Surrounded by Ghosts: Wisdom Gained From Patients Past
My exam rooms are full of ghosts, and sometimes it is standing room only.
My patients can't see them, of course, but the ghosts often are here giving advice and warning. Sometimes, when there is a particularly large crowd, the conversations are deafening.
I have worked in the same small town in Alaska for 21 years, caring for a community through all stages of life. During my time here -- as well as medical school and residency -- I have lost many people, and I freely admit that they come back to haunt me. This is not a bad thing. They are people who I liked or loved, and they still have much to offer. The hard part is translating their wisdom to those still living.
Particularly loud are the lost teenagers I hear when I talk with young patients during sports exams about not getting into a car with anyone who has been drinking. I have at least 10 ghosts in the room, all talking at once, when I have these conversations.
"Dude, listen to the doc."
"He told me the same thing."
The hardest to bear are the ghosts of infants and children when I am talking to parents about vaccinations. They don't say anything, but I still see their eyes, throats and backs because I trained in the era before the Haemophilus influenzae type b vaccine. Too much of my time on pediatric rotations in medical school and residency was spent performing lumbar punctures and taking care of periorbital cellulitis and epiglottitis.
The exam rooms are full of ghosts, I tell you. There are none, however, who died from complications of vaccines.
The ghosts are with me when I have to tell someone that they have cancer. I have been doing this long enough that they segregate depending on the type of cancer. They are also with me when I talk about the importance of quitting smoking or screening for colon, breast or cervical cancer.
The ghosts are especially present when I talk about end-of life-issues and the importance of maintaining quality of life -- even at the expense of life-sustaining measures -- and they advise me as I help patients and their families through this process.
The ghosts of those who died from alcohol and drug abuse are fatalistic and sad when I tell my patients that they must stop or they will die within the year. They nod and whisper among themselves that I told them the same thing. Sometimes I think that perhaps this particular group of patients can actually see the ghosts, but rarely is it enough to make them change their own lives.
The longer you practice as a physician, the more ghosts you have to keep you company. It's OK. They are good people. They fill the exam rooms and stand by your shoulder when you look at labs or X-rays. Sometimes they are so loud it is hard to believe that the patients can't hear them, but their voices and their stories are a gift you can give to your patients.
I admit that being haunted does take getting used to, but I would never dream of forgetting any of them.
John Cullen, M.D., is a member of the AAFP Board of Directors.
'Stop the Bleed' Aims to Turn Bystanders into 'By-doers'
Imagine yourself standing on a corner when suddenly, a car strikes someone in the crosswalk. The pedestrian is severely injured, with a leg fracture and a profusely bleeding artery.
How would you -- or the average citizen -- react? It's an important question. In the event of a major arterial bleed, an injured person has about four minutes before survival becomes impossible.
© Aaron Tang
Bystanders assist victims in the aftermath of the 2013 Boston Marathon bombing. The Obama administration recently launched an initiative that aims to educate the public on how people can help save lives in an emergency situation.
This type of scenario is the focus of an initiative recently launched by the Obama administration and the Department of Homeland Security that is designed to reduce loss of life due to bleeding.
The 2013 Boston Marathon bombing, which killed three people and injured 264 others, was one of the incidents that prompted this effort. In the aftermath of that terrorist attack, every victim who reached a Boston-area trauma center alive survived. Injured people survived many potentially fatal injuries because of the prompt responses of bystanders who applied pressure and tourniquets to bleeding extremities until emergency personnel arrived.
I recently attended the White House launch of the Stop the Bleed initiative, which aims to educate Americans about how they can offer assistance in an emergency. Family physician Kevin O'Connor, D.O., physician to the vice president, said during the event that we must move more people from being "bystanders to 'by-doers.'"
Speakers also addressed the psychology of intervening in an emergency situation. The concept of diffused responsibility in a group means that the more bystanders there are at an event, the less likely any one of them is to intervene. A lone individual is more apt to take action.
The mindset in our culture has been for the general public to wait for emergency personnel, but with life-threatening bleeding -- even with a quick response time by paramedics -- survival is not likely without immediate action.
