Lessons for Boston: FPs Can Help Amputees Move Forward
In the aftermath of the terrorist attack on the Boston Marathon, the media has put a focus on a topic that has been part of my life for nearly two decades -- amputation.
More than a dozen people have had amputations since two bombs went off near the finish line of the April 15 race.
On a day that started with celebration, lives were changed forever. In that instant, young and healthy athletes on the road to celebration (and spectators who were cheering them on) were shocked to now face the long and challenging road to recovery.
I can relate.
Just one week before the airplane accident that eventually claimed both my legs, I remember joyfully riding my bicycle up a sunshine-splashed hill, reveling in what my body could do.
A week later, I was on a ventilator in my own ICU.
In the hospital, the questions began. "Who am I now, and what can I do in this world with this radically changed body?"
Fortunately for me, I had a team there to to help me find the answers.
There were a large number of subspecialists. Trauma, ENT, orthopedic and plastic surgeons were able to save my face, hands and one foot. But it was my family physician, Tim Dudley, M.D., who had the insight and ability to take care of the whole of me.
And of all the members of the health care team that helped put me back together, it was Tim who played the most important role in the weeks, months and years that followed.
In the short term in the hospital, Tim asked important questions about nutrition, rehab and insurance. For a full recovery, it was essential to have a family physician who knew me, would listen to me and would advocate for me. When my insurance company tried to limit the number of physical therapy sessions it would cover for multiple traumas to 10 total home visits, Tim threatened them with a different covered benefit -- six months in a nursing home. The payer listened, and I got my physical therapy, at home.
To this day, Tim writes letters when I need new legs.
Tim, you could say, stands by me. Like all patients, amputees need a physician who will help them see the big picture beyond their immediate loss.
Many well-intentioned coaches and doctors focused on what I would be unable to do with prosthetics. My family, friends and Tim helped me focus on what I could do, even when we had to modify prosthetics or sports equipment.
Yes, amputation is painful, physically and emotionally. Learning to walk again is a hassle.
But re-engaging fully in a life you love makes it worth all the pain and hassle, and that was my message to those injured in the Boston bombing during a recent interview with CNN Radio.
Our job as family physicians is to help patients look forward and find things in their lives that are more important than their pain. By knowing them as people, we can better help them take the steps they need to have a full life after amputation, cancer or any loss.
One year after my accident, I rode up that same hill again on my bike, in the sun. And I marveled at the wonder of what my body, now with prosthetics, could do.
My wish for those wounded in Boston, injured veterans returning from Iraq and Afghanistan, and others facing amputation is for them to be as fortunate as I am to have a family physician like Tim who can help them take the necessary steps and guide them on their path.
And thanks to all of you for what you do for your patients every day.
Jeff Cain, M.D., is President of the AAFP.
Fit Physicians Can Lead by Example
Years ago, I attended an event where tennis legend Arthur Ashe spoke about the need for sustainable exercise -- finding something you enjoy that can be done indoors or outdoors and at any age on a regular basis. His words resonated with me. Teaching people -- including my patients and friends -- the tremendous benefits of regular exercise from an early age has always been important to me.
I have tried many sports in my time, but when my children were old enough, I signed them up for what I hoped would be a sustainable activity. When I told my kids I was enrolling them in taekwondo lessons, their response was, "Only if you do it, too." The usual negotiations ensued.
Fair enough. It's important to be a good role model.
Ten years later, I am a black belt in taekwondo and am working on becoming a second-degree black belt. It is a commitment that takes time each week. I share a weekly lesson with my husband and, typically, on the weekends we practice, train or just "play" together. I also make time to exercise -- even if it's a shorter workout, like a walk with my daughter -- on weekdays.
Our children aren't the only ones who can benefit from a good example. It helps me talk with patients about doing the right thing when I am doing the right thing myself. I tell them that if I can do it, so can they. And sometimes, you have to show them.
About 20 years ago -- before I had children -- I made a standing offer for my patients to walk with me before office hours. I said, "I'm going to be at the office at 6:30 a.m., and whoever wants to join me can. If nobody comes, I'm still doing it."
Some days only a few people came. On others, there were more than a dozen of us. That effort lasted for a few years until my office changed locations.
This wasn't targeted only at patients with diabetes or other chronic conditions. It was for anybody, because everybody should exercise.
Sadly, we know that only one-third of adult patients are advised by their physicians to exercise. We also know that physicians who lead a healthy lifestyle are more likely than those who do not to counsel patients about issues such as diet and exercise.
It is important to me to try to be a good role model. We all have too many patients who are not making good choices, but we can make a difference in their behaviors.
I have a patient who, at age 58, had slightly elevated blood sugar and elevated blood pressure. We discussed nutrition -- including high fiber and the DASH (Dietary Approaches to Stop Hypertension) diet -- and exercise, especially cardio. When the patient came back a month later, she said she was having a hard time finding low-salt and high-fiber foods. Together, we found a website that sold foods that could not be found locally. She joined the Y, started going at least three times a week and quickly lost five pounds.
At a recheck two months later, she still was following the diet and exercise plan and had lost eight more pounds.
Fast forward three years, and she is down more than 30 pounds. Her blood pressure and blood sugar are normal, and she's been able to stop taking medications for those issues. Diet and exercise were the prescription she needed.
The take-away message: We should be telling our patients about the tremendous benefits of a healthy diet and regular exercise.
There are five keys to succeed at losing weight and keeping it off:
Eat a high fiber, low-fat diet.
Weigh yourself on a regular basis for feedback.
Eat breakfast daily.
Document everything you put in your mouth so you are mindful of all the calories you are taking in.
