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Wednesday May 27, 2015

Food Desert: A Community Coping Without a Grocery Store

A couple of months ago, I heard rumors that our county grocery store might close. That’s right  -- not town, not local, not biggest, not best, but the ONLY store in the county might go out of business.  

About 500 people live in Clay, W.V., and roughly 9,000 live in the county. It seemed like one of those things that just couldn't happen because there is plenty of demand for the business. So it wasn’t until the store's sign was gone and the doors were locked that I accepted the fact that my patients no longer had access to a grocery store. A list of brittle, insulin-dependent diabetics and precariously balanced heart-failure patients flooded my mind. I worry about all of them every day. 

Since the store closed, I’ve been asking my patients where they buy their food. If they have diabetes, I ask what their sugar has been doing. My heart sinks when they say they are buying all their food at the Go-Mart. Not that it's a bad place (if you need gasoline) but the food choices are high-carb, high-salt and deep fried. (My patients also complain that it's expensive.) This isn’t just a run-of-the-mill gas station. It also offers prepared foods, and it reportedly has the best fried chicken in town. A couple of miles away are Family Dollar and Rite Aid stores, both of which have a few shelves of food as well, but, again, it is mostly processed and less than ideal.  

On May 8, the comment period ended for the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (DGAC) which is produced by the HHS Office of Disease Prevention and Health Promotion. As I read Chapter 4: Food Environment and Settings, I was surprised (and happy) to find the list of reference articles contained numerous studies regarding access to healthy food. We know what foods to avoid and what foods are better for us and our patients. But proximity to a grocery store or farmer’s market is critical to the chronic disease status of a community.

My concern as I searched through the document wasn’t how many fruit and vegetable servings we were now going to recommend, but how much social and geographical inequalities were contributing to poor health outcomes, and what was the plan for addressing it?

The CDC’s Community Health Improvement Navigator provides resources and examples of improvement strategies for various stakeholders, including physicians. It attributes 40 percent of our health outcomes to socioeconomic factors and 30 percent to health behaviors. Both far outweigh the 20 percent physicians contribute to via clinical care.

A recent study by Virginia Commonwealth's Center on Society and Health examined how life expectancies vary by ZIP code within the same communities. For example, Richmond, Va., had the starkest data with life expectancy variances of 20 years in two neighborhoods that are just 5.5 miles apart.

Understanding such health disparities is not as simple as identifying who chooses to eat fast food or smoke. It is about so much more than that. Something as simple as how a home is heated can have serious, long-term implications on patients' health. Largely due to cost, many of my patients heat their homes by burning wood or coal. Often I see a grandparent with chronic obstructive pulmonary disease raising a grandchild with asthma, and both patients suffer through the winter due to poor air quality inside their home.   

So, what does the DGAC report say about diet? Access to farmers markets and produce stands result in healthier eating habits. The data is less clear when it comes to supermarkets and grocery stores. But in the more rural, seasonal growing areas, the grocery store is the produce stand. The report readily admits that it was difficult to compare data across studies, and most were specific to one type of geography, e.g., inner city vs. rural. The report clearly found that proximity to a convenience store led to higher BMIs.

The report also studied influences and efficacy of school- and work-based interventions. In the end, the report found that multiple strategies work to improve healthy eating habits at all ages, but that a definitive, all-encompassing approach is impossible given the variability between communities. It defines areas of future research, highlighting projects that work and encouraging partnerships of all types to create thriving businesses that would improve food access as well as workplaces that promote healthy behaviors.  

A few years ago, a local health department study concluded Clay County residents lacked access to fresh produce (even with a grocery store) so the local extension service set up a farmers market. The market opens June 4, but it will only operate four hours a day, one day a week.

The growing season is just getting rolling here in West Virginia and lasts through August before dwindling in the fall. Fortunately for local families, school is running later than usual to make up for numerous snow days, so kids will get a couple of meals a day at school until June 15. After that, parents will struggle to find easily accessible food sources during what may be a trying summer break.

