The Folly of Judging Physicians Based on Patients' Foibles
Physicians write nearly 4 billion prescriptions each year in the United States, yet roughly half the patients who come to us for help fail to take their medications as directed. Among older patients, the proportion could be as high as 75 percent.
Patients often suffer the consequences when they don't take their medications as directed, but so, too, do physicians when reimbursement is tied to outcomes and community metrics. This can create an adversarial relationship between a prescriber and a "noncompliant" patient, which is antithetical to the kind of relationship family physicians want to have with their patients.
I recently attended a presentation about minimally disruptive medicine, which means simply health care that is designed to meet the goals of the patient while also considering the capacity of the patient to meet those goals.
This overall concept gets at the issue of noncompliance and whether we should even use that term. Noncompliant conjures up an image of a patient who disregards our advice because he or she doesn't value it, but the truth is that any number of factors can prevent a person from adhering to a prescribed regimen, including insurance coverage, out-of-pocket costs, health literacy, cognitive issues, social problems, transportation and more.
The speaker gave the example of a 55-year-old man who had several chronic conditions, including diabetes, high cholesterol, hypertension and obesity. Due to his multiple conditions, his physician advised him to exercise, but the man had a blue-collar job that caused him back pain. That pain rendered him largely sedentary at home, which exacerbated his chronic conditions.
In addition to his physical health concerns, the man's chemically dependent daughter had moved into his home along with her children to escape an abusive relationship. And on top of everything else, the man was suffering from depression.
The patient said he was simply overwhelmed, was unable to exercise and had little time to make the office visits his physician recommended to keep his conditions in check.
We've all had patients like this. They are aware of their health problems and would like to address them but feel unable to do so. Some are merely treading water. That leaves the physician with the unenviable choice of "firing" patients or continuing to try to help them under the very real threat of financial penalties.
Payers would like patients to fit neatly into a single mold but the reality is that patients need an individualized plan that fits their needs. Progress in addressing chronic conditions -- even if it's just baby steps -- should be valued rather than discounted, and physicians should not be penalized for being unable to force a patient with multiple chronic conditions to make miraculous improvements in the face of a litany of obstacles.
I had a patient whose hemoglobin A1c was 14. We were able to bring that number down to 10, which is a significant improvement. But from a payer's perspective, it wasn't good enough because my community metric is 8.
Using these types of quality measures across the board has unintended consequences, and physicians are being punished unfairly for failing to live up to these expectations. Drawing a line in the sand and saying, "Meet this number," fails to recognize the value of the work primary care physicians are doing to reduce the burden of illness and costs to the health care system if a patient happens to land slightly outside an ideal target area.
Being sick is emotionally, physically and financially hard on patients. We need to look at how we can partner with patients and individualize their therapies so they can make progress toward health goals that make sense for them -- not just for us and certainly not for payers.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
Thomas Wolfe Had It Wrong: You Can Go Home Again
The only doctor who ever treated me while I was growing up was the local general practitioner, so my concept of a physician was someone who took care of everyone -- from birth to end of life -- and was involved in the community. Being exposed to subspecialty care during medical school and residency didn't change my perception of what I was meant to do. I knew I wanted to be a "real doctor."
Photo Courtesy Megan Sonnier
Here I am talking to a patient who -- like many in my hometown practice -- I've known for decades. In fact, he wrote a letter of recommendation for me when I was a high school student applying for a scholarship at the University of Alabama.
Not to gainsay Thomas Wolfe's compelling novel You Can't Go Home Again, but when I left Bibb County, Ala., to attend medical school in Mobile in 1975, that was exactly what I planned to do. I wanted to practice family medicine in my community.
I live in Brent, Ala., and work in Centreville. These neighboring small towns run together and are home to roughly 6,000 people combined. When I look at my patient list in the morning, I often know patients' complaints before I see them because I've already heard about their illnesses, conditions or concerns at church, in the stores or from my nurse.
At the heart of primary care is the idea that patients should have an ongoing relationship with a family physician they know and trust. I have that kind of relationship with my patients because I've lived here most of my life, and I've practiced medicine here for more than 30 years.
There were only two other physicians in the county -- both family physicians -- when I started my practice in 1982. One was another local who had come home to practice. One thing we learned about starting new practices in our hometown is that folks typically fall into one of three groups:
- People who didn't know you before you became a physician or moved to town while you were away at medical school or residency;
- People who knew you before you were a physician and will never come to you for care because they still think of you as a kid; and
- People who knew you before you were a physician and won't see any other doctor because they know and trust you.
Patients should have the right to choose their physician, and I understand that some of my old high-school classmates might be uncomfortable being patients of mine -- particularly women. On the other hand, I've delivered the babies of some of my former classmates, so it works both ways. My patient panel also includes former teachers, coaches and my high-school principal.
My wife grew up in a small town, too, and when I finished residency, we visited a few other communities before we decided where to start my practice. In fact, I had an offer to join a friend's practice in another location. But in the end, we couldn't find anything we liked better than my hometown.
I've built strong relationships in this community. To me, that's part of being a family physician. And I love what I do.
John Meigs, M.D., is speaker of the Congress of Delegates, the governing body of the AAFP.
Curbing Childhood Obesity Requires Moving Beyond the Exam Room
A concerned parent recently brought her child to see me, worried that the child was underweight. A check of the patient's height and weight confirmed what I suspected -- the child's body mass index was normal. The problem likely is that so many of the child's peers are overweight or obese that the parent's sense of normal was skewed.
Our state, North Carolina, has the fifth-highest rate of childhood obesity in the nation, affecting nearly 20 percent of children ages 10-17 years. Nationally, more than one-third of all children and adolescents are overweight or obese.
|More than one-third of U.S. children and adolescents are overweight or obese.|
The White House recently marked the fifth anniversary of the first lady's Let's Move campaign, an ambitious national program to combat childhood obesity that the AAFP has supported. But efforts to address this epidemic have shown mixed results. In the first two years after the program launched, the obesity rate among children ages 2-5 years dropped nearly 4 percent, but the rate among those 12-19 increased more than 2 percent during the same period. Overall, the rate of childhood obesity was steady at nearly 17 percent.