Eating mindfully is essential. I advise my patients to use a calorie counter. If they have an appropriate app on their phone, they can put their food options into the calorie counter before they put the food in their mouth. Seeing the caloric imbalance of poor choices allows people to have second thoughts before an unhealthy selection passes between their lips. Is that large plate of nachos really worth it? Probably not. You would have to spend four hours running on the treadmill nonstop to burn most of those calories.
We have had good success with calorie counters because they educate people about what they're putting in their bodies and about energy balance.
Another tool that works (and it's free for Academy members) is the food and activity journal available through the Americans In Motion -- Healthy Interventions program, which positions fitness -- physical activity, nutrition and emotional well-being -- as the treatment of choice for the prevention and management of many chronic conditions.
Of course, some patients need more encouragement, and you have to be creative. I have made bets with patients about how much weight they can lose before a birthday or some other significant date. If they reach their goals, I take them out for a healthy lunch.
Now, I have to admit -- I like to win. I have been fortunate to be a volunteer physician for the U.S. Olympic Committee and Team USA, and I have served as a team physician for a local high school for 30 years. But when it comes to helping a patient push him- or herself to a healthier way of life, that is one instance where I don't mind losing.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Asking Tough Questions About Abuse Can Save Lives
It was more than 20 years ago, but some patients you never forget.
I was not the primary care physician for this new baby girl, but I was on call when her mother brought her in for a well visit. I had treated the mother, her husband and their other children before during sick visits. They seemed like an average family.
During our last visit, the mother and I talked about typical new baby topics -- car seats, breastfeeding and immunizations. What I didn't know at the time was that this young woman was desperately looking for a way out of an abusive relationship.
I was a new physician, just three years out of residency. Although I asked important questions about the child's health and safety, I didn't know to ask the mother about her own safety. Back then, we didn't know that homicide -- not bleeding, blood clots or infections -- is one of the leading causes of death in women in the first year after childbirth.
Now we know.
That woman wanted to find a better, safer place for herself and her children, but a short time later she was dead. The baby's father killed the mother, their older children and two other family members before a failed attempt to take his own life. The infant survived.
I remember my practice partner -- who was their primary care physician -- crying while dictating notes from their files. She stopped the recorder and said, "This family could have made a difference."
For me, they did.
I wanted to learn more. What could I have done differently? What was the dynamic in that family that led to this horrible act? Could it have been prevented?
The U.S. Preventive Services Task Force has published new recommendations that call on physicians to screen all women of childbearing age for intimate partner violence and to refer them to intervention services, if needed.
It's good advice. We can save lives with the right information. I have seen an extraordinary number of positive outcomes when a physician understands the dynamic of what his or her patient is living with.
One excellent screening tool is RADAR, which prompts physicians to follow these steps in a private setting:
- Routinely screen female patients;
- Ask direct questions;
- Document your findings;
- Assess patient safety; and
- Respond, review options and refer.
The recommendation to screen all women of childbearing age is a good one. I have heard disclosures about abuse from politicians, judges and colleagues. It's worth noting that men and children also are at risk. Sadly, abuse happens all the time in every community, and you never know who might need help.
A variety of conditions could raise a red flag. If a patient is experiencing things such as anxiety, chronic pain, depression or eating disorders, go upstream. What is causing those problems? Don't be afraid to ask difficult questions when you are alone with the patient, such as
- Are you safe?
- What happens when you argue?
- Are you afraid to go home?
This is something family physicians can, and should, do. And just a few minutes of our time can make an unbelievable impact in the long term.
So what do you do when a patient is willing to confide in you? Telling him or her to "just leave" an abusive relationship is not the answer. Know the resources and shelters in your community. Often, I've taken a patient to a private place in my practice, dialed a shelter for them, started that important first call and then left the room so that the patient could talk in private.
We can help our patients with a better outcome and better quality of life. But we have to be willing to start the conversation.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
As Flu Reaches Epidemic Proportions, Protect Yourself and Patients
During the past three months, hospitals in my home state of Illinois have admitted 150 patients to intensive care units with influenza-like illness. Six of those patients died. During the same time last year, Illinois had two hospitalizations and no deaths from the flu.
Closer to home in Chicago, six area hospitals were recently on bypass, in part because of the spike in influenza illnesses. And, we're not alone. The CDC said Jan. 11 that 47 states are reporting widespread influenza activity, and 24 states were reporting high influenza activity. In Boston, officials have declared a public health emergency after the number of reported influenza cases in the city jumped 10-fold over last season's total.
CDC officials have said this could be the worst flu season in a decade. We already have reached epidemic levels, and we've still got a long way to go.
So, what are we going to do about it? I got my flu shot. Have you got yours?
The CDC's Advisory Committee on Immunization Practices (ACIP) recommends that all health care workers get vaccinated annually against the flu. The AAFP adopted policy two years ago supporting mandatory influenza vaccinations for health care workers. At least 10 other medical organizations have adopted similar policies, and numerous employers -- including mine -- have taken a similar stance.
Still, the CDC estimates that fewer than 65 percent of health care workers are vaccinated against the flu, leaving our patients, colleagues and families at risk.
A hospital in Indiana recently made news when it fired eight employees who refused the vaccine. That state already has reported 21 deaths from influenza this season. So many health care workers -- from front desk staff to nurses and physicians -- come into contact with patients. Those who refuse immunizations are denying the proven safety and efficacy of the vaccine and jeopardizing the health of our most vulnerable patients.
Low flu vaccination coverage among health care workers has led to outbreaks in hospitals and long-term care facilities. Conversely, health care workers who are immunized help reduce the transmission of influenza and prevent illness and death as well as lost work days among staff.
According to a 2010 AAFP immunization survey, 94 percent of family physicians said they are immunized against the flu each year. Ninety-seven percent of respondents to the 2011 survey said their staffs were routinely immunized against the flu, so we're well on our way to ensuring our patients don't get the flu in our offices.
