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Monday Aug 22, 2016

Everyday Heroes: What We Do Today Saves Lives Tomorrow

Through detection, prevention and careful health management, primary care physicians save countless lives each day with little drama or fanfare.

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Monday Aug 15, 2016

Swing and a Miss: Do Quality Measures Have Dubious Value?

With trends pointing to an emphasis on team-based care, Kyle Jones, M.D., questions the rationale for quality measures that focus on individual physicians.[Read More]

Tuesday Aug 09, 2016

What You Need to Know on Path Through Residency and Beyond

The transition from resident to new physician can be challenging. Our new-to-practice physician bloggers offer advice for those who will follow them.

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Friday Jul 29, 2016

Artful Communication of Evidence Can Overcome Anecdotal Fears

Patients and physicians think about diagnosis and treatment in very different ways. It's up to us to clearly communicate why and how we follow the evidence. [Read More]

Friday Jul 22, 2016

Singing the Praises of a Pharma-free Practice

Natasha Bhuyan, M.D., explains how and why her practice took steps to eliminate pharmaceutical industry influence in a bid to avoid bias in prescribing.[Read More]

Monday Jul 18, 2016

Prior Authorization Call Shows Inefficiency, Absurdity of Process

Family physicians waste hours each and every week on prior authorizations. Ryan Neuhofel, D.O., M.P.H., recorded one such call to illustrate the inefficiency of the process. [Read More]

Tuesday Jul 12, 2016

Support, Flexibility at Home, Work Vital to Success in Rural Practice

I have been reflecting on this blog for several days now, waiting for a rare down moment to write about what being a rural female physician means to me. Tonight, as I finally have some time, I realize that the unique challenges of rural practice make life unpredictable and possibly difficult for other physicians to relate to.

My husband (and practice partner) had rounds this Sunday morning at the hospital, so he dropped my daughter and me off at church and headed to work. At church, I received a phone call telling me that I also was needed at the hospital for one of my obstetric patients. I let my daughter's Sunday school teacher know I would be leaving but that my husband would be back to pick her up.  

DMW Photography
My husband, Michael Oller, M.D., and I enjoy rural practice in Stockton, Kan., where we live with our daughter, Lyla, and mastiffs Mitch and Mosi.

My husband came back to church to get me, dropped me at the hospital, finished his own work and returned to church to pick up our daughter. A favor from a friend later and we each had a car at the hospital so my husband could take our daughter home while I stayed to deliver a baby.  

It might sound crazy, but these are situations we frequently encounter. With supportive partners at home and at work, as well as support from friends and our community, however, they always work out. I sit here tonight having helped bring a beautiful baby into the world but also having had to give up a large part of my Sunday. I consider it a worthwhile trade.

The impetus for this blog was a study published in the May/June issue of Annals of Family Medicine that sought to "understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction." The study was based on a survey of 25 rural female physicians in 13 states.

The authors identified three things study participants considered imperative for successful rural medicine careers: 

  • supportive relationships with spouses and partners, parents, or other members of the community;
  • reduced or flexible work hours; and 
  • maintenance of clear boundaries between their work and personal lives.

The United States has a severe shortage of rural physicians, including a dearth of female and minority physicians. The lack of female physicians limits access to care for female patients who would prefer a female clinician. Rural female physicians are more likely to attend births than our male peers, which is an important part of practice in many rural areas with a shortage of obstetric care. 

Many rural physicians choose this path because it allows them to maintain a broad scope of practice. However, this broad scope often also leads to long and unpredictable hours that vary greatly from week to week. (Today's delivery was the third this week for me, leading to longer hours than usual). Creating the support system necessary to meet patients' needs while also supporting our families takes great effort.

What attracts women to rural practice? The majority of the physicians surveyed had rural life experience. However, there are others, like me, who turned their attention to rural practice after experiencing it in a rotation. I graduated from the University of Kansas Medical School, where a rural rotation is required, and I continue to firmly believe that such experiences matter greatly in the choice of future practice. 

We must continue to model for medical students what is great about our specialty, and those of us who practice in a rural setting need to be willing to precept students. It is a rare month when my partners or I don't have a medical student in our practice, and often more than one of us have students at the same time. I am proof that having a female rural medicine preceptor can take a practice setting that had never even been on your radar and make it your career. (That preceptor is now one of my practice partners.) 

There are many challenges of rural practice. As the Annals study points out, rural physicians have fewer community resources, work more hours and care for more patients compared with their urban peers. This produces added stress and, at times, feelings of isolation. In the study, physicians with young children and those new to rural practice described feeling the stress of maintaining balance most acutely. The guilt of leaving family to care for patients and, conversely, spending time with family at the expense of time in your practice, are frequent sources of stress. 

Those with good work flexibility reported highest satisfaction. For many in the study, this meant reduced work hours, especially when their children were young. 

Supportive relationships are also key. Several of the women in the study reported male partners maintaining primary responsibility for managing the household and caring for children. Many had situations similar to mine -- married to physicians in the same practice. In all of those two-physician partnerships, one or both partners worked part time.

Work partners are also important -- other physicians who are willing to help out when family obligations and emergencies arise. We are expecting twins in the fall, and although I don't know exactly what our work schedules will look like when they come, I know that owning our own practice gives us the flexibility we need.

I received an email from my practice partners this evening saying they have devised a back-up call schedule that covers the weeks leading up to the twins' due date. This is the kind of cooperation that makes rural practice, with all of its additional stresses and challenges, sustainable.

Clear boundaries were identified as key for satisfaction. Limiting work and protecting personal time were seen as essential for personal well-being. Work partners often played an important role in this. In my experience, setting expectations for patients can be hard but is extremely important in rural environments; examples include respecting physicians' days off and time with family (i.e., not approaching them with medical questions in a public place).

