. But what if efforts are spent on those at low risk for a behavior or disease? For example, I don't smoke and have no intention of starting, so anti-tobacco efforts aimed at me won't be of any benefit. But providing me assistance in losing weight, particularly in the setting of my family history of coronary artery disease, could yield significant cost and quality of life results.

Many economists will point to things such as colonoscopies (secondary prevention), citing the extreme increase in cost if every individual 50 years and older is screened. Some have even argued against such practices on the grounds that increasing life expectancy just means that we have to spend more money in the future. But colonoscopies are not "true" (i.e. primary) prevention. There is likely no way to eradicate colon cancer 100 percent before it occurs, which then causes confusion among the general public. Should we be getting colonoscopies or not? We should in order to save lives, but we need to educate that this is early detection, not prevention.

Mammography is another good example of early detection rather than primary prevention. The U.S. Preventive Services Task Force (USPSTF) has been criticized by many for changing the recommendations on when and how often mammography should be done. The USPSTF's charge is to look at the evidence of what is effective and create guidelines based on that information. It does not take cost into account, but many in the public are upset and confused, as if the system is trying to ration their care by restricting something that instinctively seems appropriate.

So what does this all mean?

It means that we need to understand what is meant by prevention.

It means that as family physicians, we need to be able to educate our patients on what prevention means and what works, and then help them apply it to themselves.

It means that we should be part of the system-wide efforts to focus on what is most effective. This includes ensuring that the preventive quality measures on which we are monitored are based on medical evidence of what truly adds to positive patient outcomes. As Johns Hopkins Bloomberg School of Public Health professor Ron Goetzel, Ph.D., has said, "Instead of debating whether prevention or treatment saves money, we should determine the most cost-effective ways to improve population health."

In the end, preventing disease and its complications is what we do. Whether or not it saves money, it saves lives and improves quality of life; what could be more humane than that?

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 Apr 06, 2016

Shutting Rural Labor and Delivery Units Threatens Access, Health

I started writing this blog post at the OB nurses' desk at my rural hospital while waiting for two patients to deliver. Not surprisingly, I did not finish it there because I was interrupted to help bring two healthy babies into the world.

As I waited, an article about rural hospitals closing labor and delivery units made me wonder where these two patients (soon to be four) would be if I wasn't here to deliver them. Without our hospital in rural Kansas, these women would have been forced to travel to the next big town to deliver. For one of these patients that would have meant a 45-minute drive, for the other an hour. And we're not just talking about the day of delivery, but the trip there and back for every OB visit, which are numerous, especially at the end of pregnancy.  

Here I am with Cassandra Prediger and her son, Emerick, who I delivered via water birth. Cassandra chose my facility because it offers this delivery option.

With the visit and drive time, women in my community would be looking at three hours out of their day if everything goes smoothly, which is a half day off work (or three hours that you have your other children in day care or in the car and a doctor's office). Such a distance could preclude regular visits if time off work is hard to come by. It also could mean that significant others are unable to accompany the patient to office visits.

Throw in the patient with complications who needs weekly or bi-weekly ultrasounds, blood work or non-stress tests, and the time spent on the road becomes astronomical. For many of my patients, the drive to the next closest delivering hospital would be closer to two hours one way, a daunting proposition for any patient, and a terrifying one if there is bad weather or a labor that progresses quickly.

We are lucky here. Our patients can choose to have care that is close to home, and due to our hospital's strong commitment to excellence in obstetric care many of my patients actually drive from the bigger city to me to deliver.

In these times when it can be difficult for rural hospitals to thrive, I don't think the answer is closing down units but finding ways to make them viable. Our OB unit has grown greatly in the past four years because of the time and effort we have put into it. We have incorporated more complimentary medicine practices such as water birth (as far as I know I am still the only doctor in the state that provides this, and we are the only hospital where this is offered), nitrous oxide for labor analgesia (same with this), and the option to have the services of a doula that is employed by the hospital free of charge to the patient.  

Patients know that we're grounded in making every labor process one that follows the patient's wishes to the best of our ability; to have the patient delivering with the doctor who has cared for her throughout her entire pregnancy and will continue to care for her after; and to provide a supportive environment for birth, bonding and breastfeeding.

The statistics on rural hospital closures are distressing. These closures don't mean just longer drive times, but severely decreased access to care, which will lead to poorer health outcomes for the patients in the areas affected. About 500,000 women give birth each year in rural hospitals, but this number is declining as labor and delivery units close. An analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their units from 2010 to 2014.  

I have heard time and time again from our hospital's administration that the OB unit is expensive to run and insurance payments are low, especially Medicaid, which pays about half as much as private insurance for childbirth. Labor and delivery units in rural hospitals, especially those like mine that deliver fewer than 100 babies per year, are not revenue makers for the hospital.  

Thankfully our administration and hospital board understand that having access to local obstetric care is important to the health of our community, and it also brings in patients and services. Skeptics can speak to any family physician who delivers babies because we can recount the number of fathers, children, grandparents and aunts and uncles we have received into our practices after a family experiences the care provided during the birth experience.  

But the bottom line and the bills are still there, so what are rural hospitals to do?

Advocates for preserving access to rural obstetric care have come up with a number of things that could help bolster labor and delivery services. One is encouraging medical professionals to move to rural areas. A bipartisan bill introduced in Congress last year would require the federal government to designate maternity care health professional shortage areas. The National Health Services Corps gives scholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage areas.  

The hope is that that once physicians move to a community and put down roots, they'll stay. Many of our surrounding communities have ceased providing obstetric care because of the huge investment of human resources, both physician and nursing, required. You must have someone on call 24 hours a day 365 days a year, both a physician and nursing staff.  If you are in a one- or two-physician community, this leads to extreme fatigue and little time off.  