In military medicine, physicians have long referenced the importance of receiving care during the "golden hour" after an injury to improve survival. Quick action improves a wounded soldier's chances. In fact, the survival rate for soldiers who make it to a field hospital alive is more than 90 percent.
The U.S. military examined causes of death among the wounded who did not make it to field hospitals alive and found many died from extremity arterial bleeding and blood loss. This led to a change, and now every U.S. field soldier is equipped with a tourniquet and trained to use it. The prevalence of "field casualties" -- injured soldiers who die before reaching a hospital -- dropped dramatically.
Fast forward, and the administration now is implementing several efforts to educate the public about applying pressure or a tourniquet to life-threatening bleeding:
- There will be an ad campaign with a logo that features a hand and a "Stop the Bleeding" message to remind people that odds of survival increase if direct pressure is applied over bleeding.
- Bleeding control kits will be placed by defibrillators in public locations.
- The Red Cross is developing a "just in time" learning tool.
- The Federal Emergency Management Agency has developed a short video that tells the story of how a neighbor's quick action saved a woman after a motorcycle accident.
We can share related resources with patients and our communities by posting them on our websites or social media. The bottom line? Don't be a bystander, be a by-doer.
Robert Wergin, M.D., is Board chair of the AAFP.
Prescription for Pain? Important Questions Patients Should Ask
Earlier this year, I shared with you a story about being willing to take carefully considered risks, boldly sticking your neck out to make your message heard. Specifically, I made an appearance on The Dr. Oz Show in May because it was an opportunity to reach roughly 2 million TV viewers (and even more online) with a message about the importance of primary care and why everyone needs a family physician.
Fast forward a few months, and I was asked to make another appearance on the show, this time for a segment about proper use of pain medications. According to the CDC, nearly 2 million Americans abuse prescription painkillers and roughly 7,000 patients are treated every day in emergency departments for that misuse. Opioid prescribing, pain management and opioid abuse are issues the AAFP has been working on diligently for years -- including efforts related to advocacy, public health and education -- so I was eager to participate.
Here I am with Ada Cooper, D.D.S., spokesperson for the American Dental Association, and Mehmet Oz, M.D. We discussed appropriate use of opioids during a recent taping of The Dr. Oz Show.
The episode aired Oct. 19, but more on that in a minute.
It's been a rough year-and-a-half for host Mehmet Oz, M.D. He was called before Congress last year because of his promotion of weight loss medications, and a group of his peers called for his dismissal from his post at Columbia University.
His critics certainly got his attention. Oz conducted a listening tour with various medical groups this year and has vowed to make his show more evidence-based. He has sought input from many physicians and physician groups along the way, including the AAFP. I recently met with Oz, his staff, AAFP staff and members of the New York State AFP to talk about how family medicine can help make his show more evidence-based while also reflecting the importance of prevention and primary care.
The first step in this potential collaboration was the episode addressing the epidemic of opioid abuse. Use of opioid pain relievers in the United States quadrupled between 1999 and 2010. Among the 22,810 deaths related to pharmaceutical overdoses in 2011, nearly three-fourths involved opioids. In 2012, U.S. health care professionals wrote enough prescriptions -- 259 million -- for every American adult to have a bottle of pills.
So with access to an audience of millions of American patients, Oz and I discussed important questions patients should ask their doctors before starting a prescription pain medication. Here's a look at some of the questions and the information I provided.
What is the goal of taking this prescription?
This is an important question because patients need to make informed decisions. Too often, people take medication without understanding its risks and benefits and without asking if other options are available. Patients need to understand why they are taking a pain reliever, what kind of pain reliever they are taking and how much relief they should expect.
How long should I take these drugs?
Opioids are best used for the shortest time possible and at the lowest dose possible. I told the audience that they should know from the start how long they are supposed to take a medication. And if they think they have been on a medication too long, they should talk to their physician.
Are there any risks to me from these pills?
When I perform a risk assessment, I look for the following factors:
- any history of addiction to or misuse of opioids;
- any history of addiction to or misuse of alcohol or drugs other than opioids;
- depression or other behavioral health disorders; and
- is the patient taking any medications that might provoke an adverse reaction in combination with the opioid?
What do I do with extra pills?
We discussed the importance of safe disposal, including take-back programs, and the need to store pills in a secure location.