Corresponding author Julie Phillips, M.D., M.P.H., told AAFP News that rural physicians in the study showed "a really strong sense of devotion to their patients and commitment to their communities." Although it was clear that most physicians in the study loved their work, there were also those looking to change practice because they felt their current situation was unsustainable.

The authors of the study concluded that female physicians considering rural practice may be more satisfied if they seek flexible employment opportunities, choose communities where support is available and build support networks as they select practice settings.

Practicing self-care and setting boundaries are also important skills. These are skills, however, that we are not often taught. Perhaps they could be covered more in medical training, especially in residency. Female physicians entering rural practice need the support of those who have gone before them. These relationships can be fostered through state and national academies, rural interest groups (such as online forums offered by the AAFP), and preceptors encountered during training. 

Women need opportunities in residency training to rotate with rural female physicians. Those of us who live this practice style need to be available to serve as mentors and sounding boards. Female rural physicians are more likely than their male counterparts to plan on long-term rural careers, so let's continue to evaluate and work toward making more rural female physicians a reality.

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

Thursday Jun 30, 2016

Stranded Patients, Lost Meds Are Just the Beginning of Flood Disaster

In medical school I took a wilderness medicine course, but after two years of practice in rural West Virginia, I think of that training as "West Virginia medicine."

In a relatively short time, our community experienced a chemical spill in our water supply, blizzards that stranded patients at home, and the temporary loss of our grocery store. The latest crisis, however, is far worse, and its results could be long-lasting.

On June 23, areas of West Virginia received as much as 10 inches of rain in just a few hours. The flood that followed was the most devastating in the state since the Civil War and resulted in at least two dozen deaths.

Photo courtesy of Tabitha Clendenin
A church and cars in Clendenin, W.Va., are surrounded by floodwaters. The state suffered a 1,000-year flood on June 23.

The topography of West Virginia demands development at lower elevations because the mountains are often too steep, too prone to slips or mudslides, or just too difficult to build roads or housing on. Many of the state's residents live at low elevations, and the steep surrounding mountains create sluices for rainwater. 

When I got to work on Thursday, June 23, my office had no electricity or broadband connectivity, but that isn't a rarity. We can function with a propane-powered generator, and we often do. But as the day went on, the rain did not stop.

I made it home that evening, but within a few hours water was running over the top of my pond's dam. My house is at the top of a hill, but I knew my patients and neighbors were in serious trouble because the strongest of the expected storms had not yet arrived.

Water rose so quickly out of stream banks that people didn't have time to leave their homes, move their cars, or grab valuables or medications. By Friday morning, I couldn't leave my house because all routes were under water. I had cell phone service, so I could see news reports and photos of the devastation as rivers continued to rise. I saw my own town in aerial photographs broadcast on the Weather Channel's and CNN's websites. I recognized some of my patients' submerged homes.

I was able to log into my electronic health record on my phone and looked up patient phone numbers, but the landlines were long gone and I was unable to reach anyone who didn't have cell phone service. Still, I was grateful that those who I had shared my cell number with were able to update me on their conditions. 

I was scheduled to work Saturday, and the water receded just enough for me to trudge through mud-covered roads. Around every turn was one heartbreaking sight after another. Floodwater isn't just a wet mess, it carries raw sewage, chemicals and everything else imaginable. The water leaves behind foul-smelling mud that coats everything it touches. 

Before going to my office, I stopped at the gas station for water. Within 15 minutes I was able to find out news about quite a few of my patients because the store and its parking lot were full of them, their friends and their relatives since it was the only business in town with power and water.

My office remained dry, so other than having no power, phone, Internet or drinking water, it was not affected by the flood. On Saturday, I only saw a handful of patients, but I also wrote paper scripts for those who had lost theirs or were unable to access meds. 

One of my patients was seen driving around town. I knew her trailer had been damaged, and I was really worried because she had recently had a stroke and struggled to control her blood sugar. I feared she would be homeless. When I managed to find her Saturday, she was disoriented and dehydrated because floodwater had breached her trailer, knocked over her refrigerator and prevented her from accessing her insulin. 

It's rare for me to see just one person in a given family. One of my patients called Saturday distraught because she had lost everything and was stranded in an area left completely inaccessible due to road damage. I also care for her brother, a complicated patient who lost all of his home health equipment. I wrote them new paper scripts because no pharmacy had e-script or fax capacity. A friend picked up the prescriptions for the patient, but they didn't know when they would see each other. 

By the end of the day I had written 50 scripts for meds lost in the flood, and those were for the more fortunate people who still had phone service or were able to relocate to a safe place. I also saw families with sick children who were depending on the good will of friends for a place to stay.

I had no water at home so I went to the grocery store but found none. I stood in the drink aisle with my patients, all of us deciding which flavor of Gatorade to buy. 

In the parking lot I saw 10 more patients, all making it out of their hollows for the first time since the rain started, still in their mud-covered clothes, not sure where they were going next.

On my way home, I passed countless people walking along creeks looking for belongings, retrieving dog houses. 

One of my former residency classmates called and offered to take me on horseback to any patients I knew were inaccessible by motorized vehicles. I have almost all of my homebound patients accounted for so I haven't yet taken her up on the offer, but I will definitely keep it in mind. 

Yesterday we ran reports of patients on meds for high-risk conditions and called each of them to ensure they had their medications and could get out of their homes if an emergency were to arise. Many people live near privately owned bridges that have been damaged or completely destroyed, so they are safe but isolated.

As I sit in my office typing this, emergency storm sirens are going off and rain clouds are rolling in. It literally looks and sounds like a war zone. The number of people reaching out to offer help has been impressive, but with so much destruction and so much unknown (What will the Federal Emergency Management Agency condemn? Will there be emergency housing? When will the water lines be repaired?), it's hard to know where to start or what is most urgently needed. 

