Long-distance Support: Thoughts on Telemedicine at 2:30 a.m.
"You may want to use propofol," said a deep, gravelly voice that seemed to come out of nowhere.
I was caring for an older woman, and she was doing poorly. It was 2:30 a.m., the witching hour in medicine, and it looked like we might have to put her on a ventilator. I looked up at the two female nurses who were the extent of the medical team. The anonymous suggestion was welcome, but I had no idea where it had come from. It clearly was not either nurse, and I was fairly certain it was not the voice of God or an auditory hallucination.
"She appears to be decompensating," the voice said.
|In rural areas -- like my practice location in Valdez, Alaska -- telemedicine holds potential to help primary care physicians and our patients.|
Now, I may not be at my best at 2:30 a.m., but I was pretty sure that I was awake.
"You've given Lasix," the voice continued. "Good. Tell you what -- I'll put in orders for propofol while you're getting ready."
Despite my confusion, this was good news. We have an electronic health record system that requires us to type in orders before we can get medications, and I had my hands full at the moment.
That's when I noticed the cart in the corner with a camera tracking the action. We had been talking about signing up for Tele-ICU with Providence Anchorage Medical Center, although I had my doubts about its utility. There is no substitute for having a well-trained physician capable of stabilizing critically ill patients in rural communities, but I was interested in trying the system out. I just hadn't realized it was ready to go.
One of the challenges in rural medicine is the feeling of isolation during an emergency and the heightened sense of responsibility that comes with it. This likely is one of the biggest reasons why rural physicians burn out and leave. Sometimes, all it takes is one bad outcome, especially when the physician -- or the community -- thinks the patient could have been saved.
There have been many patients in Valdez who have required all hands on deck, but there is a cost in terms of lost sleep and function when the medical staff consists of only three people. It sure is nice, though, to have another doctor to talk with. Although I have only used Tele-ICU once so far, I have often called a doctor covering the ICU or ER in Anchorage -- or even a colleague in the lower 48 states -- just to discuss a difficult case. I doubt the doctors at the other end know how important those connections have been for me.
Telehealth is not new technology, although historically, it has been a solution in search of a problem. I have been angered at the money spent on telemedicine carts that could have been better invested in training new rural physicians or increasing physician payment to improve retention. These types of investments improve the rural safety net more than flashy engineering marvels that do not take into account how or why patients are actually seen.
My experience with the Tele-ICU was different. One of the most important aspects of modern medicine is the team approach and the opportunity it offers to discuss how to best to serve a patient. Rural physicians often have no access to the collaboration that occurs in metropolitan areas. So I think one problem telemedicine could solve is not so much how health care is delivered, but rather, how to collaborate at a distance through systems that support the local providers. These include broadband Internet, dedicated specialists who get paid for their work, and an attitude that the best provision of care happens locally.
Telemedicine has many potential benefits but also a number of pitfalls. For critical-access hospitals facing shrinking patient volumes, there is the potential for keeping more patients, rather than transporting them. This may require additional procedural training of rural health care professionals. If medical transportation rates decreased, this would result in significant health care savings.
Telemedicine has the potential to improve access to specialty care, but how will this affect rural practices? With proliferation of direct-to-patient sites, there may be decreased viability of the local system, and many rural physician practices are struggling as it is. Regulation currently prevents the establishment of national telehealth systems, although there is significant pressure to relax these rules. My fear is that direct-to-patient telehealth could unravel the rural safety net. Telehealth works best when it supports the local physician because there is no substitute for competent hands-on care.
Telemedicine also could allow specialists to narrow their field of study while empowering family physicians. I have a dream of sitting with my patient in front of a screen discussing her glomerulonephritis with a nephrologist who spends his day performing glomerulonephritis consults via telehealth. For this to work, a system must be in place that allows payment of the specialist and an adequate originating fee for the family physician.
It is too early to see how this will play out, but we are fast approaching a time of rapid change. From a rural perspective, I can see the allure of having another physician at your shoulder in the middle of the night when the patient is crashing. I might have done things a little differently without Tele-ICU and a virtual intensivist, but it was a good experience, and the patient did well.
John Cullen, M.D., is a member of the AAFP Board of Directors.
Patients Need Nutrition Facts From Their FP, Not Dr. Google
I enjoy discussing nutrition with my patients. It is an essential part of the lifestyle and prevention package that family physicians are uniquely positioned to prescribe.
Although I have not eaten meat in 40 years, I live with three people who consume it on a regular basis. I had to self-educate about nutrition when I chose to stop eating meat because this was before I had the benefit of the four nutrition lectures I got in medical school. During those years, I drank a lot of milkshakes and discovered that it picked me up for a short while, but fatigue would roll in within two to three hours.
Diet for a Small Planet by Frances Moore Lappe was my original textbook and guide. It's hard for me to believe that this book is now more than 40 years old. Fast forward to today, and our patients are taking nutrition advice from TV doctors, the Internet and other sources that might not be evidence based. Shouldn't they be hearing the facts from us?
Every time I sat down to write this blog post, a new latest-and-greatest declaration in some journal or meeting would derail me. But recently, the Annals of Internal Medicine published an NIH-funded study that confirmed some of the things I have been telling patients. Researchers suggest that a diet that cuts down on carbohydrates may work better than trimming fat to aid in losing weight.
There is no one diet that works for everyone. One size does not fit all. (That is one reason there are so many diets out there.) But it's worth noting that this study included males and females and was racially diverse.
The problem with limiting carbs is that it may lead patients to inadvertently skimp on dietary fiber, which is important for heart and colon health, as well as for making our patients feel "full."
I talk with my patients about moderation in a healthier diet, but the exception is dietary fiber. I talk about going from the national average intake of 14 grams a day up to 30 grams a day, increasing intake slowly. First we assess their consumption, and then we add only 3 more grams per week until we reach our goal. This regimen brought my own LDL cholesterol down by more than 40 points and has been quite effective for a number of my patients, although sometimes our guts tell us that they are not happy with our diet.
The motto of "First, do no harm" is critical, and that applies to supplements. Through my sports medicine affiliations I have been fortunate to glean excellent information on this topic. Just because something is natural does not imply it is safe. I have diagnosed new-onset hypertension in a number of patients who thought they were doing a good thing by taking a multivitamin but did not realize that in those supplements they also were taking herbs that raised their blood pressure. By taking them off the multivitamin, we were able to return patients' blood pressure to normal without medication.
At the end of the day, it is about balance and moderation and trying to get your nutrition from as primary a source as you can.