Finding nurses with obstetric experience can be difficult, as well, and because the staffing with OB patients is one-to-one, more nurses must be staffed when a labor is in progress. Rural hospitals may be able to band together to share resources, such as those to keep staff trained in complications.  

We must continue to ensure that rural voices are heard in the ongoing national dialogue on health reform. Research on reforms to improve rural health care is greatly lacking, and should be encouraged.  

Those of us in rural areas with viable facilities need to be willing to help those who are struggling, if possible, discussing changes that have been made to increase productivity and revenue and offering resources and advice.

The process of pregnancy and childbirth is one of the most special, and vulnerable, times in a patient's life. The ability to provide care for our own patients in our own communities is something everyone in rural practice should strive with all our might to maintain.

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

Tuesday Mar 29, 2016

So Long, New York, You Were Exactly the Trial This New FP Needed

As an osteopathic medical student in Arizona, I had a lot of classmates and professors question why I wanted to go across the country to New York City for my residency in family medicine.

The West Coast -- where I grew up -- has a strong family medicine tradition, whereas New York City is perceived to have a strong focus on specialty care. Not only have I met several New Yorkers who did not even know that family physicians exist, I have worked with medical students whose school has no family medicine department and with other medical students who question whether they can find a good job in NYC if they pick family medicine.

So why choose to be in an environment that might, at best, be skeptical of family medicine?

My residency, the Mount Sinai Beth Israel Residency in Urban Family Medicine offers a diversity and complexity of patients that is unique to New York. With patients from around the globe, we had to keep a broad differential in mind as we also learned to treat the "bread and butter" family medicine cases.

But there was something far more important to my learning as a physician than the diagnoses that I made. My patients not only came from different countries, had different socioeconomic backgrounds and spoke different languages, they often had differing views of disease processes and expectations of the patient-physician relationship.

In medical school, we learned the textbook ways to diagnose and treat, but in residency I learned how much patients' cultural backgrounds can influence their recounting of symptoms and their relationship with their own body. We know how crucial the history is to finding the right diagnosis, particularly as we try to minimize extraneous and expensive tests that add burdensome costs for our patients and our health care system. When the patient and the physician have wildly different life experiences, language is often not the only barrier that needs to be recognized in order to appropriately diagnose and care for the patient.

After residency, I continued with the same family medicine organization that my residency was affiliated with. I have spent nearly three years in the Bronx with an international patient population, many of whom have language, health literacy and socioeconomic barriers that make it difficult for them to navigate our health care system.

I am surrounded by all the subspecialists that New York has to offer -- several of whom are rated top in their field -- but the majority of my patients simply cannot access them. Their need for a family physician and a patient-centered medical home (PCMH) to support their health and the health of their family is dramatic.

When they enter my clinic and find friendly staff who know their name, speak their language, and do not judge them for a lack of insurance, employment or even basic reading skills, my patients begin to feel hope.

When we ask them questions about their ability to access healthy food and whether they feel safe in their current housing situation, my patients begin to realize that we in family medicine understand how much social determinants of health impact our community.

When our clinic goes to great lengths to obtain records from outside clinics and to call patients to come in for a visit after their recent trip to the emergency room, my patients begin to understand what it means to have a family physician and a medical home.

There are many community clinics throughout the country that have made a commendable effort to gain PCMH recognition and to be part of a safety net for their patients; our clinic is not unique in that respect. But there are times when the degree of disparity between my patients and the affluent patients who can access the "best" care in the nation clearly weighs on my patients. They are deeply aware of what they do not have and what they cannot access. And they are often resentful of the discrimination they have faced because of these disparities.

Working within this community has enabled me to witness firsthand what I learned while pursing my master of public health degree -- that a community's resources and environment can have an enormous impact on the health of its residents. It has been exciting to be part of my local AFP chapter and to contribute to the enactment of bills that can make a real difference in the health of New Yorkers, such as a lower speed limit to reduce pedestrian deaths and expansion of health coverage for pregnant women.

In a few months I'll be moving back to the West Coast, primarily for family reasons. It was a difficult decision, and there are many things about New York -- particularly the people I've come to know -- that I will truly miss. As is true with any major change, my upcoming relocation has given me the opportunity to reflect on my time as a family physician in New York. This is the only environment I've worked in as a practicing physician, and although I have encountered the occasional frustration when dealing with a subspecialist here and there, the overwhelming experience has been better than I even imagined when I applied during medical school.

Family physicians are a diverse group with a diverse set of skills to treat the communities we work (and often live) in. My work during the past several years has taught me a great deal about caring for communities that are in need of creative, evidence-based, compassionate primary care. I have built a foundation that will influence my practice of medicine wherever I go, and for that, I will always be grateful to New York and its patients.

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

Tuesday Mar 22, 2016

Here's My Number, Call Me (Maybe)

Both urban and rural docs in the past shared a different type of accessibility with their patients than most of us do today. Without the communication lines of social media, email and text messaging -- and when the only ways to communicate were in person or via a landline phone -- most rural doctors had their home numbers listed in the phone book. And everyone knew where they lived.  

Even today in small towns and rural areas some of that holds true, as evidenced by stories from our members. But historically it was a much more even playing field. Doctors weren’t isolated from patients but there were far fewer access points. And accessibility, to some degree, affects who chooses family medicine, particularly in rural settings. If you don’t like answering health questions at the grocery store, living and working in a rural community might not be for you.