Some families I care for are sleeping in tents because they have absolutely nothing, and unlike an isolated event such as a house fire, this flood has left an entire community in need. So I've focused on little things with direct impact, like buying people socks and underwear, providing manual labor to carry damaged furniture and carpet out of houses, or delivering pizza and water to people who have no transportation to get to distribution centers. 

The governor has encouraged anyone wanting to contribute to flood relief to use the West Virginia Voluntary Organizations Active in Disaster website. I've also suggested contributions to the Clendenin Volunteer Fire Department. Not only did these volunteers save many lives via water rescues, but their station was damaged by 5 feet of floodwater. Some fire engines were still inside because crews were out on boats. One of my neighbors continues to take vacation time from his paid job to volunteer extra shifts for the fire department.

I feel like a broken record, but we must all be prepared for disasters. We all should have a plan for addressing the possibility of losing access to food, water or electricity. And as family physicians, we need to be familiar with disaster response protocols for our communities  and our practices, or at least know where to find necessary resources or guidelines

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

Wednesday Jun 29, 2016

Clinical Case Managers Improve Chronic Care Outcomes

Every primary care physician is familiar with the complex challenges involved with comprehensive health care delivery. The task can seem particularly daunting when facing communication barriers or when treating the underserved, the disabled and the elderly. Because of this, there is a great need for third-party facilitation through care coordinators, case managers, social workers and lay medical workers.

I first experienced this when I was a resident in the South Bronx. I was intrigued by the benefit of utilizing community health workers as physician extenders who reached out to their communities through patient education and coordination, both in the clinic or hospital and in patients' homes. Now a family physician in my third year of practice, I find great value in care coordinators who facilitate and streamline transitions of care between inpatient and outpatient settings. In our medical home, I frequently use licensed clinical social workers to provide counseling and patient education in smoking cessation, weight management, chronic pain, illness and addiction recovery.  

We also have added a clinical caseworker for chronic care management to ensure optimal communication and continuity of care with our Medicare patients. This service has closed gaps in communication and maximized educational opportunities that might have been missed in the past. Chronic care management also provides a significant opportunity for improvements in medication reconciliation, care coordination, patient retention and appointment follow-through.

Despite these benefits, two main limitations prevent some Medicare patients from taking advantage of chronic care management. One is the challenge of communicating to the patient the benefits of having access to a clinical case manager. The other is the added expense incurred by the patient. Even though the cost is minimal, many patients on fixed incomes view it as an obstacle. It's important to note that when patients have supplemental insurance, we are able to reassure them that the copay likely will be covered and they usually are more willing to sign up.

Despite these barriers, I have had many patients agree to the service, and they have found it to be quite beneficial.  

I had one patient in particular who was completely unclear about the appropriate use of his medications. He had the misconception that he could take all his medications according to his own sliding scale. His reasoning was that he was concerned about side effects and the risk of becoming dependent. This patient had insulin-dependent type 2 diabetes, as well as hypertension, hyperlipidemia and testosterone deficiency, all of which was clearly out of control by the time my case manager reached him.  

Through a collaborative approach, patient education and consistent reinforcement, we were able to rein him in and get him to the point where the medications listed in his medical record actually matched what he was taking. He was proof that the more eyes on the chart and the more communication with the patient, the better.

After seeing successes like this from a physician's point of view, I wanted to hear more from others who make this physician-led collaboration work in my practice. Here's my interview with clinical case manager Cindy Cody, R.N., who joined the program when it began in 2015. It has been edited for clarity.

Q: What do you like most about this position?
A: Helping people to feel better about themselves and to realize that they are only human. So often, while working with patients to lose some weight or lower A1c levels, we can get so focused on the number and think they failed if they are not seeing big results. But it really changes your perspective when you talk with the patient and learn that they cut down from drinking five sodas a week to three or started eating a salad for a meal, etc. Little changes deserve to be recognized and can add up to the big results. That recognition often helps provide the additional motivation they need to make further changes.

Q: What do you like least about this position?
A: The chronic care management program is paid for by Medicare, but sadly it often leaves a copayment for patients. Most of these patients are either disabled or elderly and living on a fixed income. This copayment is the reason many patients do not enroll in the program.

Q: What works really well about this service?  
A: Helping to ensure all is being done for patients to improve their health and develop positive outcomes. I also find patients will be more forthcoming in a phone call in their own home environment than in conversations during an actual office visit. Patients often tell me things during these phone calls that they might be reluctant to say in the office. I also love how it's a check for these patients between visits. I have ladies in their 90s who really need that additional personal call each month to check in on their safety and health status. With these patients, I often work to help decrease fall risks and injuries. These patients then have an open line to call their clinical case manager directly during the day, where they can talk to someone they know if they have a question or problem. Many like having that security.

Q: What could use some improvement?
A: Honestly, I often hear physicians voice that they do not see the need for this program and will not utilize it, or at least not to its full potential. It can be such a benefit to the patient, as well as an extension of the physician's hands so they can reach these patients at home between clinic visits. When we are utilized to our full potential, it benefits both patients and physicians. For example, if an M.D. changes diabetic or blood pressure medications, you can ask the clinical case manager to call them in two weeks and get home readings. In doing so, a clinical case manager may also be able to provide a little additional education or reiterate what was already given to the patient to help improve results. Getting those numbers to the M.D. may provide an opportunity for another dose adjustment before the patient's followup visit. The clinical case manager can follow up again with that patient to clarify new medication instructions and verify that the desired results are achieved.   

Q: What have you learned that opened your eyes to the need for this service?   
A: So often things can fall through the cracks, and there is such a need for someone to be looking for these lost items.

There are limitations to using case managers as physician extenders. However, the more we take advantage of the services they offer as part of a physician-led team, the better we are able to coordinate care, close loopholes, improve patient education and fill gaps in physician-patient communication.  

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

Tuesday Jun 21, 2016

FP Salaries Increasing, But How Much?