The questions can be downloaded as a resource for patients receiving a prescription for pain killers.
The AAFP will continue to work on this important issue. On Oct. 21, I will be in Charleston, W.Va., when President Obama speaks with law enforcement, educators, lawmakers and health professionals during a forum on opioid addiction. Watch for more details about that event in AAFP News.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Royal Pain: Team's Chickenpox Incident Offers Lesson for Patients
The Kansas City Royals have become a shining example of how to succeed in a small market in an era when baseball teams with the highest payrolls are often the biggest winners when it comes to the playoffs. After decades of futility, the reigning American League champions reversed their fortunes by pouring money into their scouting department and creating an elite team based on speed, defense and pitching.
Unfortunately, my hometown team recently became an example of what not to do, and it's a lesson family physicians can use when talking with patients and parents who have reservations about immunizations. After the Royals built a seemingly insurmountable lead in the American League's Central Division, a vaccine-preventable disease has done what few opponents have been able to do -- make this first-place team look vulnerable.
© Keith AllisonKelvin Herrera of the Kansas City Royals delivers a pitch. Herrera and teammate Alex Rios were recently diagnosed with chicken pox.
According to The Kansas City Star, the team's medical staff collects information from players about vaccinations and childhood illnesses every year during spring training. Apparently, that information wasn't reliable this time around, because in the thick of a pennant race, otherwise healthy young men have been sidelined by chickenpox, typically considered a childhood illness.
Kelvin Herrera is a 25-year-old All-Star pitcher who can throw a baseball 100 mph and is a key figure in the Royals' vaunted bullpen. Outfielder Alex Rios is a former All-Star and 12-year veteran. Both men are millionaires who have ready access to the team's medical staff and the means to afford excellent health care.
What they didn't have was immunity to the varicella-zoster virus. Now, Herrera and Rios are expected to miss about two weeks of playing time.
The incubation period for chickenpox can last up to three weeks, so it remains to be seen whether any more players will be affected. Sports teams can be a breeding ground for disease because athletes often spend time in tight quarters during games, in locker rooms and while traveling. It was less than a year ago that a mumps outbreak swept through the National Hockey League, affecting nearly two dozen players (including two-time MVP Sidney Crosby) from five teams, as well as two referees.
The take-home message for the general public is that if these strong, world-class athletes with access to quality health care, team doctors and excellent nutrition are susceptible to vaccine-preventable diseases, obviously, so is anyone else who has not been immunized, particularly children, the elderly and people with chronic conditions.
Patient registries and electronic health records can help us identify our patients who may be at risk. Those systems should be far more reliable than the Royals' method, which appears to have included asking athletes if they remember having chickenpox when they were toddlers.
In a study recently published in the Journal of the Pediatric Infectious Diseases Society, CDC researchers compared national health care claims data from 1994 (the year before the varicella vaccine was introduced) to 2012 data and found that outpatient visits for chickenpox fell 84 percent and hospitalizations fell 93 percent. The recommendation for a second dose of the vaccine was introduced in 2007, leading to accelerated declines in the need for both inpatient and outpatient treatment.
Before the vaccine was introduced, about 4 million Americans got chickenpox each year, leading to roughly 11,000 hospitalizations and 100 to 150 deaths, according to the CDC. Despite the efficacy of vaccines, outbreaks of vaccine-preventable diseases continue because of inadequate coverage.
The United States had 23 measles outbreaks last year, affecting more than 600 patients. This year, 188 cases in 24 states had been reported through Aug. 21, with the majority of illnesses stemming from the Disneyland outbreak that started in December.
In each of the past two years, more than 28,000 cases of pertussis have been reported in the United States. There were 48,277 reported illnesses and 20 pertussis-related deaths in 2012.
These sobering numbers should be shared with parents and patients who are resistant to immunizations. Sharing stories about famous athletes forced to sit at home because of the mumps or chickenpox couldn't hurt either.
Michael Munger, M.D., is a member of the AAFP Board of Directors who practices in Overland Park, Kan.
In an Emergency, Family Physicians Have it Covered
We were six hours into a transatlantic flight when the call came over the plane's intercom that a passenger needed medical assistance. I responded, as did another family physician and an emergency room doctor.
