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Wednesday Jan 27, 2016

Win-Win? Cardiology Project Could Benefit Patients, FPs

Cardiovascular disease (CVD) is the leading cause of death in the United States, claiming more the 600,000 lives each year. That's more than the population of Wyoming.

CVD accounts for 17 percent of U.S. health expenditures, and those costs are expected to triple between 2010 and 2030. Improving prevention and care processes, however, could substantially reduce morbidity, mortality and the costs associated with CVD, and the AAFP is participating in work that aims to do just that.

I recently attended a meeting at the Brookings Institution in Washington with representatives from the American College of Cardiology, the American College of Osteopathic Family Physicians and the American College of Physicians, as well as CMS, private-payer organizations, health systems, medical schools, research groups and the Veterans Health Administration. Our goal for this meeting, and the conference calls that preceded it, is ultimately to produce a policy paper that would serve as a model to improve the way primary care physicians and cardiologists work together.

The end product could result not only in better care for our patients, but more equitable pay for primary care. Our patients and our practices both have a lot to gain in the process.

It was interesting to see how much common ground primary care has with our subspecialty colleagues. We discussed numerous opportunities to close gaps in care, reduce overtreatment and address undertreatment.

Inadequate communication between physicians, patients and caregivers is one obvious problem we agreed on, and universal dismay was expressed -- from primary care, cardiology and payers -- about the state of electronic health record systems. Current products are not meeting needs and are a barrier to innovation.

We also agreed that physicians -- regardless of specialty -- need more time with our patients than what is typically possible in the fee-for-service world of health care. Cardiology is still firmly based in that fee-for-service model. Roughly three-fourths of practices are owned by health systems. Meanwhile, a recent study showed that roughly one-third of family physicians already are pursuing value-based payment.

So how do we pull the cardiologists into our patient-centered neighborhood? A representative from CareFirst BlueCross BlueShield pointed out that the payer has had tremendous success with the patient-centered medical home (PCMH) model, lowering both ER visits and readmission rates related to CVD. Primary care practices, he said, are receiving better payment as a result of this hard work. Health systems representatives also pointed to the PCMH as a means to improve quality and lower costs.

In addition to how we might work better together, we also discussed how improving care, coordination and communication could also affect payment, including pay-for-performance programs, bundled payments, shared savings and more.

This project, which is an initiative of the new Duke-Margolis Center for Health Policy, still has a long way to go. There will be followup work still to come. But the possibilities are intriguing, and if we can get it right, this could serve as a model for how primary care works with other subspecialties, as well.

Wanda Filer, M.D., M.B.A., is president of the AAFP.

Tuesday Jan 12, 2016

U.S. Needs More Than Baby Steps on Paid Maternity Leave

Maybe, just maybe, Americans are finally waking up to a truth that has already been accepted globally: Paid maternity leave has far-reaching health implications for both mothers and their children, including facilitating breastfeeding.

Last month, Air Force Secretary Deborah Lee James said that branch of the U.S. military will triple its paid maternity leave benefit to 18 weeks, following the example set by the Navy back in August.

The international corporate world also took some big steps in the past year. Nestlé, the largest food and beverage marketer in the world, announced that it was extending its paid parental leave for primary caretakers from six weeks to 14 weeks for its workers globally, and it also will allow employees to take 12 unpaid weeks.

Nestlé CEO Paul Bulcke said in an interview with Fortune that supporting breastfeeding was one of the primary drivers behind changing the company's policy. That's an interesting step for a company that has been boycotted off and on for decades for the way it markets its infant formula.

The World Health Organization recommends that women should breastfeed for as long as two years, and the AAFP recommends breastfeeding for at least 12 months.  (The Academy's breastfeeding toolkit has resources for moms and practices.)

It is well documented that breastfeeding is healthy for both mothers and babies, boosting immunity, increasing bonding, reducing risk of postpartum depression and decreasing risk of morbid obesity in babies. With an ever-growing amount of data that support breastfeeding, why does our country have such a dismal rate of mothers who breastfeed past the first six months of life?

Roughly 80 percent of U.S. mothers are breastfeeding during the first 48 hours postpartum, according to the CDC. That drops to approximately 20 percent by six months. Disparities become more pronounced when looking further into the demographics. Women who breastfeed beyond six months tend to be Caucasian, have higher household incomes, stay home and be more educated. Those least likely to breastfeed tend to be black working moms who are less educated and are from homes with lower household incomes.

Although there are many factors that contribute to these shameful statistics, a major one is the persistent lack of parental leave for the vast majority of U.S. workers. This is despite studies that indicate mothers who have sufficient time to transition into parenting not only are more successful with breastfeeding, they also use less sick days, are more productive, suffer less burnout and demonstrate more loyalty to their employer.

The United States is the only industrialized country in the world that does not support some kind of paid parental leave. Many people have little or no time off, even unpaid. Particularly for those affected by poor postnatal outcomes, taking time off could mean risking one's job.

Some might argue that the Family Medical Leave Act, which guarantees one's job after return from a leave due to birth, adoption or the serious illness of a loved one for up to 12 weeks, is sufficient. However, the law does not require the leave to be paid and it generally applies only to people who have worked at least 12 months for an employer who has at least 50 employees.

Unfortunately, only about 12 percent of U.S. employers offer paid maternity or paternity leave, according to the Society for Human Resource Management. That's down from 17 percent in 2010.

No one can deny that becoming a parent is a life-defining moment, one that requires time to which to adjust. However, how can one take that time when there are bills to pay? In my second year of residency, I took only two weeks off after delivering my second child because I was allotted only eight weeks of paid time off and I already had used five weeks for bedrest. (I needed my last week of vacation time for job interviews.)

So why is paid leave so important to one’s ability to breastfeed? Simply put, if I have to return to work before my milk even has time to be established, then how can I be successful in maintaining my supply? Furthermore, women are expected, or perhaps feel pressured, to make up for the time they were away on leave.

Becoming a mother is one of the hardest, yet most rewarding, accomplishments I have under my belt. Let’s not lessen the impact and powerful message working mothers make when they embrace their many important roles both in and out of work. We should celebrate our many roles, including providing nourishment for our children.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Wednesday Jan 06, 2016

Telehealth Is Family Medicine’s Next Big Opportunity

Perhaps, like me, you've noticed that telehealth really hasn't lived up to its promise here in the United States. Although you may find the technology in niche markets, like satellite hospital consultations, there is hardly a transformative, mainstream movement of consumer access to family physician services online or by smartphone. 