For those of you who are not vaccinated, however, flu season typically lasts into March, so it's not too late to be vaccinated. You also can help improve vaccination rates in your patients by encouraging them to get immunized and also by dispelling myths -- such as you can't get the flu from the vaccine.
Some of your patients may refuse the vaccine because they are fearful of needles. But the flu vaccine also is available in a painless nasal spray, as well as an intradermal shot with a needle that is 90 percent shorter than those used for intramuscularly administered vaccines. Patients whose insurance offers them a choice should be made aware of those options.
It's not too late for your practice to increase the rate of vaccinations in your community by decreasing barriers to your patients getting vaccine. You can offer extended nurse visit availability or create campaigns -- alone or in partnership with local public health agencies -- that target your patients as well as the most vulnerable in your area.
If your practice is not providing vaccinations -- or if you have exhausted your supply of vaccine -- make sure you know where to refer patients and staff in your community. There are vaccine shortages in some areas, according to the CDC.
More than 90 percent of the influenza viruses that the CDC have analyzed match the viruses included in the 2012-2013 influenza vaccine. The agency said people who are immunized are 62 percent less likely to need medical care for the flu than those who are not. Although that level of efficacy is less than what we see in many other vaccines, staff and patients should be reminded that the flu vaccine still is the best way to protect themselves and their families. After spending a day with sick patients, don't take the flu home to your loved ones.
Finally, the CDC has a Web page devoted to flu resources for health care providers, including information about diagnostic tests, antiviral recommendations and surveillance. The AAFP also has a Web page devoted to immunization resources.
Protect yourself, your patients and your family. Get immunized.
Ravi Grivois-Shah, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Great American Smokeout Offers Another Opportunity to Help Patients Quit
Smoking is the No. 1 cause of preventable death in this country, contributing to more than 440,000 deaths -- or roughly one in five of all deaths in the United States -- each year. So it's no surprise that 70 percent of the nation's 43 million smokers say they would quit -- if they only could.
Millions of smokers try to quit each year, but those who go it alone are likely to fail. In fact, only 5 percent of smokers who attempt to quit on their own are successful.
But we can make a difference by helping our patients quit smoking. In fact, even simple advice increases their chances of being successful in their attempt to quit by 60 percent.
And, this week is the perfect time to brush up on our tobacco cessation skills and talk to our patients about tobacco. The Great American Smokeout is Nov. 15, and the American Cancer Society has an abundance of patient resources available to help people quit.
The AAFP also has an abundance of resources to integrate tobacco cessation efforts into our practices and to help us be successful in the long run, including tips for coding for tobacco cessation counseling, information about group visits, a pharmacologic product guide, quitline referral cards and more. You can find it all in the Ask and Act toolkit.
Sure, delivering the same message about smoking to the same patients over and over may at times feel frustrating, but the time that we spend on Ask and Act has been proven to be one of the most clinically effective things we do in our offices. Brief tobacco cessation counseling for every smoker in our practices is more cost effective than screening and treating for hypertension, lipid disorders or breast cancer.
Primary prevention is even more important. We can make a difference by talking to kids about tobacco before they start. Most smokers have their first cigarette by ages 12 to 14, are hooked by 16 and have tried unsuccessfully to quit even before they can legally buy tobacco at age 18. The Academy's Tar Wars program is a great opportunity to bring the tobacco-free message to kids in school.
Jeff Cain, M.D., is President of the AAFP.
Step Up to Help Curb Teen Medication Abuse
Today, more than 2,000 U.S. teens will use prescription drugs to get high for the first time. Sadly, for many, it won't be the last time.
One in six teenagers has abused prescription drugs at least once, and more than one-third of all prescription drug abusers in the United States are between the ages of 12 and 17. Many become addicted, and some die. In fact, drug overdoses are the leading cause of accidental deaths in more than a dozen states.
So what can we do about it?
Some practices use a patient prescription agreement, in which the patient agrees to take medication as directed, not share it and dispose of unused meds properly.
In my practice, we've taken things a step further. Patients receiving prescriptions for controlled substances have to sign a contract, which requires them to use specific pharmacies and to submit to random urinalysis. If a patient doesn't cooperate, they don't get the meds.
It may sound harsh, but with the privilege of prescribing comes the responsibility to assess the needs of each patient, the risks and benefits involved and the need to monitor their use. Physicians who abuse that privilege threaten our ability to prescribe for patients with legitimate needs.
For patients who agree to submit labs, their urine samples tell us whether or not they are taking their medication. If their labs indicate they aren't taking the meds, we want to know why not and what happened to that medication. Labs also tell us if patients are mixing the prescribed medication with any other drugs -- legal or illegal.
This isn't a message about limiting access to pain medication. It is about balancing that need for access with the need to reduce abuse. At the same time we are grappling with abuse issues, under treatment of pain is a real problem for many patients. This summer, the AAFP released a position paper that opposes regulations that limit patients' access to physician-prescribed pharmaceuticals.
This week, the Academy supported The Partnership at DrugFree.org in its launch of a weeklong public awareness campaign: "Wake Up to Medicine Abuse." The initiative -- part of a multi-year campaign called the Medicine Abuse Project -- urges parents, law enforcement, teachers and health care professionals to take action.
So, again, what can we do? The Partnership's Medicine Abuse Project has resources written specifically for health care professionals, including fact sheets about teen medicine abuse and painkiller overdoses, an FAQ about prescription monitoring, a National Institute on Drug Abuse report, screening tools and links to best practices and guidelines. The site also offers patient education resources, including posters for our practices and a hotline for parents.
You also can check out the AAFP's webpage dedicated to pain management and opioid abuse.