Often when I am in a group of physicians, I will get a text or a phone call from a patient or a patient’s family member. Without fail, the group will be divided about what is right, wrong, expected, or even should be prohibited, regarding communication with patients outside a face-to-face office visit or a patient portal. Obviously, there are HIPAA issues involved, but the bigger argument among physicians is about handing out a direct access point.

Honestly, whenever I thought the best patient care was going to result from a patient's family having my cell phone number, I gave it. End of life is one of those times when I feel it is important for the family to have 24-hour access to prevent unnecessary anxiety and/or suffering for anyone involved -- patient or family. The hurdle of calling my answering service in a panic or ending up in the ER because someone does not know what to do must be avoided when the patient’s wishes are to die comfortably at home.

Recently I started looking for guidelines to see if there were established ethics or standards for handing out my cell phone number, but I didn’t find much. There are some resources regarding social media, but most essentially say zero social media interaction should occur between patients and doctors, even though the data show patients would be receptive to receiving information from physicians via social media.  

Selfishly, I will often give a family my cell number if it is going to make things easier on me. If I know we need to communicate often, and with quick responses on both my part and theirs, it is much easier for them to contact me directly. And it means we both get the most accurate information with no distortion.

Granted, anyone who has ever worked with me will tell you I am a control freak who wants to be involved with every little decision about my patients. I want subspecialists' consult notes, I want the labs they draw, I want to know how my patients are doing the day after I see them, and I want to know what the ER workup reveals before they ever leave the ER. I'm that doctor that no subspecialist wants to hear is calling for them. I’m a patient advocate above all else, and sometimes that involves asking patients to text me as soon as they complete an imaging test so I can call for the result, or to call me when the home health nurse arrives. Most of those needs occur after normal business hours.  

After-hours care is also a big motivator for me to hand out my cell number. I feel it's much less disruptive for a patient to text me a question I can respond to without having to interrupt a board game with my son. Otherwise I would have to take a call from the answering service and then call the patient back.  

I won’t lie. I have regretted my decision to hand out my number on occasion, but it isn’t the end of the world. Just as patients can overstep boundaries in the office and we have to be professional and maintain an appropriate patient-physician relationship, the same holds true for communication outside the traditional office setting. If I get a text asking about pain or pain meds I reply that they need to call the office and schedule an appointment. If someone starts to text excessively about non-emergent issues I often have office staff call back to address the issues rather than perpetuating the situation, particularly when patients text while I am in the office. But overall, even the negative experiences haven’t changed my perspective. Often we have to step outside the perceived boundaries of our duties and expectations in order to provide the right type of care.  

One night my phone rang at 3 a.m. One of my patients' daughters was distraught and did not know what to do. One of her parents was unstable, and the other could not be left at home. I advised her to send her father to the hospital he had most recently been to where a doctor would be able to review fairly recent health information. I also advised her to have EMS communicate the need to have the triage team call her for a pertinent history over the past couple days. She felt much better, felt OK with the plan. Then I checked back in with both her and the hospital as soon as I got to my office.

I didn't know how she got my number because I hadn’t given it to her, but I honestly didn’t care. I’d helped her and her parents -- all three of them are my patients -- through the night and I felt it was an appropriate call to wake me up.  

A few days later, one of my office staff asked if I was mad at her for giving my cell number out to that family. I explained that I actually didn’t ask the patient who gave it to her and that, no, I was not at all upset. She said, "I was more worried you would be upset with me for not giving it, so I did."  

We could have an entire discussion about payment, reimbursement and the need for billing reform for this type of care, but that is honestly what I’m trying to get away from. So much discussion revolves around the "loss of the family doctor" and the "downfall of the art of medicine," etc. due to electronic health records, time constraints, data collection, quality measures and limiting the time we spend on work after work.

Personally, I want to maintain that traditional, old-school relationship with my patients in spite of the increasingly unreasonable requirements we are faced with. Just as our patients miss that relationship, so do I. Often, a text from a patient makes my day.  

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

Tuesday Mar 15, 2016

Fake Teen Doc Reflects Need for Real Minority Physicians

In mid-February, a black teen accused of posing as a doctor made national headlines. The story of "Dr. Love-Robinson" was mesmerizing. The teen reportedly had secured not only a white coat, but also an office, a website and, most incredibly, patients.  

It made me wonder, are people so hungry to have a doctor -- especially a doctor who looks like them -- that they are willing to overlook some major anomalies? I was struck by the teen's tenacity and wondered what encounter with the profession could have inspired such eagerness to pursue his dream (albeit unlawfully). It also made me reflect on my own experience with medicine as a child and my current habit of asking my young patients about their career goals during annual well child and adolescent visits.

Although blacks represent 13 percent of the U.S. population, black doctors account for only 4 percent of the physician workforce.

As a child, I loved being asked, "What do you want to do when you grow up?" It gave me the feeling that I was expected to aspire to be something. It gave me purpose and direction.

Therefore, when I was 7 and my mom was pregnant with my younger brother I went to all her prenatal appointments. As I listened to the baby's heartbeat and started the process of being an older sibling, I became enamored with my mom's OB/Gyn. Dr. Brooks was personable, caring, smart and --- most important to me -- he was black. He was the only black doctor I had exposure to as a kid, and the impression he made gave me confidence that becoming a doctor was something I could achieve. I remember him asking me what I wanted to be when I grew up, and I also recall the pride in his eyes when I responded sincerely that I wanted to be like him.

I have been surprised that when I ask this basic question of my own young patients it seems like it is the first time that they have even considered it. I have also found that that there are some common replies, which many of my peds-loving peers and I lament because these popular answers often are given without much thought or reflection of the child's true skills and abilities.  