My hope is that someone takes over the vacant store, reopens it with the county’s needs in mind, and my patients realize how much they missed having access to healthy food while the store was closed. Perhaps that will  prompt some to make up for lost time and replace all the packaged, fried food they likely will consume in the next few months with fresh, lower-calorie meals when they have the opportunity.

A few months ago, I bought cookbooks for each of my exam rooms, and my nurse encourages patients to look through them while they are waiting for me. One patient asked to borrow one and take it home, to which I obviously said yes. But right now, no one without the means to travel 40 miles to a grocery store in an adjacent county could make even one of those recipes.

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

Tuesday May 19, 2015

Far From the Madding Crowd: Whole-Patient Focus Facilitates Diagnosis

Many of us have struggled with perplexing cases in which the diagnosis remains elusive. Trying to solve these seemingly insolvable cases captures the mystery and art of the practice of medicine.

However, for patients, this can quickly become their worst nightmare. One such patient suffered with symptoms that threatened to ruin her life. It took more than three years, evaluations by two dozen physicians and more than $100,000 in medical costs to find the correct diagnosis and treat her condition.

It was that patient's story that inspired Jared Heyman to found in April of 2013. The patient was his sister.

CrowdMed is an online service that uses the “wisdom of crowds,” along with a prediction market algorithm, to generate a list of possible diagnoses and treatment suggestions for patients with conditions that have not been diagnosed by more traditional medical models. A patient using the service fills out a detailed questionnaire, uploads all of his or her test results, and then the patient's case is reviewed online by what CrowdMed calls its "medical detectives."

According to CrowdMed's website, these are people from all walks of life, although 57 percent of them work in, or are studying for careers in, medical professions. Sixty-nine percent reside in the United States, but 19 countries are represented.

Interestingly, the average age of a medical detective is 36 -- not exactly the gray-haired authority one would envision working on such difficult cases. The medical detectives brainstorm and come up with a list of possible diagnoses that are then ranked in order of most to least probable by the algorithm. The patient then takes the list back to his or her physicians, and, hopefully, a diagnosis is confirmed.

According to CrowdMed, the service comes up with an accurate diagnosis 80 percent of the time.

Of course, there are some legitimate concerns from the medical profession at large, including the ethics of such an arrangement and issues regarding liability. Patients must sign a waiver agreeing that CrowdMed is in no way liable for anything. (Don’t you wish you had that option in your own practice?) Also, although CrowdMed's privacy statement says it will not sell any information that identifies patients, the company reserves the right to sell any nonidentifying information.

CrowdMed also states it is not bound by the Health Insurance Portability and Accountability Act, so it is up to patients to safeguard their identity in anything they upload. Also, buried in the fine print on the site is the disclaimer that if CrowdMed is acquired by another company, it cannot guarantee that a new owner won't sell patients' private information.

Among other concerns about this service is that it may undermine the physician-patient relationship. Patients may start to mistrust their physician or question that physician's qualifications. And who hasn’t had to spend extra time educating a patient who came into the office with a list of diagnoses he or she dug up on Wikipedia?

As I looked at the CrowdMed website -- which has several vignettes of patients who were helped by their service -- I was struck by two things. The first is that many of the vignettes have a common thread: patients who complain they were seen by specialist after specialist without a diagnosis. I wonder, where was the primary care physician during all these subspecialist visits? Perhaps the reason the diagnosis remains elusive in some of these cases is that care is too fragmented and specialty-driven, and we simply cannot see the forest for the trees.

A family physician should be the key person compiling the results of tests and procedures, looking at the patient as a whole, and coordinating that patient's care. Of course, doing so will likely require a significant amount of collaboration, and this can be difficult in our current medical system. Time is limited, and getting multiple physicians to discuss a single case at the same time can be like herding cats.

