Prescribing for Opioid Addiction Is My Responsibility
Federal law requires physicians to pass an eight-hour course and apply for a waiver to prescribe buprenorphine. Alan Schwartzstein, M.D., explains why he thinks it's a worthwhile investment.[Read More]
Help Patients Conquer Obesity With Education, Empathy -- Not Shame
Roughly two-thirds of U.S. adults are overweight or obese. How physicians broach the subject with these patients may determine whether or not they can help.
Right Thing to Do: Making the Case for Drug Pricing Transparency
Vermont recently became the first state to require drug manufacturers to justify large price increases. Will any other states -- or the federal government -- follow?
Men's Health Campaign Offers Opportunity to Tout Family Medicine
A report on men's health the AAFP released on Aug. 9 gave Academy leaders an opportunity to tell the media about the importance of having a family physician. Two AAFP officers conducted interviews with 39 media outlets in less than six hours.[Read More]
Leveling the Playing Field: AAFP Tackles Flu Vaccine Supply Issues
Family physicians often receive their flu vaccine weeks after retail clinics get theirs. The AAFP is talking with vaccine manufacturers and other stakeholders to resolve the disparity.[Read More]
Let's All Commit to Reverse the Opioid Epidemic
Last week, AMA President Steven Stack, M.D., issued a letter entitled "Confronting a Crisis: An Open Letter to America's Physicians on the Opioid Epidemic." We have been working closely with the AMA and other physician organizations on this issue through the AMA Task Force to Reduce Opioid Abuse.
As family physicians, we see the havoc opioid abuse is causing families and communities across the United States. That's why we're working hard to provide adequate pain management for our patients who need it, while at the same time, raising awareness that addiction to opioids is a national health crisis.
© 2016 Sheri Porter/AAFP
I am discussing the nation's opioid crisis with Surgeon General Vivek Murthy, M.D., M.B.A. We met April 18 in Washington to discuss possible collaborations between the Academy and the surgeon general's office.
A recent AAFP study showed that opioids are not our first choice when we're treating patients with chronic pain -- four other treatment methods (physical and occupational therapy, oral non-aspirin nonsteroidal anti-inflammatory drugs, acetaminophen, and antidepressants) are prescribed or recommended for our patients dealing with non-malignant chronic pain before opioids. While this is not a surprise to you, it is important to share this information with patients, payers, legislators and policy makers.
Please know that your AAFP is working closely with other organizations to combat the scourge of opioid abuse -- the White House, HHS, the surgeon general of the United States, and the CDC to name a few. And we have multiple resources readily available to you -- with more to come in early June.
We all need to do our part to end this epidemic. Showing our resolve, by voluntarily increasing our individual CME hours dedicated to opioids and pain management, is a step that we can each take. The AAFP has collated the CME on this topic to make it easier for you to locate, complete and report your hours. Please log in and refresh your knowledge on these critical issues.
Family physicians are dedicated to being a part of the solution to help slow this national crisis. Please join me. Together, we can address this devastating epidemic -- balancing pain relief for our patients in need with our sincere desire to always do no harm.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
FPs Can Be Trusted Guides When the Dying Don't Specify Wishes
Each day when I walked into his hospital room, I greeted him with, "Hello there, Mr. Gold! How are you?" His cerebral amyloid angiopathy, resulting strokes and severe dementia had left him chronically debilitated and nonverbal, but his gazing eyes were enough for me to acknowledge our shared humanity.
For nearly a month, I took care of him on our inpatient service, treating him through seizures, aspiration pneumonias, intubations and extubations. I learned at his funeral service that he had gone by the nickname "Cuz," and when asked by the pastor to give a few words, I admitted that I had not had the benefit of knowing my patient in his prime. However, I had the distinct honor of helping him through his final days. And I was inspired by the love his family showered on him.
Every day, I sat down with Mrs. Gold (not the family's real name) and discussed the care plan, hopeful that her husband could return home to her capable care. But as his situation progressively worsened, it became clear that he might not ever make it home from the hospital.