Fortunately, the plane was well stocked with oxygen, a pulse oximeter, a blood pressure cuff and more. We worked as a team to determine what was wrong with a woman who had collapsed on the floor. A few minutes in, another woman appeared, identified herself as an OB/Gyn and asked if she could help.
I replied, "Well, we're two family physicians and an emergency room doctor."
She said, "Oh, you've got it covered then."
So I suggested that this fourth physician try to calm down our patient's hysterical teenage daughter.
About 15 minutes later, yet another physician appeared, identified himself as an orthopedic surgeon and asked if we needed help. I repeated that we were two family physicians and an ER physician.
He said, "Oh, thank God, we have real doctors. My wife made me come up here."
I appreciated that he understood our level of expertise.
The flight crew was prepared to divert the plane for an emergency landing, but we were able to stabilize the patient and determine that her condition did not require urgent measures. She had a history of heart problems, had been sitting for hours, stood up too quickly and passed out.
The breadth of our training makes family physicians well-equipped to react to these types of situations, which is good because they seem to be happening to me with increasing frequency.
I was in the Denver airport last year en route to Boise for the Idaho AFP meeting. But I wasn't in the airport long because I had landed at Gate 6 and had about 10 minutes to run -- literally -- to Gate 70 to make my connection.
I made it on the plane, along with several other passengers who had made the 64-gate sprint. We were about 30 minutes into the flight when I heard someone say, "There's a pair of legs sticking out of the bathroom."
A woman had lost consciousness in the bathroom and had forced the bathroom door open when she fell. I volunteered to help the woman, who was ashen and diaphoretic. She had hypoglycemia and was in and out of consciousness, but I was able to deduce what had happened.
She was one of the passengers who had hurried through the airport to make the connection. She was diabetic, had taken insulin but had not had time to eat. Her condition was exacerbated by the plane's air conditioning, which was not working properly.
I asked the flight attendant to bring her orange juice with extra sugar in it, and we packed ice on the woman's neck and under her arms. Within 20 minutes, she was doing better. A little later, she was fully awake and able to eat.
A couple who had been watching this scene unfold asked if I was a paramedic. I said no, I'm a family physician. They then said they were looking for a new doctor and asked if they could come to my practice. They were disappointed to hear that my practice is in Pennsylvania, not Idaho.
Sometimes, we can get called into action before we even get on the plane. On another trip, I was on my way to the Vermont AFP meeting when I saw an elderly woman in the bathroom struggling to get out of a wheelchair. And more importantly, she was struggling to breathe.
I told her I was a family physician and asked if she needed help. She was a tough older lady, and although she acknowledged having heart disease and lung disease, she said she was fine. In reality, she was in respiratory distress. We talked for a bit, and it turned out that we not only were going to the same place, we also were on the same flight.
So I walked her to the gate, identified myself to the gate agent as a family physician and asked her to move my seat next to this woman's so I could keep an eye on her. The woman had some rough moments on the plane, but we made it to Burlington.
When we got off the plane, she wasn't interested in a ride or calling a family member. Instead she insisted on driving herself home. But first I made her promise that she would call her family physician the next day, and she gave me that physician's name.
At the Vermont chapter meeting, I got the contact information for the woman's FP, called the practice and suggested they follow up with their patient. That doctor did call her, and she was admitted to the hospital.
A month later, I received an email from the woman thanking me after she was at home recovering.
A New England Journal of Medicine study looked at nearly 12,000 in-flight medical emergencies and found that physician passengers were able to assist nearly half the time. I'd love to hear your stories of helping fellow travelers in the comments field below.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
California's Vaccine Victory Holds Lessons for Other States
In politics and culture, California does not often align with Mississippi and West Virginia, but I feel proud to stand with those states in declaring solidarity on eliminating nonmedical vaccine exemptions.
Even before an extensive measles outbreak erupted from the so-called Happiest Place on Earth earlier this year, many states sought to tackle the issue of vaccination exemptions, and those attempts have only intensified since then. In California -- the epicenter of that outbreak -- the battle over S.B. 277 culminated in a victory for public health advocates over a small but vocal anti-vaccine contingent, including some noted celebrity opposition.