The second thing that struck me as I read the vignettes was that I often knew the correct diagnosis after the first paragraph. This has nothing to do with my clinical acumen and everything to do with taking a proper history and correctly organizing information. Have we forgotten how to take an adequate patient history?

Our current system sets us up for failure because too often we are pressed for time and put too much emphasis -- and reliance -- on test results. We sometimes forget that no test is infallible, and the results need to be interpreted in the context of the case as a whole.

In some ways, the demand for a service like CrowdMed points out how our medical system can fail patients, and as practitioners, we should do our best to avoid these shortcomings.

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

Wednesday May 13, 2015

Here's Why New Physicians Should Care About Global Health

For generations, the United States has proudly labeled itself a melting pot of cultures from around the globe. Not only has the influx of people continued -- it has accelerated. According to population projections released by the Census Bureau last year, 43.3 million documented and undocumented immigrants live in our country. Immigrants account for more than 13 percent of the U.S. population, the highest percentage in nearly a century.

With our patient populations becoming ever more culturally and ethnically diverse, it is important for us to be aware of how this cultural interplay affects our clinical encounters, treatment options and medical outcomes. Understanding and learning about my patients' cultures has improved clinical rapport, patient compliance and satisfaction. Hand-in-hand with this has come a boost in follow-up rates.

Here I am discussing international exchange opportunities available through Polaris. I spoke recently at Iberoamerican Congress of Family and Community Medicine in Montevideo, Uruguay.

As our world becomes more interconnected, both the interest in and need for global health has risen. Not surprisingly, those who have completed an international clinical rotation tend to report an improved ability to recognize disease presentations in addition to more comprehensive physical exam skills with less reliance on expensive radiographic imaging. This is important because the United States has one of the most expensive health care systems in the world, yet our outcomes lag behind those of other developed nations.

Global health initiatives allow us to interact with our international peers to learn about their medical systems, share best practices and strengthen our cultural intelligence. These opportunities are not only valuable for medical students and residents, but also for new physicians who are still solidifying their specific style and preferences for medical practice. With experiences through exchange programs such as FM360 (as described by family physician Aaron George, D.O.), who would not want to participate?

The majority of our newest physicians have grown up as part of Generation Y -- a.k.a., millennials -- and share a unique set of experiences and characteristics. Our entire lives have been inundated with modern technology, including cell phones, computers and the Internet. Notably, we are also more likely to speak a foreign language, engaging with both our local and global communities through face-to-face clinical encounters, online messaging and social media.

Although time and money can be limitations, physicians and medical students still may participate in the global health community through one of many organizations, including the AAFP or Polaris (our North American New and Future Family Doctor Movement) or via initiatives like our Balint 2.0 group and the Polaris international journal club, the AAFP Center for Global Health Initiatives, the #1WordforFamilyMedicine social media project, the FM Changemakers group and many more. Most of these novel approaches are discussed in the following section, and you can learn more by following @WoncaPolaris on Twitter or joining the Wonca Polaris group on Facebook.

Recent Events
Maria del C Colon-Gonzalez, M.D., and I recently represented the Wonca Polaris group in Montevideo, Uruguay, at both the Iberoamerican Congress of Family and Community Medicine and the Young Doctors' Movement (YDM) preconference. We served on the preconference organizing committee and as speakers and moderators for small-group discussions that took place during the preconference. Later, at the congress, we participated in the rural medical education panel, made four oral presentations, including one regarding improving research methods for residents and new physicians and presented two posters. The presentations resulted from collaboration with family doctors from countries around the region, including Peru, Uruguay, Colombia, the Dominican Republic, Portugal and Spain.

Undoubtedly, evidence of Polaris' positive effect in the Latin American region went far beyond posters and presentations. One such example was a Polaris initiative -- the Balint 2.0 Ambassadors -- which has united all seven Wonca YDMs in the first-ever multi-international online Balint group. Of the 14 international participants, five were present in Montevideo.  