The Robert Wood Johnson Foundation recently doubled down on its investment in childhood obesity programs, matching the $500 million commitment it made in 2007 with a pledge for another $500 million during the next 10 years.
But what can we as family physicians do in our own communities? When I was president of the North Carolina AFP, our chapter partnered with the state agricultural extension agency to provide nutrition education in family medicine practices. We identified children who were overweight or obese and provided education for entire families in large-group visits. We also worked with the extension office to develop a Web-based resource that included the menus of the popular fast food restaurants in our region. The database allowed users to compare nutrition information of various menu items so that they could make healthier choices when they ate out.
Both of those programs were funded by the state's Health and Wellness Trust Fund, which provided grants with money from the Tobacco Master Settlement Agreement. Although those funds are long gone, family physicians can still find creative ways to help families eat better and increase physical activity. And we can help families beyond the work we do in our exam rooms.
For example, Tommy Newton, M.D., of Clinton, N.C., created a program that rewards elementary students for achieving certain fitness goals. The 10-year-old program, used in schools across the county, has more than 3,500 students enrolled and has been shown to improve children's fitness and self-esteem.
One of the challenges many families face is the lack of a safe place for children to play. Gone are the days (in most communities) when parents felt comfortable allowing their kids to ride their bikes around town -- or even play outside in their own neighborhoods -- without supervision. One of our local communities has addressed that by completing a bike trail that stretches from one end of the city to the other, providing a safe place for families to exercise.
What is your community doing to address this crisis?
Mott Blair, M.D., is a member of the AAFP Board of Directors.
Under Attack: We Can All Join the Fight for GME Funding
For thousands of U.S. medical school seniors, the end is drawing near. In less than five months, they will be completing their fourth year of undergraduate medical training and gaining those two highly prized letters at the end of their name: M.D. But their work is far from complete.
Throughout the fall, they traveled the country interviewing for residency spots at programs large and small. Now, with the National Resident Matching Program -- better known as the Match -- only six weeks away, their anxiety is starting to grow.
Getting into medical school was difficult. According to the Association of American Medical Colleges, more than 40 percent of those who apply are turned away. Getting through medical school was difficult, too. Hours of classes, tests, clinical clerkships and overnight call. Next stop, residency. Getting in the door there is no easy task, either, and now it looks like the process could get even harder.
At a time when a shortage of primary care physicians is getting worse, hundreds of family medicine residency positions are in jeopardy.
The Patient Protection and Affordable Care Act created the Teaching Health Center Graduate Medical Education (THCGME) program to increase the number of primary care physicians. Unfortunately, the federal government's $230 million investment in that innovative program -- and other critical primary care programs -- is set to expire this year. In a survey last year, two-thirds of THCGME program directors said they likely would be unable to continue supporting current residency positions without continued federal funding.
Some aren't waiting to see whether or not Congress will act, and it's hard to blame them for being cautious.
The Fresno Bee reported Jan. 31 that the Sierra Vista Family Medicine Residency program in Fresno, Calif., already has decided not to take on a third class of residents in anticipation of a funding shortfall.
That program had received nearly 800 applications for four residency slots, but the program needs $2.4 million over three years to train each class of four residents.
Nationally, there are 60 teaching health center programs with a total of more than 500 family medicine residency slots. If Congress fails to reauthorize and adequately fund the THCGME program, how long will it be until we hear of more residencies pulling the plug on residency positions?
You've invested considerable time and money and likely amassed a daunting level of debt to pursue your goal -- your dream -- of becoming a physician. But if you're medical student, you might be wondering how this funding crisis could affect your spot in the Match. And if you're a resident at a teaching health center, you might be worried -- justifiably so -- about whether or not you get to keep yours.
So what is the AAFP doing about it?
- Last fall, the Academy released a proposal that built on recommendations for GME made by the Institute of Medicine earlier in the year. The AAFP's plan would, among other things, significantly change the way GME is financed.
- Two months later, AAFP leaders were on Capitol Hill to discuss several key issues -- including funding for teaching health centers -- with legislators and congressional staff.
- GME likely will be one of the topics on the agenda when the AAFP Board of Directors spends another day lobbying on Capitol Hill later this month.
- The AAFP and the Council of Academic Family Medicine recently responded to the House Energy and Commerce Committee's request for comments on GME reform with a letter that reinforced the concepts in the proposal released last fall, including support for community-based training programs and the need for accountability for the roughly $9 billion in federal GME funds that are funneled through academic health centers.
- That letter is just one of many the Academy has sent to Congress regarding GME reform in recent months.
Health care faces a "primary care cliff" in 2015. In addition to GME, funding for the National Health Service Corps and community health centers also is set to expire this year. We students and residents can do our part by getting directly involved in the advocacy efforts of the Academy and our state chapters. For example, efforts by students and residents last year helped the Pennsylvania AFP secure state funds for nine new family medicine residency positions and a development program for residents interested in practicing in underserved areas.
Students and residents also should be aware of scholarship opportunities to attend the Academy's Family Medicine Congressional Conference (FMCC). The May 12-13 event in Washington trains family physicians (and students) to advocate for patients and family medicine and concludes with a day of lobbying on Capitol Hill. The deadline for scholarship applications is March 6.
Whether you attend FMCC or not, your legislators need to know how funding cuts to primary care programs affect medical training and health care in their states.
Andrew Lutzkanin, M.D., is the resident member of the AAFP Board of Directors.
Maternity Care, Solid Team Training Build Strong Bonds
For me, nothing cements my relationship with patients and their families like the birth of a child. It is heart-warming for me to be part of the privileged minority of family physicians who continue to provide maternity care as part of a full-scope practice.
Getting here was no accident. I grew up in rural Washington, and when I was born in the local small community hospital, a family physician was there for the delivery. The same family physician delivered my sister and brother, and he later mentored me during high school when I worked the night shift as a hospital orderly to get a taste of a career in health care.
During my second year of medical school, I was fortunate to find a family physician preceptor for my continuity clerkship who not only practiced maternity care in the hospital but also provided care in patients' homes, working with a certified nurse midwife to provide home births and births in his office-based birthing center.
The experience of following families through prenatal care and then being invited into their homes to assist with a birth had me hooked, and watching those newborns grow and develop during the course of their well-child care set the hook for good.