This is a big problem, but family physicians can be a big part of the solution.
We can use well-child visits to talk about keeping medications up and away from children's reach.
We can educate parents of teens that this is a real problem of which they may not be aware.
We can inform patients -- adults and kids -- with legitimate need for these meds not to broadcast the fact that they're taking them because doing so could make those patients a target of people who would misuse those drugs.
Lastly, we can direct parents to unused drug disposal sites in our communities.
When you prescribe prescription pain killers for adult patients with children, what advice do you offer them? Please share your thoughts below.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
Tobacco Marketers Lie; Tell Kids in Your Community the Truth about Cigarettes
Nearly 4,000 U.S. children will smoke their first cigarette today. Nearly 4,000 more will join them tomorrow. And the sad tale will continue the day after that and the day after that -- unless someone takes action.
Who can stop them?
Children look up to physicians, and we can make a difference. Tobacco is the No. 1 cause of preventable death in this country, but if we can prevent children from starting to smoke, we can prevent them from suffering the horrible consequences.
I was a resident when I co-founded Tar Wars in 1988 as a local tobacco education program in Denver. That first year, we reached more than 7,000 children in the city. A year later, our tobacco-free message expanded across Colorado. Today, the program -- which has spread to all 50 states and beyond -- has been heard by roughly 8.5 million American kids. The program was presented by physicians and other health care professionals to an estimated 500,000 U.S children last year alone.
But we can do more, and we should.
According to the CDC, nearly 20 percent of U.S. high school students smoke at least one cigarette a month, and more than 5 percent of middle school students smoke. Clearly, we can do better.
Research has shown that Tar Wars is effective in increasing students’ understanding about the short-term consequences of tobacco use, cost of tobacco use, misleading nature of tobacco advertising and peer norms.
Kids might not understand or appreciate that long-term tobacco use can lead to things like lung cancer or emphysema. But we can frame the conversation in a way that will get their attention. For example, smoking a pack a day will cost a person -- depending on taxes in your city and state -- $1,500 to more than $3,000 a year. Little Suzie could buy a lot of friendship bracelets with that kind of dough.
Kids don't like to be lied to, but that's exactly what tobacco marketers do when they portray cigarettes as fun, sexy or cool. Tell the children in your community the truth about tobacco. Is there anything sexy about yellow teeth? How about bad breath and a hacking cough?
My inspiration for starting Tar Wars came after hearing a speaker at the AAFP's National Conference of Family Medicine Residents and Medical Students talk about the lies that marketers tell children about cigarettes. I had a patient who was dying of lung cancer at the time, and when that speech was over I was angry.
When I think about it, I still am.
How many patients have you seen suffer the effects of tobacco use? How many people have you seen reduced to toting around an oxygen tank?
More than 400,000 Americans will die this year because of tobacco-related illnesses.
Are YOU angry yet?
What are you going to do about it?
For those of you who already present Tar Wars in your local schools, thank you. For those of you who haven't yet been presenters, here's what you need to know: It's easy. A classroom presentation takes about an hour, and Tar Wars provides you with all the resources you'll need. The program will be celebrating its 25th year in the upcoming school year, and updates are being planned that will make Tar Wars even better.
Physicians who have participated tell me that the first time they presented they did it for the kids. The second time, however, they did it because they enjoyed it so much the first time. It reenergizes you.
Tar Wars isn't just for practicing docs. It's a great, ready-made program for residencies and family medicine interest groups, too.
On a lighter note, every year, the Tar Wars poster and video contest concludes at the Tar Wars National Conference in Washington, D.C. This week, 34 state poster and video contest winners attended the conference, and many of them also were able to visit Capitol Hill and meet with their elected officials.
Our first poster contest winner, back in 1988, was impressed by an exhibit we brought to her classroom that showed the difference between healthy lungs and lungs damaged by smoking. That young girl, Kelly McMullen, M.D., went on to become a family physician who now counsels her own patients about smoking.
School will be starting before you know it. Whose life will you influence?
Jeffrey Cain, M.D., of Denver, is president-elect of the AAFP.
Colonel's Request is Simple: Ask Patients if They Served in Military
After 29 years in the Army and multiple deployments to war zones, retired Col. David Sutherland understands that death is a part of battle. What he won't accept is the glaring number of U.S. military veterans who are falling through the cracks here at home.
Sutherland was one of the speakers recently at our Family Medicine Congressional Conference (FMCC). The point of his poignant story was similar to one I told you about earlier this year: Our military veterans are coming home with physical and emotional injuries that aren't being properly diagnosed and treated, and we can help by being aware of their issues and supportive of their problems.
Although some in the FMCC audience that day already may have heard about the Joining Forces Initiative, which is intended to help military families, Sutherland's powerful, heart-wrenching presentation gave us a glimpse of life in the military and a veteran's perspective. He described war as "vile." With words and photos, Sutherland told us about people he served with and the death and destruction they experienced.
Some died in service to our country.
Some survived war and returned home, but they struggled with the jarring differences between living in a combat zone and civilian life and died at their own hands.
Sutherland (pictured here with family physician Sarah Sams, M.D., of Hilliard, Ohio) also talked about veterans who made the difficult adjustment to coming home with the help and support of their families and communities -- including physicians.
Sutherland's request for the roughly 200 family physicians in attendance was simple: be aware, be supportive and be understanding of veterans and the issues they and their families are facing as they adjust to civilian life.
- About one-third of the veterans returning from Iraq and Afghanistan will experience signs or symptoms of combat stress, depression, post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI).
- Alcohol and substance abuse are significant problems, with more than one-fourth of Iraq veterans meeting criteria for alcohol abuse within four months of returning home.
- The unemployment rate for Iraq and Afghanistan veterans who have left the military is nearly 13 percent.
