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Tuesday Jan 10, 2017

Why Do Women Docs Get Better Results (and Lower Payment)?

A recent study found that female physicians achieved better outcomes than men. We asked married practice partners Beth Oller, M.D., and Mike Oller, M.D., for their thoughts on gender and medicine.

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Tuesday Nov 22, 2016

Doing My Part to Help Physician Workforce Reflect Diverse Population

When minority physicians treat patients of the same minority group, patient satisfaction often improves and care is more culturally proficient. Unfortunately, there is a dearth of minority doctors in our health care system.

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Tuesday Nov 08, 2016

Girl Power: Moving Toward Balance in Physician Workforce

Women make up more than half of the U.S. population but only about one-third of the physician workforce. However, among the younger generation of physicians, more women are entering the pipeline. In fact, this year marked the largest increase in a decade in the number of women enrolling in medical schools.

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Monday Sep 19, 2016

Community Response to Disaster Shows Beauty of Rural Practice

An epic flood ravaged her town, but what Kimberly Becher, M.D., remembers most are the selfless acts of kindness that helped her patients put their lives back together.

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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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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 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.

Monday Feb 15, 2016

Discovering a Brave New World of Medical Scribing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday Jan 18, 2016

Doctor or Patient? Who Owns Medical Records?

Rachel (not her real name) has been a patient of mine for more than three years. She has a borderline personality disorder that makes it extremely difficult for her to create and sustain relationships and causes significant fluctuations in mood.

She suffered a serious stroke a few years ago, which further impaired her cognitive abilities. Her resultant extreme mood instability led to numerous suicide attempts. Some of them were not legitimate attempts, and she later admitted they were for attention. But there also have been times when she truly wanted to die. Her psychiatrist and I meet with her frequently to try to keep her as emotionally stable as possible.

Rachel will periodically ask to see her medical records. She has a legal right to these records, but there also is concern about how she may respond to seeing doctors' written opinions about her, particularly concerning her personality disorder.

The question of who owns medical information is a big issue. Should the physician or health system own it? Records represent our medical opinions on what is presented, and therefore are not necessarily property of the patient. But why shouldn't the individual own the records? It is completely about them and for them. The issue goes beyond medical notes. Lab work is a literal part of the patient; why should someone else own that?

Different states have different laws regarding ownership. Only one state, New Hampshire, explicitly gives ownership to patients, whereas most states have no law delineating custody of records. In Utah, where I practice, the physician and/or hospital owns the record, meaning that a patient must go through a hospital medical records department, oftentimes with considerable delay, to get their own information. Many systems provide limited access to information through Web portals such as MyChart. This grants a list of a patient's conditions that are listed in patient-friendly terms, medications, lab and imaging study results, and recommended preventive health measures. Basically, everything but reading their doctor's notes.

OpenNotes, an organization that encourages full patient access to their doctor's notes, has started a revolution in this area. More than 5 million patients from at least 20 institutions around the country have full and immediate access to their medical records. They log into a Web portal that allows them to see all of their health information, including what their doctor has written about them. The operative word here is their health information.

Many physicians have been nervous about this for various reasons. What will patients think? Will they be able to understand what is written? What about patients like Rachel? Could it truly be harmful for her to read the notes from her psychiatrist and me? A recent survey shows that two out of three physicians believe that they (i.e., the physician) should own the record.

But even many skeptical physicians have been pleasantly surprised by the results of allowing full access. In one published pilot project, the 105 primary care physicians who participated all wanted to continue its use by the end of the experiment. This pilot also showed significantly improved patient satisfaction and education, and it also was thought to contribute significantly to improved patient safety.

Despite initial concerns from many physicians, it is also believed that patient access to records will lead to fewer malpractice claims because of the increase in trust and transparency. OpenNotes represents a move away from medical paternalism and toward patient engagement.

Some are also concerned, however, that greater patient access could lead to confusion. The classic example is a physician using the acronym SOB. In medical terms it means shortness of breath, but there are other obvious interpretations that a patient may have. Physicians worry that they will have to spend more time explaining their notes to patients and less time on actual care. The pilot study mentioned above did not show that, but it's likely to take more widespread adoption before many cynics will buy in.

There is a pilot underway at Beth Israel Deaconess Medical Center in Boston allowing access to psychiatric notes. It will be interesting to see what it shows. It's possible that patients similar to Rachel will do just fine with more direct access to medical information.