Editor's Note: Physician search and consulting firm Merritt Hawkins and the Medical Group Management Association recently released their annual reports on physician salaries. Both groups noted sizable increases in compensation for primary care. A few family physicians who are regular contributors to this blog changed jobs in the past year, so we asked them to offer their opinions on those reports and their insights on the job market.

Peter Rippey, M.D., Bluffton, S.C.
The most intimidating thing I had to do during my residency and fellowship training had nothing to do with patient care. It was negotiating my first employment contract.  

Of course, one of the most important parts of the contract for new physicians, who often have $200,000 or more in student debt, is the starting salary. Merritt Hawkins recently announced that for the first time in the history of the search firm's annual report on physician salaries the average starting salary for family physicians eclipsed $200,000. In fact, based on the thousands of search and consulting assignments Merritt Hawkins conducted on behalf of its clients from April 1, 2015, to March 31, 2016, the firm said the average starting salary for family physicians increased 13 percent to $225,000.    

The Medical Group Management Association recently released similar findings in its annual survey, stating that median primary care physician compensation rose more than 4 percent to $250,000.

Family medicine was Merritt Hawkins' most requested specialty for the 10th consecutive year. It's no secret there is a shortage of primary care physicians. Add the fact that a well-trained family physician can fill virtually any primary care void and you have a recipe for high demand, which is one driver of higher compensation.  

But before all of our third-year residents start salivating over these numbers, this is where I put an important asterisk.

* Individual results may vary.  

I would love to tell you that all new FPs can expect these high salaries. However, this was not my experience when I changed jobs last year. We have to mind the demographics of Merritt Hawkins' sample. The majority of the settings involved were hospital-based, employed positions and in communities with populations of more than 100,000. Salaries also vary by region and practice setting.  

Also keep in mind that Merritt Hawkins is a recruitment firm, so employers using these services may have more resources, which could translate to higher salaries. It's also possible that using a recruiting service could indicate more trouble hiring or retaining physicians, which may cause salaries to skew higher.

Personally, I am not making anywhere close to the average Merritt Hawkins is reporting, and I have a certificate of added qualifications in sports medicine to boot. I think these reports can give us a starting point for negotiating a fair salary, but I would be careful about doggedly expecting to start out making that kind of coin.

Also keep in mind there is more to a job than a salary. I have worked jobs where no amount of money could have made me stay. For me, considerations such as location and type of practice are just as important as the salary. Let's also not forget that job benefits -- including insurance, retirement and bonuses -- are not created equal.   

However, it is promising that salaries are trending up given the increased demands and responsibility of primary care physicians. I think this breeze is indicative of larger winds of change where increasingly primary care is stepping up responsibility for coordinating patient care, improving health care outcomes and increasing the efficiency of health care delivery.

The importance of primary care's central role in a vibrant health care system is finally starting to be recognized, respected and valued.  

Natasha Bhuyan, M.D., Phoenix
The shortage of primary care physicians is expected to reach 31,100 by 2025, according to the Association of American Medical Colleges. There isn't a magic bullet to alleviate this shortage; it will require health care delivery reform, incorporation of technology into health care, increased funding for residency training, and team-based care with more advanced clinical practitioners. In the meantime, groups desperate for physicians are responding to market demand with vigorous recruitment.

As a resident in search of employment last year, I was pleasantly surprised to see how aggressively family physicians are recruited. Of course, there are the standard recruitment techniques of endless mass mailings and targeted headhunters. However, with increasing primary care demand, recruitment strategies are growing more sophisticated and responsive to physicians. The most obvious recruitment tool is a competitive salary with impressive signing bonuses (an average of $40,000 in Phoenix) or loan repayment.

Many places I interviewed offered high base salaries with reasonable quality performance bonuses as well. Each interviewer offered $10,000 more than the last. I also quickly learned employers are flexible in all areas of contract negotiations, including non-compete clauses, CME and even paying for examinations/licensing and professional membership dues.

Non-financial aspects also are used as recruitment tools: better call schedules, sophisticated electronic health record systems and minimized administrative burdens. I was particularly glad to see that many places I interviewed valued primary care physicians through leadership and governance. Some have compensated committee roles for physicians -- a move that shows our ability to transform care delivery is valued as well as our direct clinical skills.

With the trends in health care, I anticipate family physician salaries will continue to increase. However, job satisfaction isn't dictated simply by money. Rather, the structure of health care delivery will have to change for primary care physicians to truly deliver on the quadruple aim of better health, better delivery, lower costs and higher physician job satisfaction.

Helen Gray, M.D., Kirkland, Wash.
In November, I wrote about my move from Nevada to Washington in this blog. I learned a lot about changes to costs of housing and living. Keeping this in mind, I made sure that when I negotiated my contract my salary would be fixed and guaranteed for the first two years, and that I would be receiving compensation commensurate to the increase in spending I would experience in a different state and bigger city.

Although the numbers are available, I had a difficult time finding data on average compensation for the location I was moving to. Eventually, after Googling for what felt like days and asking numerous colleagues in the area, I felt like I had a good idea of what I should ask for without getting laughed at when it came time to negotiate.

Negotiating and contracts are not things I'm fond of, though it's worth noting that the AAFP has resources that can help. So imagine my relief when my initial offers from the potential employers I was considering were actually comparable to the community's market. My salary increased 20 percent with the new job.

I will say, however, the starting salary offered to me as a physician now four years removed from residency in an urban area with a high cost of living is not the number noted by Merritt Hawkins.

I was involved in recruiting for my Nevada practice prior to relocating, and I can say that the starting salaries there were even lower than those here in Washington. The Merritt Hawkins numbers were a little surprising to me and my colleagues with whom I discussed the results.

It is great, though, that family medicine is becoming more desirable and that salaries are going up. This could help to address the primary care shortage.