- According to the Department of Defense, former service members account for 20 percent of suicides in this country, dying at a rate of 18 a day.
What does it all mean for family physicians? More than 2.3 million U.S. soldiers served in Afghanistan or Iraq -- or both -- during conflicts that started more than a decade ago. About half of the veterans returning from those two wars are expected to receive medical care in the private sector rather than from the U.S. Department of Veterans Affairs. This is not just a VA problem.
Sutherland said veterans often are stoic individuals who might be reluctant to volunteer information without prompting. But if family physicians make the question, "Have you or a loved one served in the military?" as routine as asking if a patient smokes, it can help. And a follow-up question as simple as, "How are you doing?" could start a life-changing conversation.
To learn more about TBI and PTSD -- including
screening tools, CME and information for patients -- visit www.aafp.org/joiningforces.
Glen Stream, M.D., M.B.I., is president of the AAFP.
A Perfect Time to Talk About Breastfeeding
Rather than celebrate mothers and motherhood on Mother's Day, Time magazine recently dared its female readers to be "mom enough." The May 21 cover story about attachment parenting featured a provocative photo of a young model -- complete with skinny jeans and tank top -- nursing her 3-year-old son, who was looking at the camera while standing on a chair to reach his mother's exposed breast.
The results were predictable. According to The New York Times, the issue was Time's best seller this year, and the magazine doubled the number of subscriptions it sells in a typical week. With more than 50,000 mentions on Twitter and more than 40,000 Facebook likes, it also set off innumerable arguments about parenting in online forums.
As a breastfeeding advocate to my patients, residents and fellow physicians, I was frustrated by this negative and unrealistic photographic portrayal of breastfeeding and the "are you mom enough" title. Time reached millions of readers, but it squandered an opportunity to educate and empower mothers, their families and the general public.
Although Time failed to properly promote the health benefits breastfeeding provides for children and their mothers, the buzz created by the magazine's controversial story provides an opportunity for physicians to do just that.
Family physicians are uniquely positioned to promote and support breastfeeding throughout a continuum of ages. FPs can make an important difference in the health of women and their babies by providing education to mothers and their families.
In its evidence-based position paper on breastfeeding, the AAFP encourages all family physicians -- regardless of whether we provide maternity care -- to support our patients’ breastfeeding goals. The Academy's breastfeeding policy -- which recommends babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first six months of life -- also encourages family physicians to have the "knowledge to promote, protect, and support breastfeeding."
The reality, however, is that although 75 percent of U.S. children are breastfed as newborns, less than 50 percent are still receiving breast milk by age 6 months. Only 13 percent of mothers follow recommendations to feed breast milk exclusively for the first six months of their child's life.
The United States was ranked 36th -- dead last -- in breastfeeding support among industrialized nations in a recent report by Save the Children, the international children's rights organization.
Last year, Surgeon General Regina Benjamin, M.D., M.B.A., a family physician from Bayou La Batre, Ala., called on physicians and others to support breastfeeding efforts. In her report, Benjamin said basic support for breastfeeding should be a standard of care for midwives, obstetricians, family physicians, nurse practitioners and pediatricians. She also said all health professionals who care for women and children should have education and training in breastfeeding.
Although the United States has made strides in improving its breastfeeding rates, we continue to achieve lower rates than national goals. Let’s use this time of heightened awareness about breastfeeding to offer accurate, family-centered information to our patients.
Julie Wood, M.D., of Lee's Summit, Mo., is a first-year member of the AAFP Board of Directors.
Editor's Note: The Academy is offering a session titled "Clinician Role in the Promotion of Successful Breastfeeding" (as well as related sessions) during a Family Centered Maternity Care CME event August 8-11 in Portland, Ore.
Planning Ahead Makes End-of-Life Care Easier for Everyone
Too often, planning for end-of-life care is left to the end of a life. But that stressful, chaotic time is often too late for a patient to make his or her wishes clear, and difficult decisions are left to be made -- and sometimes argued about -- by their relatives.
It doesn't have to be that way.
One of my severely disabled patients, who was in his 30s, recently died after a lengthy illness. His mother choose not to prolong his life with a feeding tube and watched her son waste away. She was at peace with that painful -- but correct -- decision because the family knew what was coming, had time to think it through and was prepared when the time came. My patient died peacefully, painlessly and without fruitless interventions because of advance planning.
End-of-life care is a compelling topic that needs to be discussed before a patient has a health crisis. Unfortunately, a minority of patients will bring up advance directives or living wills with their doctors. More than likely, it will be up to us as family physicians to broach the subject, and that discussion shouldn't wait until a person is in transition from healthy patient to terminally ill.
Too many people think, "It can't happen to me," but the reality is that serious accidents and life-threatening diseases can -- and do -- strike young, healthy people.
Remember Terri Schiavo? She was 27 when she suffered cardiac arrest and brain damage due to a lack of oxygen. Schiavo was in a vegetative state for eight years before her husband petitioned to remove her feeding tube. With Schiavo's wishes unclear, her parents challenged that petition, sparking a seven-year legal battle that reached the Florida Supreme Court.
With a little guidance from us, patients can plan ahead, make their wishes known and reduce the burden on their family during an already difficult time.
We can discuss the subject of end-of-life care in a nonthreatening way far in advance of a patient needing it if we bring it up as a routine matter in the same way we regularly ask "What meds are you on?" Questions about end-of-life planning should become second nature so patients become accustomed to it.
When a patient reaches the age of maturity, it's time to start the conversation. They don't have to decide everything at 18, but the conversation needs to be initiated.
Health organizations in Lacrosse, Wis., developed a community-wide planning system in the 1990s called Respecting Choices. That system includes defined roles and expectations for physicians, patient engagement, incorporating advance directives in clinical care and protocols for emergency personnel.