Yet the trends are unmistakable:

  • Estimates vary, but perhaps 20 percent of what family physicians do in the office could be accomplished remotely. I would even go so far to say that much of what is happening now in retail clinics could be safely performed as a telehealth visit. (Will retail health be disrupted next?)
  • Although the fee-for-service model has barely paid for telemedicine, the advent of new models such as direct primary care and accountable care organizations could create a sustainable funding source for services that were previously not paid for.
  • Regulators at the state and national level are continuing to modernize the laws around telehealth and telemedicine to encourage physicians to engage patients remotely within clear boundaries that are safe and have utility to consumers.
  • The proliferation of Bluetooth-enabled biosensors that can communicate with smartphones and sync data to cloud-based health information exchanges allow for remote monitoring of patients. These patients are empowered to decide with whom they will share that information. For some patients and family physicians, this might allow for a novel telehealth visit with vitals.

So what does the United States need to do to start participating more? Well, according to the American Telemedicine Association, we are about halfway there. State legislatures and policymakers must continue to remove regulatory barriers such as only requiring insurers to pay for telehealth for rural patients, because suburban and urban areas also have health care disparities and access problems.

Family physicians should not be required to document a barrier to an in-person visit before a health benefit plan covers telemedicine. And nothing should require the use of telemedicine when in-person care by a participating physician is available within the member’s geographic area, or when a family physician determines it is inappropriate. In other words, actual plan networks cannot be remote.

I am amazed at how many patients in this economy may have a tablet computer or a smartphone, but not an automobile. Moreover, just as we use Skype and Facetime with friends and family more than with strangers, I predict the strongest future for telehealth will be between family physicians and their long-time patients, not between strangers connecting to chat.

John Bender, M.D., M.B.A., is a member of the AAFP Board of Directors.

Monday Dec 21, 2015

Government Hears From FPs on Opioid Abuse Crisis

In the 1990s, physicians were told we weren't doing enough to address pain. Millions of Americans were suffering with chronic pain, affecting more patients than diabetes, heart disease and cancer combined. Essentially, we were told we were failing these patients.

Naturally, physicians responded.

© 2015 Shawn Martin/AAFP

Here I am with Surgeon General Vivek Murthy, M.D., M.B.A. Murthy gathered a group of stakeholders Dec. 16 in Washington to address prescription painkiller abuse.

In 1995, the American Pain Society introduced the slogan "Pain: the fifth vital sign," to raise awareness of the need to treat pain. By 1999, the Joint Commission on Accreditation of Healthcare Organizations was on board as well, and that organization published new standards for pain management a year later.

Unfortunately, the pendulum has swung too far. The number of prescriptions written for opioids jumped from 87 million in 1995 to 219 million in 2011. From 2003 to 2013, the number of Americans who died as a result of opioid abuse surged from 4.5 per 100,000 to 7.8 per 100,000. In 2014, 19,000 people died as a result of such abuse.

Now we find ourselves in a difficult situation as federal agencies ask us to curb our prescribing at the same time that our patients are living longer and with more chronic conditions. How do we find a balance and bring that pendulum back to the middle?

Last week I devoted an entire day in Washington to this issue, meeting with staff members from the offices of Sens. Pat Toomey, R-Pa., and Bob Casey, D-Pa., speaking with a national media outlet and participating in a meeting called by the surgeon general.

Toomey and Casey, senators from my state, are hearing a lot from federal agencies, the public and the medical community, and they are trying to determine whether there is a legislative solution. I made them aware of the delicate art and science of caring for patients in pain, and the work that family medicine and AAFP have been doing to curb opioid diversion and deaths.

I also spoke with National Public Radio host Robert Siegel for an upcoming segment of All Things Considered that focuses on our nation's pain and opioid dilemma. One of the things he asked me was how often family physicians have to deal with the issue of pain.

As you know, every day we care for patients with pain because roughly 100 million Americans suffer from chronic pain. So we discussed how to decide who should be treated -- or not -- with prescription medications and what steps we can take to ensure that medications are used appropriately and only for as long as needed. I also highlighted the importance of having an ongoing relationship with a primary care physician.

Many of these same issues rose that day during an event organized by Surgeon General Vivek Murthy, M.D., M.B.A. In addition to the AAFP, representatives from many other health care groups -- including the American College of Physicians, American Congress of Obstetricians and Gynecologists, American Dental Association, AMA, American Osteopathic Association and American Association of Nurse Practitioners -- were present.
The day before this meeting, a study published in JAMA Internal Medicine reported that primary care professionals were the biggest prescribers of painkillers, with family medicine recording 15.3 million prescriptions, internal medicine 12.8 million, nurse practitioners 4.1 million and physician assistants 3.1 million. So you might have expected our specialty to be in the crosshairs during this meeting with federal officials.

However, HHS acknowledged that this is a public health issue that is multifactorial. We also agreed that it's not surprising that family physicians see a large number of patients suffering with chronic pain because FPs provide roughly one in five U.S. office visits.

It was refreshing that this event was essentially a listening session for the federal health agencies. We told them what we are experiencing and what needs to improve. For example, we talked about the importance of physicians participating in prescription drug monitoring programs (PDMPs), working with states to make PDMPs more robust when needed, using real-time data and achieving interoperability among state programs. We also discussed safety issues and the need to reduce diversion.

The CDC recently released a draft of its new guidelines for opioid prescribing, and it's not yet clear what the surgeon general's next step will be. But we do know the AAFP will continue to work with the federal agencies, as our policy on this issue states, "to allow effective and safe opioid prescribing for patients in their pain management programs by their family physicians."

Wanda Filer, M.D., M.B.A., is president of the AAFP.

Wednesday Dec 16, 2015

At the Crux of Art and Science: I'm a Family Physician

My mother walked the hospital corridors with me at her side. I escorted her around the facilities, showing her my place of work. She turned to me with a proud look in her eyes and said, "Remember that what you do is sacred."

I don't think I will ever forget that day. Growing up in an immigrant household, there was nothing more revered than the work of doctors and clergymen. In my culture, they almost go hand in hand. Care is taken to heal the soul, not to simply treat an ailment. There is a keen art in doing so.

Or at least, there was.

I'm not sure how or when medicine turned from an honored profession to an outcome-based mill. I certainly don't recall when patients turned from people to products. However, this is how practicing medicine now sometimes feels.

We are hindered by protocols, quality measures and satisfaction scores, which make fostering relationships with our patients difficult. And as family physicians, aren't relationships the reason we chose our specialty?

Don't get me wrong. Quality plays an important role in delivering good patient care. What I do not agree with, however, is how the health care system defines quality.

