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.
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.
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.
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.
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.
Patients Need Nutrition Facts From Their FP, Not Dr. Google
I enjoy discussing nutrition with my patients. It is an essential part of the lifestyle and prevention package that family physicians are uniquely positioned to prescribe.
Although I have not eaten meat in 40 years, I live with three people who consume it on a regular basis. I had to self-educate about nutrition when I chose to stop eating meat because this was before I had the benefit of the four nutrition lectures I got in medical school. During those years, I drank a lot of milkshakes and discovered that it picked me up for a short while, but fatigue would roll in within two to three hours.
Diet for a Small Planet by Frances Moore Lappe was my original textbook and guide. It's hard for me to believe that this book is now more than 40 years old. Fast forward to today, and our patients are taking nutrition advice from TV doctors, the Internet and other sources that might not be evidence based. Shouldn't they be hearing the facts from us?
Every time I sat down to write this blog post, a new latest-and-greatest declaration in some journal or meeting would derail me. But recently, the Annals of Internal Medicine published an NIH-funded study that confirmed some of the things I have been telling patients. Researchers suggest that a diet that cuts down on carbohydrates may work better than trimming fat to aid in losing weight.
There is no one diet that works for everyone. One size does not fit all. (That is one reason there are so many diets out there.) But it's worth noting that this study included males and females and was racially diverse.
The problem with limiting carbs is that it may lead patients to inadvertently skimp on dietary fiber, which is important for heart and colon health, as well as for making our patients feel "full."
I talk with my patients about moderation in a healthier diet, but the exception is dietary fiber. I talk about going from the national average intake of 14 grams a day up to 30 grams a day, increasing intake slowly. First we assess their consumption, and then we add only 3 more grams per week until we reach our goal. This regimen brought my own LDL cholesterol down by more than 40 points and has been quite effective for a number of my patients, although sometimes our guts tell us that they are not happy with our diet.
The motto of "First, do no harm" is critical, and that applies to supplements. Through my sports medicine affiliations I have been fortunate to glean excellent information on this topic. Just because something is natural does not imply it is safe. I have diagnosed new-onset hypertension in a number of patients who thought they were doing a good thing by taking a multivitamin but did not realize that in those supplements they also were taking herbs that raised their blood pressure. By taking them off the multivitamin, we were able to return patients' blood pressure to normal without medication.
At the end of the day, it is about balance and moderation and trying to get your nutrition from as primary a source as you can.
After I finish my term on the AAFP Board of Directors this month -- and eventually finish the patient-centered medical home recognition process, achieving meaningful use and transitioning to ICD-10 codes -- I think I will sit with a cup of tea and start an outline for a nutrition piece for American Family Physician to update our information because obesity is a prevalent disease, and family physicians are in a position to make a major impact.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Heads Up: School Sports Season Is Upon Us
My practice of family medicine includes sports medicine, and I care for a number of athletes in my community. However, it was an athlete I never cared for -- someone from the other side of the country, in fact -- who changed my practice and the care of young athletes across the United States.
Zackery Lystedt was playing football for his junior high school when he was injured in a game in 2006. He did not lose consciousness, and he returned to the field in the second half. He collapsed and had to be air-lifted out of the area for life-saving surgery. After several strokes and three months in a coma, Zack woke up. But it took nine months before Zack could begin to speak again and nearly three years before he could stand on his own.
I learned about Zack during a presentation by Stanley Herring, M.D. -- a team physician for the Seattle Mariners and Seahawks and a member of the Head, Neck and Spine Committee of the National Football League (NFL) -- at an American College of Sports Medicine (ACSM) meeting in 2009. He described how Zack and his family had taken up the cause of trying to prevent other young athletes from suffering similar experiences. That same year, the Washington state legislature passed the Lystedt Law, which requires concussed athletes to be cleared by a physician knowledgeable in traumatic brain injury before being allowed to play again.