An evaluation of that program showed that 85 percent of adults who died in the community during an 11-month period had an advance directive, and treatment decisions were consistent with patients' wishes 98 percent of the time when they did have directives.
The program now has been initiated in more than 80 communities in the United States.
Though many of our communities don't have similar initiatives, that doesn't mean patients can't be proactive or that their physicians shouldn't encourage them to plan ahead. Several models have been developed that are more specific and more useful than standard do-not-resuscitate forms or living wills. Here are just a few.
Five Wishes is an advance directive that covers more issues than a typical living will or power of attorney document. The document, which meets legal requirements in more than 40 states, lets physicians and a patient's family know:
- who should make health care decisions for a patient when they can't;
- medical treatment they want (or don't);
- how comfortable they want to be;
- how they want to be treated; and
- what they want loved ones to know.
"Let Me Decide" is an advance directive book written by a geriatrician. Each book contains a four-page form designed to clearly state patient's wishes, as well as a sample form. The author encourages patients to consult their health care professional before completing the document.
The document is designed to:
- give individuals the opportunity to choose different levels of treatment according to his or her wishes;
- relieve family and friends from the burden of decision making; and
- guide physicians in making important decisions when family members are unavailable.
Physician Orders for Life-Sustaining Treatment, or POLST, uses a form that converts patient preferences into written medical orders based on a health care professional's conversation with the patient and/or a proxy. POLST programs have been implemented in at least a dozen states and are in development in at least 20 more.
The AAFP also has resources that can help. American Family Physician offers a collection of articles on end-of-life care. FamilyDoctor.org offers resources for patients, including information about advance directives and do-not-resuscitate orders.
Regardless of what approach is used, patient interaction with a physician and documentation of their wishes is critical. Some physicians feel uncomfortable having this discussion because it is an emotional, complex task, and reimbursement also is an issue. But we can help our patients, their families and the health care system by encouraging patients to have a plan in place.
How do you talk to your patients about end of life care?
Richard Madden, M.D., of Belen, N.M., is a second-year member of the AAFP Board of Directors. He is a practicing family physician and a clinical assistant professor of family and community medicine at the University of New Mexico School of Medicine, Albuquerque.
What Happens When a Doctor Becomes the Patient?
It is a nice, but cold, calm spring day. We haven't had one of those in a while, so I saddle my horse, Cimarron, and walk him around the arena. (That's Cimarron and me in the photo below.)
it is good to be back in the saddle again. From a walk to a trot, then a trot
to a lope, Cimarron cruises like he has not had time off for the winter. He
stops on a dime, and then we lope in the other direction. Well, I think, I
better not work him too hard on his first day back in action. Just as I decide
that, his right front hoof catches a rock. He tries to recover, but fails as he
falls to his knees and crashes on his face.
I am thrown forward, and my chest hits the saddle horn before I'm tossed in front of Cimarron. The 1,300-pound horse rolls on top of me.
Darkness. Then pain. Have I broken my back?
My feeble yells do not bring help.
"I guess no one is coming," I think.
I move one leg and then the other. That's a relief. I move my head, and my c-spine seems OK. I am, however, starting to develop significant left upper quadrant pain.
"Well, it's now or never," I say to myself as I get on my feet. I don't feel half-bad standing. Cimarron, who is fine, looks at me to see if I'm OK. It's a cowboy thing to get back in the saddle if you fall off so the horse still understands who is boss. I try to put my foot in the stirrup, but that is not going to happen.
I lead Cimarron 300 yards back to the barn and take off his saddle. What amazes me is that this doesn't cause any pain. I put Cimarron in his stall and head to the house. The closer I get, the more pain I feel. Everything hurts, and I'm lightheaded.
"Are you OK?" my wife asks. "What happened?"
"You don't look so good," she adds as I pass out on the living room floor.
When I come around, my abdomen is hurting. We live a half hour from town. I think it will be quicker to have my wife drive me to the emergency department (ED) than to call paramedics. I don't want to scare her, so I tell her it will be OK. As we drive, my left upper quadrant is feeling more swollen, and I am getting more lightheaded.
The medical assistant at the ED bay grabs my shoulders and chest and pivots me into a wheelchair. Well, I guess this is good test to make sure I don't have a spine injury. I almost pass out from the pain.
The assistant asks what happened, and I am able to say, "Horse accident, blunt trauma LUQ, near syncopal."
She gives me a quizzical look and says, "Would that be trauma?"
"Yes, that would be trauma."
Things move fast, then. They start an IV in my left antecubital fossa. "Not there," I tell them, but I am ignored.
I tell them I am allergic to shellfish, iodine and most narcotics. They fill me with Solu-Medrol and Benadryl and take me off for a CT scan. The room is air conditioned, and I am naked. I shiver, exacerbating the pain. I am unable to move from the gurney to the CT table, so they roll me over. They pull my arms over my head for the CT scan. More pain, and I am shaking visibly.
Back to the ED room. The nurse finally gives me warmed blankets. Yes! I am informed I can't have anything for pain because of my allergies, but I eventually talk them into Toradol. That helps a lot.
I am told that the trauma surgeon was called for a motor vehicle accident, and it will be a while before I will be seen. Five hours later, the surgeon enters the room laughing. "I bet you are in pain, aren't you?"
Hilarious. Luckily, I don't have a fractured spine or spleen. My blood work is fairly normal. Interestingly, my blood pressure is slightly high. Gee, I wonder why.
What I do have is five fractured ribs, both anteriorly and posteriorly. Believe it or not, there is no pneumothorax. I am admitted to the ICU because of my allergies to narcotics, and they can monitor me better there.