Tuesday Jun 14, 2016

Arrival of Superbug Highlights Need for New Antibiotics, New Approach

Reports in the mainstream media are finally catching up to what the medical literature has been saying for months: We have bacteria that have developed or acquired resistance to all available antibiotics.

One strain of gram-negative, urinary-tract-infecting bacteria is now resistant to colistin, a drug of last resort for many multidrug-resistant organisms.

More than 50,000 health care-associated Pseudomonas aeruginosa infections occur each year, according to the CDC. Roughly 13 percent of these are multidrug-resistant.

There are already limits on which antibiotics work on different types of bacteria. For some infections, only one or two classes of antibiotics proved effective against them in the first place, so developing resistance to existing drugs can be easier than it sounds. Multiple mechanisms can confer resistance to antibiotics, whether via enzymes that break down the drug, pumps that remove it from the bacterial cell or some that are as yet unknown.

And once a mechanism exists, passing it on to other species is relatively easy. Several bacteria can transfer genetic material in the form of plasmids, which then confer resistance in the receptive bacterium. Replication going forward includes the plasmid, meaning the genetic offspring of that single bacterium all carry that resistance. Other bacteria may develop novel mutations that make them different enough that the medications meant to combat them no longer find the expected target and cannot work as designed.

So we as scientists and physicians try different medication targets or different combinations of medications to overcome the resistance mechanics, and the bacteria continue to develop new defenses.

The arms race escalates daily.

If you think that such a doomsday scenario would have the pharmaceutical industry scrambling to prioritize the development of new antibiotics, think again.

A Reuters article that broke the news of the superbug in Pennsylvania put it this way: "Many drugmakers have been reluctant to spend the money needed to develop new antibiotics, preferring to use their resources on medicines for cancer and rare diseases that command very high prices and lead to much larger profits."

In fact, dozens of pharmaceutical companies signed a declaration in January calling for government incentives to support the development of new antibiotics.

I initially considered writing this post as an open letter to the pharmaceutical industry, encouraging manufacturers to urgently do something about this problem. But the more I thought about it, the more I came to realize that was not the right plan. The idea that a single company or industry might be able to fix this problem alone makes the scientist in me cringe. This problem extends far beyond one group or industry. At some level, we are all to blame.

Thus, here's an open letter to all of us -- pharmaceutical companies, physicians and patients:

The recent recognition that a bacterium resistant to all known antibiotics caused infection in a patient in Pennsylvania catalyzed discussion about the problem of antibiotic resistance. But this isn't a new problem.

We've been fighting this battle for decades, and we as humans are losing.

Hospitals and physician groups develop infection control teams and protocols for dealing with infectious diseases. Governing bodies mandate hand-washing and isolation protocols. Policy statements about appropriate antibiotic use appear in major medical publications. And yet, we still see the growing threat of antibiotic resistance.

We need a new strategy -- a new way of looking at this problem. Education is good. Mandating infection control is good, too. But throwing money and time at the problem is not the only answer. This is not just about profit or loss. This is not about shareholders or investors or bottom lines. This isn't about ensuring CEO bonuses. This battle is not about one group or industry "fixing" the problem.

This is about the greater good and preserving lives. This is about using science to protect and serve all of humanity. Everyone involved in infection care and control must work together, each doing their part. No one gets a pass.

We physicians and allied health professionals can continue to educate ourselves and our patients about using existing treatments appropriately. We must end the strongly ingrained habits of inappropriate antibiotic use and work to improve our diagnostic skills and testing. We can work together to build the body of knowledge about infectious diseases and appropriate use of antibiotics. No more caving to the whims of the consumer or doing what we've always done.

Instead, we must follow validated medical evidence. Whether in the inpatient or outpatient setting, we need to be good stewards, using our tools appropriately and implementing plans that ensure proper use of existing medications. We can teach our patients why we do what we do and what the appropriate practices entail. We can spread the word about infection control procedures that work, not just anecdotally, but with hard scientific evidence. And where that evidence does not exist, we should continue to study the problem.

Patients must learn to trust that evidence in the face of discomfort, especially for problems that are often improperly treated with antibiotics at patient request. We can help by re-educating everyone about safe and smart use of antibiotics for appropriate situations. We need a cultural shift away from the mindset of "I have to have a pill to get better" and toward appropriate use of antibiotics in established cases of bacterial infection. No more antibiotics for viral upper respiratory infections.

Each of us -- only one bacterial infection away from becoming a patient -- should do our part to encourage patient stewardship, as well. Take the full prescription of antibiotics, even if you begin to feel better. Throw away unused medications if there are leftover pills, and avoid the temptation to use leftover pills to treat future illness.

The pharmaceutical industry can continue working to discover novel medications and formulations. Innovation, while difficult, is necessary. Every year, the major companies look at hundreds if not thousands of compounds, searching for "the next big thing." Our society will benefit from companies devoting a larger portion of their substantial resources to the discovery of the next class of antibiotics.

Even better, drug manufacturers can continue to seek out novel mechanisms of action that don't allow for resistance. Give our immune system a new tool. Find a way to target specific species without adversely affecting noninfective species. I'll wager the profits from such a discovery will pay off monetarily in the long run, and the dividends in human lives saved will be immeasurable.

It's easy to wait for someone else to do it. Avoiding the challenge is safer for the bottom line and for patient satisfaction scores, but this path leads to debility and death. No matter what we do, we cannot just cross our fingers and hope this problem goes away. It won't. And lives are at stake.

We can fight back against this common enemy, but we must work together. We must seek answers to the hard questions and be willing and ready to change if the scientific evidence dictates it. And we must always, always keep going.

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

Monday Jun 06, 2016

Paging Dr. Mom: Becoming a Parent Made Me a Better Physician

When my daughter recently turned 1, we celebrated her birthday and I paused to reflect on all the things I'd learned as a new parent that helped me become a better family physician.