With so much information available in an instant, it is all too common for patients to come to me with a diagnosis in hand, seeking a pill they want to try or a remedy they have seen on TV. The problem is that not all information strewn about various media is valid. How many times have you had patients demand antibiotics for sputum they perceived to be greenish in color?

This concept of drive-through medicine is costing the country millions of dollars in unnecessary testing and medication. So how do we fix this "Have it your way" culture at a time when we're judged, at least in part, on patient satisfaction?

A regular reminder I share with not only my patients, but also administrators, is that health is no more a product than is the wind. It flows and is dynamic. Protocols are guidelines, and I certainly am not a dictator when it comes to the care of my patients. Ultimately, they need to remain informed about their conditions and live with the consequences of their decisions. I am their consultant, I remind them, one who collaborates to help them reach their goals.

I am not a personal assistant. Although I guide my patients regarding their health and wellness, that does not necessitate total agreement. Not every ache and pain requires a CT scan or MRI. Not every cough or sniffle requires an antibiotic. Not every person requires a Pap smear or colonoscopy. To best serve my patients, I need the ability to practice the art of medicine.

In the world of fee-for-service health care, we are measured by how many patients we see per day. We feel the pressure of time limitations. Important conversations about effective treatment options often give way to scheduling restrictions. However, we all know that so-called productivity does not necessarily equate to quality. Somehow, a term used to assess factory-based businesses has crept into the medical field.

I am increasingly reassured that the AAFP’s consistent work to change our health care payment structure to a more value-based model is a win-win. But quality takes time, and more family physicians need to be at the head of the table for discussions affecting all aspects of the health care delivery system so this message resonates at all levels. Who would better understand work flow, quality measures and patient-centered teams than a family physician? We need strong family physicians in leadership roles to continue advocating and directing a shift in the current payment model.

The research stands for itself. Family physicians not only give good care, we do so in the most cost-effective manner. A recent retrospective study found that greater family physician comprehensiveness of care, especially as judged by claims measures, is associated with decreasing Medicare costs and hospitalizations.

So how do we educate our patients about sticking to tests and treatments that are necessary and evidence-based? We remain engaged. We continue to advocate and fight for a system of care that values quality instead of procedures. We focus on health and wellness instead of simply fixing broken bodies. We put the patient back into the center of our care. Otherwise, we will continue to face challenges based on information patients receive from Dr. Google.

In essence, we must remember that more does not equal better. In fact, more can actually be detrimental. Just ask my patient who suffers from urinary incontinence after having a radical prostatectomy for low-grade prostate cancer while in his 70s.

Or ask my patient who was taking more than 20 different medications for management of various symptoms before being whittled down to the six she really needed.

Ask the elderly patient who was taking three different brand names of the same anti-arrythmic drug before her family doctor went through her medications with her.

Ask the young lady who developed Clostridium difficile infection after being treated for multiple "respiratory infections."

The list could go on and on.

After all is said and done, we cannot reduce the practice of medicine to a simple black and white algorithm. Trust between physician and patient must be first and foremost. We must resist the urge to allow insurance companies, pharmaceutical agencies and the media to give misinformed guidance in how we provide care to our patients. If not, then our role as family physicians becomes diluted.

How do we change this "Have it your way" culture? One patient at a time.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Wednesday Dec 09, 2015

Seeking Solutions to Gun Violence at the Scene of the Crime

A couple of months ago, I was invited to participate in an event at the Emanuel African Methodist Episcopal Church in Charleston, S.C., which was the site of a racially motivated shooting earlier this year. The purpose of the event was to bring together stakeholders from legal/judicial, health care, public health, law enforcement, political, faith and other communities to address gun violence prevention.

From the time I started preparing for this event in early October until it actually took place on Dec. 4, the United States witnessed more than 50 other incidents in which three or more people were shot. In just two months, such shootings claimed 90 lives and wounded more than 200 others.

Michael Bowman/Voice of America
A memorial forms outside the Emanuel African Methodist Episcopal Church. Nine members of the congregation died during a June 17 shooting at the Charleston, S.C., church. I participated in a forum on gun violence Dec. 4 at the church.

As a nation, we cannot allow ourselves to grow numb to such tragedy. By the time we convened last week in the same room where nine members of Emanuel's congregation had been gunned down in June, places such as Colorado Springs, Colo., and San Bernardino, Calif. -- where other high-profile, deadly attacks occurred -- had been thrust into the national spotlight.

It was powerful and poignant to be in that church in Charleston. More than 300 people, including state legislators and the presidents of the American Bar Association and the American College of Physicians, participated. The AAFP was represented by state and national leaders, and I participated in a health care panel discussion.

We talked about the scope of gun violence, which has claimed the lives of more than 406,000 Americans in the past 14 years. In the past four years alone, gun-related deaths have exceeded the number of American lives lost in the Vietnam, Korean, Iraq and Afghanistan wars combined.

The issues discussed included adverse childhood experiences, domestic violence, racial disparities, the Second Amendment and more. We learned from a speaker from the American Psychiatric Association that most gun violence homicides are not related to mental health, although conventional conversations would make us believe otherwise. We also discussed the petitions physician groups delivered to Congress a few days earlier (hours before the San Bernadino shooting), seeking repeal of a shameful law that bans the CDC and NIH from conducting research on gun violence.

The obvious question is what can be done about this crisis -- which one speaker, from the Johns Hopkins Bloomberg School of Public Health's Center on Gun Violence, called a social contagion -- in a sharply politically divided country? On one end of the spectrum, there are those calling for bans on guns, while those on the other end believe the solution is to buy more guns.

How do we find middle ground that effectively addresses the problem? Can we reduce gun violence while respecting the Second Amendment? According to constitutional law experts who participated in the event, the answer is a resounding "yes."

For example, speakers pointed to the need to close loopholes in existing gun laws. The FBI has acknowledged that the Charleston shooter should not have been able to legally buy a gun because of his criminal record. However, federal law allows gun dealers to proceed with sales if FBI examiners do not respond within three days. In the Charleston case, clerical errors prevented the FBI from acting before the transaction was completed. Clearly, the system needs improvements, and the three-day period should be re-evaluated.

Meanwhile, some states are actually easing gun laws. Earlier this year, for example, Kansas passed legislation that allows people to carry concealed handguns without a permit and with no training. Although the gun industry promotes its products as keeping families safe, too often, gun owners are doing the exact opposite. During the first 10 months of this year, 13 U.S. toddlers inadvertently killed themselves when adults left loaded guns in places these children could access. Eighteen others injured themselves, 10 injured others, and two killed other people.