She struggled with granting an "allow natural death" status that would forfend the high-caliber interventions that were becoming more and more futile. The only direction she had received from her husband on this difficult topic before his illness was that if his heart stopped, he wanted to be brought back.
Never mentioned in their conversations was a scenario in which he had progressive dementia and organ failure. Never discussed was the option of withdrawing care in the context of loss of dignity and quality of life.
So, in this situation neither of them had foreseen, she was doing her best to extrapolate what his end-of-life preferences would be from the minimal information he had imparted.
Reluctantly, she agreed to press on with full code interventions. By the second intubation, the palliative care team and I discussed with her the option of in-hospital hospice, where he could be extubated and spend his final days in the company of family without invasive tubes, lines, bells and whistles. He passed there peacefully, but his family's ordeal may have been less traumatic if he had made his wishes clear.
The Health is Primary campaign released patient materials earlier this year that discuss palliative care and advance directives, and American Family Physician has a collection of journal articles related to end-of-life care that include content for patients as well as physicians. These tools can help your practice and your patients with end-of-life discussions.
Often, family members are put in situations that require them to make decisions on behalf of their loved ones. Sometimes they disagree on how these decisions should be made or carried out. Difficult conversations can often be managed skillfully by family doctors who have developed trust and intimate knowledge of those they care for. Being able to give people a wide array of options is an honor. Putting the needs of those we serve above our own is an even higher honor.
Helping Mrs. Gold through this process was deeply inspiring for me. In the closing paragraphs of Mr. Gold's funeral service program, she quoted an anonymous poem: "So I gave to you life's greatest gift, the gift of letting go."
It's worth noting that a growing number of dying patients will soon have the ability to control their fate, allowing them to experience a far different process than my patient in Maryland. A new law in California that goes into effect June 9 will allow qualified patients the ability to self-administer a prescribed medication to aid in the dying process. For many, this would be preferred to the common hospital scenario of prolonged suffering, often alone.
The California AFP has responded with a set of resources that includes a series of four podcasts (each less than 10 minutes) on end-of-life conversations, an American Board of Family Medicine Part IV (Performance in Practice) Maintenance of Certification Module, a guide to weaving palliative care into your practice and additional information on the new California law (which is similar to laws already in place in Washington and Oregon).
Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.
Seeing the Diseases Vaccines Prevent Illustrates Importance of Immunizations
Editor's Note: In recognition of National Infant Immunization Week, the AAFP is participating in a blog relay to discuss the critical role vaccines play in protecting children, families and communities against vaccine-preventable diseases. You can follow the conversation on social media using #NIIW.
It was a hot, humid day in Cap-Haitien. I was a premed student serving as both an extra pair of hands and as a medical interpreter during my first medical mission trip to Haiti.
The magic of being in the country of my roots enveloped my senses. A deep sense of pride swelled within me as I heard the ocean in the distance, smelled the spices that I had grown up eating and marveled at the intense beauty of the terrain. However, that pride was repeatedly flattened by grief from the immense poverty that surrounded me. Even though it has been more than 10 years since that trip, the images of so many people in need of the type of care I had taken for granted continue to drive me today.
I remember seeing a teenager stiff from tetanus and unable to swallow. His mother held him and pleaded for help.
I held an infant, feverish with pneumonia, who improved after my group paid for penicillin, IV fluids and oxygen.
We forget that American children used to routinely die from diseases that now can be prevented by vaccines. However, this is not the reality in many countries.
Today marks the beginning of National Infant Immunization Week which highlights the importance of protecting infants from vaccine-preventable diseases and celebrates the achievements of immunization programs across the country.
As a family doctor, one of the most important roles I play in my patients' lives is preventing disease and improving health. Every day I discuss the role of vaccines in health maintenance with my patients as a means to protect them and at-risk populations.
Thankfully, we are in an era where terrible diseases like polio, Haemophilus influenzae type B and measles are no longer commonplace in our country. However, in California (where I live), there are many parents who still choose not to vaccinate their children despite overwhelming evidence that demonstrates the safety and effectiveness of immunizations. As a result, we have witnessed the devastating effects of disease outbreaks.