The journey hasn't been easy. But she survived, and so did I, through my first year of juggling the responsibility of nurturing a new life with all of the other tasks I have been trying to do well. Breastfeeding was much harder than I expected. And my baby's well visits weren't the straightforward encounters of just shots and anticipatory guidance that make family docs smile during an otherwise busy workday.  

It changed my counseling. I have developed more confidence and empathy, now counseling based on experience and a developing intuition instead of relying solely on my training. I have gained more insight as part of a community of parents where I have witnessed variation in child development, experiences and parental response.  

I am more supportive of those who are anxious about the things that run through a parent's mind at 3 a.m. Despite all of my medical knowledge and experience caring for sick children, I have watched over my baby's chest at night to make sure she is still breathing. And I have agonized after accidentally clipping skin instead of nails.   

Up until this past year, I didn't fully comprehend the emotion behind the vaccines debate because "science ruled." But after having a child, I understand that any controversy raises red flags for new parents, and I respect a parent's decision to make a choice -- even when I disagree. My job as a doctor is to help parents make the healthiest decision for their child by being supportive and providing evidence-based information.

I have also learned how much influence family and friends have on new parents, as the volume of their day-to-day advice about parenthood can overshadow what I say at well visits. This dominant force in a young parent's life shouldn't be ignored. Knowing what is being said to new parents and helping to provide a different perspective is fundamental to the concept of anticipatory guidance.

I have learned to listen. I fired my child's first physician because she didn't. Her assumption that I was "worried well" made her deaf to my complaints and unsympathetic to my concerns. The doctor was fixated on my daughter's diagnosis being nothing, so she looked for nothing. Meanwhile, I was observing exactly what was going on with my child.

It's important that we listen to families. The parent in me saw that my child had difficulty latching, seemed to have developed an aversion to my breast, was smaller than other children her age, frequently seemed uncomfortable with bowel movements, had dry skin and vomited every time I gave her formula to help supplement.

Still, I was shocked when the doctor told me during the 2-month visit that my baby was only at the second percentile for weight and she recommended starting formula -- even though I had previously mentioned we had already started formula out of necessity.

Reassurance is not always reassuring. The doctor offered no other solutions. In fact, I was told to be patient. Thankfully, the doctor in me woke up after observing another emaciated child in the waiting room, and the reality of a failure-to-thrive diagnosis set in. My 2-month old infant was showing many signs of a milk allergy, everything except the tell-tale sign of bloody stools.  

This led to my next big realization: Emotions really do get in the way of objectivity, which is why as a parent it is impossible to be your child's physician. However, you can be your child's biggest advocate. It is important to surround your family with those who listen and whom you trust. After all, we are all human. Parenthood often exposes the vulnerability of all people, including physicians.  

I belong to a strong community of knowledge. Besides joining the Physician Moms in Family Medicine Facebook group, which has been extremely helpful, I also have been tapping more into the resources I already have. In regard to my daughter's health, I organized a teleconference with an FP colleague who works as a lactation consultant, a college friend who works as a med-peds doctor, and two of my friends from medical school (one is a pediatrician and the other has two young children and had gone through something similar).  

As a family physician, there is so much to know and even more to learn. Tapping into the collective knowledge of those who have practiced for decades, those who practice in different specialties, and those who are parents helped me to organize and develop a plan to put my daughter on the road to better health. Similarly, I have been called on more frequently by my friends, family and community to offer advice and second opinions for virtually all things kid- and family-related. As a new physician, I notice even my patients, especially the older ones, trust and respect me more now that I am a parent.

The transition hasn't been easy, but it has taught me much in this first year. I look forward to future lessons, and I hope it will make me more humble, resourceful and knowledgeable for the benefit of those I wish to help and serve.

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

Tuesday May 31, 2016

Diagnosis Dangerous: What Do You Do When a Patient is Armed, Hostile?

I don't get nervous easily, I don't avoid confrontation, and I usually feel safe in situations where others might not. I do a lot of home visits, and I am not afraid to confront patients if I think they are lying to me. And I don't hesitate to have difficult conversations with patients even when they are angry.

I actually would say I have a track record of making patients angry because I am honest and willing to confront them, especially about narcotics. And like most family doctors, I have had my fair share of threats.

I've had answering service calls from patients who say they will die if I don't refill their benzos, that they will kill themselves if I don't prescribe pain pills. I've had face-to-face threats from patients who say they are going to sue me, report me to the board of medicine and tell everyone I'm a terrible a doctor. (I consider that good publicity most of the time.) Often, this involves yelling and swearing. Through years of dealing with irrational, repetitive drug-seeking behavior, I've developed a thick skin.

But when a patient brings a loaded gun into my office, I feel 100 percent terrified.

Before I go on, I should give some background about my experience with guns. I own guns. I grew up with guns. I don't have a concealed carry permit, and I don't carry a gun on home visits, but I am not frightened by the presence of a gun.

In residency, we had to do a patient education video, and one of my colleagues and I focused ours on gun safety. It explained how to unload and turn on the safety mechanism on different types of handguns.

I live in a part of the United States where guns are part of life. I think every house in my neighborhood has a gun (or lots of them). That is why this is such a difficult topic, and why I was so surprised I was shaken by a patient who came into my exam room with two loaded handguns.

He wasn't pointing them at me and demanding meds. He actually handed them to my nurse so she could do an electrocardiogram. The thing that made it scary was that I didn't feel comfortable around this patient even before he showed up with guns.

As physicians we are in difficult situations all day, making diagnoses, struggling to find the right treatment for a complicated patient, delivering bad news or even saying goodbye. We have to be comfortable with uncertainty, but we make evidence-based decisions and probably look things up more than we need to just to be certain our memory is accurate about a medication dose or length of treatment. We spend hours at home reading and researching yet we still sometimes have to make decisions about people's lives that are not clear, and we reassess and re-evaluate those patients to ensure we've made the right choices. And through all of that we often ignore ourselves, putting the patient first.