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 Jan 05, 2016

Looking for a Hero: Kids Need Medical Role Models

One of my community's elementary schools invites local professionals in every Friday to speak about their jobs and answer kids' questions. Although the program is designed primarily to introduce children to varied professions, it also serves as an introduction to local professionals and possible mentors. Student attendance is voluntary, so those who participate show interest, even if they don't all ask questions.

The school recently invited me to speak to a group of fourth- and fifth-grade students about being a physician. There were the typical questions about salary and education. They asked about other specialties and allied health professions such as physical therapy. But many questions focused on specific diseases or disorders. Multiple students asked about problems facing their families and friends. They asked about pneumonia and other infections. They even asked about medical anomalies they themselves faced. 

Although health professionals are concerned about the Health Insurance Portability and Accountability Act and privacy rights, these kids weren't worried about who knew their problems. The students just wanted to know as much as possible about the challenges they face.

As I discussed health issues such as abscesses and broken limbs, I realized how little education some of these students had received about even the basic functioning of the body. Although they all seemed to grasp the answers I gave, each question led to many more, and we had to limit ourselves somewhat because of the time we had available.

And then it dawned on me. They -- just like their parents -- are victims of the same time constraints placed on primary care physicians. Likely, these children have never had the opportunity to ask their questions in a comfortable setting. Much like the five-minute office visits that have become all too common, there had been no time for these young minds to be curious without an agenda. We fill up our days with curriculum and planning, both in and out of the classroom. We've sacrificed the time to be curious.

We as physicians serve a hugely important role as educators. This knowledge we gained is not to be hoarded, but shared. Inherent in our job description is arming patients with appropriate knowledge and preparation. Too often we can choose the easy path of "do it because I said so," whether because of time constraints or our own limited understanding, but we owe it to our patients to equip them to deal with their maladies.

In multiple languages, the word for doctor and the word for teacher derive from the same root. Traditionally, medical knowledge was passed from one teacher to only a single or select few apprentices. The traditional Hippocratic Oath even begins with the following passage:

"I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary for his support, and will consider his sons as brothers. I will teach them my art without reward or agreement; and I will impart all my acquirement, instructions, and whatever I know, to my master's children, as to my own; and likewise to all my pupils, who shall bind and tie themselves by a professional oath, but to none else."

Teaching persists as an integral part of medical education and practice. From our first days as medical students, we are indoctrinated with the directive "See one, do one, teach one." Inherent in this phrase is the message that teaching someone a skill ranks equally in importance with the ability to perform the skill ourselves. Teaching the details, preparing for questions, and cultivating the ability to adequately communicate the intricacies of even the simplest procedures or concepts requires a high level of understanding. This includes the education of not only students and residents, but of our patients, as well.

Much like the students with whom I conversed, many patients are innately curious about their disease processes. We must take care not to stifle that curiosity but devise innovative ways for teaching and fostering education within the bounds of the current system. Although time constraints and economic concerns dictate parts of our practice, we must keep looking forward to better systems that will eventually replace the broken pieces. Whether through social media, group classes or some fledgling technology such as augmented reality, we need new tools for education and sharing information.

Education researchers in the 1950s demonstrated a correlation between increased curiosity and improved learning and retention. Think about the things you recall even after decades have passed. Nearly all of them relate to things that piqued your interest. I grew up watching scientists like Mr. Wizard and Bill Nye the Science Guy conduct experiments on television. I had teachers and physicians who taught me about the world around me and inside me. Without access to those individuals, I may have chosen another career path entirely.

One oft-proposed solution for physician shortages centers on starting recruitment and increasing student interest early in the education process. With the growing interest in science, technology, engineering, art and mathematics (STEAM) education, there has never been a better time to begin introducing medicine, especially the concept of whole-patient primary care -- family medicine -- to the next generation. Why not strike when naturally curious students are looking for answers? We need science heroes like the athletes and media personalities that our children often idolize.

We have thousands of well-qualified, intelligent physicians in communities across the country who appear ready and willing to lead that charge. AAFP President Wanda Filer, M.D., M.B.A., for example, has appeared on The Dr. Oz Show twice in the past nine months, discussing the importance of primary care and the dangers of prescription drug abuse. Regardless of what you think of that particular venue, there's no denying the fact that the platform allowed her to reach millions of viewers with those key messages.