After I finish my term on the AAFP Board of Directors this month -- and eventually finish the patient-centered medical home recognition process, achieving meaningful use and transitioning to ICD-10 codes -- I think I will sit with a cup of tea and start an outline for a nutrition piece for American Family Physician to update our information because obesity is a prevalent disease, and family physicians are in a position to make a major impact.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Heads Up: School Sports Season Is Upon Us
My practice of family medicine includes sports medicine, and I care for a number of athletes in my community. However, it was an athlete I never cared for -- someone from the other side of the country, in fact -- who changed my practice and the care of young athletes across the United States.
Zackery Lystedt was playing football for his junior high school when he was injured in a game in 2006. He did not lose consciousness, and he returned to the field in the second half. He collapsed and had to be air-lifted out of the area for life-saving surgery. After several strokes and three months in a coma, Zack woke up. But it took nine months before Zack could begin to speak again and nearly three years before he could stand on his own.
I learned about Zack during a presentation by Stanley Herring, M.D. -- a team physician for the Seattle Mariners and Seahawks and a member of the Head, Neck and Spine Committee of the National Football League (NFL) -- at an American College of Sports Medicine (ACSM) meeting in 2009. He described how Zack and his family had taken up the cause of trying to prevent other young athletes from suffering similar experiences. That same year, the Washington state legislature passed the Lystedt Law, which requires concussed athletes to be cleared by a physician knowledgeable in traumatic brain injury before being allowed to play again.
I had met Herring 10 years earlier when I served as the AAFP liaison at the ACSM's Team Physician Consensus Conference. He played a major role in advocating for the Lystedt Law in Washington, and he asked me to spearhead advocacy efforts for similar legislation in Delaware. It was a great learning experience in policy making as I worked with a state legislator, the NFL and others, and the law was signed by our governor in 2011. By 2013, all 50 states had passed legislation that prevents a concussed athlete from returning to practice or competition for at least 24 hours, and their return to play depends on clearance by a clinician.
There is still much to learn about concussions, as highlighted by a recent White House summit that brought together a diverse group of stakeholders, including the AAFP. Protecting young athletes is an important part of our job as family physicians, and there are resources worth highlighting.
- With support from the NFL and the CDC Foundation, the CDC has created tools for health care professionals as part of its Heads Up campaign.
- The agency's resources include a free online CME course that applies not only to young athletes, but also to other concussed patients.
- The AAFP's sports safety Web page links to journal articles on the topic, including the American Academy of Neurology's guidelines for managing concussions in athletes, as well as to other resources.
- With schools around the country starting soon, now is a good time to think about preparticipation exams to ensure that our young athletes are in the best possible condition for competition before their season starts.
May all of our patients be safer because we learn to protect them from injuries like the one Zack Lystedt and his family live with every day.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Women's Health: Do You See the Big Picture?
I had a new patient come to me last year, a woman in her 60s, complaining of back pain. Over the course of several months and multiple visits, and after indicated tests and imaging, we worked together to formulate and execute a pain management plan. Her acute condition improved, but I found myself wondering: Had I done a thorough job? Or had I let myself get caught up in dealing with one specific problem and had failed to see the bigger picture? Had I offered this patient all of the other tests and screenings -- such as colonoscopy -- that were recommended for her age group?
Patients often, and understandably, focus on the problem that is bothering them right now. But back pain isn't what is going to eventually kill that patient. Cancer, heart disease and other factors are much more likely to cause serious, long-term problems. As physicians, it's our job to stress the importance of doing all the other things that can help keep patients healthier longer.
So how are we doing?
A CDC study published this month in JAMA Internal Medicine indicates that when it comes to women's health, we could do better -- possibly much better. Researchers looked at data from more than 60 million preventive health visits to OB/Gyns and primary care physicians and compared what services were being offered by the two types of physicians.
Perhaps not surprisingly, OB/Gyns were more than twice as likely as primary care physicians to offer screenings for breast cancer and cervical cancer and almost twice as likely to test for chlamydia. However, women who saw a primary care physician were likely to receive a much broader range of services.
For example, 34.5 percent of women 45 or older received cholesterol screenings from their primary care physicians compared to only 5.4 percent of those who saw an OB/Gyn. Women who saw a primary care physician were four times more likely to be tested for diabetes.
But both OB/Gyns and primary care physicians have room for improvement. Colon cancer is the third-leading cause of cancer-related death in women. But the study found that among women ages 50-75, a total of only 6.1 percent were screened -- 7.2 percent of women who saw a primary care physician and 3.9 percent of those who saw an OB/Gyn.
The study also examined whether women received counseling about four key health issues: diet, exercise, obesity and tobacco use. Researchers found that 81.5 percent of women who saw an OB/Gyn and 73.5 percent of women who saw a primary care physician did not receive counseling on any of those important topics. Although not all patients need counseling on these issues, the numbers seem shockingly high given that more than one-third of U.S. adults are obese and nearly one-fifth smoke.
Despite the low overall numbers, primary care physicians fared better than OB/Gyns in all four areas. A little more than 19 percent of primary care visits involved counseling for diet compared to 12.4 percent of visits with OB/Gyns, 14.3 percent of primary care physicians offered counseling about exercise compared to 9.9 percent of OB/Gyns, 7.5 percent offered counseling for obesity compared to 4.2 percent of OB/Gyns, and 3.4 percent offered counseling for tobacco compared to 2.6 percent of OB/Gyns.
Time is obviously a factor. There's only so much ground we can cover in a 15-minute appointment, and patients often come with their own questions and concerns that have to be addressed. But taking a few seconds to show a patient where he or she stands stand on the BMI chart can be powerful, eye-opening and the first step in pointing that patient in a new direction. Patients who want to stop smoking can be referred to quitlines. We also can schedule a follow-up for patients who need more time to address their issues.
Communication likely is another factor. We need to let our patients know what tests and screenings are recommended and appropriate for their age. For our patients who see both an FP and an OB/Gyn, we also may need to do a better job communicating with our OB/Gyn colleagues to ensure that someone is taking responsibility for offering the appropriate services.
It's worth noting that the study's data were drawn from visits during 2007-2010 -- before the Patient Protection and Affordable Care Act mandated that health plans cover a wide range of preventive services. If this issue is re-examined in a few years, it will be interesting to see how much our numbers improve.
How does your practice use electronic health records, patient registries or other tools to ensure that patients receive recommended tests or screenings?
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
It Takes a Village: Become a Breastfeeding Advocate
Over the years, the Academy of Breastfeeding Medicine (ABM) has received significant leadership contributions from AAFP members, including past ABM officers Anne Montgomery, M.D., Julie Wood, M.D., and Tim Tobolic, M.D. AAFP member Anne Eglash, M.D., in fact, was a founding member of the ABM. But no AAFP officer had ever been invited to participate in the ABM's Annual Summit on Breastfeeding, even though our colleagues from the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics have routinely attended.
But this year, for the first time in the event's six-year history, all the specialties that care for newborns and mothers were represented at the recent two-day summit in Washington.