I know most of the ICU nurses. That is a comfort until I realize that I am going to have to urinate eventually.
I don't have an allergic reaction to a test dose of fentanyl, so they give me a regular dose. I am feeling better -- and hungry. It has been 18 hours since I last ate.
"Sorry, the kitchen is closed. Maybe your wife can go get you something."
No wonder I have not had to urinate -- yet.
Like most ICUs, there are no doors, bathrooms or privacy. Little things start to bother me, like the fact that it is 2 a.m., and the nurses are talking at normal volume and laughing at jokes.
"Dr. Spogen, why don't you sleep some? You will feel better in the morning."
I can't sleep, and every time I flex my left arm, the IV alert rings until the nurse silences it. That is why I didn't want them to put the IV there.
I don't feel better. In fact, every inch of me hurts. Worse yet, I have to pee. I finally muster the confidence to ask the nurse. They pull a curtain around me while holding my shoulder so I don't fall.
That urgent problem solved, I now notice that I am hot. My skin is burning up, and I am really red. Everyone decides I must be having an allergic reaction. I get another shot of Solu-Medrol.
Guess what? I get redder. Then it dawns on me that one of the side effects of steroids is flushing. As the Solu-Medrol works its way out of my body, the redness fades.
Finally, I get out of the ICU and am transferred to the medical floor. Maybe now I can sleep? The nurses on that floor are all quite nice. "Just let us know if you are having pain, Dr. Spogen, and I will get you some fentanyl. It's already ordered."
A couple of hours later I start to cough. If you ever have coughed with broken ribs, you know it is not comfortable. The more I try not to cough, the more I want to cough and the more painful it becomes. I finally call to ask the nurse for pain meds. She answers on the intercom that she will be right with me. Two hours later, she arrives and wonders why I refuse the medicine. The thing about broken ribs is that if you don't cough, sneeze or move, the pain goes away. My coughing fit had passed already.
On the second night of my stay, I try to go to sleep at 10 p.m. At 11, the nurse brings me ibuprofen. At midnight, the nursing assistant comes to check my vital signs. Every time I flex my arm, the IV alarm goes off, so the assistant shows me how to silence it. At 3 a.m., I get another round of meds. At 4 a.m., the phlebotomist comes for a blood draw. At 5 a.m., another set of vitals.
The nursing assistant asks how I slept. Is she kidding?
I begin to feel strange, somewhat like I am getting a viral infection. I feel myalgias, neuralgias, slightly nauseated and lightheaded. The nursing assistant checks my vitals. My pulse is OK. My blood pressure is OK. I don't have a fever.
"That's strange," she says.
"Your oxygen saturation is 78 percent. Why don't you take a couple of deep breaths?"
I do. No change in the oximetry.
"I'll go get the nurse."
What's odd is I don't feel short of breath. But it makes sense that I might have a little atelectasis, so I get out the incentive spirometer. Gradually, I feel better. Finally, at 7 a.m., two and a half hours later, the nurse comes in, mainly because there is a shift change.
"What about my oximetry?" I ask.
"Just keep taking deep breaths."
"How about you check my oximetry, just for fun?"
It is 95 percent.
They decide to keep me in the hospital another night because of my low oxygen. My pain is fairly well controlled with a fentanyl patch and ibuprofen, so they hook me up to a continuous pulse ox. The day passes uneventfully. I get ready to sleep at 10 p.m. I'm soon fast asleep, but the pulse ox alarm, which is set to go off if my saturation falls below 87 percent, wakes me up. I call for the nurse. A half an hour later, the alarm continues to blare and still no nurse. I struggle to get out of bed and manage to silence the alarm. I go back to bed and immediately fall back to sleep, but what seems like seconds later, the alarm rings again. This happens 12 more times before the nurse finally shows up.
I am furious, exhausted and maybe a little drug impaired.
They finally put me on supplemental oxygen. The alarm does not go off, but now I can't sleep. I get up at 5 a.m. and take the oxygen off because when I am up my oximetry is fine.
When the nurses change at 7 a.m., I ask them when the doctor is making rounds. They have no idea. How did I know that would be the answer?
I don't want to spend another night in the hospital, but I do need home oxygen. Having discharged a lot of patients on oxygen in the past, I know that getting insurance verification takes hours, so I am proactive and ask the nurse to see if the doctor can order home oxygen. Hours pass. No comments from nurses or doctors.
At 11:30, I'm pretty upset because there is no communication, and the ward clerk doesn't know anything. Shortly after that, transportation comes in to take me down for a chest x-ray.
"Good morning, Mr. Spongen. I'm here to get you for a chest x-ray. Do you know why you are getting an x-ray today?"
Already frustrated, this pushes me too far.
"That is DR. SPOGEN, to you. And NO, I have no idea why I am getting an x-ray."
I hate to play the doctor card, but I'm angry. I realize that this is the wrong person to vent my frustrations on, but it gets things done. The tech goes to the desk, and the nurse immediately appears. I tell her what I think needs to be done if I am to go home on oxygen, and she calls the doctor's office.
I get the x-ray, and when I return to my room, the doctor's nurse practitioner is there. He warns me that he needs to do a complete exam so they can send me home. Apparently, he has no clue what a complete exam is because all he does is listen to my chest and check my grip strength. I am pulling more than 3,000 cc on the incentive spirometry, so he confesses there is no reason to keep me in the hospital. He agrees that I should have home oxygen for at night, and says he will put in the order. He gives me two weeks of narcotics and tells me I should be OK to work in four days, but "Don't work or drive on narcotics."
Hmm … that does not compute. Oh well, I am getting out of here.
My wife arrives a few hours later. The nurse says I'm OK to leave. No signing papers, no wheelchair ride, just goodbye.