Family physicians can play a key role in helping keep people -- especially children -- safe, but the First Amendment rights of physicians aren't being held in the same regard as the Second Amendment rights of gun owners. Florida passed a law in 2011 that restricts physicians' rights to ask patients whether they own guns. Roughly a dozen other state legislatures have since introduced similar measures. The AAFP strongly opposes these dangerous restrictions on patient-physician conversations that focus on prevention.

Why would physicians ask patients about guns? For the same reason we ask parents about bike helmets and child car seats: We can help parents make good decisions that make their families safer. In this case, we can counsel them about safe gun storage.

Changing gun laws, or passing new ones, likely would be extraordinarily difficult in a political environment where our two major parties can't agree on far less divisive issues. But what if we instead approached gun violence as a public health issue? Cure Violence is one such model that is showing success.

A combination of regulation, education and taxation has led to a dramatic decline in smoking rates, from 42.4 percent of U.S. adults in 1965 to 18 percent in 2014. What combination of education, public health, mental health and health care programs could help reduce gun violence?

Clearly, something has to change, but we must do it in a way that protects people's rights -- and not only their Second Amendment rights. This conversation will be coming to your community. When it does, what will you say as a family physician?

Wanda Filer, M.D., M.B.A., is president of the AAFP.

Tuesday Dec 01, 2015

Stillbirths: Mourning the Children I Never Got to Know

It was one of those weeks. You know what I mean. I had returned from a great weekend spent as a family medicine delegate to the annual meeting of the California Medical Association House of Delegates, and I felt like my energy had been restored.  

Then I opened my laptop.

I had 25 patients on my schedule, including an induction for a first-time mom who was past her due date. After seeing a few patients, I headed next door to the hospital to review the induction process with my patient. She had a couple of risk factors that are all too common nowadays. Smoking and being overweight, I reminded her, could make jump-starting her body into labor take a bit longer.  

I returned to the clinic to see other patients, answer phone calls, catch up on paperwork and attend meetings, but I stayed in close contact with the labor-and-delivery nurse and watched the fetal tracings remotely. Nothing about the scenario to that point struck me as out of the ordinary. However, after two days of induction and a subsequent cesarean section for fetal intolerance of labor, the result was not as expected.

I recalled going to simulation labs in med school and learning how to give bad news to patients. We were taught how to deal with poor outcomes in residency. I have held the hands of many patients' family members as they said their final goodbyes to loved ones. Death is a natural part of the circle of life. As a family physician, one of my roles in the family context is to usher my patients -- and their families -- into that next part of their journey. I feel great privilege in being there at both ends of the life spectrum, and I strive to honor that life to the best of my ability.  

Birth and death are two of the most vulnerable experiences we face. A woman must essentially relinquish herself to the process of labor as she charges her baby into life.  Similarly, those last moments of life also create an atmosphere where one bears only the necessary. The space for insecurities eventually dwindles. What if, though, life and death happen in a matter of minutes? What if for some unforeseen reason, a neonate is delivered without the breath of life?

Before going into private practice, I experienced only one stillbirth during residency. A young, independent mother made the decision to bring life into the world even after the father of the baby refused to take his part. She came to all her appointments and asked good questions. One day, she presented to labor and delivery after not feeling a previously boisterous baby girl move for two days. I still remember the silence around her as she cried in emotional and physical agony. I still remember the intense grief that filled the room. At the time, I had a toddler of my own waiting for me to get home, but I could not help but pause to ponder why these events happen.   

My hardest experiences are still in these rare but tragic moments. I don’t think any amount of training can completely prepare someone for such a situation. Even when a clear-cut answer comes back via autopsy or placental pathology, a much harder -- and, I think, deeper -- question remains unanswered.

Why?

As I look into the eyes of a woman whose dreams have been crushed, the "why" they ask is organic. "Why did you let this happen?" or "Why am I a mother without ever mothering a child?"

I will never have an adequate answer to these questions because I am just as human as my patients.  

As a physician, I deal with two losses. I have lost a life that never really had a chance to begin, but I also have likely lost that mother as a patient. Often, I do not see the parents any longer. Of the stillbirths that I have been a part of, only one mother returned to continue care with me. I understand how coming to an office filled with pregnant women and young families can torment them. As one mother put it, seeing me forced her to relive her pain.

As a mother myself, I am not sure how I would react if I were in their shoes. There remains such an emotional void from these abrupt farewells that I wonder how we can better support these families.  

What about the patient I started this post with? Well, the father of the baby burst out with hateful words that night. A large family had spent those two days waiting, and they wanted answers.

I stayed. I took the hot words as daggers to my heart. I spoke with the rest of the family, I cried with them, and I hoped they believed me when I told them how sorry I was for such tragedy. The nurses, house supervisor and I created a small area where the family could see the baby and cry out to God for a life lost before it began. I sang an old hymn with them, and I prayed with them and for them. I made sure that my patient was cared for and actually stayed in the hospital the entire next day.  

Everyone at the hospital, from start to end, performed to the highest standards. I am so proud to be able to work with these nurses, respiratory therapists and staff. They truly care about this little community, and so do I.

Mothers and fathers undergo a tremendous amount of stress during these situations. I have found that although there are online support groups, parents and family members affected by such loss need more tangible resources.

We must do a better job as a society to remove the stigma behind death, especially the death of children. I encourage my colleagues to talk about these issues and have close followup with patients who live with loss. We must resist the urge to count ourselves omnipotent and not be afraid to say "I'm sorry." Sometimes the best thing to do is admit one's humanity.

As the holiday season comes into full swing, I urge you to remember how hard this time of year can be for those suffering a loss. Take a moment to think of those who will have their first Christmas without a special person, and hug your loved ones tightly.

I register a star with the name of each baby lost and send the certificate to the parents as a remembrance of a child I never got to fully know.

To The Child I Never Knew

I was there when they heard your heart for the first time
The sheer joy and shock of having new life
The hope you brought
The joy

I was there when you would play hide and seek
Running away from my Doppler as I searched
Throughout the pregnancy
Gauging the time
Precious time

We spoke of their hopes for you
Your name, its meaning
How you would look and when you would walk
The lives you would change

I was there when you came
Without the breath of life
Still beautiful, still sacred

I was there with tears of mourning
Dreams now faded
Reality seems blurry
To the life that did not yet live

I thank you
For teaching me to live in every moment
For bringing hope and beauty even
Before you were born

I hope you dance among the stars
The Milky Way, now your table
Your presence still present

Be the comfort that I cannot become
Fill the void that I cannot fill
Bring peace once more to a heart that my sutures cannot mend
Shine on brightly

Marie-Elizabeth Ramas, M.D.,  is the new physician member of the AAFP Board of Directors.