If a child doesn't want to be a professional athlete, he or she often wants to be a coach or manager. Other popular choices are a singer or rapper for the younger children, and forensic science or correctional officers for the older children. These kids, no doubt, are influenced by the media and awareness that minority athletes and entertainers often have incomes of seven figures or more. Career choices can also be influenced by the systems children and families have more familiarity with, even if it is the prison system.  

I recently asked an older teen what she aspired to be when she grew up, and she responded, "A stripper!"  

After my initial surprise about her choice and the enthusiasm with which she stated it, I realized the best way to respond was to not be judgmental but to engage her further. I asked about her decision, and she mentioned that people she knew who had this job always had a lot of money. It also allowed her to do another thing she enjoyed, which was dance. I asked her what other things she thought she was good at. After some reflection -- and an initial response that she wasn't good at anything else -- she mentioned cosmetology.

After more probing, she revealed she no longer attended school. The smell of marijuana on her clothes, the frequent STD testing noted in her chart, and the mention of an older boyfriend who had just been released from jail (prompting her current visit to the doctor) shed some light on some of her more recent activities. I left her with some encouragement as well as a handful of condoms.   

I also desired to leave her with hope for a better life -- even if it was just my presence as a female doctor of color and someone who cared enough to ask.

Although blacks, Latinos, and Native Americans make up 13 percent, 17 percent, and 1 percent of the U.S. population respectively, these groups make up a mere 4 percent, 4 percent, and 0.4 percent respectively of the U.S. physician workforce. Increasing the diversity of the physician workforce depends greatly on developing the pipeline -- where children and young adults are exposed to, academically prepared for, and encouraged to join our profession. In the age of struggling public school systems and fewer students going into STEM fields, we need more role modeling, mentoring and academic success programs so that there are more minorities applying to our medical schools. And of course, once they reach the doors of our universities, we need to be willing to admit dedicated and capable students.

Sadly, we are losing ground. Despite an increase in the number of black males graduating from U.S. colleges, the number of black male applicants to medicals school dropped from 1,410 in 1978 to 1,337 in 2014. During the same time span, the number of black males enrolling in med schools fell from 542 in 1978 to 515 in 2014.

One day, hopefully, there won't be such an unmet demand for a doctor of color that people could be willing to put their health in the hands of a teen playing dress up.

Venis Wilder, M.D., is a board-certified family physician who practices at a federally qualified health center in Harlem, New York. She also considers herself a community health practitioner working at the intersection of primary care and public health.

Tuesday Mar 08, 2016

Barriers to Care Persist for GLBT Patients

One of the great joys of being a family physician is providing care to everyone. On a recent -- and typical -- Tuesday, I managed a miscarriage, diagnosed atrial fibrillation, cheered a patient’s weight loss and started another patient on emtricitabine/tenofovir disoproxil fumarate (Truvada) for pre-exposure prophylaxis (PrEP).

With the gratification of direct patient interactions comes the mundane: the charting, FMLA forms and prior authorization paperwork. I've accepted it all as part of my career, as part of my advocacy and care for patients.

But I've also faced a glaring reality. Although the GLBT community has made tremendous progress in gaining equal rights, it still faces multiple barriers -- often surreptitious -- in the realm of health care.

I've recently noted an increase in prior authorization rejections, particularly concerning care for my GLBT patients. The reasons for the rejections are varied. I've had a few rejections for PrEP because I'm not an "HIV specialist."

That's unfortunate because providing this treatment has nothing to do with subspecialty care. The CDC has noted that primary care physicians can safely prescribe PrEP, and leading HIV prevention groups have pointed out that there simply aren't enough HIV specialists to adequately reach all patients who could be on PrEP.

PrEP has been proven to reduce the risk of HIV infection in people who are at high risk by 92 percent, according to the CDC. However, only about 30,000 Americans are using PrEP, although 415,000 may be eligible.

Primary care physicians also are facing prior authorization rejections for hormone therapy for transgender patients, with some payers demanding patients see an endocrinologist. Often, insurance companies won’t cover hormone therapy at all.

The prior authorization process, like so much of the bureaucracy of medicine, was created principally to curb spending. However, activity related to prior authorizations costs a full-time physician $3,430 a year, according to a study in the Journal of the American Board of Family Medicine. The recent prior authorization rejections I have experienced were absurd barriers to care that didn't improve patient safety or control costs. Decisions like denying PrEP by a primary care physician in lieu of specialty care will ultimately cost more. In fact, studies have demonstrated the cost-effectiveness of PrEP, so its widespread use stands to benefit insurance companies in the long run.

The promise of primary care to deliver on the Triple Aim is rooted in the ability of family medicine physicians to continue caring for diverse patient populations. An important study by the Robert Graham Center found that family doctors who provide more comprehensive care drive down health care costs.

Although it is a special privilege to care for GLBT patients, it’s not subspecialty care. Insurance companies limiting the scope of practice of family physicians for these patients is a dangerous precedent at a time when primary care doctors are needed the most.

So what do we do? I've written appeal letters. I've faxed the payers the CDC's guidelines and pertinent medical journal articles. In many instances, after several phone calls, the initial rejections were reversed.

Payers continue to wade into scope of practice issues, so in the best interests of our patients, physicians need to recognize and fight the health care barriers that come in many forms, including papers marked "prior authorization rejected."

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

Wednesday Mar 02, 2016

Leadership Conference Gives Voice to Family Physicians

On May 5, current and future family medicine leaders will devote three days to shaping and strengthening our specialty through two focused tracks at the AAFP Leadership Conference in Kansas City, Mo. One track, the Annual Chapter Leader Forum (ACLF), is tailored for the leaders who concentrate on issues specific to where their colleagues work and live, while the National Conference of Constituency Leaders (NCCL) amplifies the voice of the underrepresented in Academy leadership.