On my way out, I get a call from the home oxygen supply company. The order was not placed until 3 p.m., and they can't get insurance verification. They tell me I might want to spend an extra night in the hospital if I need oxygen because they cannot deliver it without verification. I cannot believe it! Finally, they agree to leave the oxygen if I give them a check for $1,500 in case insurance does not cover it.
I am home now and recovering from my injuries. I am a respected doctor who works every day in this hospital, yet look how I was treated. I now understand why some of my patients are upset with their hospital care.
The biggest flaw was poor communication. I had considered having my family doctor admit me instead of the surgeon. My family doctor would have listened to my concerns and would have communicated to me why I was getting an x-ray (I still don't know if it was ever read) and would have known to order the oxygen early enough to make sure there was insurance verification.
It was a good lesson for me, however. I will handle my inpatients differently in the future, and I will make sure they have their orders on time. I have admitted patients in the past who are doctors or nurses. As their physician, I will make sure they get private rooms, and that their privacy is respected. My students and residents will hear about my experience, and they will know the issues patients face.
As a physician, I knew when my treatment was not ideal, but most patients do not have this same knowledge. Maybe if all doctors and nurses spent some time as patients, we could make the system better.
Daniel Spogen, M.D., of Reno, Nev., is a first-year member of the AAFP Board of Directors. He is a professor and chairman of the Department of Family and Community Medicine and director of medical education at the University of Nevada School of Medicine.
Let's Help Our Patients Make Informed Decisions on Tests, Procedures
Nearly one-third of health care delivered in the United States is unnecessary. Ordering tests or procedures that aren't recommended puts our patients at risk and drives up the already skyrocketing cost of health care, which is projected to account for nearly 20 percent of the nation's gross domestic product by the end of the decade -- unless things change.
And change is exactly what we're recommending.
Today, the AAFP released a list of five tests and treatments family physicians and our patients should question because they often are overused or misused. According to a study in the Archives of Internal Medicine, tests and procedures being overused in primary care are costing the health care system more than $6 billion a year.
One example of overuse is prescribing patterns for antibiotics. These drugs are prescribed in more than 80 percent of the 16 million annual office visits for sinusitis, despite recommendations against the practice.
The AAFP created its top five list of overused tests and treatments as part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign, which is focused on identifying tests and/or procedures commonly used in medical specialties that may not always be necessary. The Academy is one of nine physician specialty organizations that initially agreed to participate in the collaboration.
The AAFP's goal in participating in the Choosing Wisely campaign is to provide evidence-based clinical information that we can use -- along with AAFP consumer education materials -- to start conversations about tests and procedures with our patients. This information will provide a solid foundation for shared decision making between us and our patients that is directed toward the best possible care while avoiding unnecessary and potentially harmful testing and treatment. It will make it easier for everyone to make the best possible choices.
Although we have taken an important step in developing our list of tests and procedures, our work is not done. In the coming weeks and months, Consumer Reports will be issuing patient education materials on each of the five issues we are addressing. As those resources are released, our Web page on the Choosing Wisely campaign will be updated.
Family physicians have a dual opportunity and responsibility regarding Choosing Wisely. First, we must use best evidence for the care we provide. And second, we must be a resource to our patients when they need subspecialty care. Many of our subspecialty colleagues are participating in the Choosing Wisely campaign as well, and I applaud them for their efforts. You can read all nine of the lists released today on a Choosing Wisely Web page.
Glen Stream, M.D., M.B.I., of Spokane, Wash., is president of the AAFP.
Office Champions Project is Opportunity for FP Offices to Improve Smoking Cessation Efforts
You probably know that cigarettes are the leading cause of preventable death in this country, contributing to roughly 443,000 -- or one in five -- deaths each year. Staggering, but not surprising when you consider than nearly one in five U.S. adults smokes, and high school seniors are close behind at nearly 19 percent.
What you might not know is what a huge difference you can
make. In fact, talking to your patients about quitting tobacco is one of the
most effective prevention activities that family physicians can do in their
offices. According to the surgeon general, 70 percent of smokers want to quit.
And patients who are advised to stop smoking by their physicians have a 66
percent higher rate of success in doing so.
The AAFP is doing its part to help family physicians be even more successful with tobacco cessation by offering you effective tools with our successful Office Champions Tobacco Cessation project. Based on the Academy's evidence-based Ask and Act smoking cessation program, the Office Champions quality improvement project trains a physician or staff member to identify and implement changes that promote the integration of tobacco cessation activities into daily office routines.
We know the program can be successfully implemented in busy family medicine offices. In fact, last year, 49 primary care practices completed a 13-month pilot project and successfully implemented 85 percent of the tools (e.g., quit-smoking posters, patient education materials and other Academy resources) they had included in their implementation plans. Ninety-eight percent of practices expressed confidence that the changes they made could be sustained.
Office Champions is a proven way to increase awareness about tobacco cessation in your practice. It also helps you identify who needs help. In the pilot, the percentage of patient charts with documentation of tobacco use status increased from 82.1 percent to 90.2 percent. Documentation that patients were offered cessation assistance increased from less than 50 percent to 72.1 percent.
Now the Academy is recruiting 50 family medicine practices -- with an emphasis on states with a smoking prevalence of more than 20 percent -- for nationwide dissemination of the Office Champions project.
Practices that complete the program will receive $2,000 to cover administrative costs. The deadline to apply is May 8. Applications and additional information are available online.
Together, we can make a difference.
Jeffrey Cain, M.D., of Denver, is president-elect of the AAFP. He is the chief of family medicine at Children’s Hospital Colorado and an associate professor in the Department of Family Medicine at the University of Colorado Health Sciences Center. He also is a co-founder of Tar Wars¸ the Academy's award-winning, tobacco-free education program for children.