In the multicultural community my medical school served, it was not uncommon to have multiple generations present for births and well-child visits. The safe birth of a healthy baby often came as a relief to the elder members of the families, whose previous experiences with childbirth had not always been so joyful.
The contrast between taking care of a selected, “low-risk” population of women having home births and my experiences as a medical student on the OB service of a quaternary care university hospital was enormous; I saw that a comprehensive education and residency training program in family medicine, taking care of the highest-risk/highest-acuity pregnancies, was definitely a necessary start on my path to a full-scope practice. Little did I know how much I would miss taking care of the low-risk patients until those first few months of residency in the county hospital, where every patient seemed to have a myriad of medical and social challenges. The vaginal delivery of a healthy, term baby was rare, except for patients who received prenatal care through our family medicine clinic. Although they had many of the same demographics as the rest of our county hospital patients, and many of the same obstetrical challenges, the clinic patients had the advantage of continuity of the team and integrated care of the family.
Now, more than 30 years after residency, I am sitting in the labor and delivery unit, reflecting on the experiences I have shared with the family I am caring for tonight. We have a long history together; this is their second child, coming more than 15 years after the birth of their first. That beautiful baby girl, who has grown into a mature young lady, is here with her dad, helping coach her mom during labor. Between her birth and tonight, there have been three miscarriages, including a molar pregnancy.
The couple had almost given up hope of another child, but tonight, hope comes home to stay. We have time to talk about their first childbirth and the family medicine resident who was there with me. That resident subsequently became a partner in my practice. We reminisce about that stubborn little girl who decided she was going to arrive in the wee hours of the morning. She had a compound presentation that required extra help and effort. Everything turned out fine, but I am reminded how challenging it was to keep panic out of the room that morning until help arrived.
And yet I am confident this evening -- working with another resident -- that no matter what the challenges may be with this labor and delivery, panic will not show its ugly face. How can I be so confident? I sum it up in one simple but profound concept.
A team of experts does not automatically make an expert team. That is one of the tag lines in the “Safety in Maternity Care” chapter I helped write for the AAFP’s Advanced Life Support in Obstetrics (ALSO) program when I joined the ALSO Board years ago. Teamwork training, as simple as it may sound, saves lives. There is a growing body of evidence that simulation and teamwork training specifically regarding obstetrical emergencies saves mothers and babies no matter the setting, whether it be in the regional perinatal center (like the one I am sitting in this evening), a rural hospital in Tanzania or the maternity hospital in Baghdad (where I taught an ALSO course last year).
Tonight’s team is different from the team I worked with nearly 16 years ago; everyone on the labor and delivery unit tonight has been through an ALSO course. Five years ago, after some adverse events that could have been prevented, the obstetricians, family physicians, nurse midwives, labor nurses and mother-baby nurses here voted to require ALSO certification and ongoing maintenance of that certification for every person working on the unit. We are proud that safety has become the focus of our care. Teamwork is integral to everything we do, and this high-risk perinatal center serving a high-risk, multiethnic population has the lowest C-section rate and highest safety ratings of any hospital in our state.
I salute the AAFP’s commitment to ongoing education in maternity care, from the ALSO courses for practicing physicians and other maternity care professionals, to the Academy's Family Centered Maternity Care course, to the Basic Life Support in Obstetrics courses targeted to medical and nursing students, prehospital care professionals and emergency department staffs and, finally, to the international work ALSO and Global ALSO continue to do.
I have to go now. The newest member of the family is about to arrive.
Carl Olden, M.D., is a member of the AAFP Board of Directors.
Health Tech Developers Could Use Physician Input
I always wanted to attend the Consumer Electronics Show, not only to see what all the hype was about but also to find out if there were innovative ideas that could be used to strengthen primary care and help family physicians better meet our patients' needs. Finding ways to improve patient access, care coordination and engagement while achieving the Triple Aim -- better care, better outcomes and lower cost -- may require new approaches and an open mind, and I wanted to see if any technologies were on the horizon as part of those solutions.
I couldn't have picked a better year to finally make it to Las Vegas. The number of biotech and health companies participating in the recent international show increased by more than 30 percent this year.
Photo Courtesy the Consumer Electronics Show
Attendees look at
smart watches on display at the Consumer Electronics Show. More than 50
wearable health and wellness products were on exhibit last month at the show in
More than 150,000 people trekked to the Las Vegas Convention Center to see the latest high-tech gadgets. Exhibitors covered more than 2 million square feet with the latest innovations in automobiles, televisions, headphones and more. I didn't have time to see everything, so I focused on the exhibits that had the potential to improve health and wellness.
What did I see?
How about bike pedals that can track a cyclist's speed, distance, elevation, calories burned and record his or her route?
Or a patch that can monitor a patient's temperature for 24 hours, tracks changes and send alerts to physicians?
Could your patients benefit from a product that tracks calories through a wrist sensor and monitors heart rate, blood flow and fluid levels?
Although there were plenty of innovative ideas on display, the biggest trend was wearable devices. There were dozens of companies hoping to be the next Fitbit. In fact, more than 50 wearable products were being promoted at the show.
Why the glut? Roughly 19 million wearable products were sold last year, and that number is expected to more than triple within the next three years. But as I made the rounds and talked to these companies on the show floor, I had to question how much some of these companies knew about U.S. health care. And were they making a product because it fit a need or simply because they had developed a cool, new technology?
For example, I talked to representatives of the company promoting the temperature monitor. That product is being marketed primarily as a pediatric device. When I asked them, "What about geriatric patients?" they admitted they hadn't considered that possibility.
I talked with multiple foreign developers who were each marketing more than a half dozen gadgets that can monitor a user's temperature, blood pressure, blood sugar, etc., and they each had their own proprietary platform that feeds data into one place. A patient could easily use such a system to send his or her information to a physician. The problem is that a consumer would have to buy all these gadgets from the same vendor because the competing systems aren't interoperable. Sound familiar?
The disconnect between developers and health care was one of the reasons I was glad to see family medicine prominently featured at the show. A panel of physicians representing the Health is Primary campaign hosted a panel discussion that urged increased collaboration among technology companies, physicians and consumers during a presentation about health technology.