In 1990 what has become  NCCL convened for the first time as the National Conference of Women, Minority and New Physicians with the promise to begin "the 1990s as a 'Decade of Transition,' during which the AAFP will strive to more effectively integrate the perspectives and concerns of Academy members from these important constituencies, to the benefit of an increasingly diverse membership and patient population."

© 2016 Tiffany Matson/AAFP
Here I am testifying during the 2015 National Conference of Constituency Leaders. This year's event will be held May 5-7 in Kansas City, Mo., as part of the AAFP Leadership Conference.

Through the last two and a half decades, member constituencies -- now women, minorities, new physicians, international medical graduates (IMGs), physicians who self-identify as gay, lesbian, bisexual or transgender (GLBT) or who support GLBT issues -- have gathered each spring to discuss important issues and advance AAFP policy.

When the NCCL convenes for the 26th time this year, the event will be slightly different, in that the traditional new attendee orientation will take place during the evening of May 4, prior to the official start of the conference. We also have the privilege of hosting several amazing speakers and teachers as well as the yearly policymaking and business sessions.   

I first attended the National Conference of Special Constituencies (a previous name of NCCL) in 2012 as the new physician delegate from Kentucky. I was in awe of the camaraderie and amazing ideas flowing from this incredibly diverse group of individuals. Even with disparate viewpoints, backgrounds and practice environments, the attendees worked together to craft important resolutions that have impacted the larger membership as a whole.

This will mark my fifth consecutive NCCL, and I can't wait to hear what my colleagues have to say about the many issues our specialty faces. I will continue to come back each year, whether in a leadership position or not, so I can support the idea that everyone needs a voice.

This year, I have the privilege and responsibility of being the convener for the conference. That means I get to help plan the meeting and guide those plans to fruition with lots and lots of help from both AAFP staff and my co-convener team, a group of elected physicians representing each of the constituency groups. We've already been working hard to put together not only the content portion of the conference, but also to encourage every state chapter to register and send delegates to represent each of the constituency groups. The Academy even sets aside funding, available to each chapter, to offset the cost of travel for one new physician delegate. If you or someone you know is interested in representing your state as a new physician or in one of the other constituency groups, contact your chapter leadership.

Much like the conferences of years past, our goal is to give voice to the members of the AAFP who may otherwise lack representation. We want to hear from you! Whether as a new physician, woman, minority, member of the GLBT community, or international medical graduate, we all need a voice and a way to be heard. This conference provides that venue and encourages all of us to represent our "increasingly diverse membership and patient population." Any attendee can also volunteer to participate with the reference committees responsible for reviewing subsets of the resolutions put forth by the members in attendance or run for one of several leadership positions, including the constituency co-conveners and the new physician member of the AAFP Board of Directors.

On the other track of the leadership conference, chapter-elected leaders, aspiring leaders and chapter staff will refine their leadership skills, learn from each others' experiences and strengthen their relationships at ACLF.

Whether you are interested in a leadership position or not, the conference offers a unique opportunity that most other medical organizations have only begun to embrace. We each have a voice and things we are passionate about. Let your voice be heard and plan to attend the 2016 AAFP Leadership Conference May 5-7 in Kansas City.

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

Monday Feb 22, 2016

FPs May Be Best Advocates for Housing Challenges

In the last month, I have used the ICD-10 codes Z59.0 (homelessness), Z59. 1 (inadequate housing) and Z59.9 (unspecified housing or economic problem) far more than I ever would have imagined. 

Several patients came into my urban clinic with varied chief complaints, including issues with uncontrolled asthma, chest pain, stress, worsening knee pain and sciatica. However, after listening and asking questions I quickly realized that all of these initial complaints shared a commonality -- distress about housing.

My first patient had recently left transitional veteran housing provided by Volunteers of America to get his own permanent housing elsewhere. However, he soon realized the housing conditions at his former residence were much better than the rodent-, cockroach- and mold-infested single-room occupancy he had been granted by the local housing authority. His new residence featured a caved-in roof.

During his visit with me, he requested adjustments to his asthma medications because the numerous triggers he encountered at his new address had already led to an ED visit earlier in the month. He asked me to write a letter to the housing authority, communicating the severe consequences the poor environment was having on his health. I learned then that inadequate housing is a billable diagnosis if there is lack of heating, restriction of space, technical defects in the home preventing adequate care or unsatisfactory surroundings.

A week later, another patient followed up with me regarding an orthopedic surgeon’s evaluation for her severe bilateral knee osteoarthritis. Although she agreed total knee replacements were likely in her near future, there was no way she would be able to heal properly after surgery if she continued to live in her fifth-floor walk-up apartment. I wondered how she could even move into a new home in her current condition. 

The last patient I saw, an elderly male, openly wept about having nowhere to go after completing a month of medical rehabilitation. He was essentially homeless, exchanging food stamps for a space on a not-so-good friend’s couch.

My response to these stories and others was to reassure patients that I have someone who can help them. At my clinic, which is a patient-centered medical home, we have in-house case management services, professionals who are familiar with community resources and services. The case managers can help make referrals outside the medical establishment to help address some of the social determinants of health that impede patient wellness. 

I was surprised to find out, however, that the case managers felt overwhelmed by the number of housing requests being referred to them. In a general staff meeting, we were encouraged to set realistic expectations for patients prior to their visits with the case manager. Many patients were coming to the visit thinking their housing woes would be quickly resolved, but the reality was bleak because affordable housing in New York City is becoming harder to find and the shelter system is overwhelmed. 