Family physicians, including president-elect Julie Taylor, M.D., M.Sc., (right) have played an important role in the Academy of Breastfeeding Medicine. I met with her at the recent Annual Summit on Breastfeeding.
This breakthrough represented an important opportunity for the AAFP because attendees at this event included not only representatives of the medical professional organizations noted above, but also leaders from CMS, HHS and other governmental agencies; federal legislators; representatives from such diverse stakeholder groups as the W.K. Kellogg Foundation, Kaiser Permanente and the March of Dimes, as well as academics, state health officials and others.
Unfortunately, many of these groups have not coordinated their efforts with one another and were not aware of other groups' activities. In particular, these other stakeholders were not familiar with the important work the AAFP has done in the areas of breastfeeding support, advocacy and policy. Therefore, I saw at least part of my role in attending the event as helping to break down existing silos.
I found it encouraging that everyone present seemed to readily recognize this need. We forged new relationships, connecting to the right people to improve our collaboration. In between agenda sessions, people were talking, exchanging cards, and sharing resources and links. I felt a great deal of enthusiasm and energy throughout the entire event.
Best of all, this summit provided me another opportunity to help other groups understand who family physicians are and what we do. I was able to point to our unique role in taking care of these special patients, noting that because we are the only specialty that truly does cradle-to-grave care, we have multiple opportunities to talk not only about breastfeeding, but also the many diverse issues relating to rearing children.
An especially important message for attendees to hear was about our ability to educate not just the mother, but also the father and, perhaps even more essential, the maternal grandmother! Family physicians are truly the medical specialists who can pull everything together after the blessed event, because we see both mother and baby together at subsequent visits. With this kind of postpartum follow-up, we can directly impact the sad decrease in breastfeeding rates that occurs after women go home from the hospital. At the time of discharge, about 75 percent of U.S. women are breastfeeding, but that rate drops to roughly 28 percent within a few weeks of going home.
Family physicians can take the lead in addressing this critical public health issue because we understand that breastfeeding is really a family matter, not just a personal one. We witness the powerful role of relationships within families and with our practices every day, with every patient.
The ABM has a number of resources to support breastfeeding, just as the AAFP does. One of our resources, the Academy's breastfeeding position paper, is even now being updated as part of a regular evidence review by our Breastfeeding Advisory Committee. That update likely will be published in the fall and will be accompanied by an education campaign aimed at helping to create breastfeeding-friendly family physician offices.
Other resources family physicians may find helpful include the Baby-Friendly USA initiative and its 10 steps to creating breastfeeding-friendly hospitals. Even for family physicians who don't work in hospitals or provide obstetric care, it's still important to advocate on patients' behalf to ensure that that the first exposure during and after delivery reflects strong support for "the first food" and not formula.
It's also worth noting that 28 percent of all medical students in this country are members of the AAFP, so we have a unique opportunity to begin emphasizing breastfeeding benefits early on regardless of what specialty each student eventually selects. Moreover, our residencies are working to become breastfeeding-friendly for our trainees. This new policy is the result of resolutions passed by the 2013 Congress of Delegates that initially were brought forward by our students and residents.
Finally, I was able to share the critical need for all of us to network better with each other. Even in this meeting that focused on an issue of common ground, I still saw evidence of our fragmented health care system. Different groups don't always share as well as they could. This is one of our challenges in these days of advanced communications technology -- we can forget the power of face-to-face discussions. That is one reason I am so eager to say "Yes!" to these kinds of invitations. Nothing can beat actually talking with people in person.
That said, we need to recognize that the mothers and families of today are different, and I challenged everyone at the meeting to get comfortable with social media because it's one more avenue to increase awareness about breastfeeding.
One final note: Just as family physicians were critical to the founding of the ABM, so we are to its leadership now. The current president of the ABM is Wendy Broadribb, M.B.B.S., a family physician from Australia. Julie Taylor, M.D., M.Sc., a family physician on faculty at Brown University, will be taking over next year. I look forward to future opportunities for the Academy to interact and grow together with other stakeholders on this important issue.
Reid Blackwelder, M.D., is president of the AAFP.
Measles and Mumps and MERS, Oh my…
It's not hard for me to remember that it's that time of the year again because my daughters are frequently singing Olaf's song from the Disney movie "Frozen." "When life gets rough, I like to hold on to my dream, of relaxing in the summer sun, just lettin' off steam … in summer."
My family is heading to Hawaii for our summer vacation, and we won't be alone. After a harsh winter in many parts of the country, a busy summer travel season is expected. The American Automobile Association (AAA) estimated that nearly 32 million Americans traveled at least 50 miles by automobile during the Memorial Day holiday alone, and another 2.6 million traveled by plane. It marked the second-highest travel volume for the holiday in more than a decade.
Airlines for America, an industry lobbying organization, projects summer air travel will rise to its highest level in six years. Roughly 210 million passengers are expected to fly U.S.-based airlines from June through August, including a record 30 million passengers traveling internationally on U.S. carriers.
With that summer fun comes some potential risks. Measles remains common in many parts of the world, including areas of Europe, Africa, Asia and the Pacific. For example, the Philippines had more than 31,000 suspected cases of the disease (and 70 deaths) through May 20 of this year.
In an average year, only about 60 cases of measles are reported in the United States. Unfortunately, international travelers are bringing home more than just souvenir T-shirts. This year, the United States has had more than 300 cases of measles -- including 15 outbreaks covering 18 states -- reported since Jan. 1. That's the highest total since public health officials declared the disease eliminated here in 2000. According to the CDC, the vast majority of reported cases (97 percent) have been associated with either foreign visitors or U.S. travelers returning home from international trips.
Meanwhile, the CDC also reports that from Jan. 1 to May 2, 464 cases of mumps have been reported. That total already is higher than all the mumps cases reported last year.
Although nearly half of the measles importations have been linked to the Philippines, other cases imported into the United States have been associated with travel to other countries in Southeast Asia, Europe and what the World Health Organization refers to as the Western Pacific region and the Eastern Mediterranean region.
Measles isn't the only health issue for travelers and their physicians to think about. With new reports of infection caused by the novel Middle East respiratory syndrome coronavirus (MERS-CoV), many of my patients are now concerned about what they otherwise would have thought of as simply a mild cough or seasonal allergies. I, too, have found myself being more diligent in asking about travel history when confronted with patients who present with fever or upper respiratory symptoms.
Although few of us may remember seeing -- much less treating -- measles, even fewer have experience managing suspected cases of MERS-CoV infection. I remember the hypervigilance of our health care community in 2003 after the World Health Organization issued a global alert regarding the severe acute respiratory syndrome (SARS) outbreak, how we masked every patient who presented with cough, how there was a run on local pharmacy supplies of N-95 masks, and how every traveler returning from Asia was screened via infrared cameras on their entry into the United States.