Tuesday Oct 27, 2015

Surrounded by Ghosts: Wisdom Gained From Patients Past

My exam rooms are full of ghosts, and sometimes it is standing room only.

My patients can't see them, of course, but the ghosts often are here giving advice and warning. Sometimes, when there is a particularly large crowd, the conversations are deafening.

I have worked in the same small town in Alaska for 21 years, caring for a community through all stages of life. During my time here -- as well as medical school and residency -- I have lost many people, and I freely admit that they come back to haunt me. This is not a bad thing. They are people who I liked or loved, and they still have much to offer. The hard part is translating their wisdom to those still living.

Particularly loud are the lost teenagers I hear when I talk with young patients during sports exams about not getting into a car with anyone who has been drinking. I have at least 10 ghosts in the room, all talking at once, when I have these conversations.

"Dude, listen to the doc."

"He told me the same thing."

The hardest to bear are the ghosts of infants and children when I am talking to parents about vaccinations. They don't say anything, but I still see their eyes, throats and backs because I trained in the era before the Haemophilus influenzae type b vaccine. Too much of my time on pediatric rotations in medical school and residency was spent performing lumbar punctures and taking care of periorbital cellulitis and epiglottitis.

The exam rooms are full of ghosts, I tell you. There are none, however, who died from complications of vaccines.

The ghosts are with me when I have to tell someone that they have cancer. I have been doing this long enough that they segregate depending on the type of cancer. They are also with me when I talk about the importance of quitting smoking or screening for colon, breast or cervical cancer.

The ghosts are especially present when I talk about end-of life-issues and the importance of maintaining quality of life -- even at the expense of life-sustaining measures -- and they advise me as I help patients and their families through this process.

The ghosts of those who died from alcohol and drug abuse are fatalistic and sad when I tell my patients that they must stop or they will die within the year. They nod and whisper among themselves that I told them the same thing. Sometimes I think that perhaps this particular group of patients can actually see the ghosts, but rarely is it enough to make them change their own lives.

The longer you practice as a physician, the more ghosts you have to keep you company. It's OK. They are good people. They fill the exam rooms and stand by your shoulder when you look at labs or X-rays. Sometimes they are so loud it is hard to believe that the patients can't hear them, but their voices and their stories are a gift you can give to your patients.

I admit that being haunted does take getting used to, but I would never dream of forgetting any of them.

John Cullen, M.D., is a member of the AAFP Board of Directors.

Friday Oct 23, 2015

'Stop the Bleed' Aims to Turn Bystanders into 'By-doers'

Imagine yourself standing on a corner when suddenly, a car strikes someone in the crosswalk. The pedestrian is severely injured, with a leg fracture and a profusely bleeding artery.

How would you -- or the average citizen -- react? It's an important question. In the event of a major arterial bleed, an injured person has about four minutes before survival becomes impossible.

© Aaron Tang

Bystanders assist victims in the aftermath of the 2013 Boston Marathon bombing. The Obama administration recently launched an initiative that aims to educate the public on how people can help save lives in an emergency situation.

This type of scenario is the focus of an initiative recently launched by the Obama administration and the Department of Homeland Security that is designed to reduce loss of life due to bleeding.

The 2013 Boston Marathon bombing, which killed three people and injured 264 others, was one of the incidents that prompted this effort. In the aftermath of that terrorist attack, every victim who reached a Boston-area trauma center alive survived. Injured people survived many potentially fatal injuries because of the prompt responses of bystanders who applied pressure and tourniquets to bleeding extremities until emergency personnel arrived.

I recently attended the White House launch of the Stop the Bleed initiative, which aims to educate Americans about how they can offer assistance in an emergency. Family physician Kevin O'Connor, D.O., physician to the vice president, said during the event that we must move more people from being "bystanders to 'by-doers.'"

Speakers also addressed the psychology of intervening in an emergency situation. The concept of diffused responsibility in a group means that the more bystanders there are at an event, the less likely any one of them is to intervene. A lone individual is more apt to take action.

The mindset in our culture has been for the general public to wait for emergency personnel, but with life-threatening bleeding -- even with a quick response time by paramedics -- survival is not likely without immediate action.

In military medicine, physicians have long referenced the importance of receiving care during the "golden hour" after an injury to improve survival. Quick action improves a wounded soldier's chances. In fact, the survival rate for soldiers who make it to a field hospital alive is more than 90 percent.

The U.S. military examined causes of death among the wounded who did not make it to field hospitals alive and found many died from extremity arterial bleeding and blood loss. This led to a change, and now every U.S. field soldier is equipped with a tourniquet and trained to use it. The prevalence of "field casualties" -- injured soldiers who die before reaching a hospital -- dropped dramatically.

Fast forward, and the administration now is implementing several efforts to educate the public about applying pressure or a tourniquet to life-threatening bleeding:

  • There will be an ad campaign with a logo that features a hand and a "Stop the Bleeding" message to remind people that odds of survival increase if direct pressure is applied over bleeding.
  • Bleeding control kits will be placed by defibrillators in public locations. 
  • The Red Cross is developing a "just in time" learning tool.
  • The Federal Emergency Management Agency has developed a short video that tells the story of how a neighbor's quick action saved a woman after a motorcycle accident.

We can share related resources with patients and our communities by posting them on our websites or social media. The bottom line? Don't be a bystander, be a by-doer.

Robert Wergin, M.D., is Board chair of the AAFP.

Monday Oct 19, 2015

Prescription for Pain? Important Questions Patients Should Ask

Earlier this year, I shared with you a story about being willing to take carefully considered risks, boldly sticking your neck out to make your message heard. Specifically, I made an appearance on The Dr. Oz Show in May because it was an opportunity to reach roughly 2 million TV viewers (and even more online) with a message about the importance of primary care and why everyone needs a family physician.

Fast forward a few months, and I was asked to make another appearance on the show, this time for a segment about proper use of pain medications. According to the CDC, nearly 2 million Americans abuse prescription painkillers and roughly 7,000 patients are treated every day in emergency departments for that misuse. Opioid prescribing, pain management and opioid abuse are issues the AAFP has been working on diligently for years -- including efforts related to advocacy, public health and education -- so I was eager to participate.

Here I am with Ada Cooper, D.D.S., spokesperson for the American Dental Association, and Mehmet Oz, M.D. We discussed appropriate use of opioids during a recent taping of The Dr. Oz Show.