Family physicians and other primary care stakeholders in my state have had to work hard mitigating a measles outbreak and the dangerous rise of pertussis, or whooping cough, in recent years.
The importance of vaccination resonates with me, personally, as a mother of three. When I returned to work after the birth of my youngest child, I had to consider exposing my child to potential antigens brought home from work. I was concerned that the decisions of others could affect the health of my own newborn.
I changed my practice and became more proactive in educating parents about vaccinations. Some parents entrusted their children to my counsel. For others, I decided that I may not be the right physician for them. Although I was torn between caring for patients and doing no harm, I knew I could not withhold vaccinations from a child who lacks the ability to make an informed decision. I also knew that not vaccinating families put others in our community at risk. With that said, I have gladly welcomed families who may have questions about immunizations or decide to use a catch-up schedule.
In California, we have adopted a law that emphasizes an individual's obligation to protect others. Specifically, it eliminates religious and personal belief exemptions for vaccines. This is an important step because the benefits of immunizations are not confined to the individual. Vaccination -- or lack of it -- can affect others unknowingly. Consider the newborn, too young to get vaccinated, or the immunocompromised person undergoing chemotherapy.
In a world that is so interconnected, we must be diligent to protect those at most risk, our children. Giving children the recommended immunizations by age 2 is the best way to protect them from more than a dozen serious -- but preventable -- diseases.
The CDC is right to trumpet the role immunizations have played in reducing the burden of illness in our society. Primary care physicians can add our voice by posting information in our waiting rooms and exam rooms. The CDC also has resources to help physicians get the word out by working with local media, using social media and more. We all can do our part.
It is easy to forget our past and to ignore the fact that the threat of preventable disease is palpable in other countries. For me, I remember those days on the mission field and the children whose fates were sealed without the option of prevention that too many among the privileged are rejecting.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Thoughts on Empathy Under the Northern Lights
The other night I was treated to a spectacular display of the aurora borealis. The sky glowed with shimmering light in a spectrum of green and red. It is amazing how something as ephemeral and yet complex as solar wind interacting with Earth’s magnetic field and atmosphere can create such beauty.
At the same time, I have been thinking a lot lately about empathy and how it relates to patient care, burnout and electronic health records (EHRs). Like the northern lights, empathy has a scientific basis, but is still nebulous and beautiful.
I use empathy as a diagnostic tool. My mind is geared to understand and mirror the emotions of others. Although I use logic and evidence-based medicine, I cannot deny that a large part of my assessment in the exam room is based on my reaction to how the patient feels. Our brains are uniquely wired for precisely this process and the trillions of neural connections along with experience trigger patterns of diagnosis. The way a patient moves onto the exam table, the small facial expressions, eye contact, skin color and the way the heart beats mean as much to me as do the history and lab work. I use all of this information to answer the fundamental question: Is this patient sick or not?
To feel what someone else is feeling is a gift given to us by an evolutionary legacy of living as social animals, and I use this gift in my work each day. Several years ago I walked into an exam room and within seconds realized that my 4-year-old patient had cancer. Knowing instantaneously what my diagnosis would be, I dedicated the remainder of the visit to fleshing out the history, conducting a physical exam and obtaining lab work that would identify her leukemia. This is not the only time this has happened to me, and I am not alone.
When the aurora is bright, the light comes in shimmering streamers from multiple directions at once across a large part of the sky. It is not sequential or directional, but manifests as parallel lines of color and light that come in waves and swirls.
Advances in neuroscience, such as functional magnetic resonance imaging, have shown us similar action in specific parts of the brain correlated with empathy. The neurologic basis of empathy is extremely complex and involves multiple areas of the brain. Memory is connected to our senses. Interpretation of visual cues is balanced with experience. Mirror neurons, the cingulate gyrus, and anterior insula, are all involved and all of this parallel processing occurs beneath the level of cognition. There is a good body of evidence to show that the same parts of the brain activate in response to pain -- whether it is personal or vicarious -- through empathy.