According to an AAFP survey released at the event, more than 50 percent of family physicians recommend health and wellness apps to their patients, and more than 40 percent use apps at the point of care.
So what's the problem? Roughly 40 percent of respondents indicated they had reservations about using apps because of questions regarding the evidence or proven effectiveness of these products. With more collaboration that could change because we could help developers make better products to help our patients.
That isn't to say product developers don't have good ideas. I talked with one exhibitor who has developed a new app that helps consumers create appropriate diets for patients with diabetes. The app assists with menu planning, recipes and grocery lists. The developer hopes to make the app free to patients by working with stores and manufacturers to distribute relevant coupons through the app.
Again, I wondered if this idea could go further. Could it, say, help patients with heart disease adhere to a low-sodium diet? The developer hadn't thought of that possibility.
In the short time since the show ended, I've already exchanged emails with a few developers who realize family physicians can help improve their products, making them more beneficial to a wider audience.
I also realized that not only could family physicians help product manufacturers, we could bring our own ideas forward. For example, I know a family physician in Kentucky who has developed an app that allows practices to offer after-hours visits via a smartphone. With ever improving technology, not every visit needs to be face to face.
Tech developers could certainly benefit from our experience. Too often, physicians have been the victims of well-intended technology that was developed without sufficient physician input. Technology should be a tool, not a burden.
Do you have ideas for new or improved tools that could benefit our patients and our practices?
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
New AAFP Guideline Adds to Evidence Supporting VBAC
It has been more than four years since the American College of Obstetricians and Gynecologists updated its recommendations for vaginal birth after cesarean (VBAC), stating that VBAC is "a safe and appropriate choice" for most women who have had a cesarean delivery. Still, women are frequently denied labor after cesarean (LAC) because of hospital or practice policies that conflict with evidence-based guidelines.
Fortunately, this hasn't been an issue for me or my patients at either of the hospitals where I provide maternity care. My practice encourages VBAC whenever possible because the overall risks associated with a vaginal delivery are actually lower than the risks associated with a C-section, and certainly with subsequent C-sections. The recovery time is much faster with VBAC, and that shorter recovery contributes to a more positive experience for moms and also makes it easier for them to do other things, such as breastfeeding their babies.
LAC, of course, doesn't always lead to a vaginal delivery. In fact, less than a third of my patients who attempt it are actually successful. The two main challenges have been maternal exhaustion and the inability to help labor along with certain medications.
That second challenge, however, is changing. Although ACOG's recommendation statement offered limited and somewhat conflicting information about the use of oxytocin to induce labor, the majority of research in this area pointed to an increased risk of uterine rupture. Regarding the use of oxytocin to augment contractions, however, "The varying outcomes of available studies and small absolute magnitude of the risk reported in those studies support that oxytocin augmentation may be used in patients undergoing (trial of labor after cesarean)."
For me, that wasn't a strong enough endorsement at the time. But now, the AAFP has published a new VBAC guideline that also supports the use of oxytocin for induction and augmentation of labor.
In fact, the guideline states that "there does not appear to be an increased risk of uterine rupture associated with oxytocin augmentation of labor." It also says that "augmentation of labor with oxytocin is associated with a 68 percent rate of VBAC."
For my practice, this changes everything and provides a new pathway to help my patients who want to try LAC. Having that chance is so important because some moms who want a vaginal delivery feel bad and blame themselves when they have to have a C-section. Having an attempt at vaginal delivery -- even if unsuccessful -- takes away some of that guilt because they know they did everything they could. This aspect shouldn't be overlooked given the importance of mental well-being during the postpartum period.
And when these moms succeed, the joy is immeasurable. They not only have the pride and happiness that is typical of a new mother, but they have accomplished something they previously were told they could not do and achieved the kind of delivery they wanted the first time.
Emily Briggs, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
When Opportunities Arise, You Have to Jump
"OK, it's time to jump.
I have jumped into many challenges during my professional career -- from being an assistant residency director to practicing full-scope family medicine in the small town where I grew up to leadership positions in the AAFP -- but I had never done anything like this.
The U.S. Army recently invited Academy leaders to tour Fort Sam Houston and Brooke Army Medical Center in San Antonio, and I made the trip along with Andrew Lutzkanin, M.D., the resident member of the Board of Directors. The tour provided insights into the world of military medicine as we visited the facility's level-one trauma center, a burn treatment unit and the ICU.
We also toured the Center for the Intrepid, a world-class rehabilitation and prosthesis center. We heard inspiring stories from soldiers who had the will and personal stamina to rehabilitate themselves with the goal of returning to their units. The bond they feel with their comrades is truly hard to describe. In many ways, I thought of family physicians and the common bond we share to help our patients.
We also visited Camp Bullis, a military training site near San Antonio that includes a replica of a forward hospital medical treatment facility. The Army can construct one of these 84-bed facilities -- complete with operating rooms and ICUs -- in as little as three days. Medics and physicians train in this mock up "tent hospital" that could be run off of a generator.
But what about the jump? As part of our three-day visit to San Antonio, we also had the opportunity to make tandem parachute jumps with the elite Army Golden Knights Parachute Team. It was quite an adrenalin rush to leap out of an airplane at 14,000 feet and free fall for about a minute before feeling the chute open with a jolt and then simply floating. I had no experience with parachutes, but when given the chance, I jumped.
© 2014 Ashley Bentley/AAFPHere I am meeting with our student leaders via Google Hangout. Our family medicine interest group network leaders work to help promote family medicine at campuses across the country.
With our hectic schedules, it's sometimes difficult for family physicians to make the most of every opportunity that comes along. But I also had been asked to meet -- online -- with new family medicine interest group (FMIG) leaders. Their orientation meeting at AAFP headquarters in Leawood, Kan., was taking place at the same time Andrew and I were attending the Army's All-American Bowl, which features 90 of the nation's best high-school football players.
When it comes to speaking with medical students, you find a way to make it happen. Although an Alamo Dome filled with thousands of cheering fans and a marching band might not seem like the ideal place to hold a video chat, Andrew and I managed to find a quiet stairwell in the stadium and met the students via Google Hangout.