The episode aired Oct. 19, but more on that in a minute.

It's been a rough year-and-a-half for host Mehmet Oz, M.D. He was called before Congress last year because of his promotion of weight loss medications, and a group of his peers called for his dismissal from his post at Columbia University.

His critics certainly got his attention. Oz conducted a listening tour with various medical groups this year and has vowed to make his show more evidence-based. He has sought input from many physicians and physician groups along the way, including the AAFP. I recently met with Oz, his staff, AAFP staff and members of the New York State AFP to talk about how family medicine can help make his show more evidence-based while also reflecting the importance of prevention and primary care.

The first step in this potential collaboration was the episode addressing the epidemic of opioid abuse. Use of opioid pain relievers in the United States quadrupled between 1999 and 2010. Among the 22,810 deaths related to pharmaceutical overdoses in 2011, nearly three-fourths involved opioids. In 2012, U.S. health care professionals wrote enough prescriptions -- 259 million -- for every American adult to have a bottle of pills.

So with access to an audience of millions of American patients, Oz and I discussed important questions patients should ask their doctors before starting a prescription pain medication. Here's a look at some of the questions and the information I provided.

What is the goal of taking this prescription?
This is an important question because patients need to make informed decisions. Too often, people take medication without understanding its risks and benefits and without asking if other options are available. Patients need to understand why they are taking a pain reliever, what kind of pain reliever they are taking and how much relief they should expect.

How long should I take these drugs?
Opioids are best used for the shortest time possible and at the lowest dose possible. I told the audience that they should know from the start how long they are supposed to take a medication. And if they think they have been on a medication too long, they should talk to their physician.

Are there any risks to me from these pills?
When I perform a risk assessment, I look for the following factors:

  • any history of addiction to or misuse of opioids;
  • any history of addiction to or misuse of alcohol or drugs other than opioids;
  • depression or other behavioral health disorders; and
  • is the patient taking any medications that might provoke an adverse reaction in combination with the opioid?

What do I do with extra pills?
We discussed the importance of safe disposal, including take-back programs, and the need to store pills in a secure location.

The questions can be downloaded as a resource for patients receiving a prescription for pain killers.

The AAFP will continue to work on this important issue. On Oct. 21, I will be in Charleston, W.Va., when President Obama speaks with law enforcement, educators, lawmakers and health professionals during a forum on opioid addiction. Watch for more details about that event in AAFP News.

Wanda Filer, M.D., M.B.A., is president of the AAFP.

Friday Sep 04, 2015

Royal Pain: Team's Chickenpox Incident Offers Lesson for Patients

The Kansas City Royals have become a shining example of how to succeed in a small market in an era when baseball teams with the highest payrolls are often the biggest winners when it comes to the playoffs. After decades of futility, the reigning American League champions reversed their fortunes by pouring money into their scouting department and creating an elite team based on speed, defense and pitching.

Unfortunately, my hometown team recently became an example of what not to do, and it's a lesson family physicians can use when talking with patients and parents who have reservations about immunizations. After the Royals built a seemingly insurmountable lead in the American League's Central Division, a vaccine-preventable disease has done what few opponents have been able to do -- make this first-place team look vulnerable.

© Keith Allison
Kelvin Herrera of the Kansas City Royals delivers a pitch. Herrera and teammate Alex Rios were recently diagnosed with chicken pox.

According to The Kansas City Star, the team's medical staff collects information from players about vaccinations and childhood illnesses every year during spring training. Apparently, that information wasn't reliable this time around, because in the thick of a pennant race, otherwise healthy young men have been sidelined by chickenpox, typically considered a childhood illness.

Kelvin Herrera is a 25-year-old All-Star pitcher who can throw a baseball 100 mph and is a key figure in the Royals' vaunted bullpen. Outfielder Alex Rios is a former All-Star and 12-year veteran. Both men are millionaires who have ready access to the team's medical staff and the means to afford excellent health care.

What they didn't have was immunity to the varicella-zoster virus. Now, Herrera and Rios are expected to miss about two weeks of playing time.

The incubation period for chickenpox can last up to three weeks, so it remains to be seen whether any more players will be affected. Sports teams can be a breeding ground for disease because athletes often spend time in tight quarters during games, in locker rooms and while traveling. It was less than a year ago that a mumps outbreak swept through the National Hockey League, affecting nearly two dozen players (including two-time MVP Sidney Crosby) from five teams, as well as two referees.

The take-home message for the general public is that if these strong, world-class athletes with access to quality health care, team doctors and excellent nutrition are susceptible to vaccine-preventable diseases, obviously, so is anyone else who has not been immunized, particularly children, the elderly and people with chronic conditions.

Patient registries and electronic health records can help us identify our patients who may be at risk. Those systems should be far more reliable than the Royals' method, which appears to have included asking athletes if they remember having chickenpox when they were toddlers.

In a study recently published in the Journal of the Pediatric Infectious Diseases Society, CDC researchers compared national health care claims data from 1994 (the year before the varicella vaccine was introduced) to 2012 data and found that outpatient visits for chickenpox fell 84 percent and hospitalizations fell 93 percent. The recommendation for a second dose of the vaccine was introduced in 2007, leading to accelerated declines in the need for both inpatient and outpatient treatment.

Before the vaccine was introduced, about 4 million Americans got chickenpox each year, leading to roughly 11,000 hospitalizations and 100 to 150 deaths, according to the CDC. Despite the efficacy of vaccines, outbreaks of vaccine-preventable diseases continue because of inadequate coverage.

The United States had 23 measles outbreaks last year, affecting more than 600 patients. This year, 188 cases in 24 states had been reported through Aug. 21, with the majority of illnesses stemming from the Disneyland outbreak that started in December.

In each of the past two years, more than 28,000 cases of pertussis have been reported in the United States. There were 48,277 reported illnesses and 20 pertussis-related deaths in 2012.

These sobering numbers should be shared with parents and patients who are resistant to immunizations. Sharing stories about famous athletes forced to sit at home because of the mumps or chickenpox couldn't hurt either.

Michael Munger, M.D., is a member of the AAFP Board of Directors who practices in Overland Park, Kan.

Wednesday Sep 02, 2015

In an Emergency, Family Physicians Have it Covered

We were six hours into a transatlantic flight when the call came over the plane's intercom that a passenger needed medical assistance. I responded, as did another family physician and an emergency room doctor.