A case manager named gentrification as the problem, and said the prognosis was not good for the established members of our community. There is limited housing, higher rent and uncertainty about families' continued existence in a neighborhood they can no longer afford. 

As a physician, I might be in the best position to advocate for my patients and find the best resources to improve their wellness.

Another patient’s enthusiastic hug a month ago -- her sincere thank you for writing a letter that resulted in her getting a new home that accommodates her medical needs -- reminded me that my role as a physician extends beyond physical exams and prescription writing. It is about advocating for my patients and the community I serve. If I desire to truly help my patients and address social determinants of health, I have a responsibility to learn more and do more about housing. This can no longer be an issue that is relegated to the realm of social work and case management.

Venis Wilder, M.D., is a board-certified family physician who practices at a federally qualified health center in Harlem, New York. She also considers herself a community health practitioner working at the intersection of primary care and public health.

Monday Feb 15, 2016

Discovering a Brave New World of Medical Scribing

Electronic health records. Just the term itself can unleash a torrent of feelings among physicians. We love them. We hate them. We depend on them, but we resent our dependence on them. We are told that they should help streamline our practices, but in reality they often slow us down.   

Our daily workflow rhythm is set by a cacophony of clicks on a mouse or keypad. I recall the time management challenges I faced during my second year of residency when we made the difficult transition from paper to electronic records. Beset by a new array of documentation requirements, my thought at that point was that this was a massive waste of time and had little to do with patient care. I wanted to be liberated from working on the computer so I could get back to the warm bodies that needed my attention.  

Tyla Buxbaum, R.N., documents a visit while I examine a patient. My practice's system of medical scribing has improved efficiency and documentation while reducing errors.

I remember joking back then that what I needed was a scribe. Little did I know that this would someday become a reality. Not only was I soon to learn about the benefits of having a medical scribe, but I was also about to discover that having this additional staff member would open a world of possibilities for productive workflow innovation and efficient practice management.

Enter the medical scribe
To my good fortune, I was hired by a hospital-owned practice that already had an established medical scribe program that allows for one scribe per physician, as long as we meet reasonable productivity requirements.

This staff member is in addition to the rooming nurse assigned to each physician. Funds for this program are dispensed out of the clinic's staff salary allotment based on the premise that physicians are more productive and do better documenting when they have a scribe. Hence, more patients can be seen and more work is captured in the notes, resulting in better reimbursement.

So, how does the rooming-and-scribing system work? My rooming nurse opens the chart and starts the note, and then she gets the patient from the waiting room, takes vitals, reconciles meds, narrows the focus of the visit, and obtains a brief history and review of systems. On my instruction, she may also order any preliminary tests or administer any needed vaccines. The rooming nurse also pulls into my note any labs, imaging, or reports to be reviewed with the patient during the encounter.

Meanwhile, I am working with my scribe on completing previous notes or preparing for the next encounter. If time allows, my scribe will often start the note for the next patient and help predict the agenda for the visit based on past notes or the reason for the visit we get from scheduling. Much ground can be covered this way before we even enter the room. Of course, I still have the option of bringing my laptop into the room to review the chart with the patient. An added bonus is I always have an assistant in the room to help me with procedures, and my scribe serves as a built-in chaperone, assuring that I am never alone with a patient and that I have someone who can corroborate everything that transpired during a patient encounter.  

Once the visit is complete, my scribe may follow me immediately or may stay to review instructions or complete other nursing tasks with the patient. Meanwhile, I am free to move on to charting or to seeing the next patient.

Taking it to the next level
So, here's where efficiency really picks up: cross training. I noticed there often was a disconnect between the agenda my rooming nurse and the patient had discussed and what became evident once my scribe and I entered the room. Naturally, this slowed things down. Although it was enormously helpful to have my scribe linger in the room to finalize things with the patient after I stepped out, I could easily get behind by waiting for her to be ready or by moving on without her there to document. To remedy this, I started cross training my rooming nurse as a scribe with the support of my clinic management. When I thought she was ready to take on the full responsibility of scribing, I began what I call the piggyback approach to rooming and scribing. This approach works because my scribe is also a nurse, but it would work about as well if she was a medical assistant.

The piggyback system is simple: The cross-trained nurse/scribe starts the note, rooms the patient, and stays in the room from beginning to end, scribing all the while and providing any nursing services as needed. By doing this, the nurse/scribe is better able to help keep the visit focused in a way that addresses the patient’s agenda while also meeting my own. I find that documentation is more seamless, and more work actually gets done because the nurse who rooms the patient feels no pressure to rush out and move on to the next patient. This results in better agenda-setting, more accurate medication reconciliation and renewal, and more complete history and health maintenance updating.

An added bonus is that patients never wait in the room alone, so they may have the perception of shorter wait times or at least feel attended to while waiting for the physician. By the time I get in the room, much of the history of present illness has been written, the patient has had many questions answered by the nurse, medication issues have been addressed, any in-clinic labs/imaging have been obtained, required vaccines have been given, and often mammograms or colonoscopies have been ordered along with any other health maintenance updates.

My nurses tell me they love this method because they feel more ownership of the visits, are less tired because they are seeing half the patients, and feel less stressed overall. All this amounts to more patient and staff satisfaction, increased efficiency, fewer errors, and better documentation.  

The only downsides I have seen to the piggyback method are the tendency to lose the sense of urgency to move on to the next patient and the bind you get in if one of your nurse/scribes is unable to work. The first is easily remedied by a team huddle and the second requires a shift back to the old way of rooming and scribing until more than one nurse/scribe is available.