Each FMIG leader asked me a question related to the big issues -- such as scope of practice, student debt and new models of care -- that are affecting their peers' specialty choices. I addressed these questions, and I pledged to them that the AAFP will continue to work on issues that matter to students because they matter to the future of our specialty. I also reinforced the importance of the work these students will do this year to increase student interest in family medicine by working to strengthen FMIGs at medical schools across the country.
Before we returned to the game, Andrew -- who is a former FMIG network leader himself -- shared his experience with the students and also discussed how our young leaders will work together in the year ahead. Kristina Zimmerman, the student member of the AAFP Board; Richard Bruno, M.D., M.P.H., resident chair of the AAFP National Conference of Family Medicine Residents and Medical Students; and Brian Blank, student chair of the conference, also participated in the call.
During our visit in San Antonio, we met with several military officers. At one meeting, I pointed out to Andrew there were five generals in the room discussing the challenges they face in military medicine. Family medicine, no doubt, faces its own challenges. But meeting with our student and resident leaders, and spending a few days with Andrew, confirmed what I already knew. Our future is in good hands.
Robert Wergin, M.D., is president of the AAFP.
Annual Exams? Tailor Visit Frequency to Patients' Needs
Ezekiel Emanuel, M.D., recently offered some interesting advice to the more than 2 million readers of The New York Times. Emanuel, who is an oncologist, said Americans should skip their "worthless" annual physicals.
This message -- conveyed via our nation's largest metro newspaper -- has caused a great deal of concern among primary care physicians, as well as confusion among our patients. As with so many things, significant aspects of this issue are overt, but many more are nuanced.
One of the issues Emanuel raises is the increasing evidence that doing a complete annual physical exam does not improve morbidity and mortality. This correlation is actually fairly well proven. In fact, significant data, including the book Overdiagnosed: Making People Sick in the Pursuit of Health, by Dartmouth professor H. Gilbert Welch, M.D., M.P.H., suggest that reliance on routine complete physicals and indiscriminate use of various labs and screenings actually confer more harm than benefit. Such evidence is the basis of Choosing Wisely, the AAFP-supported initiative that identifies overused tests and procedures and encourages physicians and patients to discuss those options before incorporating them into a treatment plan. The Academy has identified more than a dozen tests and procedures that have questionable value for certain groups of patients.
© 2014 Sheri Porter/AAFPHere I am listening to a patient during an office visit. A recent New York Times editorial against annual exams minimized the importance of the physician-patient relationship.
And although the AAFP does not have a guideline recommending annual exams, we certainly aren't recommending that patients stay home until they have an acute illness. The frequency of visits should be tailored to the patient, based on recommended screenings and conversations between the physician and patient.
It's worth noting that much of Emanuel's argument against annual exams is built on a 2012 Cochrane Collaboration review that considered only asymptomatic patients. According to the CDC, half of U.S. adults have at least one chronic condition, and 25 percent have two or more. Now ask yourself, "What percentage of my patient panel would I feel comfortable not seeing until they had an acute illness?"
Every patient deserves individualized care. Family physicians don't treat the "average" patient. We don't treat diseases, and we don't treat labs. We treat people and families. Accordingly, we have to take the evidence and put it into the context of that specific patient and his or her needs. This can include a patient who feels strongly that he or she should have a screening test or a complete physical even with the awareness that it may lead to a cascade of labs or evaluations that might not be otherwise indicated. Being patient-centered means having these conversations and supporting our patients in their choices even if they go against the evidence.
Emanuel briefly, and grudgingly, acknowledges that an annual exam provides an opportunity to "reaffirm the physician-patient relationship." But in dismissing the exam as having no benefit, he minimizes the importance of that ongoing physician-patient relationship. The annual exam is an opportunity for primary care physicians to strengthen this bond by speaking with our patients and getting to know them better. This helps us provide better care when they ultimately need it and enhances their trust in us.
Establishing this relationship early is critical to yielding the best dividends when people become ill. This trust and caring can only be created in the setting of an ongoing and growing relationship that requires face-to-face visits. The relationship also facilitates the primary care physician's role as a cost-effective coordinator of the patient's health services by making early detection of problems possible.
So what about frequency? Patients should be seen based on their age, their gender, their health care philosophy and needs, their problems and diseases, and multiple other factors. The ultimate goal should be to maintain and nurture the relationship. We should focus on appropriately addressing the patients' concerns, as well as on formulating an agenda based on our understanding of where that patient is in achieving health and minimizing disease. So, not only do we consider what an appropriate screening protocol is for each patient, we also address the all-important behavioral and lifestyle aspects that impact morbidity and mortality.
What we need isn't reliance on an annual physical. Instead, we need to continue to push for changes in our health care system that ensure the care we deliver is focused on prevention and evidence-supported measures that are individualized for each patient. Family physicians are ideal for this role. We must continue to move health care delivery in this direction, and physician payment should reflect the value and power of this relationship and what we provide.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Beating Burnout: Get Involved, Call for Change
During AAFP Assembly last fall in Washington, keynote speaker Dike Drummond, M.D., asked family physicians in a packed ballroom to raise their hands if they had experienced symptoms of burnout. Hundreds of hands -- far too many -- went up.
Although disheartening, the response certainly wasn't surprising. According to a 2013 Medscape survey, more than 40 percent of U.S. physicians reported experiencing at least one symptom of burnout (loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment). A 2012 study in JAMA Internal Medicine found that more than one-third of physicians were burned out.
|More than 40 percent of U.S. physicians experience at least one symptom of burnout.|
Some of the reasons for this crisis -- such as administrative burden, difficulty finding work-life balance, feeling undervalued, frustrations with referral networks, government regulations, and (of course) reimbursement issues -- are shared across different types of family medicine practices. Other factors may vary from practice to practice. For example, employed physicians like me may be struggling with the loss of control over our day-to-day practice. Meanwhile, some small and solo independent practice physicians may be having difficulty figuring out how to meet the latest regulatory requirements with limited staff resources.
In addition to these challenges, physicians face more and more pressure to meet or exceed patient expectations. Patients want to be heard and family physicians want to listen, but in our stressed work environments, we often don't have enough time -- more than the typical 15 minutes – or adequate resources to meet the needs of our complex patients. I've had patients thank me for listening and for being thorough, but how often do we hear that? Based on the current environment, I would say not nearly enough.