Fortunately, the plane was well stocked with oxygen, a pulse oximeter, a blood pressure cuff and more. We worked as a team to determine what was wrong with a woman who had collapsed on the floor. A few minutes in, another woman appeared, identified herself as an OB/Gyn and asked if she could help.

I replied, "Well, we're two family physicians and an emergency room doctor."

She said, "Oh, you've got it covered then."

So I suggested that this fourth physician try to calm down our patient's hysterical teenage daughter.

About 15 minutes later, yet another physician appeared, identified himself as an orthopedic surgeon and asked if we needed help. I repeated that we were two family physicians and an ER physician.

He said, "Oh, thank God, we have real doctors. My wife made me come up here."

I appreciated that he understood our level of expertise.

The flight crew was prepared to divert the plane for an emergency landing, but we were able to stabilize the patient and determine that her condition did not require urgent measures. She had a history of heart problems, had been sitting for hours, stood up too quickly and passed out.

The breadth of our training makes family physicians well-equipped to react to these types of situations, which is good because they seem to be happening to me with increasing frequency.

I was in the Denver airport last year en route to Boise for the Idaho AFP meeting. But I wasn't in the airport long because I had landed at Gate 6 and had about 10 minutes to run -- literally -- to Gate 70 to make my connection.

I made it on the plane, along with several other passengers who had made the 64-gate sprint. We were about 30 minutes into the flight when I heard someone say, "There's a pair of legs sticking out of the bathroom."

A woman had lost consciousness in the bathroom and had forced the bathroom door open when she fell. I volunteered to help the woman, who was ashen and diaphoretic. She had hypoglycemia and was in and out of consciousness, but I was able to deduce what had happened.

She was one of the passengers who had hurried through the airport to make the connection. She was diabetic, had taken insulin but had not had time to eat. Her condition was exacerbated by the plane's air conditioning, which was not working properly.

I asked the flight attendant to bring her orange juice with extra sugar in it, and we packed ice on the woman's neck and under her arms. Within 20 minutes, she was doing better. A little later, she was fully awake and able to eat.

A couple who had been watching this scene unfold asked if I was a paramedic. I said no, I'm a family physician. They then said they were looking for a new doctor and asked if they could come to my practice. They were disappointed to hear that my practice is in Pennsylvania, not Idaho.

Sometimes, we can get called into action before we even get on the plane. On another trip, I was on my way to the Vermont AFP meeting when I saw an elderly woman in the bathroom struggling to get out of a wheelchair. And more importantly, she was struggling to breathe.

I told her I was a family physician and asked if she needed help. She was a tough older lady, and although she acknowledged having heart disease and lung disease, she said she was fine. In reality, she was in respiratory distress. We talked for a bit, and it turned out that we not only were going to the same place, we also were on the same flight.

So I walked her to the gate, identified myself to the gate agent as a family physician and asked her to move my seat next to this woman's so I could keep an eye on her. The woman had some rough moments on the plane, but we made it to Burlington.

When we got off the plane, she wasn't interested in a ride or calling a family member. Instead she insisted on driving herself home. But first I made her promise that she would call her family physician the next day, and she gave me that physician's name.

At the Vermont chapter meeting, I got the contact information for the woman's FP, called the practice and suggested they follow up with their patient. That doctor did call her, and she was admitted to the hospital.

A month later, I received an email from the woman thanking me after she was at home recovering.

A New England Journal of Medicine study looked at nearly 12,000 in-flight medical emergencies and found that physician passengers were able to assist nearly half the time. I'd love to hear your stories of helping fellow travelers in the comments field below.

Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.

Friday Jul 17, 2015

California's Vaccine Victory Holds Lessons for Other States

In politics and culture, California does not often align with Mississippi and West Virginia, but I feel proud to stand with those states in declaring solidarity on eliminating nonmedical vaccine exemptions.

Even before an extensive measles outbreak erupted from the so-called Happiest Place on Earth earlier this year, many states sought to tackle the issue of vaccination exemptions, and those attempts have only intensified since then. In California -- the epicenter of that outbreak -- the battle over S.B. 277 culminated in a victory for public health advocates over a small but vocal anti-vaccine contingent, including some noted celebrity opposition.

In California and everywhere else these battles have been waged, childhood vaccination should have been a motherhood-and-apple-pie issue, yet debate about requiring vaccines and removing personal and religious exemptions elicited visceral reactions from both sides of the ideological divide.

Surely, such heated discourse couldn't be focused solely on refuting the science and evidence behind immunizations. Even Jenny McCarthy has backpedaled somewhat from her earlier anti-vaccine statements that, arguably, set childhood immunization efforts back a decade. No, what this debate really boiled down to was the notion of preserving individual rights at the cost of placing others in harm's way.

Throughout its history and in virtually all areas of public discourse, our country has tried to carefully balance the needs of individuals against the greater societal good. Nowhere has this been more evident than in our protection of individuals' religious freedom. In this case, one of the primary arguments to remove religious exemptions to vaccines is completely consistent with this goal. After all, no major religion in the world (we're not talking about Scientology here) is against vaccination; we can rely on our pastors and priests, rabbis and imams to agree on this point.

So, we're back to personal freedom. The crux of anti-vaccine supporters' argument against removing the personal/philosophical exemption stems from a fear that the government is dictating -- and, thus, overruling parental control of -- children's health care matters. But consider this perspective: The California law allows an exception to the vaccine mandate for home-schooled children, which, in essence, preserves parents' right to decide whether their children will participate in a community-sponsored benefit or opt out of that process.

Moreover, this law continues to allow medical exemptions as determined by a physician, so we can and will continue to discuss this important issue with our patients. In fact, Gov. Jerry Brown cited the continuation of the medical exemption as the sole reason he signed this bill into law. To some, this clause may appear to allow a loophole for vaccine-hesitant parents to go doctor-shopping. And, no doubt, there still will be some physicians ready to cast doubt on the science of vaccines, but they will continue to be in the minority. Ultimately, the decision will be in the hands of the physician and the child's parents after an evidence-based discussion that takes place behind exam room doors.

One last thought: Perhaps sensing the inevitability of passing this legislation, opponents of the California bill vilified its primary author, Sen. Richard Pan, M.D., a practicing pediatrician -- and good friend -- who represents the state's 6th District. Fortunately, Dr. Pan wisely built a coalition of citizen groups and medical organizations -- including the California AFP -- that worked together to overcome this opposition. For those of you familiar with Sen. Pan, you know he has been a stalwart champion of primary care and public health, even winning CAFP's Champion of Family Medicine award in 2013

My challenge to you, my fellow family physicians, is to take up this public health banner and run with it: no personal exemptions, no religious exemptions. Three states down, 47 to go.