After my first visit with this patient -- just a few months before this gun-in-the-exam-room encounter -- I told my office manager that if any patient were ever going to shoot me, I had just met him.

I didn't have anything specific on which to pin that feeling, although multiple people witnessed uncomfortable exchanges between the patient and me, and a few even said they didn't think I should keep taking care of him. But he is complicated, and it's a really long drive to the next primary care doctor. Besides, why should I subject some other doctor to him instead of dealing with him myself?

During a visit with me the week before, he voiced a threat toward a subspecialist to whom I had referred him. I notified that doctor, fully expecting him to dismiss the patient, but it never occurred to me to consider all the reasons I should dismiss him until he presented with two loaded guns.

It was pretty darn clear at that point -- so clear that I felt I had jeopardized the safety of my entire office by not dismissing him sooner.

What came next is my motivation for writing this blog.

I have dismissed other patients for threatening me or my staff. I give them 30 days to find a new medical home and will see them for emergencies. But I didn't want this patient anywhere near the office again. I wanted his dismissal to be effective the moment he walked out the door.

What I found, however, is that I didn't have the ability to make that happen. Law enforcement officers told me I would have had to confront him about the guns, specifically that he was not allowed to have them in my office. I needed to point out that we have a sign on the front door stating no weapons are allowed on the premises, and that he was violating our policy. Then, and only if he refused to take the guns out of the building, did I have the right to keep him out of my office.

It took so long to figure this out that he came back to the office before we had a chance to write our dismissal letter. Fortunately, the receptionist told him she would need to take a message, and he left without any conflict.

When we have doctors getting shot in hospitals and offices around the country -- sometimes by accident -- why am I not allowed to stop a patient from coming into my office with loaded guns?

As a physician, I don't feel I can simply refuse to see patients based on who makes me uncomfortable. I have an obligation to take care of people with violent histories, and I have no moral issue with that. But I am struggling to decide where to draw the line.

I'm not the only physician thinking about safety. During the AAFP's recent National Conference of Constituency Leaders, delegates adopted resolutions that addressed workplace violence. One substitute resolution that was adopted requested that the AAFP help state chapters advocate for legislation that protects physicians from violence. Another one asked the AAFP to oppose legislation that allows guns in civilian clinical settings.

Unfortunately, some states are passing laws that will reduce protection for us and our patients. And that is how I see it: Allowing guns in clinical settings means less protection. I shouldn't have to have a conversation about an inconsistent urine drug screen or board of pharmacy report with a patient holding a gun. And just as I don't want to get shot in my office, I definitely don't want one of my patients to get shot, either.

Starting next year, legislation will make it legal for people in Kansas to carry concealed weapons on college campuses and in health care facilities with no requirement for permits or training. In West Virginia, our state legislature eliminated a concealed carry permit process that included a gun safety class.

I know that after my experience I want my guns in my house where they've always been, and I want no guns in my exam rooms where I sometimes make people mad while I'm alone with them behind a closed door.

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

Tuesday May 24, 2016

How Can Family Physicians Turn Back the Rising Suicide Rate?

As both a physician and someone who suffers from depression and anxiety, I have been alarmed by what appears to be a dramatic rise in mental illness in our country. With this in mind, I was extremely saddened -- but not shocked -- to see that the U.S. suicide rate has reached a 30-year high, according to a recent CDC report.

 Nearly 20 percent of Americans have a mental disorder, but 60 percent of people with mental illness do not receive treatment.

Depression and other mental illnesses have long carried a stigma of failure and weakness among Americans. We are a country of rugged individualism, self-sufficiency and economic advancement. Mental illness runs counter to these notions but is nevertheless increasing among wide swaths of the U.S. population.

It is estimated that 18 percent of Americans suffer from a mental disorder, a rate that appears to have increased dramatically from the 1930s to the early 1990s.

You might expect suicide rates to decrease because of improved diagnosis and treatment options. But suicide rates have increased 24 percent since 1999, supporting the idea that a growing number of individuals have mental illness. (Ninety percent of people who commit suicide suffer from a psychiatric diagnosis.) This trend holds in both women and men, in adolescents and the middle-aged, and among nearly all ethnic and racial groups. And although rates of suicide among the elderly have not increased, these individuals are still at high risk for suicide.

Attempted suicide is also increasing among youth, suggesting that the increased rate of suicide is not just an increase in "successful" attempts." More than one-third of college students report that in the past 12 months, they experienced depression to the extent that it affected their ability to function. And although individuals in the gay, lesbian, bisexual or transgender (GLBT) community are more likely to have mental illness, they are also more likely to run into discrimination in health care, thus lowering their rate of diagnosis and treatment.

Among veterans, post-traumatic stress disorder (PTSD) has caused significant morbidity since the Vietnam era. As many as 31 percent of Vietnam combat veterans have had PTSD, as has a similar percentage of those who served in the Iraq and Afghanistan wars. In fact, according to the Department of Veterans Affairs, one veteran commits suicide nearly every hour.

However, this is not just an American problem. Suicide is the third-leading cause of death in the world for individuals ages 15 to 44, having increased by 60 percent since the 1970s. One person commits suicide every eight minutes the Americas. This tells us that the problem is not one of just culture, environment or health care, but a situation that crosses all of these variables.

So what is our role as family physicians? Assisting in diagnosis and treatment could make a difference because 60 percent of individuals with mental illness do not receive treatment. A broader goal should be to help individuals overcome the stigma of mental illness so those who need treatment will seek it. Working with our clinic populations, along with local health departments or other community groups, we can educate the public about the legitimacy of mental illness and the crucial need for treatment.