The conclusion: Scribes increase practice efficiency, especially when employed in tandem using the piggyback method.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri. A version of this post originally appeared in January-March issue of Missouri Family Physician.

Tuesday Feb 09, 2016

A Primary Care Approach to Curbing Dangerous Teen Trends

Teenagers, no matter how smart, sometimes do senseless things. There are countless viral challenges and trends online, ranging from silly to downright dangerous, that physicians and parents should be aware of.

Need a few examples?

Two Tennessee teens died in mid-January after drinking "dewshine," a toxic mixture of racing fuel and Mountain Dew.

That same week, a 14-year-old boy in Washington shattered his eye socket and cheek bone and landed in the hospital with a brain aneurysm after suffering a fall during a "duct tape challenge."

And car surfing resulted in the deaths of several young people in the past year.

Risky behavior during adolescence is not new. Historically, physicians have associated risky behavior in youth with drugs, sexual activity and alcohol. These days, the modern influence of technology has added additional concerns such as texting while driving, meeting strangers online, participating in social media trends and a host of other issues that have parents unnerved.

Predictors of risky teen behavior are often complicated but include parental monitoring, peer influence and the teen’s mental health. Violence at home, academic difficulties, poverty and lack of extracurricular activities are also associated with risky behavior.

For physicians, helping to curb risky teen behavior is a complex proposition. Screening tools such as the Rapid Assessment for Adolescent Preventive Services (RAAPS) are validated but underutilized because of limited evidence on outcomes. Primary care teams of physicians, behavioral health specialists and social workers should be comfortable with any followup preventive interventions based on the screening results.

The HEADSS assessment (home/habits, education/employment/exercise, accidents/ambition/activities/abuse, drugs/diet/depression, sexual activity/suicidal ideation) is a standard part of the adolescent exam, but physicians should make sure they are careful, not cursory, in their history-taking. Awareness of current trends can narrow the societal gap between patients and their physicians.

Communication is also key to adolescent care. Physicians should approach teens in a way that is nonjudgmental with open-ended questions. Although most of the exam should be done without a parent in the room, including a parent in the discussion at the end of a visit offers a unique opportunity to start a conversation. Physicians can often play a powerful role in creating a safe space to facilitate discussions between teens and their caregivers.

Parents can minimize risky behavior though open communication and social media monitoring. They should be aware of and connected to their child’s peer network, teachers, etc.

Society can address some dangers through legislative efforts, such as banning texting while driving, but these efforts cannot guarantee teenagers will be safe from their own poor decision-making. Nonetheless, as times change, our approaches to adolescent care should evolve as well.

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

Monday Feb 01, 2016

Should We Reject Unvaccinated Patients?

Potential patients -- usually parents -- occasionally ask me if I am "vaccine-friendly." After having this question posed to me numerous times, I’m prepared for the conversation that follows. I’ve tried to ease into it in various ways, but none has proven universally comfortable.

The question's phrasing is telling about a person's perspective. It implies that their previous experiences with physicians were perceived as "unfriendly." Also, my defensive side infers it would be unfriendly for me to answer in any way other than a vague affirmative.

Patients who decline vaccines can be understandably frustrating. Even with our deep knowledge, experience and the best intentions, our pleas often seem ineffective. We are usually at a loss about how to improve our sales pitch when faced with vaccine refusal. As we see vaccination rates declining in some areas, the angst among physicians is understandable.

Professionally, we must consider our organization's and our own practices' policies on vaccine matters. The AAFP has a policy against immunization exemptions. However, this sort of a physician-oriented policy doesn't have much bearing in states that lack strong school requirements for vaccines and allow general parental belief exemptions.

Also, increasing numbers of U.S. kids are homeschooled; that number now stands at more than 1.7 million, according to the Department of Education. So ultimately, many patients -- children and adults -- can and will remain unvaccinated. And these unvaccinated families will be seeking primary care.

Despite an American Academy of Pediatrics policy discouraging practices from discharging patients because of parental refusal to vaccinate, a growing number of pediatric practices are doing just that. I understand why practices create such policies in an effort to protect newborns and kids with weakened immune systems. I support their right to do so, but I fear these policies will only worsen vaccination rates.

It is our duty to protect our individual patients from unnecessary harm, but how to promote the best public health in our communities is a complex issue. By barring the unvaccinated, we might be able to lower the risk of infections spread by sick patients in our waiting areas and exam rooms, but this practice fosters a false sense of security. Our patients are just as likely to come in contact with unvaccinated sick children at a park, school or library, or, as in the case of last year's measles outbreak, an amusement park. Ultimately, unvaccinated sick kids will seek care somewhere -- walk-in retail clinics, urgent care centers or ERs -- that cannot possibly proactively screen vaccine status or refuse care.

After a lot of consideration, I have elected to provide care to children and adults who decline my vaccine recommendations. My community, Lawrence, Kan., has higher rates of vaccine refusal than do most in the Midwest. Through the first few years of my practice, I have had lots of opportunities to hone my message when the "vaccine-friendly" question arises.

"I always try to be friendly," is one common response. "Regarding vaccines, I think it's understandable to be cautious of injecting or ingesting artificial substances into your or your child's body," is another comment that has proven to be disarming.

The reasons for vaccine refusal are numerous and varied, so I try not to make assumptions about a person's position or concerns. Asking, "What specific concerns do you have about vaccines?" is always a great starting point. The usual litany of disproven vaccine harms are common, but there is a wide spectrum of specificity from "I just don't like unnatural things" to "I am ethically opposed to using fetal tissue in medical treatments."

