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Wednesday Mar 22, 2017

AHCA Won't Help Patients Who Need It Most

We asked our new physician bloggers how the American Health Care Act would affect their patients. Most said the legislation would hurt the poor, the elderly and the disabled.

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Wednesday Feb 15, 2017

Why Do We Adopt Evidence-based Data at a Snail's Pace?

It takes nearly two decades for the U.S. health care system to adopt new evidence-based findings. Kyle Jones, M.D., ponders the problem.

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Friday Dec 02, 2016

Gallows Humor Is No Laughing Matter

Does physicians' use of so-called gallows humor impact patient care and/or physician burnout? Kyle Jones, M.D., writes that it just might.

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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]

Friday Jul 29, 2016

Artful Communication of Evidence Can Overcome Anecdotal Fears

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

Tuesday May 24, 2016

How Can Family Physicians Turn Back the Rising Suicide Rate?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday Apr 12, 2016

Does Prevention Save Money? That's the Wrong Question

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

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

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

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

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

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

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

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

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

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

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

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

So what does this all mean?

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

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

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

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

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

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 Dec 01, 2015

High Costs (and Profits) of Prescription Drugs Make Me Sick

Reggie is a spunky, 38-year-old patient of mine who makes my clinic day more enjoyable. His collection of chronic health problems -- including type 2 diabetes, near-complete hearing loss, bipolar disorder, active hepatitis C from prior IV drug use with no current liver fibrosis and chronic migraines -- certainly make life more difficult for him, making his buoyant personality all the more remarkable.

Reggie and I have been working on these conditions since I started practice a few years ago -- well, except for the hepatitis C, even though he does have a treatable strain. Because many of his other conditions would likely be significantly worsened by the standard treatment regimen of interferon and ribavirin, he has never been a good candidate for therapy.

You can imagine my excitement when many new treatment regimens with considerably fewer side effects began receiving FDA approval, beginning with sofosbuvir (Sovaldi) and simeprevir (Olysio) in 2013. I began coordinating with a hepatologist at that point to get Reggie the care he needed, but we quickly discovered that none of these regimens would be approved for him because of the exorbitant cost, reportedly more than $84,000 for a 12-week treatment course. Reggie is covered by both Medicaid and Medicare, but neither payer would cover the cost because, ironically, his disease had not yet progressed far enough.

Likely every family physician has stories like this, whether about patients with hepatitis C or other conditions requiring expensive medications. If every person in Utah afflicted with active hepatitis C disease were to receive treatment with Sovaldi, it would consume the entire Medicaid budget for my state. The average cost of medications for complicated conditions such as cancer, rheumatoid arthritis and multiple sclerosis is now higher than the median household income in the United States. So it's no surprise that rising prescription drug costs are now the biggest health care concern for the general public.

After years of ignoring the problem (and, in some cases, contributing to it), politicians and policymakers have started discussing the crisis. HHS recently hosted a summit on prescription drug prices. Presidential candidates have weighed in on the topic in their stump speeches and debates. A Senate committee recently grilled President Obama’s nominee to head the FDA on this issue. All this may or may not lead to change, but at least the issue is reaching a national level of discourse.

But what has led to exorbitant price increases in medications? Why do Americans pay so much more for the exact same medications than do patients in other countries? There are multiple likely culprits:

  • Price of innovation -- It simply costs money to come up with new, effective medications, but how much is “reasonable” for a company to spend on research and development of new drugs is a controversial question. Many think that the investment drug companies claim to make in R&D is an excuse to reap higher profits, whereas others argue it is simply the cost of doing business.
  • Direct-to-consumer advertising -- The FDA loosened regulations on advertising pharmaceutical products directly to patients in 1999. There has been a significant increase in drug prices since that time, but it is unknown if the agency's action was the cause. The AMA recently came out against this practice as have many patient advocacy groups, and the AAFP says direct-to-consumer ads should not mention prescription drugs by name.
  • Patent laws -- Many laws passed during the past two or three decades have lengthened the life of pharmaceutical patents. This keeps generic medications from coming to market until much later, allowing the developing company a larger profit on its product. And 27 percent of generic medications increased in price in 2013, including the long-time generic medications doxycycline and pravastatin. Because of this, it is unclear if changing patent laws would significantly decrease prices.
  • Changing insurance market -- The long-term trend in health insurance is leading to more out-of-pocket costs, including those for medications. Patients may be simply more aware now of the high costs of medication.
  • Medicare restrictions on price negotiations -- Medicare is prohibited from directly negotiating drug prices with pharmaceutical companies, leading to significantly higher prices compared with those of national systems in countries that do negotiate prices. Correcting this is one of the most widely discussed potential solutions, likely because it is in direct control of the federal government, and because the bulk buying power of Medicare could significantly alter drug costs in the United States. For these reasons, it is my opinion that this is the most likely first step to be taken in addressing the problem.
  • Reimportation ban -- It is illegal to reimport medications from other countries for cheaper sale. Many Americans do travel elsewhere, particularly to Canada, to buy prescription drugs, but opponents claim that raises potential safety issues. Whether that is a significant concern or not, the limited supply of medications in other countries makes reimportation an unrealistic solution on a broad scale.

So what about Reggie and treatment for his hepatitis C? I have tried multiple avenues, but there is likely no hope for getting any appropriate regimen covered for him at this time. There is a limit to what I can do for my patients. Many pharmaceutical companies offer rebate or discount programs for medications, and occasionally, direct appeals to insurance companies (beyond prior authorizations) can be successful, but there is no easy fix to this problem.

Considering the immense power of the pharmaceutical lobby, the solution may need to come from patients up, instead of from the government down.  

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 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.

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