I had met Herring 10 years earlier when I served as the AAFP liaison at the ACSM's Team Physician Consensus Conference. He played a major role in advocating for the Lystedt Law in Washington, and he asked me to spearhead advocacy efforts for similar legislation in Delaware. It was a great learning experience in policy making as I worked with a state legislator, the NFL and others, and the law was signed by our governor in 2011. By 2013, all 50 states had passed legislation that prevents a concussed athlete from returning to practice or competition for at least 24 hours, and their return to play depends on clearance by a clinician.
There is still much to learn about concussions, as highlighted by a recent White House summit that brought together a diverse group of stakeholders, including the AAFP. Protecting young athletes is an important part of our job as family physicians, and there are resources worth highlighting.
- With support from the NFL and the CDC Foundation, the CDC has created tools for health care professionals as part of its Heads Up campaign.
- The agency's resources include a free online CME course that applies not only to young athletes, but also to other concussed patients.
- The AAFP's sports safety Web page links to journal articles on the topic, including the American Academy of Neurology's guidelines for managing concussions in athletes, as well as to other resources.
- With schools around the country starting soon, now is a good time to think about preparticipation exams to ensure that our young athletes are in the best possible condition for competition before their season starts.
May all of our patients be safer because we learn to protect them from injuries like the one Zack Lystedt and his family live with every day.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Women's Health: Do You See the Big Picture?
I had a new patient come to me last year, a woman in her 60s, complaining of back pain. Over the course of several months and multiple visits, and after indicated tests and imaging, we worked together to formulate and execute a pain management plan. Her acute condition improved, but I found myself wondering: Had I done a thorough job? Or had I let myself get caught up in dealing with one specific problem and had failed to see the bigger picture? Had I offered this patient all of the other tests and screenings -- such as colonoscopy -- that were recommended for her age group?
Patients often, and understandably, focus on the problem that is bothering them right now. But back pain isn't what is going to eventually kill that patient. Cancer, heart disease and other factors are much more likely to cause serious, long-term problems. As physicians, it's our job to stress the importance of doing all the other things that can help keep patients healthier longer.
So how are we doing?
A CDC study published this month in JAMA Internal Medicine indicates that when it comes to women's health, we could do better -- possibly much better. Researchers looked at data from more than 60 million preventive health visits to OB/Gyns and primary care physicians and compared what services were being offered by the two types of physicians.
Perhaps not surprisingly, OB/Gyns were more than twice as likely as primary care physicians to offer screenings for breast cancer and cervical cancer and almost twice as likely to test for chlamydia. However, women who saw a primary care physician were likely to receive a much broader range of services.
For example, 34.5 percent of women 45 or older received cholesterol screenings from their primary care physicians compared to only 5.4 percent of those who saw an OB/Gyn. Women who saw a primary care physician were four times more likely to be tested for diabetes.
But both OB/Gyns and primary care physicians have room for improvement. Colon cancer is the third-leading cause of cancer-related death in women. But the study found that among women ages 50-75, a total of only 6.1 percent were screened -- 7.2 percent of women who saw a primary care physician and 3.9 percent of those who saw an OB/Gyn.
The study also examined whether women received counseling about four key health issues: diet, exercise, obesity and tobacco use. Researchers found that 81.5 percent of women who saw an OB/Gyn and 73.5 percent of women who saw a primary care physician did not receive counseling on any of those important topics. Although not all patients need counseling on these issues, the numbers seem shockingly high given that more than one-third of U.S. adults are obese and nearly one-fifth smoke.
Despite the low overall numbers, primary care physicians fared better than OB/Gyns in all four areas. A little more than 19 percent of primary care visits involved counseling for diet compared to 12.4 percent of visits with OB/Gyns, 14.3 percent of primary care physicians offered counseling about exercise compared to 9.9 percent of OB/Gyns, 7.5 percent offered counseling for obesity compared to 4.2 percent of OB/Gyns, and 3.4 percent offered counseling for tobacco compared to 2.6 percent of OB/Gyns.
Time is obviously a factor. There's only so much ground we can cover in a 15-minute appointment, and patients often come with their own questions and concerns that have to be addressed. But taking a few seconds to show a patient where he or she stands stand on the BMI chart can be powerful, eye-opening and the first step in pointing that patient in a new direction. Patients who want to stop smoking can be referred to quitlines. We also can schedule a follow-up for patients who need more time to address their issues.