We can talk to our young patients about their career goals and interests, but we also can look for broader opportunities in our local schools and through groups like the YMCA, Boys and Girls Clubs, etc. Physicians are in a unique position to be an inspiration for not only the young people we see, but also for patients of all ages. We can encourage their curiosity and give them tools they need to succeed and lead healthy lives.

Do you have suggestions or stories about how you've included education inside or outside your practice? Sound off in the comments below.

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

Tuesday Nov 24, 2015

Moving On: Finding the Right Job Worth the Effort

Starting over is scary.

After surviving college, medical school and residency -- and the many moves and transitions that come with those stages of our training -- the last thing we want is more upheaval. We finally have some stability, more income and something resembling a routine. We make connections with colleagues and build a patient panel.

So when things aren't ideal and payers and others are making life difficult, physicians often stick it out. We feel obligations to our communities, our practices and our patients.

But sometimes, we have to go. We have to do what is best for our careers and our families.

And sometimes you have to follow your heart.

In August, I moved from Reno, Nev., to the Seattle area, leaving behind the community where I had completed medical school, residency and then practiced for four years. I delivered babies in residency and had those families follow me into private practice. I developed relationships not only with my patients but also the medical community in my city and state. I built a reputation in the community. I knew the payers, the specialists and the layout of the community hospitals. I had a safety net and a village of medical support at my fingertips should I experience a difficult case.

In Seattle, I knew my new husband and … hardly anyone else. I knew nothing of the medical community or culture in this area. I had no local colleagues to vouch for my abilities as a physician. I now had to re-establish myself and my practice and go through the process of figuring out what type of practice would suit me.

So how do you find not only a job but the right job? I knew the change was coming, so when I attended AAFP events -- such as the Congress of Delegates or the National Conference of Constituency Leaders -- I sought out the Washington delegates, told them about the move I was pondering and asked about potential employers I should look at it. I also reached out to a few old med school and residency friends who had relocated here for advice on local groups they worked with.

That meant my job search was based on networking and informed opinions rather than random Internet searches and the biased opinions of recruiters. I visited many clinics, spoke to many employees of all ranks within those teams, and in the end I found a place that fits how I practice and has a better flow, organizational goal and payer mix than the practice I left.

Keeping an open mind helps, too. At my old practice, I had a dedicated medical assistant (MA). We had a traditional system where patients checked in at the front desk and then had a seat in the waiting room. In my new practice, the MAs rotate among the physicians, and patients are checked in directly to rooms. There were other changes to adapt to, including how we handle referrals and phone triage. But ultimately, patient flow is improved and everyone on our staff works to the highest level of their training. That's a refreshing change that allows me to spend more of my time with patients.

Starting over, of course, brings new challenges. I'm building a new patient panel and starting new relationships. I'm learning a new set of subspecialists for when my patients need care that I can't provide. I rely more on my colleagues to ensure I am performing tasks in the right flow for this clinic. I’m learning a new electronic health record (EHR) system while still having to perform meaningful use measures.

There also were numerous hoops to jump through. I had to find my transcripts from medical school and the U.S. Medical Licensing Examination to go through the Washington state medical boards to obtain my new license. I needed signatures from the residency and hospitals where I had privileges in Nevada. I needed to go through orientation again and EHR training.

There were numerous tedious steps to get through in the credentialing process, and I have to prove myself again in the privileging process.

I learned through this process that moving in general is a stressful time, but finding and establishing a new practice has its own set of stressors. Many of them are logistical -- licensing and finding a good fit for what you want in a practice. I found that using a spreadsheet to compare each practice helped me visualize what each clinic offered in terms of payers, practice type, EHR, etc. Although it was tiring at times, I was able to obtain a great amount of knowledge on the culture and relationships of each practice by approaching and talking with all members of the teams.

I also realized that I was not a physician fresh out of residency and therefore was able to negotiate compensation differently than I did four years ago.

Moving across state lines can be challenging for physicians, but it can be done. And you might just find a better life on the other side.

Helen Gray, M.D., is an employed family physician in Kirkland, Wash., working in a regional medical center.