Additionally, the social media project #1WordforFamilyMedicine, which launched eight months ago during the AAFP Global Health Workshop, has gone viral in Iberoamerica. The project asks family physicians and residents to describe their favorite part of our profession in a single word on Facebook or Twitter. Responses are then collected and the lists are turned into "word cloud" images that represent the specific participating region/country. Of the 50 countries that have participated, almost half are in the Iberoamerican region.

Evidence of the project was abundant during the conference in the form of T-shirts, photos, mugs, posters and more. This ongoing project has helped unite young family physicians from different parts of the world and has improved our specialty's image around the world.  

World Family Doctor Day
May 19th marks a special day for family physicians: World Family Doctor Day. The AAFP and family medicine organizations around the world will be celebrating in different ways. Family physicians are asked to display the #1WordforFamilyMedicine image on our social media profiles. An online interactive map shows the countries that have provided images to date. Go to the map, and click on the image over your country. Right click, save and display on your profile.

Also on May 19, I will be speaking with medical students about the intersection of family medicine and global health through the live social media series Family Medicine On Air hosted by the AAFP's Family Medicine Interest Group Network.

Lastly, the Polaris-led ASPIRE Global Leader Program will launch on World Family Doctor Day. We welcome medical students, residents and new physicians who want solidify their leadership skills and become more involved in global health to participate.

Looking Ahead
Polaris is focusing its efforts on organizing Wonca North America's first international preconference, which will take place on Oct. 1 in Denver before the AAFP Global Health Workshop. Both of those events are being held in conjunction with the AAFP's 2015 Family Medicine Experience (formerly Assembly).

In addition to our Canadian and Caribbean colleagues, the preconference's organizing committee is delighted to have assistance from other regions' YDMs. The preconference and the Global Health Workshop will give medical students, residents and new physicians opportunities to develop in the areas of research and scholarly activities, as well as in leadership and mentorship.

Kyle Hoedebecke, M.D. is a 2013 graduate of the Womack Family Medicine Residency in Fort Bragg, N.C.  He is a clinician in the U.S. Army, an assistant professor at the Uniformed Services University and serves as the chair of Polaris. Speaking Spanish, Portuguese and Guarani, his passions include global health, traveling and spending time with his family.

Wednesday May 06, 2015

Dealing With Addiction at Home

Roughly 320 million people live in the United States. Ponder that number for a moment while considering that in 2012, U.S. health care professionals wrote 259 million prescriptions for opioid pain killers. My state, Nevada, ranked on the high end, with more than 82 pain killer prescriptions per 100 people.

So, although it is frustrating for physicians trying to help patients with legitimate pain issues, it's no surprise that state lawmakers have put additional restrictions on prescribers. Legislation our governor signed into law this week authorizes the state's medical licensing board -- and the licensing boards for all other health care professionals able to prescribe opioids -- to establish new CME requirements for doing so and requires prescribers to register with a prescription drug monitoring program.

(According to the AAFP's position paper on pain management and opioid abuse, the Academy opposes mandatory CME as a prerequisite to licensure "due to the limitations on patient access to legitimate pain management needs that may occur.")

The new law comes on the heels of research that shows that roughly one-fourth of prescription painkillers are misused, and about 10 percent of patients who take them become addicted.

Dealing with chronic pain is common for family physicians in my state, where there are too few pain specialists and patients face long waits for appointments. Although we've all dealt with chronic pain in our practices, I've wondered a lot in the past year how many of my colleagues would know what to do when addiction becomes not only a professional issue but also a personal one.

This is my family's story.

My husband -- now ex-husband -- began taking prescription painkillers while recovering from an injury. If there were red flags -- and there probably were -- I missed them while working full-time and raising four kids. So it was a shock when I learned that my husband had been discharged from a family medicine practice because he was misusing his medication.

