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.
E-prescribing Holds Potential to Curb Opioid Abuse
Nearly 2 million Americans have substance use disorders involving prescription pain relievers. Roughly 44 of them will die today, and 44 more the day after that, because prescription opioid abuse leads to more than 16,000 deaths each year.
The problem is complex, and there are no easy answers. However, one step we should all be considering seems obvious. Since Vermont came on board in August, electronic prescribing of controlled substances is now possible in all 50 states. E-prescribing provides better tracking and reduces diversion by creating a direct link between the physician and the pharmacy.
According to a report published in May 2015, nearly three-fourths of U.S. pharmacies were capable of receiving electronic prescriptions for controlled substances in 2014. Based on recent conversations with industry sources, the number now may be closer to 85 percent.
So if e-prescribing is the answer to reducing death and diversion, physicians must be rushing to get on board, right?
According to that same May 2015 report, only 1.4 percent of physicians who write physicians for controlled substances are set up to do so electronically. The fault, however, doesn't lie solely with prescribers.
In many cases, physicians are handcuffed by the limitations of their electronic health records systems and vendors' reluctance to make any changes without additional investments. Instead, they would prefer to nickel and dime physicians while people continue to die.
Family physicians are repeatedly asked by payers, the administration and others to make changes that require investment. Last year, the Academy joined a White House-led effort to curb opioid abuse. As part of that initiative, the Academy set goals to increase
- family physician education in appropriate opioid prescribing practices,
- the number of family physicians who complete training in how to provide medication-assisted treatment for opioid addiction, and
- overall awareness about opioid abuse and pain management.
The Academy also joined the AMA Task Force to Reduce Opioid Abuse, a group of more than two dozen physician organizations seeking to identify best practices to combat abuse and implement those practices nationwide.
The White House asked for our help, and we've responded. Family physicians are taking more education about opioids and pain management. According to the American Board of Family Medicine, more than 22,700 family physicians have completed the ABFM's pain management self-assessment module in the past six years. Furthermore, in each of the past four years, more than 16,000 family physicians per year have reported CME credits related to pain management or opioids, and those FPs reported completing an average of eight CME credits on this important topic.
Now it is time for electronic health record system vendors to also take responsibility for public health and ensure physicians have the tools available to address this crisis without the burden of another crippling expense.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
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.
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.
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.
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.
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.
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 AmericaA 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.
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.
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
I was there when you would play hide and seek
Running away from my Doppler as I searched
Throughout the pregnancy
Gauging the 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.
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.
'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.
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