Jack Chou, M.D., is a member of the AAFP Board of Directors.

Wednesday Jul 08, 2015

AAFP Teams Up With NFL Foundation to Raise Concussion Awareness

More than 1.6 million concussions occur in sports and other recreational activities each year in the United States. Making matters worse, athletes, parents and coaches often are unaware of recommendations regarding returning to play and the need to seek medical attention.

A study published last year in JAMA Pediatrics found that 59 percent of female middle-school soccer players played with concussion symptoms, and more than half of the players reporting concussion symptoms were not evaluated by a physician. According to the Center for Injury Research and Policy, at least 40 percent of concussed high-school athletes return to play too soon. In fact, 16 percent of concussed football players returned to play the same day they were injured.

Concussions can occur even in sports that you don't necessarily associate with head injuries. For example, women's lacrosse is supposed to be a noncontact sport, but the ball travels at speeds in excess of 60 mph. At the recent AMA annual meeting, delegates voted to adopt a measure recommending helmets for girls and women playing that sport.

Like many family physicians, I treat sports-related injuries in my practice and also work as a team physician for the local high school. I often have to educate coaches and parents about the need to hold athletes out of practices and games while they recover. And we've also had to take helmets away from injured football players during games when they were far too eager to get right back into the action.

So how do we raise public awareness about the serious nature of concussions, their long-term effects and the fact that they often can be successfully managed? The AAFP has entered a partnership that will pair the evidence-based medical knowledge of the Academy with the influence of the National Football League Foundation. The initiative will produce three free webinars for family physicians, as well as patient education materials. The AAFP will have full control of all educational materials and will retain final editorial authority over the materials.

The Academy will be able to use the NFL's brand and logo on the patient education materials, which should help get the public's attention. NFL games reached more than 200 million unique viewers last season, when the league averaged 17.6 million viewers per game.

Here is a look at what to expect:

  • Sports Concussions 101: The Current State of the Game, July 23, 8 p.m. CDT. This webinar will enable participants to define a concussion, and to identify the signs and symptoms of a concussion during an initial evaluation. The event will be presented by Stanley Herring, M.D., medical director of sports, spine and orthopedic health for University of Washington Medicine, co-medical director of the Sports Concussion Program, and a team physician for the Seattle Seahawks and Seattle Mariners; and family physician Matthew Silvis, M.D., associate professor in the departments of Family and Community Medicine, Orthopaedics, and Rehabilitation, and medical director of primary care sports medicine at Penn States's Hershey Medical Center.
  • Sports Concussions 102: If You've Seen One Concussion, You've Seen One Concussion, Aug. 6, 8 p.m. CDT. Participants will be able to analyze the variability of the clinical presentation of concussion, construct an individualized, evidence-based treatment plan and recognize when to seek consultation or referral for a concussed athlete. The webinar will be presented by Jason Matuszak, M.D., the director of the Sports Concussion Center in Buffalo, N.Y., and Yvette Rooks, M.D., assistant professor of family and community medicine at the University of Maryland School of Medicine and a team physician for the University of Maryland Terrapins.
  • Sports Concussions 103: Debates and Controversies, Aug. 20, 8 p.m. CDT. This webinar will cover long-term brain health in athletes; rule changes, practice and play modifications, and legislative efforts regarding sports concussions; limitations of protective equipment; and counseling parents about sports participation for young athletes. This webinar will be presented by Herring, Matuszak, Rooks and Silvis.

Patient education materials will be mailed to all active AAFP members in August and also will be posted on FamilyDoctor.org. These materials are intended to help patients understand the definition of concussion and its signs and symptoms, know when to seek medical evaluation, understand concerns about long-term brain health in athletes, and understand the limitations of protective equipment.

As part of the initiative, Family Medicine SmartBrief will publish a special report regarding concussions in August. You can sign up to receive SmartBrief, a daily wrap-up of news that affects family medicine.

Family physicians often are the first line of care for patients of all ages. We’re the first to spot these injuries, the first to treat them and the first to discuss the dangers of concussions with patients. This educational initiative will help family physicians and our patients by focusing on safety, the importance of reporting, evaluation of concussions and return-to-play protocol.

Concussions are a serious public health risk, and this educational initiative is the right thing to do.

Robert Wergin, M.D., is president of the AAFP.

Wednesday Jul 01, 2015

What Patients Don't Know Can Hurt Them

It has been more than five years since the Patient Protection and Affordable Care Act (ACA) became law, but many consumers still remain unaware of one of the law's signature provisions: coverage of preventive services without cost-sharing.

A baby receives the rotavirus vaccine. Many Americans remain unaware that most health plans are now required to cover preventive services, including vaccinations, without cost-sharing.

The White House and HHS recently launched a joint Healthy Self campaign, which is designed to connect Americans to the health care they need and encourage them to take a more active role in their health. Fifty events will be held across the country in August to connect patients with care. The effort includes educating people -- particularly the newly insured -- about preventive services they are guaranteed under the ACA, which survived another Supreme Court challenge last week.

A Kaiser Family Foundation poll conducted shortly before last year's open enrollment deadline, showed that less than half of uninsured Americans were aware that the recommended preventive services most health plans are now required to cover must be provided with no cost-sharing. Those services include:

  • blood pressure screening;
  • breastfeeding support and supplies;
  • contraception;
  • depression screening;
  • domestic violence screening and counseling;
  • HIV screening;
  • immunizations;
  • obesity screening and counseling;
  • tobacco cessation interventions;
  • well-child visits; and 
  • well-woman visits.

Considering that lack of awareness about these benefits, it's no surprise that half of the uninsured who were polled said they planned to stay uninsured.

However, more than 16 million people have gained health coverage under the ACA, according to the Healthy Self campaign announcement. That's significant because prevention is the key to true health care. Chronic diseases are responsible for 70 percent of U.S. deaths and 75 percent of our health care costs. Imagine the difference we can make simply by helping patients understand the services they have access to in our practices. If people delay preventive care because of cost concerns, they're more likely to eventually end up spending even more money at urgent care centers and ERs.

So what can we do as family physicians? We can use electronic health records to review what services patients haven't had. Our practices can use phones, email, portals and even social media to encourage patients to come in for preventive care. We also can use acute visits to identify preventive service gaps and schedule follow-up.

It's worth noting that CMS has launched a Web page with resources to help the newly insured understand their benefits and to connect them with primary care physicians who can provide preventive services.

Reid Blackwelder, M.D., is Board chair of the AAFP.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.