Our patients need this connection as well. As physicians we use empathy as a diagnostic tool, but both we and our patients need it to cope with disease at hand. Touch and eye contact have been shown to be an essential part of the physician-patient relationship and healing in and of themselves. A patient of mine once told me that she wished someone could see through her eyes and feel what it is to live with her chronic condition. The reality is that I try. I must because that is how our brains are wired. Empathy requires that to some degree, I model what others are feeling.
In medical school I was taught that it was important to empathize, but not sympathize. The intended lesson was for physicians in training to learn how to go home at the end of each day and be unaffected by the pain and suffering that we witnessed in the medical world. But our neuroanatomy precludes this model of training, especially in family medicine. We have to use every tool at our disposal to care for an undifferentiated complex population, and empathy is supremely important. However, there is a cost. We feel our patient’s pain. I have learned how to grieve efficiently.
Computers work differently, in series rather than in parallel and often the complex interplay experienced in the exam room does not translate to an electronic record. Further, stressful events may limit the use of an EHR entirely. I recently had such an experience. There was a tragic accident during a snowstorm, and after resuscitation I could not transfer my patient to a tertiary care hospital because of the weather. For 12 hours, I sat at her bedside with her family, completely in tune with my dying patient, her family and the team I was working with. For days after, I found that I was unable to use my EHR. I could see patients. I needed to see patients. But I could not use the EHR. It was like I had EHR aphasia, and it frustrated me immensely.
The burnout rate among family physicians has increased significantly since the advent of the EHR. There are many reasons for this, including increased administrative burden, less time per patient, and less time for family and exercise, which all leaves us with a feeling of decreased autonomy. Perhaps one of the problems is that computers are interfering with our ability to connect with our patients. Checking boxes decreases our ability to hold eye contact, and computers often get in the way of patient care. We need this connection as much as our patients do.
We feel the pain of our patients. To deny this is to discount one of the primary ways that we interact with one another. Our brains are wired to feel what others are feeling, and we need empathy if we are to care for our patients. And as with all gifts, there is a cost. We take some of our patient’s pain onto ourselves and share their burden. We need to recognize that as a result we often are grieving, and that this is the natural consequence of what we do.
We need to take care of ourselves physically and emotionally, turn to loved ones, have faith in a higher power and appreciate beauty where we find it. That was exactly my intention when I walked outside late that cold night to watch and to wonder at the phenomenon of the aurora borealis.
John Cullen, M.D., is a member of the AAFP Board of Directors.
Meet the Press: Why Working With the Media Makes Sense
When I woke up on March 17, I found more than three dozen messages from AAFP members in my voicemail and email. They weren’t calling or writing to tell me Happy St. Patrick’s Day.
The previous evening, The New York Times had posted a lengthy feature story about the challenge of balancing the need to curb opioid abuse with the need to help patients who have legitimate pain in a primary care practice. That practice, in this case, happened to be mine. A reporter and a photographer spent several days in Milford, Neb., shadowing me, interviewing my patients (and their families) and taking photographs. The result was an excellent, in-depth piece that makes it clear for any legislator, regulator or payer paying attention that this is not a situation that calls for a quick fix. This is a complex problem that will require a well-considered solution. Our patients do not need a one-size-fits-all approach to health care, and our members do not need a government-approved algorithm to determine treatment.
The family physicians who contacted me thanked me for helping tell this important story. Some said it must have been "onerous" to have a journalist in my exam rooms for several days. The reality is that I didn't mind at all, and my patients were eager to tell their stories -- often sharing extremely personal details with The Times and its 2.1 million readers. Nebraska is one of many states taking measures to limit opioid prescribing, and patients with compression fractures, cancer, fibromyalgia and more shared how such limitations will affect their ability to manage their pain and, thus, their ability to function and go about their daily routines.