Wednesday Nov 18, 2015

They're (Usually) Not Doctors, but They Play Them on TV

When I was an undergrad, I decided to pursue my emergency medical technician license at a nearby community college. I would get home from class each week just in time to watch ER. I joked with my roommates that I had to watch it as homework. I got excited when I started to understand what the doctors, nurses and others were talking about and could point out the show's medical inconsistencies and mistakes.

Helga Esteb/Shutterstock.com
Actor Ken Jeong, M.D., a former internist, arrives at a Hollywood premier with his wife, family physician Tran Ho, M.D. Jeong plays the title role in the new sitcom Dr. Ken.

Numerous medical programs have come and gone in the 21 years since ER began its 15-year run, but more often than not, TV still gets it wrong. Most medical dramas glorify and romanticize physicians' relationships with each other, nurses and even patients. These shows also manage to get so many things wrong about medicine that it leaves you wondering if the writers even bothered to have a medical team review their scripts.

Ironically, the only show in recent years that demonstrated any medical accuracy was Scrubs, a goofy comedy that did not take itself seriously.

There are a host of new medical shows making their debuts this fall. Will they be any more realistic?

  • Code Black takes place in the Los Angeles County Hospital ER and is based on a documentary by the same name.
  • Heartbreaker is based on the experiences of a real-life heart surgeon.
  • Chicago Med is a sister show to Chicago Fire and Chicago P.D. that is set in a trauma center.
  • Dr. Ken is the lone sitcom among the new medical shows and features physician-turned-actor Ken Jeong, M.D., probably best known for his roles in the Hangover movies.

It's worth thinking about the impact TV medical shows may have on our patients and whether physicians should be concerned about how our profession is portrayed. Everyone knows these shows are unrealistic … right? NBC, for example, gushes that the main character on Heartbreaker has "a racy personal life that's a full-time job in itself."

Ugh.

I'm not worried that my patients think I sneaked away to supply closets for romantic escapades during my training. But could these shows be contributing to unrealistic expectations of what medicine can actually do? Do they glorify saving lives in the ER setting? Do these shows negatively impact our attempts to educate patients about the importance of primary and preventive care?

During residency, when we admitted patients and discussed their code status preferences, I often found myself wondering how TV portrayals of CPR were affecting their decisions. As the Radiolab podcast article "The Bitter End" discusses, there is a huge discrepancy between what doctors would chose at the end of their lives versus what patients choose. And this is largely because we know realistically what CPR does and doesn't do. One study found that 75 percent of patients on TV are successfully resuscitated, and 67 percent survive long enough to be discharged from the hospital. The reality is that only about 40 percent of CPR administered in the hospital is successful, and a mere 10 percent to 20 percent of patients live to be discharged.

So when it comes to addressing what medicine can offer my patients, I often tell them that what they have seen on TV is not in line with what I have seen in real life.

As I watched a clip from Code Black, a comment about "saving someone's life" reminded me of friends who have said to me -- while discussing their own stressful days -- "Well, it isn't like I was saving lives like you, but … "

Our roles as family physicians are crucial as we strive to improve the health of our country. An ad for One Medical Group, which uses a novel approach to delivering primary care, came on while I was writing this very piece and wondering why there are no television shows about primary care. The answer, unfortunately, is because watching a patient sit in a waiting room or discussing Pap smear results doesn't make for an entertaining show.

The way that we as family physicians save lives is often not what our friends, family and patients might expect based on what they see on TV. And the tools we use to do it are not necessarily the CT scans, frequently excessive labs and involvement of several subspecialists that are the norm in TV dramas that fail to emphasize patient-centered care and clinical skills.

But there may be some hope for how medicine is portrayed on TV. The executive producer for Code Black, Ryan McGarry, M.D., is the ER physician who directed the documentary that the new show is based on. Before filming ever started, the show's cast went through a medical bootcamp, and the actors actually work 12-hour shifts to reflect conditions that one might experience as a resident physician or a nurse. So although the dramatic "saving lives in the ER" aspect is still present -- against the backdrop of one of the busiest ERs in the country -- at least there is an attempt at medical accuracy.

It's worth noting that the sitcom Dr. Ken does not take place solely in the main character's primary care clinic because the show also is about his role as a father and husband -- like so many of my colleagues' lives are. When he tries to make his job sound important, his wife -- a therapist -- angrily retorts that "it's family medicine, not the ER."