Communication likely is another factor. We need to let our patients know what tests and screenings are recommended and appropriate for their age. For our patients who see both an FP and an OB/Gyn, we also may need to do a better job communicating with our OB/Gyn colleagues to ensure that someone is taking responsibility for offering the appropriate services.
It's worth noting that the study's data were drawn from visits during 2007-2010 -- before the Patient Protection and Affordable Care Act mandated that health plans cover a wide range of preventive services. If this issue is re-examined in a few years, it will be interesting to see how much our numbers improve.
How does your practice use electronic health records, patient registries or other tools to ensure that patients receive recommended tests or screenings?
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
It Takes a Village: Become a Breastfeeding Advocate
Over the years, the Academy of Breastfeeding Medicine (ABM) has received significant leadership contributions from AAFP members, including past ABM officers Anne Montgomery, M.D., Julie Wood, M.D., and Tim Tobolic, M.D. AAFP member Anne Eglash, M.D., in fact, was a founding member of the ABM. But no AAFP officer had ever been invited to participate in the ABM's Annual Summit on Breastfeeding, even though our colleagues from the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics have routinely attended.
But this year, for the first time in the event's six-year history, all the specialties that care for newborns and mothers were represented at the recent two-day summit in Washington.
Family physicians, including president-elect Julie Taylor, M.D., M.Sc., (right) have played an important role in the Academy of Breastfeeding Medicine. I met with her at the recent Annual Summit on Breastfeeding.
This breakthrough represented an important opportunity for the AAFP because attendees at this event included not only representatives of the medical professional organizations noted above, but also leaders from CMS, HHS and other governmental agencies; federal legislators; representatives from such diverse stakeholder groups as the W.K. Kellogg Foundation, Kaiser Permanente and the March of Dimes, as well as academics, state health officials and others.
Unfortunately, many of these groups have not coordinated their efforts with one another and were not aware of other groups' activities. In particular, these other stakeholders were not familiar with the important work the AAFP has done in the areas of breastfeeding support, advocacy and policy. Therefore, I saw at least part of my role in attending the event as helping to break down existing silos.
I found it encouraging that everyone present seemed to readily recognize this need. We forged new relationships, connecting to the right people to improve our collaboration. In between agenda sessions, people were talking, exchanging cards, and sharing resources and links. I felt a great deal of enthusiasm and energy throughout the entire event.
Best of all, this summit provided me another opportunity to help other groups understand who family physicians are and what we do. I was able to point to our unique role in taking care of these special patients, noting that because we are the only specialty that truly does cradle-to-grave care, we have multiple opportunities to talk not only about breastfeeding, but also the many diverse issues relating to rearing children.
An especially important message for attendees to hear was about our ability to educate not just the mother, but also the father and, perhaps even more essential, the maternal grandmother! Family physicians are truly the medical specialists who can pull everything together after the blessed event, because we see both mother and baby together at subsequent visits. With this kind of postpartum follow-up, we can directly impact the sad decrease in breastfeeding rates that occurs after women go home from the hospital. At the time of discharge, about 75 percent of U.S. women are breastfeeding, but that rate drops to roughly 28 percent within a few weeks of going home.
Family physicians can take the lead in addressing this critical public health issue because we understand that breastfeeding is really a family matter, not just a personal one. We witness the powerful role of relationships within families and with our practices every day, with every patient.
The ABM has a number of resources to support breastfeeding, just as the AAFP does. One of our resources, the Academy's breastfeeding position paper, is even now being updated as part of a regular evidence review by our Breastfeeding Advisory Committee. That update likely will be published in the fall and will be accompanied by an education campaign aimed at helping to create breastfeeding-friendly family physician offices.
Other resources family physicians may find helpful include the Baby-Friendly USA initiative and its 10 steps to creating breastfeeding-friendly hospitals. Even for family physicians who don't work in hospitals or provide obstetric care, it's still important to advocate on patients' behalf to ensure that that the first exposure during and after delivery reflects strong support for "the first food" and not formula.