My patients are not drug seekers but everyday people with their own perspectives on an issue that affects them greatly. They personalized the issue for a wide audience.
After spending a few days with me, the journalist got it. At one point, reporter Jan Hoffman said to me, "These aren't pain patients. They're just patients."
These are people with complex conditions and co-morbidities that are intertwined. Their pain is just one chapter of a much longer book. By sharing these stories we hope people can begin to understand how complicated this issue truly is.
When I met with legislators recently on Capitol Hill, they were eager for a solution to the opioid crisis. "We have to do something" was a frequent refrain. It's true that we have rising numbers of overdoses and accidental deaths, but it also is true that we need a well-developed plan and not a Band-Aid. If we move too rapidly, the complexity of the situation could get lost. We also need to stop pointing fingers at doctors and patients and get to the issue of treating pain effectively.
During her time with me, Jan saw patients dealing with issues like renal failure, heart failure and an array of physical problems. At one point, she asked me, "Is there anything you don't do?" Not only did she walk away with a greater understanding of the opioid issue, Jan also saw the breadth and depth of family medicine.
I'm excited to see such a well-written story with a family medicine perspective in a publication with such a large audience. Our stories -- and also our patients’ stories -- have power and value in our states and communities when we tell them at the local level. Showing your local media and/or your legislators how issues affect family physicians and the families we care for is time well spent.
Robert Wergin, M.D., is Board chair of the AAFP.
FPs Must Demystify Colorectal Cancer Screening
During the nearly two decades I worked as a health correspondent for our local NBC affiliate, my cameraman was a kind, funny man who seemed to know everyone in town. Phil not only was my colleague but also my friend.
Phil and I talked about the health segments we were working on, and he also frequently asked my opinion about health issues he and his family members were dealing with. He wanted my perspective on immunizations, medications and more.
Unfortunately, one health topic Phil never asked me about was colorectal cancer. I was heartbroken when I learned this wonderful man recently died a preventable death just a few weeks shy of his 61st birthday.
If Phil had asked me about colorectal cancer, I would have told him that his age and his race put him at increased risk, and screening would have been appropriate. Blacks have the highest incidence of colorectal cancer and the highest mortality rates of all racial groups.
Colorectal cancer is the second-leading cause of cancer deaths in the United States, yet nearly one-third of adults ages 50 to 75 aren't screened as recommended. Two years ago, the AAFP joined the National Colorectal Cancer Roundtable, which seeks to increase the percentage of adults ages 50 and older who are screened to 80 percent by 2018. It has been estimated that reaching that goal would avert roughly 280,000 new cancer cases and 200,000 cancer deaths within 20 years.
Family physicians can help by screening patients -- or referring patients to screening when appropriate -- and also by answering questions and demystifying the process.
It's worth noting that the U.S. Preventive Services Task Force issued a draft of updated screening recommendations in October. The Academy has offered feedback for the final recommendation, which is pending.
Others are doing research to learn how we can increase screening rates and close gaps in care. For example, the Patient-Centered Outcomes Research Institute (PCORI) -- an independent nonprofit that seeks to improve the quality and relevance of evidence available to help patients, physicians and others make informed health decisions -- is funding several projects related to colorectal cancer screening and treatment.
- Screening rates are substantially lower among Hispanics than non-Hispanic whites. A project at Thomas Jefferson University aims to improve screening rates among Hispanics by implementing an intervention that will identify the participant's preferred screening test and work with patients and their primary care providers to facilitate testing.
- A project at Indiana University will provide clinical evidence and patient input to guide decision-aid designers on how to present patients with comparative effectiveness information about screening methods.
- A North Carolina project aims to survey more than 1,000 colorectal cancer patients to develop measures for use in improving communications between physicians and patients.
Years ago, I lost an aunt to colorectal cancer in an era when screening was not yet widely accepted. She often was on my mind when I spent years lobbying in my state's capital for legislation that now requires insurers to cover screening.
Today, patients have more access to care and more options for potentially life-saving screening. It is up to us to ensure that they understand their risks and their choices.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
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