In California and everywhere else these battles have been waged, childhood vaccination should have been a motherhood-and-apple-pie issue, yet debate about requiring vaccines and removing personal and religious exemptions elicited visceral reactions from both sides of the ideological divide.
Surely, such heated discourse couldn't be focused solely on refuting the science and evidence behind immunizations. Even Jenny McCarthy has backpedaled somewhat from her earlier anti-vaccine statements that, arguably, set childhood immunization efforts back a decade. No, what this debate really boiled down to was the notion of preserving individual rights at the cost of placing others in harm's way.
Throughout its history and in virtually all areas of public discourse, our country has tried to carefully balance the needs of individuals against the greater societal good. Nowhere has this been more evident than in our protection of individuals' religious freedom. In this case, one of the primary arguments to remove religious exemptions to vaccines is completely consistent with this goal. After all, no major religion in the world (we're not talking about Scientology here) is against vaccination; we can rely on our pastors and priests, rabbis and imams to agree on this point.
So, we're back to personal freedom. The crux of anti-vaccine supporters' argument against removing the personal/philosophical exemption stems from a fear that the government is dictating -- and, thus, overruling parental control of -- children's health care matters. But consider this perspective: The California law allows an exception to the vaccine mandate for home-schooled children, which, in essence, preserves parents' right to decide whether their children will participate in a community-sponsored benefit or opt out of that process.
Moreover, this law continues to allow medical exemptions as determined by a physician, so we can and will continue to discuss this important issue with our patients. In fact, Gov. Jerry Brown cited the continuation of the medical exemption as the sole reason he signed this bill into law. To some, this clause may appear to allow a loophole for vaccine-hesitant parents to go doctor-shopping. And, no doubt, there still will be some physicians ready to cast doubt on the science of vaccines, but they will continue to be in the minority. Ultimately, the decision will be in the hands of the physician and the child's parents after an evidence-based discussion that takes place behind exam room doors.
One last thought: Perhaps sensing the inevitability of passing this legislation, opponents of the California bill vilified its primary author, Sen. Richard Pan, M.D., a practicing pediatrician -- and good friend -- who represents the state's 6th District. Fortunately, Dr. Pan wisely built a coalition of citizen groups and medical organizations -- including the California AFP -- that worked together to overcome this opposition. For those of you familiar with Sen. Pan, you know he has been a stalwart champion of primary care and public health, even winning CAFP's Champion of Family Medicine award in 2013
My challenge to you, my fellow family physicians, is to take up this public health banner and run with it: no personal exemptions, no religious exemptions. Three states down, 47 to go.
Jack Chou, M.D., is a member of the AAFP Board of Directors.
AAFP Teams Up With NFL Foundation to Raise Concussion Awareness
More than 1.6 million concussions occur in sports and other recreational activities each year in the United States. Making matters worse, athletes, parents and coaches often are unaware of recommendations regarding returning to play and the need to seek medical attention.
A study published last year in JAMA Pediatrics found that 59 percent of female middle-school soccer players played with concussion symptoms, and more than half of the players reporting concussion symptoms were not evaluated by a physician. According to the Center for Injury Research and Policy, at least 40 percent of concussed high-school athletes return to play too soon. In fact, 16 percent of concussed football players returned to play the same day they were injured.
Concussions can occur even in sports that you don't necessarily associate with head injuries. For example, women's lacrosse is supposed to be a noncontact sport, but the ball travels at speeds in excess of 60 mph. At the recent AMA annual meeting, delegates voted to adopt a measure recommending helmets for girls and women playing that sport.
Like many family physicians, I treat sports-related injuries in my practice and also work as a team physician for the local high school. I often have to educate coaches and parents about the need to hold athletes out of practices and games while they recover. And we've also had to take helmets away from injured football players during games when they were far too eager to get right back into the action.
So how do we raise public awareness about the serious nature of concussions, their long-term effects and the fact that they often can be successfully managed? The AAFP has entered a partnership that will pair the evidence-based medical knowledge of the Academy with the influence of the National Football League Foundation. The initiative will produce three free webinars for family physicians, as well as patient education materials. The AAFP will have full control of all educational materials and will retain final editorial authority over the materials.