The general public may be lulled into a false sense of security when infectious diseases such as measles, smallpox or polio are eliminated domestically or when a particular outbreak "dies out," as SARS did. It is our responsibility as trusted physicians to remain vigilant about global trends in communicable diseases and outbreaks. It is our role as patient advocates to ensure that our patients are protected from preventable illnesses in this global community. And it is our role as public health defenders to convince those who are reluctant to get vaccinated that it really is in their own best interests -- and the best interests of those around them -- to do so.
But one of the most difficult challenges in my daily practice is to know what advice to give when patients travel to locales unfamiliar to me. So when I ask my patients' their about summer travel plans, I breathe a sigh of relief if they mention some place like Japan or Cancun. But how about a honeymoon trip to Tahiti, the annual Hajj pilgrimage to Mecca, or a medical mission to Haiti?
Well, I recommend a quick search on the CDC's Travelers' Health Web page, which provides the latest information and advisories about communicable disease outbreaks around the world. It also has information -- searchable by country -- for both clinicians and lay travelers about vaccination requirements and other recommendations. You also can find travel tips for patients heading abroad (including the fact that they should be vaccinated at least six weeks before leaving home) on FamilyDoctor.org.
Armed with these invaluable resources, I can confidently advise my patients and protect my community from the latest outbreak of polio in Syria, dengue in Brazil and Ebola in Liberia.
So, when you see your patients this summer, don't forget to ask them about their travel plans.
Jack Chou, M.D., is a member of the AAFP Board of Directors.
White House Invitation Shows Importance, Recognition of Family Medicine
In our advocacy efforts, we often talk about the importance of being "at the table" when important discussions are taking place. The Academy is getting a good seat at that proverbial table more and more often.
Last week, I had the opportunity to represent the AAFP at a White House event for the second time in less than 18 months. This most recent trip was prompted by an invitation to attend the president's Healthy Kids and Safe Sports Concussion Summit, which brought together select medical experts and representatives from collegiate and professional sports organizations to address this serious problem.
|I attended the Healthy Kids and Safe Sports Concussion Summit May 29 at the White House.|
My previous White House invitation stemmed from the first lady's request that an AAFP representative attend a meeting about Joining Forces (a national initiative to support military service members and their families) along with the representatives from the Department of Defense, the Department of Veterans Affairs and other stakeholders. At that meeting, we addressed the challenges of providing care to special groups within our armed services, including service women and veterans needing mental health services.
I'm pleased that the administration is demonstrating an increasing recognition of the critical, foundational role that family physicians play in our health care system. Concussions, traumatic brain injury, mental health and women's health needs are significant health issues. Unfortunately, it is common for legislators and administrators to view these issues strictly in terms of subspecialty services, which can easily lead to fragmented care.
Family medicine is the only specialty that doesn't limit itself based on organ systems, disease groups, specific problems or age of patients. Instead, we are on the frontlines of managing all of these issues in our patients every day. One of the Academy's goals is to help those in leadership positions better understand who family physicians are and what we can provide. The fact that the AAFP is repeatedly being invited to meetings like these indicates our message is getting through.
During his remarks at the concussion summit, the president mentioned that although U.S. emergency rooms see roughly 250,000 children each year for head injuries, that doesn't include the number of children who are taken to see their "family doctor." I appreciate his recognition that family physicians are instrumental in the care being provided to children for such health issues. We are able to address the acute issues of affected children and the appropriate concerns of their families. We can educate these families and discuss how to prevent these injuries.
Perhaps even more important are our relationships within our communities. Family physicians provide numerous community services in many different venues, and 40 percent of our members provide some sports medicine services. Many are right there on the sidelines to educate coaches and teams.
Moreover, the direct connection we have with patients allows us to be there for the challenges created when someone has a severe concussion and its sequelae -- such as post-concussion symptoms and even career- or life-changing events. We are the only physicians with the combination of comprehensive education, extensive training and skills to handle complexity that allows us to care for all of our patients’ needs and help manage the impact on their families.
One of the promises that our officers and Board made to all Academy members was to continue to advocate that we be at the table and, thus, off the menu for such keenly important health care issues. I think we are well on our way in this regard. Our invitation to, and attendance at, these high-level meetings allow us to continue to educate those in health and government administration not only about the need for family physicians to be right at the frontlines, which we already are, but also to be respected in that critical role.
Thank you for all of your service and for all that you do. More and more people are recognizing the important work family physicians have always done, and they are starting to value those contributions appropriately.
Reid Blackwelder, M.D., is president of the AAFP.
Ask the Question: Screening for Alcohol Misuse Can Save Lives
I recently returned home from an incredibly inspiring weekend at the AAFP's Annual Leadership Forum and National Conference of Special Constituencies in Kansas City, Mo., but my good mood quickly faded when I found the local Chicago news filled with stories of yet another accident caused by drinking and driving.
A man driving an SUV entered the northbound lanes of Lake Shore Drive headed south and struck a taxi head-on. According to police reports, the man’s blood-alcohol content was more than twice the legal limit.
A young law student who was riding in the taxi died in the crash. She was reported to be an accomplished and big-hearted leader among students, was on schedule to graduate next month and had already received and accepted a job offer.
Sadly, she won't be graduating with her classmates or celebrating her accomplishments with her family. And her story, tragically, is just one of many.
In fact, the World Health Organization (WHO) said in a report released this week that alcohol contributed to 3.3 million deaths -- or 6 percent of all deaths -- worldwide in 2012. That staggering total means that roughly every 10 seconds, someone dies an alcohol-related death. Accidents, including car crashes, accounted for 17 percent of all alcohol-related deaths.
Here in the United States, excessive alcohol use is the third-leading preventable cause of death, claiming roughly 80,000 lives annually. Alcoholic liver disease is the second-leading indication for transplantation in the United States.
So what are we doing about it in our practices?
"Do you drink?" is a question we are trained to ask in medical school, but are enough of us actually asking it? According to the CDC, only one in six U.S. adults have ever talked to a health care professional about alcohol use. That's unfortunate because, according to the agency, alcohol screening and brief counseling can reduce the amount excessive drinkers consume by as much as 25 percent.
Of course, there are reasons why a primary care physician might hesitate to ask the question. Some physicians tend to shy away from questions about substance abuse. Not only can it be an uncomfortable topic, but some practices and communities lack adequate resources for treatment. It's also likely that some patients are less than forthcoming about their struggles.
Health care payers require us, and offer incentives, to ask every patient at every visit about certain other clinical issues, such as tobacco use, pain and asthma. In a health care environment where an office visit may be limited to 15 minutes or less, there are many issues to cover in a limited amount of time.
But considering that excessive alcohol use costs our country roughly $185 billion a year in health care costs, criminal justice expenses and lost productivity, wouldn't it make sense for alcohol use to be just as important a question as tobacco use when taking a patient's health history?