Although that snippet of dialogue was disappointing, the pilot episode demonstrated the true significance of having a family physician. Dr. Ken sends a patient for a colonoscopy and receives a letter of gratitude because the polyp that was removed could have been "fatal." Perhaps TV's Dr. Ken -- who in real-life is an internist married to a family physician -- will expose our patients to the importance of making health primary.

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

Tuesday Oct 27, 2015

Digging Out of Medical School Debt

The number of students enrolling in U.S. medical schools has reached a record high, despite the fact that the cost of becoming a physician also continues to climb. The number of first-year allopathic medical students increased to 20,630 this year, up 1.4 percent from last year's record-breaking enrollment.

Although these brilliant young students can look forward to a future of serving their communities, healing the sick and comforting the dying, many also will face a future burdened by significant debt.

It is estimated that between education costs and years of lost earning potential, it costs at least $1 million to become a physician. And medical debt burden is growing at an alarming rate. In 2006, the average medical student's educational debt was more than $120,000. Less than a decade later, that figure has grown to an average of $180,000.

But does it have to be this way? The Association of American Medical Colleges projects a shortage of as many as 90,000 physicians by 2025, so we cannot let students who are interested in careers in medicine be deterred by the high cost of training. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care estimates that the shortage of primary care physicians alone will be in excess of 33,000 by 2035.

Wayne State University in Detroit recently announced plans for an innovative way to provide medical education for students from disadvantaged backgrounds. Each year, 10 students who agree to study health disparities as part of their medical career will receive free undergraduate tuition, free housing, guaranteed acceptance into medical school and free medical school tuition. This program will be paid for through donations, and the goal is for the university to become a national hub for the study of health disparities.  

Other programs like this are slowly cropping up across the country, and there is a huge need -- not only to help physicians pay off their burdensome debts, but also to address health disparities.

But what about those of us who already made it through medical school without the benefit of a program like the one at Wayne State?

I graduated from a private medical school in 2009 with roughly $215,000 in education debt, making my load significantly higher than the national average. With my growing family, I was unable to start payments until after residency, using the forbearance option on my loans. I have been paying slightly more than the minimum payments during my three years of practice and I currently owe … $215,000. Because of high interest rates, I have not yet gained any ground.

There are, fortunately, some programs to assist physicians with their debt burden. I recently took advantage of the AAFP’s new partnership with SoFi to consolidate and refinance my remaining loans. This has provided a lower interest rate, lower monthly payments and the ability to pay off my loans faster.

There are numerous loan repayment and forgiveness programs, as well as other resources. I recently authored a resolution adopted during the AAFP’s 2015 Congress of Delegates (COD) that calls for the Academy to add to its website a page listing various national options for repayment because it is often difficult to find them all on your own. The Academy's website already features many resources about debt for medical students.

My resolution also asked for the AAFP to assist state chapters in lobbying for programs that have been effective in other states. According to the Association of American Medical Colleges, there are currently 70 state-based repayment, forgiveness or scholarship programs open to physicians, the majority of which are aimed specifically at primary care.

In Utah, we have recently had some success in recreating a loan repayment program for physicians practicing in rural areas. That program was defunded during the recession, but now we are hoping to expand it. At least three other states also passed bills this year related to physician loan repayment.

Another resolution adopted by the COD calls for the Academy to advocate for greater loan reimbursement for those in the National Health Service Corps who are not working full time. Many employers also offer some loan payback options to entice family physicians to work in areas of high need.  

I am glad I chose family medicine; I wouldn’t change my mind if I had to do it over again. But medical debt burden is a common problem facing physicians in all specialties. The best thing we can do is to share our stories, continuing to lobby both lawmakers and individual institutions to make costs more reasonable, decrease loan interest rates, provide more scholarships, and increase opportunities for loan forgiveness and repayment.

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 Oct 06, 2015

Cloudy With a Chance of Misdiagnosis

"As an adolescent, I aspired to lasting fame, I craved factual certainty and I thirsted for a meaningful vision of human life -- so I became a scientist. This is like becoming an archbishop so you can meet girls."