It's also worth noting that 28 percent of all medical students in this country are members of the AAFP, so we have a unique opportunity to begin emphasizing breastfeeding benefits early on regardless of what specialty each student eventually selects. Moreover, our residencies are working to become breastfeeding-friendly for our trainees. This new policy is the result of resolutions passed by the 2013 Congress of Delegates that initially were brought forward by our students and residents.
Finally, I was able to share the critical need for all of us to network better with each other. Even in this meeting that focused on an issue of common ground, I still saw evidence of our fragmented health care system. Different groups don't always share as well as they could. This is one of our challenges in these days of advanced communications technology -- we can forget the power of face-to-face discussions. That is one reason I am so eager to say "Yes!" to these kinds of invitations. Nothing can beat actually talking with people in person.
That said, we need to recognize that the mothers and families of today are different, and I challenged everyone at the meeting to get comfortable with social media because it's one more avenue to increase awareness about breastfeeding.
One final note: Just as family physicians were critical to the founding of the ABM, so we are to its leadership now. The current president of the ABM is Wendy Broadribb, M.B.B.S., a family physician from Australia. Julie Taylor, M.D., M.Sc., a family physician on faculty at Brown University, will be taking over next year. I look forward to future opportunities for the Academy to interact and grow together with other stakeholders on this important issue.
Reid Blackwelder, M.D., is president of the AAFP.
Measles and Mumps and MERS, Oh my…
It's not hard for me to remember that it's that time of the year again because my daughters are frequently singing Olaf's song from the Disney movie "Frozen." "When life gets rough, I like to hold on to my dream, of relaxing in the summer sun, just lettin' off steam … in summer."
My family is heading to Hawaii for our summer vacation, and we won't be alone. After a harsh winter in many parts of the country, a busy summer travel season is expected. The American Automobile Association (AAA) estimated that nearly 32 million Americans traveled at least 50 miles by automobile during the Memorial Day holiday alone, and another 2.6 million traveled by plane. It marked the second-highest travel volume for the holiday in more than a decade.
Airlines for America, an industry lobbying organization, projects summer air travel will rise to its highest level in six years. Roughly 210 million passengers are expected to fly U.S.-based airlines from June through August, including a record 30 million passengers traveling internationally on U.S. carriers.
With that summer fun comes some potential risks. Measles remains common in many parts of the world, including areas of Europe, Africa, Asia and the Pacific. For example, the Philippines had more than 31,000 suspected cases of the disease (and 70 deaths) through May 20 of this year.
In an average year, only about 60 cases of measles are reported in the United States. Unfortunately, international travelers are bringing home more than just souvenir T-shirts. This year, the United States has had more than 300 cases of measles -- including 15 outbreaks covering 18 states -- reported since Jan. 1. That's the highest total since public health officials declared the disease eliminated here in 2000. According to the CDC, the vast majority of reported cases (97 percent) have been associated with either foreign visitors or U.S. travelers returning home from international trips.
Meanwhile, the CDC also reports that from Jan. 1 to May 2, 464 cases of mumps have been reported. That total already is higher than all the mumps cases reported last year.
Although nearly half of the measles importations have been linked to the Philippines, other cases imported into the United States have been associated with travel to other countries in Southeast Asia, Europe and what the World Health Organization refers to as the Western Pacific region and the Eastern Mediterranean region.
Measles isn't the only health issue for travelers and their physicians to think about. With new reports of infection caused by the novel Middle East respiratory syndrome coronavirus (MERS-CoV), many of my patients are now concerned about what they otherwise would have thought of as simply a mild cough or seasonal allergies. I, too, have found myself being more diligent in asking about travel history when confronted with patients who present with fever or upper respiratory symptoms.
Although few of us may remember seeing -- much less treating -- measles, even fewer have experience managing suspected cases of MERS-CoV infection. I remember the hypervigilance of our health care community in 2003 after the World Health Organization issued a global alert regarding the severe acute respiratory syndrome (SARS) outbreak, how we masked every patient who presented with cough, how there was a run on local pharmacy supplies of N-95 masks, and how every traveler returning from Asia was screened via infrared cameras on their entry into the United States.