The Academy will be able to use the NFL's brand and logo on the patient education materials, which should help get the public's attention. NFL games reached more than 200 million unique viewers last season, when the league averaged 17.6 million viewers per game.
Here is a look at what to expect:
- Sports Concussions 101: The Current State of the Game, July 23, 8 p.m. CDT. This webinar will enable participants to define a concussion, and to identify the signs and symptoms of a concussion during an initial evaluation. The event will be presented by Stanley Herring, M.D., medical director of sports, spine and orthopedic health for University of Washington Medicine, co-medical director of the Sports Concussion Program, and a team physician for the Seattle Seahawks and Seattle Mariners; and family physician Matthew Silvis, M.D., associate professor in the departments of Family and Community Medicine, Orthopaedics, and Rehabilitation, and medical director of primary care sports medicine at Penn States's Hershey Medical Center.
- Sports Concussions 102: If You've Seen One Concussion, You've Seen One Concussion, Aug. 6, 8 p.m. CDT. Participants will be able to analyze the variability of the clinical presentation of concussion, construct an individualized, evidence-based treatment plan and recognize when to seek consultation or referral for a concussed athlete. The webinar will be presented by Jason Matuszak, M.D., the director of the Sports Concussion Center in Buffalo, N.Y., and Yvette Rooks, M.D., assistant professor of family and community medicine at the University of Maryland School of Medicine and a team physician for the University of Maryland Terrapins.
- Sports Concussions 103: Debates and Controversies, Aug. 20, 8 p.m. CDT. This webinar will cover long-term brain health in athletes; rule changes, practice and play modifications, and legislative efforts regarding sports concussions; limitations of protective equipment; and counseling parents about sports participation for young athletes. This webinar will be presented by Herring, Matuszak, Rooks and Silvis.
Patient education materials will be mailed to all active AAFP members in August and also will be posted on FamilyDoctor.org. These materials are intended to help patients understand the definition of concussion and its signs and symptoms, know when to seek medical evaluation, understand concerns about long-term brain health in athletes, and understand the limitations of protective equipment.
As part of the initiative, Family Medicine SmartBrief will publish a special report regarding concussions in August. You can sign up to receive SmartBrief, a daily wrap-up of news that affects family medicine.
Family physicians often are the first line of care for patients of all ages. We’re the first to spot these injuries, the first to treat them and the first to discuss the dangers of concussions with patients. This educational initiative will help family physicians and our patients by focusing on safety, the importance of reporting, evaluation of concussions and return-to-play protocol.
Concussions are a serious public health risk, and this educational initiative is the right thing to do.
Robert Wergin, M.D., is president of the AAFP.
What Patients Don't Know Can Hurt Them
It has been more than five years since the Patient Protection and Affordable Care Act (ACA) became law, but many consumers still remain unaware of one of the law's signature provisions: coverage of preventive services without cost-sharing.
A baby receives the rotavirus vaccine. Many Americans remain unaware that most health plans are now required to cover preventive services, including vaccinations, without cost-sharing.
The White House and HHS recently launched a joint Healthy Self campaign, which is designed to connect Americans to the health care they need and encourage them to take a more active role in their health. Fifty events will be held across the country in August to connect patients with care. The effort includes educating people -- particularly the newly insured -- about preventive services they are guaranteed under the ACA, which survived another Supreme Court challenge last week.
A Kaiser Family Foundation poll conducted shortly before last year's open enrollment deadline, showed that less than half of uninsured Americans were aware that the recommended preventive services most health plans are now required to cover must be provided with no cost-sharing. Those services include:
- blood pressure screening;
- breastfeeding support and supplies;
- depression screening;
- domestic violence screening and counseling;
- HIV screening;
- obesity screening and counseling;
- tobacco cessation interventions;
- well-child visits; and
- well-woman visits.
Considering that lack of awareness about these benefits, it's no surprise that half of the uninsured who were polled said they planned to stay uninsured.
However, more than 16 million people have gained health coverage under the ACA, according to the Healthy Self campaign announcement. That's significant because prevention is the key to true health care. Chronic diseases are responsible for 70 percent of U.S. deaths and 75 percent of our health care costs. Imagine the difference we can make simply by helping patients understand the services they have access to in our practices. If people delay preventive care because of cost concerns, they're more likely to eventually end up spending even more money at urgent care centers and ERs.