A growing number of my colleagues seem discouraged, and it saddens me to hear family physicians say things like, "I don't know if I can do this anymore." Many physicians are responding to burnout by limiting their scope of practice, reducing their work hours, or leaving the practice of medicine altogether. According to a 2012 Urban Institute data analysis 30 percent of primary care physicians ages 35-49 planned to leave their practices within five years. The rate was more than 50 percent among physicians 50 and older. Those numbers should alarm anyone aware of the already glaring shortage of primary care physicians.
Clearly, this is becoming a crucial public health issue. The drivers of burnout are different for each individual physician, but the impact of physician burnout is affecting health and health care delivery for every consumer in the country. If we don't address these drivers and take care of the physicians we have, there will not be enough of us left to care for the health of our nation.
An article published in the November/December issue of Annals of Family Medicine suggested that the triple aim framework -- which calls for better care, an enhanced patient experience and lower health care costs -- needs the additional aim of improving the work life of physicians and our staff members.
So what do we do about it? Individual physicians may be able to help themselves by better managing their stress or by seeking support. But what about change on a broader scale?
I've had my own experience with burnout. When I felt that I needed to get off the hamster wheel, one of the things that helped me refocus was getting involved and advocating for change. I've been involved with the Academy for years through the Congress of Delegates, commission work and the National Conference of Special Constituencies. But the No. 1 issue that prompted me to run for the Academy's Board of Directors last year was burnout. I don't know all the answers to solving burnout, but I know it must be addressed.
The Academy adopted a position paper on the issue last year. And it's worth noting that the AAFP last year created 10 member interest groups to provide a forum for members with shared professional interests. The MIGs provide new outlets for members to make their voices heard.
The AAFP also is working to address many of the drivers that lead to burnout, including payment reform and administrative burdens related to electronic health records.
Finally, we need to remove the stigma from burnout. Physician who need help shouldn't be afraid to ask for it. If you feel burned out, know that this is not a weakness or a character flaw, and you are not alone.
You can help yourself with resources that support personal resilience and time management skills, but you also can tackle the problem on a broader scale by working within your organization to address the drivers of burnout in your practice. And know that the AAFP will continue to work to alleviate regulatory burdens and other factors that contribute to burnout.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
New Year Brings New Life, New Hope
As the year winds down, the holidays give us an opportunity to share time with our family and friends. It is a time when the young create new memories and the old share theirs.
One of my most memorable holidays as a family physician happened just a few years ago. Brenda and I were preparing for New Year's Eve -- packing things to take to a friend’s house to celebrate the new year with friends and family -- when I got a call from the hospital. One of my maternity patients had arrived and was contracting. I admitted her and told the nurse I would stop by and check on her shortly. On my way to the party, I stopped at the hospital and confirmed my patient was in labor.
© 2014 Sheri Porter/AAFPHere I am checking on a new patient in the hospital. Maternity care can make things challenging during the holiday season.
I spent the early part of the evening with good friends and family and limited my celebration to sodas and coffee. I received hourly updates about my patient, and by 10:30 p.m., her labor had progressed enough that I excused myself from the gathering and made arrangements for my brother to take Brenda home.
I went to the hospital and sat with my patient and her husband, monitoring her labor’s progress. At 11:30, it was time to start pushing. She did well, and around 12:30 a.m. -- at the start of a new year -- we celebrated the birth of their new son.
Both parents were elated, although the father did ask if we could have "rushed this along a little" so the tax deduction that comes with a new child could have been applied to the year that had just ended. I told him I didn’t have much to do with the timing, and he agreed. The next day, however, the local newspaper took a photograph of the county's first baby of the year, and the family received many gift certificates and congratulations from businesses in the community.
I headed home around 1:30 a.m. Brenda got up, and we opened a bottle of champagne and celebrated the new year, a healthy new baby boy, and a new patient in my practice.
That is family medicine. Sometimes our families have to make sacrifices, but it is part of who we are. And our communities are stronger for it. This was a memorable New Year's for me and this family. I'd like to hear the story of your most memorable holiday spent with patients in the comments field below.
Happy New Year from the AAFP. Take a look at this video to see some of what we accomplished in 2014. And here's to a prosperous 2015.
Robert Wergin, M.D., is president of the AAFP.
Digital Media: It's Here to Stay, and That's a Good Thing
When I started medical school almost four years ago, I still used paper notes. I printed out lecture slides and scribbled my notes during live lectures. Oftentimes, I had to go back to the recorded, archived lecture to fill in any notes I missed. By the end of the year, my bookshelves were buckling under thick binders full of lecture notes -- notes that I could not readily refer back to because it was too time-consuming to flip through thousands of pages to locate one specific detail. It was faster and easier to search for the information electronically.
This, combined with my desire to be more environmentally conscientious, compelled me to go paperless during my second year in medical school. I downloaded lectures on my laptop and organized them for easy retrieval. I could type my notes more quickly than I could write them, and I could more easily link those notes to specific parts of the lecture. While studying, I used tools on my computer to find keywords and topics within seconds rather than wasting hours leafing through shelves of paper. After making the switch to electronic media, I never looked back.
Not only do electronic files take up less space, but electronic media can be read virtually anywhere and also can be listened to in the car or on the subway.
Now that my medical education has moved beyond the lecture hall into clinics and hospitals where hypothetical scenarios are replaced with real-time patient interactions, easily accessible information is even more important. I cannot bring bookshelves full of notes and clinical pearls from home. And only so much information can fit into a small, white coat-sized notebook. Plus, there's still the issue of quick retrieval. Fortunately, we live in an era when electronic media are readily available. Unlike generations of physicians before me, I only need one information retrieval tool in my white coat pocket -- my smartphone -- and I carry it now more than ever.
From my smartphone, I have quick, easy and unlimited access to the most relevant and up-to-date information I need to verify a diagnosis and/or treatment plan, as well as tools to help me educate patients. Among the electronic resources I use every day are the AAFP website; my medical school library's databases of DynaMed, PubMed and New England Journal of Medicine; and apps such as Epocrates, Micromedex, UpToDate, the American Heart Association's Cardiovascular Risk Calculator, Evernote, and the AAFP journals American Family Physician and Family Practice Management. I can use Dropbox to store my notes and important documents on the Web for retrieval on any of my electronic devices -- my tablet, smartphone or computer.