The general public may be lulled into a false sense of security when infectious diseases such as measles, smallpox or polio are eliminated domestically or when a particular outbreak "dies out," as SARS did. It is our responsibility as trusted physicians to remain vigilant about global trends in communicable diseases and outbreaks. It is our role as patient advocates to ensure that our patients are protected from preventable illnesses in this global community. And it is our role as public health defenders to convince those who are reluctant to get vaccinated that it really is in their own best interests -- and the best interests of those around them -- to do so.
But one of the most difficult challenges in my daily practice is to know what advice to give when patients travel to locales unfamiliar to me. So when I ask my patients' their about summer travel plans, I breathe a sigh of relief if they mention some place like Japan or Cancun. But how about a honeymoon trip to Tahiti, the annual Hajj pilgrimage to Mecca, or a medical mission to Haiti?
Well, I recommend a quick search on the CDC's Travelers' Health Web page, which provides the latest information and advisories about communicable disease outbreaks around the world. It also has information -- searchable by country -- for both clinicians and lay travelers about vaccination requirements and other recommendations. You also can find travel tips for patients heading abroad (including the fact that they should be vaccinated at least six weeks before leaving home) on FamilyDoctor.org.
Armed with these invaluable resources, I can confidently advise my patients and protect my community from the latest outbreak of polio in Syria, dengue in Brazil and Ebola in Liberia.
So, when you see your patients this summer, don't forget to ask them about their travel plans.
Jack Chou, M.D., is a member of the AAFP Board of Directors.
White House Invitation Shows Importance, Recognition of Family Medicine
In our advocacy efforts, we often talk about the importance of being "at the table" when important discussions are taking place. The Academy is getting a good seat at that proverbial table more and more often.
Last week, I had the opportunity to represent the AAFP at a White House event for the second time in less than 18 months. This most recent trip was prompted by an invitation to attend the president's Healthy Kids and Safe Sports Concussion Summit, which brought together select medical experts and representatives from collegiate and professional sports organizations to address this serious problem.
|I attended the Healthy Kids and Safe Sports Concussion Summit May 29 at the White House.|
My previous White House invitation stemmed from the first lady's request that an AAFP representative attend a meeting about Joining Forces (a national initiative to support military service members and their families) along with the representatives from the Department of Defense, the Department of Veterans Affairs and other stakeholders. At that meeting, we addressed the challenges of providing care to special groups within our armed services, including service women and veterans needing mental health services.
I'm pleased that the administration is demonstrating an increasing recognition of the critical, foundational role that family physicians play in our health care system. Concussions, traumatic brain injury, mental health and women's health needs are significant health issues. Unfortunately, it is common for legislators and administrators to view these issues strictly in terms of subspecialty services, which can easily lead to fragmented care.
Family medicine is the only specialty that doesn't limit itself based on organ systems, disease groups, specific problems or age of patients. Instead, we are on the frontlines of managing all of these issues in our patients every day. One of the Academy's goals is to help those in leadership positions better understand who family physicians are and what we can provide. The fact that the AAFP is repeatedly being invited to meetings like these indicates our message is getting through.
During his remarks at the concussion summit, the president mentioned that although U.S. emergency rooms see roughly 250,000 children each year for head injuries, that doesn't include the number of children who are taken to see their "family doctor." I appreciate his recognition that family physicians are instrumental in the care being provided to children for such health issues. We are able to address the acute issues of affected children and the appropriate concerns of their families. We can educate these families and discuss how to prevent these injuries.
Perhaps even more important are our relationships within our communities. Family physicians provide numerous community services in many different venues, and 40 percent of our members provide some sports medicine services. Many are right there on the sidelines to educate coaches and teams.
Moreover, the direct connection we have with patients allows us to be there for the challenges created when someone has a severe concussion and its sequelae -- such as post-concussion symptoms and even career- or life-changing events. We are the only physicians with the combination of comprehensive education, extensive training and skills to handle complexity that allows us to care for all of our patients’ needs and help manage the impact on their families.