According to the WHO report, 7 percent of U.S. men and 2.6 percent of U.S. women are alcohol-dependent. More than 10 percent of men and more than 4 percent of women have an alcohol disorder, meaning either dependence or harmful use of alcohol. However, only 15 percent of people with such a disorder seek treatment, according to the National Institute on Alcohol Abuse and Alcoholism.
If none of those statistics grabbed your attention, consider that 10 percent of U.S. children live with an adult who has an alcohol problem. So what can we do to help patients and their families?
It's really very simple: We need to ask the question. The AAFP recommends that physicians screen adults for alcohol misuse and provide patients engaged in risky or hazardous drinking with brief behavioral counseling interventions.
Although time certainly can be a barrier during an office visit, there are many simple screening tools that are easy and quick to use. For example, the CAGE questionnaire consists of just four questions. The WHO's Alcohol Use Disorders Identification Test can be completed in as little as two minutes.
Once we've asked that difficult first question, these tools can help us determine whether a patient needs counseling. If your practice isn't equipped to offer counseling, take the time to inform yourself about the resources that are available in your community.
The third-leading cause of preventable death in our country is an issue we can't continue to be silent about.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
Visit to Army Medical Center Provides Insight Into Military Care
Recently, I had the good fortune to tour Brooke Army Medical Center (BAMC) Fort Sam Houston in San Antonio, and I came away extremely impressed by the great job that the Army does in caring for our soldiers on multiple levels: keeping healthy soldiers healthy, treating the acutely injured and helping the injured recover.
I also was impressed by the many opportunities available for family physicians to serve in military medicine. And it would be hard not to be awed by the largest inpatient medical facility run by the Department of Defense.
I recently toured Brooke Army Medical Center Fort Sam Houston in San Antonio with Col. Karrie Fristoe, commander of the U.S. Army's Medical Recruiting Brigade, and Rebecca Hooper, Ph.D., retired Col., and former assistant director of BAMC's Center for the Intrepid.
But to me, even more impressive was the commitment to improving the overall health of our soldiers and our country. One of our hosts, Lt. Gen. Patricia Horoho, U.S. Army surgeon general, stressed the importance of both the patient-centered medical home and efforts to emphasize health, not just treating illness and injuries. The Army Medicine Performance Triad -- eating well, being active and sleeping well -- are guides for soldiers to lead a better life with more engagement, energy and fulfillment.
The 2.1 million-square-foot, 425-bed San Antonio Military Medical Center has a certified Level 1 Trauma Center that handles more than 5,700 ER visits per month, yet it also offers primary care, pediatrics, OB/Gyn, bone marrow transplants, a cardiac catheterization lab and psychiatric care to service members, their families, veterans and civilians.
BAMC is home to the Army Burn Center, part of the Army Institute of Surgical Research. We were able to see how the Burn Center has the ability to project ICU level burn care anywhere in the world, to bring injured soldiers home in a mobile ICU, and treat them all the way through rehab and recovery.
It also is the site of the Center for the Intrepid (CFI), a world class facility for service members recovering from amputation. Here you can really see the benefit of combining the complete range of state-of-the-art amputee treatment in one facility: prosthetists, psychologists, challenging sports equipment and even virtual reality systems with one aim: bringing wounded warriors back to the highest level of functioning possible. The CFI and their athletes are inspiring, and the facility is far beyond anything offered in the civilian world.
Most family physicians likely know that the Armed Forces Health Professionals Scholarships Program (HPSP) offers full scholarships for medical school, but during my visit, I was struck by the wide number of opportunities available to family physicians practicing in the military. Indeed, by the age of 42 one of my hosts, Lt. Col. Tom Hustead, M.D., family physician and AAFP member, has already served as a clinic director, a flight surgeon, and a department chair in family medicine. In addition, he has been deployed in a military service area.
Hustead said many of the more than 550 Army family physicians, like him, initially joined out of a desire to serve our country, but they remain for the camaraderie and opportunity found in the in Army Medical Corps.
There are nearly 2,000 active AAFP members in our Uniformed Services chapter.
My message today is for them: Thank you for your service.
Jeff Cain, M.D., is Board Chair of the AAFP.
The Truth About E-Cigarettes: Unregulated, Unproven and Unhealthy
Here is a burgeoning twist to the tobacco wars and a new public health risk.
In a new television advertisement, electronic cigarettes are being touted as better than traditional cigarettes because the byproduct is "only vapor," not tobacco smoke. Consumers -- including children -- are being told that e-cigarettes are the “smart alternative” to smoking. The implication is that e-cigarettes are safe for the user and the people around them. The truth is the vapor from e-cigarettes contains carcinogens, including arsenic, benzene and formaldehyde.
|Here I am speaking at a news conference to address Chicago's ban on the use of electronic cigarettes in public places. Family physicians can make a difference in public health issues not only in our exam rooms but also through advocacy.|
A preliminary study recently presented at the Society for Research on Nicotine and Tobacco found that second-hand exposure to e-cigarettes can cause harm after the user has left the room or turned off an e-cigarette because nicotine released by the products leaves residue on indoor surfaces.
Tobacco companies have long tried to glamorize their deadly products, and now e-cigarette marketers are doing the same thing, including using high-profile celebrity endorsements.
But the marketers' unsavory tactics don't stop there. Although proponents will argue that e-cigarettes are tobacco cessation devices, the fact is that manufacturers are targeting the next generation of smokers by marketing their products to kids.
If you have doubts, ask yourself how many middle-aged men are reaching for the e-cigarettes that come in cotton candy and bubble gum flavors. Those clearly are intended for kids, and the percentage of middle school and high school students who have tried e-cigarettes doubled from 2011 to 2012.
That's a huge problem because the products aren't regulated, so the amount of nicotine and other chemicals can vary from cartridge to cartridge.
And those touting e-cigarettes as the "smart alternative" to tobacco are ignoring the fact that many consumers are doubling up, using both conventional cigarettes and their electronic counterparts. In fact, a CDC survey found that more than three-fourths of middle school and high school students who use e-cigarettes also smoke. A recent study in JAMA Pediatrics concluded that the use of e-cigarettes "does not discourage, and may encourage, conventional cigarette use among U.S. adolescents."
A recent survey of e-cigarette users found that only 12 percent were former smokers who use the electronic products exclusively. A study in JAMA Internal Medicine found that e-cigarette users did not quit with greater frequency than nonusers. In fact, among smokers who called a quitline, e-cigarette users were less likely to quit than nonusers.
It's also worth noting that poisoning incidents related to e-liquids increased 300 percent in the past year.
So what are we, as a society, going to do to counter a billion-dollar industry that is spending more than $20 million a year
The FDA was granted the authority to regulate cigarettes and other tobacco products in 2009, and the agency has been trying to gain similar control of e-cigarettes for years. Meanwhile, children are allowed to buy products that could adversely affect their health for the rest of their lives, and targeted advertising is unregulated.