What about preventing suicide? Some of the suspected causes for the increase in suicide in recent years include divorce, drug addiction, economic concerns and increased social isolation that stems from Internet and social media use. These are areas we rarely cover in our anticipatory counseling, but where education can make a huge difference in our patients and communities.

Recognizing the populations at highest risk, such as adolescents, veterans and members of the GLBT community, helps us tailor our prevention efforts. According to a U.S. Preventive Services Task Force evidence review, psychotherapy can reduce suicide by nearly one-third in adults. Considering the biggest antecedents to the recent rise in suicide, it also may be helpful to focus more on patients' personal relationships, economic stresses and even social media use. NIH has some great resources on healthy screen time and personal relationship-building that can be beneficial to patients and families.

There are many CME options related to the diagnosis and treatment of mental illness. For example, the AAFP is offering a Maintenance of Certification for Family Physicians self-assessment module that focuses on improving care of depression and coincides with the Family Medicine Experience Sept. 24 in Orlando, Fla.

Social determinants of health, issues that family physicians are acutely aware of in the public health realm, are believed to be the biggest contributors to suicide. The World Health Organization offers assistance in addressing these issues with our patients.

Mental illness and suicide are huge problems. But as with many problems in medicine, family physicians are poised to provide meaningful solutions.

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 May 17, 2016

Six Lessons From Six Months as Medical Director

Take calculated risks. Lead by example. Be inspirational.

When I became the medical director of our office, I had a smattering of leadership clichés in mind that I thought I should follow. I anticipated that in my new role, I would communicate updates to the team, handle conflicts and set objectives.

But my first six months as medical director of our office involved little of the above. Instead, it's been a whirlwind of navigating teams and strengthening the patient and staff experience. Each day comes with 40 new lessons of you-don't-know-what-you-don't-know moments, personal growth and professional opportunities.

Here are a few of the interesting lessons I've learned.

Culture eats strategy for breakfast. Those who understand organizational psychology embrace this as gospel. It's the key factor in why companies with innovative ideas and solid revenue streams still fail. It's a business philosophy, but I've found it to be even more important in medicine.

An organization's core values need to be woven into decision-making at every level. We don't exist just to prescribe patients' medications. We are not here simply to track labs. Every person in my office is mission-driven (to transform health care). This is evident in both grand insurance battles and small gestures. Our team is diligent about prior authorizations and advocating for care our patients deserve. But we also never hesitate to make tea for a sad or an anxious patient in our waiting room. Our positive culture leads to internal coherence that sees opportunities in challenges. This didn't happen by accident. We invested in defining our culture.

Everyone -- including patients -- should feel ownership of your organization. In medicine, the term "stakeholders" applies broadly to employees, insurance companies, the specialists we refer to, the imaging centers we use and so on. But the most important stakeholders in medicine are the patients, who often feel as though they have little impact on health care. As a result, many medical organizations have started patient advisory groups. It's a good step, but I've learned patient feedback should be continuously integrated into health care organizations in as many ways as possible, not just via a feedback survey or siloed groups. My patients love sharing their experiences -- whether it's about their care, the lab or parking.

The next part is key: Be nimble enough to use feedback as a catalyst for change in your organization. We've expanded our services (we now perform endometrial biopsies, for example) as the result of patient feedback. We've even changed processes, such as instituting an RN consult before placing an intrauterine device. Listening to feedback is a key part of making sure patients feel ownership.

You'll know you are doing it right when patients refer to your office as "we" instead of "you guys."

Infuse your organization with a constant stream of new ideas. People who spend countless hours together start to think like each other. In fact, they start to sound like each other. They even use the same phrases. It's easy to spiral into an echo chamber where no one challenges group consensus. Ways to avoid the prevalence of stagnation include creative hiring and fostering a culture where individuals feel comfortable dismantling the status quo. In fact, 94 percent of senior business leaders said the right people and culture are the most important drivers of innovation, according to global consulting firm McKinsey & Co.

Meetings should be productive, clear and frequent. There are so many meetings. They are in person. They are via video conference. They are on the phone. Some meetings have just two people. Other meetings include hundreds from across our organization. At first, my meeting schedule was exhausting. I took a deep dive into the literature on meetings (this actually exists) and learned meetings require active management, with strict guidelines, attendees, timelines, etc. And it's better to meet frequently, because this contributes to accessibility and responsiveness. As a result, our meeting agenda includes goals and action items for each topic. We have developed a meeting cadence and determined who should be part of each meeting -- and who shouldn't. Our meetings are now more productive and efficient, and we avoid meeting fatigue.

Data without context is dangerous. In this big data era, everyone loves hard numbers. But sifting through those numbers without understanding how they fit an organization's mission is counterproductive. Even worse, sifting through them without realizing any trends or meaning is pointless. Patient volume, patient satisfaction scores, lab reporting times -- these are important, but they don't tell the whole story of an office or patient care. The clinical quality numbers (emergency department visits, blood pressure control, A1cs) can be even more nebulous without understanding your patient population. I'm still figuring this one out.

Invest in professional, leadership and team development. We hire people for potential, not perfection. They generally have core values that align with ours, but they still require structured training, careful mentoring and a path that will challenge them. Even in my short time at my practice, I've been delighted to see admins transition into membership advisers and site stewards become phlebotomists. And we emphasize that one role isn't above another -- it's just a different contribution to the team. It's for good reason: Companies with engaged employees who are inspired, empowered, confident and enthusiastic outperform those without by as much as 202 percent, according to Gallup.

Our team has learned the value of collective leadership. It makes sense that a group, and not just an individual, will have the best solutions to complex issues.

These leadership lessons don't include what I have learned about patient care. Those lessons can't be contained in one blog post. They are more suited for a novel.

This reminds me of another cliché: life-long learning. It's valuable to embrace. I anticipate the next six months (then six years, then six decades) will be rich with lessons.

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

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