I tried to help him, and I (and others) urged him to get help. But things actually got worse. After we separated, I was again surprised when several of my physician colleagues informed me that he had approached them with requests for prescriptions. He had been doctor-shopping our friends.

Although my husband's physician was limited in what he could say to me because of the Health Insurance Portability and Accountability Act, these other physicians had no such restrictions. Why hadn't anyone talked to me sooner?

They likely weren't sure what to do or say, and it certainly would have been an incredibly awkward conversation. But maybe an early intervention might have made a difference. When there are obvious signs that a person -- and a family -- need help, it's important to speak up. Even if the conversation is difficult, you can walk away with a clear conscience knowing you had good intent.

In retrospect, I realize that I also could have benefitted from asking for help as my family went through this difficult transition. At the time, I was embarrassed that this terrible problem that I have helped my patients with had found its way into my own home. I was concerned there would be a stigma in our health care community.

I should have known better. My colleagues have been incredibly supportive. They understand addiction.

Now, I feel like I understand it better, as well. Our life experiences can affect how we treat patients, and I think I'm more empathetic now when dealing with patients who have addictions. I better understand what it's like to be that person who has to make a difficult life choice for his or her well-being and that of his or her family.

Sadly, we likely will be hearing more stories about families like mine.

It's worth noting that American Family Physician has compiled a collection of journal articles and other Academy resources related to the treatment of chronic pain. The Web page even includes links to the Academy's CME activities on management of chronic pain.

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

Wednesday Apr 29, 2015

Family Leave Policies Failing U.S. Families

It has been more than 20 years since President Clinton signed the Family Medical Leave Act (FMLA) into law, guaranteeing 12 weeks of unpaid leave to employees for certain family or medical reasons. That law was an important first step, but a number of restrictions on FMLA -- size of employer, length of employment and full-time vs. part-time employment -- render it useless to roughly 40 percent of U.S. workers.

Even more troubling is that since FMLA became law, little progress has been made nationally to support working parents with newborn or adopted children. President Obama, however, vowed to prioritize paid leave earlier this year in his State of the Union Address.

Here I am with my daughter at our mom-and-baby yoga class. Maternity leave not only gave me time to focus on the care of my child but also time for us to bond.

The United States lags far behind most developed countries on this issue. In fact, an International Labour Organization report published last year examined information from 185 countries and territories and found only two that did not offer some form of paid maternity leave. Sadly, the two exceptions were Papua New Guinea and the United States.

A map published last June by The Atlantic graphically illustrates how poorly we compare to the rest of the world. Only three states (California, New Jersey and Rhode Island) offer some form of paid family leave.

I recently returned to work after the birth of my daughter and am grateful for a revamped parental leave policy at my job that is more in line with those that benefit families in other advanced countries. Not only did I benefit directly from this support, I was proud that my workplace acknowledged the importance of supporting all of its staff -- and our families -- during one of our most important life events.

This is significant because we strive to be leaders in the communities where we work. For our patients, many of whom come from low-income, disadvantaged populations with poor health outcomes, we are better equipped to advocate for their rights when we are able to see first-hand the impact of such policies.

Why should we, as family physicians, be leading the charge for paid parental leave? Family leave has broad public health implications, from maternal mental health and breastfeeding to infant mortality and child development.

In my clinic, we screen for postpartum depression at every well-child check. The questions are built into our electronic health record system. Research has found that women experience a wider range of disorders now being called maternal mental illness, a term that recognizes the symptoms of postpartum depression can begin any time from before the baby is born through the first year after giving birth. A 2013 article in JAMA Psychiatry found that one in five women suffer from depression during the first postpartum year. Another study found that returning to work less than six months after childbirth increased the risk of postpartum depression.

Additional research is needed on this topic, but it is becoming more apparent that there is a correlation between maternal mental health and the kind of support -- financial as well as social -- women receive during that critical postpartum period.