Depending on the initial responses and circumstances, I may address those concerns immediately or offer to continue the dialogue at a later time. I've realized a single conversation in the clinic -- or even a few -- is unlikely to change someone's mind on the vaccine issue. I have found an email exchange to be a wonderful method of communication for this and other contentious issues.

A 2014 article in Family Practice Management is a great guide on understanding the rationale behind vaccine refusals, and it offers tips on how to best respond. Whether in person or by email, I often start with some basic education on how our immune system works and how vaccines work to boost that process. Even a basic understanding of how something works can make it seem less scary.

The article's final section about trust rings most true to my experience. Although most of my patient encounters will not be specifically about vaccine-related issues, each episode of care allows the patient to see I am caring for them in a rational, thoughtful manner.

My practice numbers are small, but I estimate that 20 percent to 30 percent of unvaccinated kids who start with me become vaccinated within one year. I'd love to see that number above 50 percent and hope that longer relationships can achieve that. I recognize some people will not vaccinate no matter how much they trust me with their other health issues -- a frustrating paradox, for sure.

Ultimately, if we deny access, I fear vaccine skeptics' mistrust of mainstream medicine and the percentage of unvaccinated children will only grow. I think the only plausible way to convince a skeptical parent or patient is through a trusting relationship with a primary care physician.

How do you handle unvaccinated patients in your practice?

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

Monday Jan 25, 2016

In Family Medicine, Sometimes the Hoofbeats Are Zebras

How many times have you heard people say they want to work in subspecialty care because they think they might get bored if they choose a career in primary care?  

I have heard it from medical students, physician assistant students and nurse practitioners. I heard it from my classmates in medical school and from internal medicine residents during residency. I even heard it as a med student from a subspecialist who was determined to talk me out of pursuing family medicine.

Well, I’m happy to say that I haven't had a boring day yet. Even when it snows, the power is out, the phones don’t work, and I only see the few patients who brave the elements to get here, I’m not bored by family medicine. If nobody can reach my practice in rural West Virginia because of the weather, I’m still busy reading or writing appeal letters for durable medical equipment supplies or calculating weight loss plans for patients.

And I’ve always got a zebra I’m trying to figure out on the back burner. Any given family medicine office will have its share of rare disease cases -- "zebras on the commons" -- in the works, whether in conjunction with a specialist or on its own.

In medical school and residency, we are taught to rule out the common diagnoses before we move on to the rare disease workup. Common things are common. And that is all some people think family physicians and other primary care professionals do -- treat common diseases with common treatments. But we know that isn’t true.

During the past 18 months, I have found myself diagnosing and treating diseases that I thought only existed on board exams. Within my first month as a new physician, I was reading about connexin mutations because I have a patient with one. My family medicine colleague taught me about McArdle’s disease after one of her patients presented with muscle pain.

I don’t sit in my office treating hypertension with ACE inhibitors all day, or simply treating ear infections. Between seeing five patients with viral upper respiratory infections, I diagnose things -- really interesting things -- that change people’s lives forever.  

Patients with rare diagnoses typically have a long journey from symptom onset to diagnosis. They usually see multiple doctors. And patients often are upset about how long it takes to get to an accurate diagnosis. A recent KevinMD blog reminds us that basic physical exam findings shouldn't be discounted simply because they point to a less likely diagnosis.

The best part about being a family doctor is continuity. Most of us see patients over decades and have the benefit of knowing our patients well enough to recognize subtle changes. We also know when someone is truly sick, and we often know that in the context of their family history from first-hand experience. And when we can’t figure out the diagnosis, we don’t stop, we look harder, and we look for the zebras.  

I recently diagnosed a case of Behcet’s disease in a pediatric patient. It was the perfect example of a patient bouncing between subspecialists. Each physician was doing a wonderful job of assessing their own system of expertise, but they were not looking at the bigger picture. Each time my patient saw one of these physicians, I was relentless about getting each consult note, any labs or tests that were ordered, and talking to the patient's mom to get feedback. I spent hours reading this patient’s old hospital records, scouring over new labs and reading the literature about the differential diagnosis of some of his isolated complaints.

He was on my mind all the time, and every time I saw him it added another piece to his complicated puzzle. Then one day while driving to work it just clicked. I had a question on my family medicine boards that I had gone home and researched because I wasn’t sure I had gotten it right. I read about Behcet’s, and now that one board question led me to recognize this constellation of symptoms in this patient, despite him being far outside the expected age range for typical presentation.

When I got to work, I called the mom and told her to write the word Behcet’s on a piece of paper and hand it to the pediatric gastrointestinal specialist that her son was scheduled to see later that week. I also referred him to pediatric rheumatology.  

I tell this boy often that he has made me a much smarter doctor. He continues to teach me things as he starts new treatments and has new side effects. I didn’t diagnose him because I’m smart. Rather, I was able to narrow it down because I had a long time to think about it since he is my patient for the long haul.  

I have another patient who I’ve had the benefit of caring for even longer because she followed me from residency to my new office. She is the zebra of zebras. This month we thought we had finally diagnosed her with hereditary coproporphyria because all of her labs and symptoms were consistent with the diagnosis, and the hematologist even confirmed it and ordered hematin after reviewing her workup. She has had multiple surgeries, procedures, consults, imaging studies, medication trials, but even more heartbreak. She could write a book about what it feels like to have an undiagnosed rare disease if she had the energy to do so.  

But a genetic test didn’t confirm the diagnosis. There was no mutation to the coproporphyinogen oxidase gene. We were heartbroken together.

But unlike the innumerable subspecialists she has seen who have dismissed her as not having whatever disease it is that they happen to diagnose and treat, I will keep searching. Because I don’t treat diseases, I treat patients.  

And I’m definitely not bored.  

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

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