We have a duty to protect those children and our communities, and if a product looks like a cigarette and contains nicotine like a cigarette, it should be regulated like one. So while we wait for the FDA to act nationally, we can advocate locally.
Here in Chicago, the Illinois AFP supported a city ordinance passed earlier this year that will subject e-cigarettes to the same sales restrictions as tobacco, and it also subjects the products to the city's Clean Indoor Air Act.
New York, Los Angeles and several counties across the nation also have implemented similar laws that ban the use of e-cigarettes in public places. Some states, including Illinois, prohibit the sale of e-cigarettes to minors. Legislation regarding sales restrictions and use in public places is pending in several states.
But legislators aren't the only ones who need to hear from family physicians about this health issue. Our patients are hearing about e-cigarettes from paid endorsers of the products on a regular basis, but what are we telling them?
Parents need to know that children are using these products, and there are numerous possible harms. Patients who are ready to quit smoking should be encouraged to use evidence-based methods that have been proven safe and effective.
Smoking rates for adults and teens are at historic lows. We must ensure that trend isn't reversed by misinformation and questionable marketing practices.
You can read the AAFP policy on e-cigarettes here. And to learn more about how to talk to your patients about e-cigarettes, the Illinois AFP, the AMA and the Chicago Department of Public Health recently offered a free webinar that is archived online.
Javette Orgain, M.D., M.P.H., is the Vice Speaker of the AAFP.
Food Security: Take a Lesson From Your Patients
A recent study in Health Affairs found that low-income Californians with diagnosed diabetes were more likely than the state's higher-income residents to be admitted to the hospital for hypoglycemia. The results were particularly striking when evaluated on a week-by-week basis because low-income residents had a 27 percent increased risk of being admitted for hypoglycemia during the last week of the month compared with the first week.
The study's authors suggest a correlation between economics and health. As patients' funds become limited, so did their access to healthy food. The results indicate that those most vulnerable to food insecurity -- defined as limited or uncertain availability of nutritionally adequate and safe food -- may also suffer adverse health outcomes when resources are scarce.
The results are not surprising, and other studies have suggested a link between food insecurity and adverse health outcomes. These studies should remind us of the importance of asking patients about their access to food. It rang clear for me through my interactions with one of my patients, who we'll call Dennis.
Dennis was in his mid-40s and obese. He also had diabetes and hypertension. When I took over his care, his conditions were well-controlled, and he was compliant with his medications. After seeing him for about a year, his hemoglobin A1c rose significantly and his blood pressure became uncontrolled.
He told me that he wasn't eating as well as he knew he should. We reviewed carbohydrate and sodium goals, and he promised to try to eat more salad. I suggested adding insulin, but he said he wasn't ready to take that step.
At his next visit, when we hadn't seen much change in his numbers, I finally asked why things changed so dramatically. It was at this point that he admitted he now was homeless, surviving on food stamps and the good will of others.
His diet consisted almost entirely of eating at fast food restaurants and soup kitchens, he told me. He was still reluctant to use insulin because he feared he would be robbed for the needles. With that knowledge, we were able to strategize how to use his limited food dollars to get the nutrients he needed and how to titrate his medications more appropriately to match his food intake.
For me, it was a wake-up call to ask not only what people are eating, but also how often they are eating. It opened my eyes to the need to ask my patients about their eating habits. I'm sure I'm not the only family physician who has encountered mothers who water down their baby's formula to make it stretch, elderly patients getting by on tea and toast, or parents who go hungry so their kids don't have to.
Patients often are reluctant to admit that they are having a hard time putting food on the table. And the impact of food insecurity on health is vast, including both malnutrition (from lack of nutrient-rich food) and obesity (due to eating cheap, calorie-dense and nutrient-poor food) , as well as all of the complications associated with those problems.
According to the U.S. Department of Agriculture, 14.5 percent of households were food insecure at some point during 2012. As family physicians, the most important thing we can do to help our patients regarding this issue is to ask about their food practices, especially when there is a change in their health status. There are federal, state, and local programs to help individuals who may be food insecure, including the Supplemental Nutrition Assistance Program for adults; the Special Supplemental Nutrition Program for Women, Infants, and Children, better known as WIC; and national school breakfast and lunch programs for children and families.
For my patient Dennis, asking the right questions about his food practices was the key to getting his health back on track.
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Adaptive Sports, Peer Support Give Patients New Perspective
You could feel the discouragement just walking in the exam room door.
Roy sat with his head down and shoulders hunched. His cane was propped against the wall. As the preceptor in clinic, I had been asked by our third-year resident to meet Roy, a 50-year-old patient with diabetes who recently had lost his leg and was having a hard time learning to walk on a new prosthesis.
of this blog may know that I wear two prosthetic legs
since an accident long ago, but when I walked in the room Roy didn’t know that.
With just a glimpse of my carbon fiber ankles, his eyes flew open wide.
“But how can you be an amputee? You’re the doctor!”
It was just a glance, followed by a few words of encouragement and direction to a couple of resources for amputees, but Roy walked out of the room smiling, his back a little straighter, his perception of living well with amputation altered.
Driving home that night, I couldn’t help but ask myself what was it that had brightened Roy’s day, and what had made it possible for me to successfully walk that same path of uncertainty so many years ago?
For me, three reasons came to mind.
The first images to meet my eyes when I woke up in the ICU after my accident were those of amputees engaged in sports. My best friend had gone online, found photos of people wearing prosthetics while doing crazy, fun things, and posted them throughout my room.
Secondly, as a lifelong skier, every ski season has started with a viewing of one of director Warren Miller’s fabulous ski movies. Warren has always included images of adaptive athletes, kicking it on the mountains, in his movies. These images were planted so deeply in my mind that, on my first night out of the ICU, I sat on the edge of my bed visualizing making my first turns on a snowboard while wearing a prosthesis that I had yet to even see.
It was a gift from the filmmaker that I hadn’t even known I had received.
And lastly, but perhaps most importantly, my family physician and friend Tim Dudley, M.D., made me call the National Sports Center for the Disabled (NSCD) from my hospital room before I went home.
The NSCD is one of the nation’s oldest and largest adaptive sports centers and helps people with disabilities discover joy and freedom beyond their perceived limits of disability. It offers skiing in the winter, as well as summer activities such as bike and horseback riding.
With help from the NSCD, I rediscovered the mountains and the thrill of skiing. And together, we introduced a new device, the ski bike, to the North American adaptive ski community.
The great thing about skiing for people with disabilities is that a physical activity that may have been limited by muscle strength or discomfort can be overcome by adaptive equipment and the power of gravity. With adaptive skis or a ski bike, people with disabilities find freedom through speed and movement and the joy of keeping pace all day with their family and friends.