Some may argue that use of technology in the exam room diminishes meaningful patient interactions and harms the doctor-patient relationship. This has not been my experience. In fact, I would argue that proper use of electronics during a patient visit actually strengthens the interaction and engages patients more fully. For example:
- There are many instances where the computer screen can be shown to patients, such as when reviewing blood work results, growth or vitals. These numbers and trends can, and should, be shared and discussed with patients.
- Using electronic health records, various health trends can often be shown on graphs so patients can see how they are doing over time.
- When documenting/charting patient information, we can let patients see what we are typing and verify with them that the information is correct.
- Photos can be helpful when reviewing items such as rashes, anatomy or plants they are allergic to, etc. We also can clarify which medications a patient is taking by showing them pictures of the medication on the Epocrates app.
- And of course, we can use our electronic devices to quickly find an answer to a patient's question when we don't know the answer.
I have done all of these things, and patients have said that it has made many health topics easier for them to understand and has helped them feel more like a part of their health care team. Many patients appreciate the visuals, especially when they can access them again later at home.
During one patient interaction, I showed a patient two images of the English plantain, which was the source of his allergy symptoms. One image was a pencil drawing in a book from 1946. The second was a color photograph from Google Images. The patient found the photo more helpful and was happy he would be able to find it later if he forgot what it looked like.
Another reason it is important for physicians to become familiar and comfortable with electronic resources is that our patients are using them. Patients are trying to educate themselves by using the Internet and apps to look up health information and symptoms, track their health and fitness activities, etc. We need to keep up. We need to know what tools they are using and where they are getting their information so that we can guide them to valid, useful facts.
Are they using Wikipedia, WebMD, Google Scholar, MyFitnessPal, Apple Health, something else? Why are they using certain resources? These are conversations that are important to have. Many patients want to be more engaged in their health. They want to use electronic health tools to access their personal health information through an online portal, track health and fitness goals, and transmit their health data -- such as daily weights, blood pressures, glucose readings -- directly to their medical homes. As physicians, we have to be ready to navigate these new technologies and make them work to our patients' benefit.
Technology will keep moving forward. As it evolves, we need to be sure our ability to use it effectively with our patients does, too.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
Medicaid Cuts Threaten Primary Care Practices, Access to Care
The year is ending with bad news regarding physician payment, and pending cuts may affect patients' access to care.
Section 1202 of the Patient Protection and Affordable Care Act (ACA) increased Medicaid payments for specified primary care services to Medicare payment levels for certain primary care physicians in 2013 and 2014. The provision was designed to help improve access for the significant and increasing number of Americans who are covered by Medicaid, and states received an estimated $12 billion to bolster their Medicaid primary care delivery systems during those two years.
© 2014 Sheri Porter/AAFP
Here I am examining a young patient. Congress' recent failure to extend Medicaid parity payments for primary care will hurt primary care practices and hinder our ability to care for Medicaid patients.
More than half the states have agreed to expand their Medicaid programs, and nationally, Medicaid enrollment has increased by 7.5 million people since the fall of 2013. But with payment rates for Medicaid scheduled to revert to 2012 levels on Jan. 1, will the newly insured still be able to find care?
When the American College of Physicians surveyed its members earlier this year, 40 percent of respondents said they would accept fewer Medicaid patients in 2015 if the parity payments stopped, and 6 percent said they would stop participating in Medicaid completely if that scenario were to occur.
The reaction isn't hard to understand. On average, Medicaid pays physicians less than 60 percent of what Medicare pays for primary care services, and that gap discourages many primary care physicians from treating Medicaid patients. In fact, when the ACA became law in 2010, 36 percent of family physicians surveyed by the AAFP were not accepting new Medicaid patients because of low reimbursement rates, and 20 percent of our members surveyed were not seeing any Medicaid patients at that time.
Unfortunately, with only a two-year period in which outcomes can be considered -- combined with delays in the implementation process -- it is difficult to judge how much of an impact the parity payments made on access. Physicians were asked to expand access to their practices while facing the stark reality that they might have to either accept reduced payment for treating those patients or turn their backs on those new patients after a relatively short time. Sadly, that choice will soon be at hand unless the 114th Congress acts when it convenes in January.
The good news -- for some -- is that more than a dozen states have indicated they will maintain Medicaid parity payments even without federal funds. From these states, we may be able to better judge how physician payment affects patient access and outcomes. A much larger number of states, however, have said they will not extend Medicaid parity.
The pending payment cuts will vary from state to state, but on average, Medicaid payment for primary care will fall 42.8 percent. The largest cut would be in Rhode Island, with a 67 percent drop, while physicians in California, New York, New Jersey, Florida and Pennsylvania would all see reductions of more than 50 percent.
Unfortunately, many states will have physicians who are unable to keep their doors open to Medicaid patients because of low reimbursement rates. This will once again force patients to get the wrong care in the wrong place at the wrong time, utilizing emergency rooms for both acute and chronic care issues. The goal of our advocacy efforts on this issue has been to ensure that patients get the right care, in the right place, at the right time, and from the right person. That means ensuring access to primary care, where health issues can be identified and treated before they progress too far down the clinical pathway.
Will the end of parity payments affect the number of Medicaid patients in your practice?
Reid Blackwelder, M.D., is Board chair of the AAFP.
Penny Wise, Pound Foolish: We Can't Afford to Cut Our Investment in Teaching Health Centers
Not that long ago, Pardee Hospital in Hendersonville, N.C., was considering dropping its family medicine residency. Although such a move would have saved the not-for-profit facility roughly $1 million a year, it would have been a severe blow to primary care and the primary care workforce in the area.