One of the promises that our officers and Board made to all Academy members was to continue to advocate that we be at the table and, thus, off the menu for such keenly important health care issues. I think we are well on our way in this regard. Our invitation to, and attendance at, these high-level meetings allow us to continue to educate those in health and government administration not only about the need for family physicians to be right at the frontlines, which we already are, but also to be respected in that critical role.
Thank you for all of your service and for all that you do. More and more people are recognizing the important work family physicians have always done, and they are starting to value those contributions appropriately.
Reid Blackwelder, M.D., is president of the AAFP.
Ask the Question: Screening for Alcohol Misuse Can Save Lives
I recently returned home from an incredibly inspiring weekend at the AAFP's Annual Leadership Forum and National Conference of Special Constituencies in Kansas City, Mo., but my good mood quickly faded when I found the local Chicago news filled with stories of yet another accident caused by drinking and driving.
A man driving an SUV entered the northbound lanes of Lake Shore Drive headed south and struck a taxi head-on. According to police reports, the man’s blood-alcohol content was more than twice the legal limit.
A young law student who was riding in the taxi died in the crash. She was reported to be an accomplished and big-hearted leader among students, was on schedule to graduate next month and had already received and accepted a job offer.
Sadly, she won't be graduating with her classmates or celebrating her accomplishments with her family. And her story, tragically, is just one of many.
In fact, the World Health Organization (WHO) said in a report released this week that alcohol contributed to 3.3 million deaths -- or 6 percent of all deaths -- worldwide in 2012. That staggering total means that roughly every 10 seconds, someone dies an alcohol-related death. Accidents, including car crashes, accounted for 17 percent of all alcohol-related deaths.
Here in the United States, excessive alcohol use is the third-leading preventable cause of death, claiming roughly 80,000 lives annually. Alcoholic liver disease is the second-leading indication for transplantation in the United States.
So what are we doing about it in our practices?
"Do you drink?" is a question we are trained to ask in medical school, but are enough of us actually asking it? According to the CDC, only one in six U.S. adults have ever talked to a health care professional about alcohol use. That's unfortunate because, according to the agency, alcohol screening and brief counseling can reduce the amount excessive drinkers consume by as much as 25 percent.
Of course, there are reasons why a primary care physician might hesitate to ask the question. Some physicians tend to shy away from questions about substance abuse. Not only can it be an uncomfortable topic, but some practices and communities lack adequate resources for treatment. It's also likely that some patients are less than forthcoming about their struggles.
Health care payers require us, and offer incentives, to ask every patient at every visit about certain other clinical issues, such as tobacco use, pain and asthma. In a health care environment where an office visit may be limited to 15 minutes or less, there are many issues to cover in a limited amount of time.
But considering that excessive alcohol use costs our country roughly $185 billion a year in health care costs, criminal justice expenses and lost productivity, wouldn't it make sense for alcohol use to be just as important a question as tobacco use when taking a patient's health history?
According to the WHO report, 7 percent of U.S. men and 2.6 percent of U.S. women are alcohol-dependent. More than 10 percent of men and more than 4 percent of women have an alcohol disorder, meaning either dependence or harmful use of alcohol. However, only 15 percent of people with such a disorder seek treatment, according to the National Institute on Alcohol Abuse and Alcoholism.
If none of those statistics grabbed your attention, consider that 10 percent of U.S. children live with an adult who has an alcohol problem. So what can we do to help patients and their families?
It's really very simple: We need to ask the question. The AAFP recommends that physicians screen adults for alcohol misuse and provide patients engaged in risky or hazardous drinking with brief behavioral counseling interventions.
Although time certainly can be a barrier during an office visit, there are many simple screening tools that are easy and quick to use. For example, the CAGE questionnaire consists of just four questions. The WHO's Alcohol Use Disorders Identification Test can be completed in as little as two minutes.
Once we've asked that difficult first question, these tools can help us determine whether a patient needs counseling. If your practice isn't equipped to offer counseling, take the time to inform yourself about the resources that are available in your community.
The third-leading cause of preventable death in our country is an issue we can't continue to be silent about.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
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