The AAFP recommends that "all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first six months of life" and that breastfeeding "should continue with the addition of complementary foods throughout the second half of the first year."

Although laws now require that workplaces accommodate employees who need to pump, the reality is that it can still be difficult. I am fortunate to work in a supportive atmosphere where my pumping sessions are scheduled so that no patients are scheduled during that time, and my staff are protective of that time. A colleague of mine has almost given up pumping during the day because her clinic has done nothing to ensure that she has the time or necessary staff arrangements to make pumping an actuality.

If mothers had the option of staying home for the first six months, knowing their leave was at least partially paid and that their job was protected, perhaps the rate of breastfeeding in this country would be closer to our goals.

Child Health
It's not news that the United States doesn't lead by example when it comes to infant mortality. In 2014, the infant mortality rate was 6.1 deaths per 1,000 live births, which put our nation last on a list of 26 developed nations.

Research has shown that when maternity leave increases, infant mortality rates decrease. Years before the United States adopted FMLA, research showed that 10 weeks of maternity leave decreased infant mortality rates 1 percent to 2 percent, and 30 weeks produced a 7 percent to 9 percent reduction. Although our infant mortality rates are the result of many variables, we should not ignore the fact that they are higher than those of every other advanced country, even as our parental leave policies trail behind theirs.

Families that are struggling with an infant whose health is failing shouldn't also be faced with financial concerns and possible job loss when they need to take extra time to care for that child.

Child development is intricately linked to the maternal-child relationship and has lasting effects on the child's health.

Many of my pediatric patients in the Bronx struggle with obesity, learning disabilities and mental health disorders. I often wonder what their future will be like. Will they still be living in the Bronx, dealing with a low-paying job, struggling with the physical ailments that result from being obese their entire lives? What if their mothers had the opportunity to have a supportive maternity leave that ensured some wages and a job to return to postpartum? This is an area of health that is multifactorial, but if a multipronged approach is needed to improve the mental and physical health of the children we care for, certainly better parental leave should be one of those prongs.

It comes as no surprise that unpaid parental leave disproportionately impacts low-income, single and minority mothers and fathers. As family physicians, we are the ones who care for the patients in rural areas, the patients who are uninsured, the patients who have problems accessing medical care. We must advocate for the health of these patients on a broader scale, and helping them secure a substantial parental leave could have significant health implications for them and their families.

Finally, although much of the research on this topic evaluates maternity leave, fathers' access to a protected and paid time off after the birth of a child is also important and, not surprisingly, is yet another place where we lag behind many other countries. Research shows that paternity leave benefits women and their communities.

For the health of the families we have dedicated our careers to caring for, and for the health of the communities we work in, we, as family physicians, need to join the fight for a better parental leave policy nationwide.

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

Wednesday Apr 22, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Apr 15, 2015

Respect, Support Moms' Breastfeeding Decisions

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

Translation: I was extremely fortunate. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Apr 07, 2015

Step by Step: Proper Planning Essential for Quality Improvement

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

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

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

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

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

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

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

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

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

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

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

Tuesday Mar 31, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Mar 24, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Mar 18, 2015

Is Your Stethoscope Making Patients Sick?

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

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

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

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

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

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

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

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

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

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

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

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

Common sense cleaning can cut out a lot of risk.

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

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

Wednesday Mar 11, 2015

Media's Focus on Dietary Cholesterol Masks Bigger News

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Mar 04, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

So what am I going to do?

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

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

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

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

Tuesday Feb 24, 2015

Overcoming the Slings and Arrows: How Humor Can Save Us

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

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

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

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

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

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

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

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

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

Sarah is one of them.

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

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

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

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

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

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

"OK," she said.

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

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

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

"I think that would be just fine."

She smiled, satisfied with our unusual conversation.

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

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

Tuesday Feb 17, 2015

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

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

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

© 2014 David Mitchell/AAFP

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

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

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

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

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

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

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

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

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

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

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

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

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