Whether it's skiing, horseback riding, kayaking or any other activity, with the NSCD, people with physical challenges can find ways to enjoy the outdoors and lead an active lifestyle. And it isn't just about sports. Recreation is for everyone, and the benefits -- physical, mental, social and spiritual -- are transformative for body and soul.
Adaptive sports programs also helped connect me with others facing challenges. I met and saw peers who are active and drew inspiration from their experience. It broadened my perception of what is possible, not only in sports but in life.
Perhaps most importantly, organizations like the NSCD are also "stealth" peer support programs. Lessons are personal, visual and more powerful than any printed words, website or stories -- even those from a physician or therapist. For people with physical challenges, peer support can replace self-images of disability with images of ability.
What had brightened Roy's day and what had helped me so much was the power of peer support, which helps us understand we are not alone by allowing us to learn from those with the same challenges.
Groups like the NSCD and the Amputee Coalition certainly helped me with the nuts and bolts of dealing with amputation, like how to ride a bike, travel and even how to answer the questions of inquisitive children at the pool. ("Who would ever guess that sharks could live in chlorinated water?")
More importantly, these groups provided me with life lessons on how to live in a different body.
My hope for you as family physicians is that the next time you sit across from a patient who is discouraged with a new diagnosis of a disease or disability, you will find a way to offer him or her hope through adaptive sports and peer mentoring programs. Remember, peer mentoring programs are not just for people with disabilities; they have been proven to improve lives and outcomes for patients with diabetes, arthritis and even cancer.
Need a few starters? The NSCD is based in my home state of Colorado, but there are adaptive sports programs in almost every city and state in the country. Disabled Sports USA has dozens of chapters nationwide and is a great resource to connect people of all abilities with recreation and the outdoors. Most chronic diseases have online support groups and resources, as well.
Recreation and peer support help people become more active, confident and independent.
Your short conversation, invitation or encouragement can make a huge difference.
Just ask Roy.
Jeff Cain, M.D., is President of the AAFP.
Understanding Patients' Literacy Level is Crucial Step in Care
Fewer than half of U.S. patients have the necessary skills to read and follow drug label instructions, respond to insurance forms, provide a patient history or communicate effectively with a physician, according to the National Institutes of Health.
If patients don't understand us, how can we possibly expect them to follow our instructions? This massive shortcoming puts patient safety at risk, jeopardizes our patients' quality of life and adds costs to the health care system. According to the NIH, health literacy -- or lack of it -- costs our nation up to $236 billion a year.
The problem isn't new. More than 20 years ago, researchers at the University of Arizona found that the health care costs of Medicare patients with low levels of health literacy were more than four times higher than those who were health literate. In 1993, a national survey found that up to 22 percent of Americans were unable to read a medicine bottle.
The numbers aren't surprising when you consider that more than 40 percent of the U.S. population speaks something other than English as a first language. But this issue is not limited to immigrants or those with low levels of education. It is pervasive, affecting all ethnic, economic and age groups.
The 2003 National Assessment of Adult Literacy ranked subjects into four categories based on their skill levels: proficient, intermediate, basic and below basic. That study found that only 12 percent of Americans (14 percent of whites, 4 percent of Hispanics and 2 percent of blacks) were considered proficient. Meanwhile, 41 percent of Hispanics, 24 percent of blacks and 9 percent of whites were considered below basic.
Although patients with higher levels of education
scored better, only 30 percent of subjects with a bachelor's degree or higher
were considered proficient.
So where does that leave us? Do we understand the extent to which people are health literate? Do we speak and write instructions at a level our patients understand?
One easy, critical step to gauge the level of health literacy in our practices is to include the following question on patient history forms: "How far did you go in school?" Then include check boxes so patients can indicate the appropriate grade level. It should be a standard question, and we need to teach our medical students and residents to ask it.
Sadly, students and residents receive little formal training on this important issue. If you work with residents and students, listen to how they speak to patients, and challenge them to speak at a level patients understand. And ask patients, "Do you understand what is being said?"
Teaching back is vitally important, not only for students and residents, but for all health care professionals. At least 40 percent of information patients receive is forgotten soon after an appointment, and roughly half of what they do remember is inaccurate. The brief time it takes to ask a patient to repeat the instructions you have given them can make a huge difference in compliance and outcomes.
We also should educate our staff members who have contact with patients to be aware of patients' education levels. Not only that, we need to ask in what language patients prefer information -- both written and spoken -- be delivered.
Health education material should be written at a fourth- or fifth-grade level, but it often is prepared at an eighth-grade level. The problem can be even worse when materials are translated into other languages. For example, college-level Spanish isn't helpful to Spanish-speaking patients with a lower education level.
I specifically look for educational materials that address health literacy, and I have even taken the step of making my own handouts when necessary. Keep in mind that pictures and symbols say a lot to patients who aren't literate. Reading isn't the only skill in question. Numbers and measurements are barriers for some patients, who may need extra help from you or your staff.
If you know what issue a patient is being seen for and what their literacy level is, you can give them appropriate materials to read while they wait during their appointment. (FamilyDoctor.org has a number of patient education resources available.) Hopefully, this will help them understand their condition and help them ask questions during their visit.
Patients often don't know what they should ask. The NIH initiative has resources for patients to help them prepare for an office visit and suggests questions they should ask related to a wide variety of conditions, including heart disease, diabetes, weight loss and more.
We might have the best training, the right diagnosis and great bed side manner, but if we don't take the time to understand where our patients are coming from, they might not understand us.
Javette Orgain, M.D., M.P.H., is Vice Speaker of the AAFP.
Child Abuse: We Have a Role to Play
Sometimes, child abuse is painfully obvious. Broken bones, suspicious marks and bruises are things we all are trained to identify, treat and question.
Other times, though, the red flags are more subtle.
When the patient is being examined during a well-child visit, what is the
interaction like between the parent and child? What is the demeanor of the
child? How is he or she doing in school?
Physicians in all 50 states are required to report suspected maltreatment of a child. Reporting one such suspicion once cost my practice more than a dozen patients from one family. My suspicion was determined to be "founded," and the child and family got needed help. Although losing a group of patients is never easy, especially when you are fulfilling a difficult job requirement, it is critical to remember that we have a professional obligation to children and their future well-being.
According to HHS, roughly 680,000 children were confirmed victims of maltreatment in 2011. Note the emphasis on "confirmed." How many abused children went undetected, unreported and untreated? What role should we play?
The AAFP and the U.S. Preventive Services Task Force recently issued final recommendations stating that current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent maltreatment in asymptomatic children.
Unfortunately, the red flags often aren't easy to see. Most children are asymptomatic. Children heal quickly. Those that have been sexually assaulted usually appear normal during exams.