Instead, Blue Ridge Community Health Center, a federally qualified health center (FQHC), joined a collaboration last year that already included Pardee and the Mountain Area Health Education Center of Asheville. The move not only preserved a valuable training program, it also gave residents exposure to a second outpatient setting -- an integrated FQHC that offers dental, behavioral health, radiographic and laboratory services; an on-site pharmacy; and interpretive services for a patient panel that includes a large Spanish-speaking population.
| Here I am touring the Hendersonville Family Medicine Residency with program director Geoffrey Jones, M.D., (left) and faculty member Magdalena Hayes, M.D. I visited the program Dec. 3 in Hendersonville, N.C.
The changes didn't stop there. After Pardee ceded control of the residency to the FQHC, the program increased its number of residents from three per class to four with funding from the Teaching Health Center Graduate Medical Education (THCGME) program.
That five-year, $230 million initiative provides funds directly to community-based teaching sites with a goal of producing more primary care physicians. One hundred primary care residents have graduated from teaching health centers in the first three years of the program's existence. That's noteworthy because we know that residents who train in underserved areas are more likely to practice in those settings.
I toured the Hendersonville residency Dec. 3 and saw first-hand what a teaching health center is about. I came away impressed by the residents, the faculty and the facilities.
Unfortunately, the Hendersonville program -- and other teaching health centers in 24 states -- face uncertain futures because of funding. Barring a reauthorization by Congress, funding for the THCGME program will end in 2015. That means first-year residents took a giant leap of faith when they entered these programs this summer. Still, residents I talked with this week were focused on their training and optimistic that a solution will be found.
The AAFP is doing its part. The Academy and more than 100 other medical and social service organizations sent a letter to congressional leaders last month, urging that funding for teaching health centers and other important primary care programs be extended.
The second issue facing teaching health centers is that the Health Resources and Services Administration (HRSA) recently announced that it plans to reduce payments for each resident during the 2015-16 school year. The AAFP has responded with letters to HRSA and Congress urging that full funding be restored.
During a recent trip to Capitol Hill, Academy leaders discussed both the need to restore funding for the 2015-16 academic year and the need to extend funding for the program beyond 2015 with congressional leaders and staff. At a time when our nation already faces a dire shortage of primary care physicians, we cannot afford to abandon a program that shows great promise for producing more family physicians.
Robert Wergin, M.D., is president of the AAFP.
Long-distance Support: Thoughts on Telemedicine at 2:30 a.m.
"You may want to use propofol," said a deep, gravelly voice that seemed to come out of nowhere.
I was caring for an older woman, and she was doing poorly. It was 2:30 a.m., the witching hour in medicine, and it looked like we might have to put her on a ventilator. I looked up at the two female nurses who were the extent of the medical team. The anonymous suggestion was welcome, but I had no idea where it had come from. It clearly was not either nurse, and I was fairly certain it was not the voice of God or an auditory hallucination.
"She appears to be decompensating," the voice said.
|In rural areas -- like my practice location in Valdez, Alaska -- telemedicine holds potential to help primary care physicians and our patients.|
Now, I may not be at my best at 2:30 a.m., but I was pretty sure that I was awake.
"You've given Lasix," the voice continued. "Good. Tell you what -- I'll put in orders for propofol while you're getting ready."
Despite my confusion, this was good news. We have an electronic health record system that requires us to type in orders before we can get medications, and I had my hands full at the moment.
That's when I noticed the cart in the corner with a camera tracking the action. We had been talking about signing up for Tele-ICU with Providence Anchorage Medical Center, although I had my doubts about its utility. There is no substitute for having a well-trained physician capable of stabilizing critically ill patients in rural communities, but I was interested in trying the system out. I just hadn't realized it was ready to go.
One of the challenges in rural medicine is the feeling of isolation during an emergency and the heightened sense of responsibility that comes with it. This likely is one of the biggest reasons why rural physicians burn out and leave. Sometimes, all it takes is one bad outcome, especially when the physician -- or the community -- thinks the patient could have been saved.
There have been many patients in Valdez who have required all hands on deck, but there is a cost in terms of lost sleep and function when the medical staff consists of only three people. It sure is nice, though, to have another doctor to talk with. Although I have only used Tele-ICU once so far, I have often called a doctor covering the ICU or ER in Anchorage -- or even a colleague in the lower 48 states -- just to discuss a difficult case. I doubt the doctors at the other end know how important those connections have been for me.
Telehealth is not new technology, although historically, it has been a solution in search of a problem. I have been angered at the money spent on telemedicine carts that could have been better invested in training new rural physicians or increasing physician payment to improve retention. These types of investments improve the rural safety net more than flashy engineering marvels that do not take into account how or why patients are actually seen.
My experience with the Tele-ICU was different. One of the most important aspects of modern medicine is the team approach and the opportunity it offers to discuss how to best to serve a patient. Rural physicians often have no access to the collaboration that occurs in metropolitan areas. So I think one problem telemedicine could solve is not so much how health care is delivered, but rather, how to collaborate at a distance through systems that support the local providers. These include broadband Internet, dedicated specialists who get paid for their work, and an attitude that the best provision of care happens locally.
Telemedicine has many potential benefits but also a number of pitfalls. For critical-access hospitals facing shrinking patient volumes, there is the potential for keeping more patients, rather than transporting them. This may require additional procedural training of rural health care professionals. If medical transportation rates decreased, this would result in significant health care savings.
Telemedicine has the potential to improve access to specialty care, but how will this affect rural practices? With proliferation of direct-to-patient sites, there may be decreased viability of the local system, and many rural physician practices are struggling as it is. Regulation currently prevents the establishment of national telehealth systems, although there is significant pressure to relax these rules. My fear is that direct-to-patient telehealth could unravel the rural safety net. Telehealth works best when it supports the local physician because there is no substitute for competent hands-on care.
Telemedicine also could allow specialists to narrow their field of study while empowering family physicians. I have a dream of sitting with my patient in front of a screen discussing her glomerulonephritis with a nephrologist who spends his day performing glomerulonephritis consults via telehealth. For this to work, a system must be in place that allows payment of the specialist and an adequate originating fee for the family physician.
It is too early to see how this will play out, but we are fast approaching a time of rapid change. From a rural perspective, I can see the allure of having another physician at your shoulder in the middle of the night when the patient is crashing. I might have done things a little differently without Tele-ICU and a virtual intensivist, but it was a good experience, and the patient did well.
John Cullen, M.D., is a member of the AAFP Board of Directors.
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