-- Matt Cartmill, Ph.D.
"Seventy-five Reasons to Become a Scientist
,"
American Scientist
(Sep/Oct 1988)

"Predictions show a steady low.
You're feeling just the same.
But seasons come and seasons go.
I'll make you smile again.
If you don't believe me,
Take me by the hand.
Can't you feel you're warming up?
Yeah, I'm your weatherman."
-- Delbert McClinton, "Weatherman"

As the sum of our knowledge grows, it becomes more apparent how much more there is to learn. What we think of as fact can be easily and rapidly overturned by new observations and understanding. During the past month, I've heard more than one person discuss the "old days" of medicine, often lamenting that their doctor now gives them choices in their care.

"I miss when they would just tell me what was wrong and give me a medicine to fix it," I heard one person say. My first instinct was to defend the rights of the patient and to expound on the greatness of patient autonomy. I queued up long discussions of the antiquated paternalistic model of medicine and why the informative and deliberative models are far superior. My internal anarchist railed against blindly following those who have confidence and who assume they know what is best.

But then I stopped and looked at the situation from the perspective of these patients. What would someone -- raised among the miracles of technology, without any training in pathology or diagnostics -- see from the outside in the paternalistic model? The doctor listens, examines, and then pronounces with absolute certainty a diagnosis and treatment plan. It’s the magical black box. Information goes in and apparent cure comes out. As physicians, we know the truth. The reality is far more mundane and far less certain.

This fundamental misunderstanding of the actual amount of knowledge we as physicians possess and how we apply it leads to a mismatch in expectations and reality. Most patients don’t understand that a large proportion of what we do is based on statistical probability. The informative and deliberative models of medicine we were taught in medical school encourage us to share the thought processes and basic science behind our differential, but the process underlying our diagnostics is fundamentally no different from the paternalistic model. We observe, collect data, calculate probability and choose the most likely etiology.

It strikes me, as I contemplate this process, how closely we resemble another group of scientists -- meteorologists. We deal with complex systems. Both climate and human pathology involve hundreds, if not thousands, of variables. We collect data and select the most pertinent facts for inclusion in our models. We move from the general to the specific and make predictions based on collected data. We choose the models with the highest probability and share those with our constituents. As time passes, we collect more data, which often improves the probability analysis. We compile a differential diagnosis or a forecast. And, unfortunately, hindsight often makes fools of us all.

The more pertinent information we collect, the better our predictive models will be. Whether a function of more time or better tests, higher volumes of data improve predictions. To that end, both medicine and meteorology now outsource data collection for stronger models. Not only do we use measurements from inside the clinic, but patient-collected data from health trackers and fitness tools expand the pool of available data. We also use stronger computing tools to crunch the higher volumes of numbers. Advanced computing solutions such as IBM’s Watson can assess facts and context and ultimately output predictive models on par with those of many physicians and meteorologists. And with the growth of precision medicine and molecular genetics, we now have more specific data about the molecular underpinnings of our biology.

Although there are many facets of medicine -- and meteorology -- that carry high levels of certainty, few outcomes approach 100 percent probability. There is always a chance we are wrong. We describe most diagnostics in terms of sensitivity and specificity, or what’s the probability that a positive test result is truly positive or that a negative test result is truly negative. If there are too many false-positives or false-negatives, the test doesn’t help us with accurate prediction.

Which brings us back to the initial discussion of patient perception. Under the paternalistic model of medicine, the process was the same, but the internal mathematics remained hidden from the patient. This gave the mistaken appearance that progression from simple discussion to diagnosis followed an absolute and direct causal pathway. Tell the doctor the symptoms, and the doctor tells you what caused them. No mention of process. No peeks behind the curtain. From the lay perspective, it looked like magic. Multiple generations of patients grew up thinking many diseases and disorders were easily and rapidly cured with the magic prescription pad. The trouble with that belief isn't just that it fed skewed understanding of causality and correlation, but more that if the disease wasn't immediately cured or the problem resolved completely, the patient assumed the treatment was inadequate or incorrect and the doctor incompetent, even if both treatment and physician were medically correct.

Much like incorrect forecasts have left us skeptical of the abilities of meteorologists, incorrect or incomplete diagnoses do little to endear us to our patients. If we wish to combat this phenomenon, further explanation and discussion of the probabilities and process involved in differential diagnosis will go a long way toward improving patient compliance.

Perhaps the focus should not be on misdiagnosis, but rather the process of diagnosis as a whole and how we can improve it over time.

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.

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