So what do the new recommendations mean?
Well, they don't mean we should stop evaluating children, thinking about abuse in our differential, asking the tough questions when indicated and doing a thorough exam. A child or teen who starts wetting the bed, who is fighting an eating disorder or who is pregnant may be a victim of forms of abuse. We must do our best to prevent and stop abuse. We must educate ourselves about trauma survivorship and its clinical presentations and advocate for healthy homes and communities for our children.
And it means that more research is needed to tell us what interventions make a difference. Can we change the trajectory of an abused child? I know that I have made a difference by asking questions, even when the abuse was long ago but the scars still linger. Letting a patient know that you will believe -- using active listening and referring for effective counseling, when needed -- can go a long way to helping a patient find the path to true health in the fullest sense of the word.
Sadly, many cases of abuse go unnoticed. That makes it so important that family physicians be aware of the long-lasting effects that childhood abuse can have on our adult patients. Abuse and neglect can haunt people for years after they have stopped, and they can have profound effects on an individual's health.
Every day in a typical family medicine practice, I see these patients, You likely see them as well. Do you know who they are? Do you know how to inquire and what to do with a positive response? Is it your coworkers? Is it you? Do you know which community resources are trauma informed and provide effective help?
The Adverse Childhood Experience (ACE) study, an ongoing collaboration between the CDC and Kaiser Permanente, follows more than 17,000 patients who underwent comprehensive physical examinations and provided detailed information about their childhood experiences. The original research was published in 1998, but more than 60 scientific articles have been published based on the research.
Patients derive their ACE scores by assigning one point to each of the 10 following adverse experiences: abuse (emotional, physical or sexual); neglect (emotional or physical); or dysfunctional household (a household member who had mental illness, substance abuse problems and/or was incarnated; parental separation or divorce; and a mother who was treated violently).
Sixty-four percent of patients experienced at least one adverse experience, 16 percent experienced two, 10 percent experienced three and 12.5 percent experienced four or more.
Researchers found that as ACE scores (and childhood stress) increase, so do patients' risks for a number of health problems, including
- adolescent pregnancy,
- alcohol abuse,
- chronic obstructive pulmonary disease,
- early initiation of smoking,
- early initiation of sexual activity,
- illicit drug use,
- intimate partner violence,
- ischemic heart disease,
- liver disease,
- sexually transmitted diseases,
- suicide attempts and
- unintended pregnancies.
Researchers estimate these long-term health effects can shorten a person's life by nearly 20 years.
The good news is that we can help. If we know what to look for and ask the right questions, we can help our patients unburden themselves from the old secrets they have kept and help them start to heal.
We've all been exasperated by patients who are noncompliant with their medications and others who don't follow up with our referrals. Why don't they take our advice? Maybe they never learned that they are valuable human beings.
Unfortunately, some patients do not realize that they are worthy of care because of the way others, often those who were supposed to love them, mistreated them in the past. And certain exams and procedures -- going to the dentist, colonoscopy, pelvic and rectal exams, etc. -- can cause people who have been violated and traumatized to relive that trauma.
I've presented ACE at medical conferences, and every time, at least one person from the audience has approached me afterwards and told me that they counted their own ACE score, and they don't know how they made it through. Often, they confide that even their own wife or husband doesn't know what they endured.
Too often, victims of abuse never tell anyone.
Will they talk to us? Are you prepared to listen and respond?
Family physicians can make a difference because we treat entire families. We can build relationships with young parents; steer them to parenting classes; and give them good advice about supporting each other, being resilient and providing a nurturing environment.
And because we take care of both the parents and the children, we also are more likely than our subspecialty colleagues to know when something isn't right. It is our obligation to the child to report abuse and neglect.
We also can make a difference for our adult patients who still are dealing with old scars and current health challenges related to the past.
See the big picture. Educate yourself and advocate for children and families in your community.
Take action when it's needed.
We can help. This is family and community medicine at its finest.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
Hospice Experience Can be Rewarding
It used to be that when I had a patient whose health was declining and he or she was nearing the end of life, I would direct the patient to hospice care.
Hospice would take responsibility for the patient's
care, and I would receive updates by phone. I might go by and see the patient once or
twice. Ultimately, I would be notified that the patient had died, and I would
call the family to offer my condolences.
That was my standard procedure for more than 20 years.
Life goes on.
Then my own mother was diagnosed with cancer. Her health declined, and she went to hospice. There, I was free to be her son and not another doctor in the room. We listened to the old 1950s music that she loved and reminisced. I will always be grateful that we had those 21 days together.
My mother's physician at the hospice was a general internist who had his own practice but who also worked at the hospice on the side. I was intrigued, and, rather than following the old routine of referring my terminal patients to someone else, I started following them through hospice care myself.
It only makes sense. Family physicians help bring new lives into the world. Then we care for those patients throughout their lives and help them make that life as healthy and productive as possible. At the end of life, we can help them be as comfortable as possible.
The hospice in San Antonio is near the hospital to which I refer my patients, so I make rounds at both facilities. I was at hospice often enough checking on my own patients that, after a few years, I was asked if I would take calls a few times a month. So now I work two weekdays and one weekend a month at hospice in addition to my own practice. And after I take on a hospice patient, I follow him or her through the process.
Hospice can be an uncomfortable topic for physicians, but I've found it incredibly rewarding. The opportunity to build relationships with patients is why many of us chose family medicine in the first place. We build connections over years with our patients. In hospice care, similar bonds can form in a much shorter time.
One of the patients I met at hospice was a 42-year-old single mother. She had terminal throat cancer and could no longer talk. During rounds one day, I asked if she had any pain. She did not look up from her notepad and simply wrote, "No." I asked if I could do anything for her. Again, she wrote, "No."
So I went on and completed my rounds. But when I was done, I went back to her room and sat down by her bed. She wrote that she did not want to talk, but I told her that we should talk anyway.
Then I asked her what she was afraid of.
I looked down at her notepad waiting for a response, but what I saw next were not words but tears dropping on the page.
She was afraid that the cancer would eventually erode a major artery in her throat, and she would drown in her own blood. I assured her that if her condition deteriorated to that point, we would give her medication to make her sleep, and she would not suffer. She asked me to promise, which I did.
She then told me about her adult daughter and her 6-year-old son and that she wanted the daughter to have custody of the boy. The paperwork had not been completed, so I arranged for a social worker to meet with them, and it got done.
At one point, she took my arm and told me, in writing, that two oncologists, two surgeons, an otolaryngologist and two radiologists had seen her during her treatment, but I was the first doctor who had sat down and talked with her.
Well, that's what family physicians do, isn't it?
In 72 hours, she was gone. But after those three days, it seemed like I had known her for years.
That's what the hospice experience can be.
If you think you don't have anything to offer to hospice care, you might be wrong.
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
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