So what can we do as family physicians? We can use electronic health records to review what services patients haven't had. Our practices can use phones, email, portals and even social media to encourage patients to come in for preventive care. We also can use acute visits to identify preventive service gaps and schedule follow-up.
It's worth noting that CMS has launched a Web page with resources to help the newly insured understand their benefits and to connect them with primary care physicians who can provide preventive services.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Learning Matters: How Education Affects Health
The recession has been over for nearly six years, and although recovery can be seen in many aspects of our economy -- including employment statistics and housing data -- the same can't be said for our public schools.
At the start of the 2014-15 school year, more than half the states were providing less funding per student than they had before the recession began in 2007. In fact, 14 states have cut per-pupil spending by more than 10 percent. Kansas took things even further, cutting funding for education by more than $50 million during the school year to help cover a massive $400 million budget shortfall.
What many legislators fail to realize is that cutting funding for education now raises health care costs in the future.
Photo courtesy of Reach Out and Read
A physician shares a book with a young patient as part of the Reach Out and Read program. Research indicates that education improves health and increases life expectancy.
How are health and education related? Steven Woolf, M.D., M.P.H., professor of family medicine and population health at Virginia Commonwealth University and director of the VCU Center on Society and Health, recently gave a presentation to the AAFP Board of Directors that illustrated the significant impact education has on health. Based on reports published last year by the Center on Society and Health's Education and Health Initiative, Woolf's presentation focused on how education can increase a person's life expectancy and the quality of that life.
The authors of the report put it succinctly, "Disinvestment in education leads to more illness and higher medical care costs that offset the intended 'savings' of these same budget cuts."
For example, in 2011 the prevalence of diabetes in the United States was 15 percent for adults who did not complete high school. That was twice as high as the rate among college graduates. In the same year, more than one-fourth of adults without a high school diploma were smokers, compared to 8 percent of college graduates. Adults who don't finish high school also can expect to live nine years less than their college-educated peers. And that already sizable gap is widening.
The reasons for the health disparities are numerous, and many should be fairly obvious. Education typically leads to better jobs, more money and many other benefits, including better health insurance, which leads to better access to quality health care. Higher earnings also allow workers to afford homes in safer neighborhoods as well as healthier diets. The median wage for college graduates in 2012 was one-and-a-half times higher than that of high school graduates and more than double that of workers who lacked a high school diploma.
People with lower incomes often live in neighborhoods or communities that present numerous challenges that affect their health, including less access to supermarkets and healthy food choices, less access to green space or other recreational areas, higher crime rates, lower quality schools, fewer jobs and increased levels of pollution.
Low-income areas also often have shortages of primary care physicians and other health care professionals. However, the report points out that people with lower levels of education have worse health than those with more education even when access to care is equal. For example, a 2011 survey of patients in the same health system found that nearly 70 percent of college graduates ages 25-64 described their health as very good or excellent, compared to 32 percent of adults who had not completed high school.
The bottom line is that strengthening schools likely would make our nation healthier and reduce health care spending in the long run. Even if our legislators fail to see the connection between education and health, we can make sure that our patients -- especially children and their parents -- do.
In 2013, 66 percent of U.S. fourth-graders were reading below proficiency levels. Part of the problem is that parents who were not read to as children may not understand the importance of reading to their own kids. In fact, less than half of young children in this country are read to daily, and minority and low-income children are less likely to be read to than others.
So what can we do? Last year, the AAFP entered into an agreement with the Reach Out and Read National Center. That program trains and supports physicians, who give new books to children ages 6 months to 5 years and advise parents about the importance of reading aloud. The program aims to promote early childhood literacy and language development, particularly in low-income families.
Graduation rates -- like immunization rates -- have a huge impact on the health of our communities. Reach Out and Read offers numerous resources for physicians who would like to participate.
Robert Lee, M.D., is a member of the AAFP Board of Directors.
Doctors Need the Straight Dope on Medical Marijuana
Nearly half the states, and the District of Columbia have adopted comprehensive medical marijuana programs, and more than a dozen more have approved use for a limited number of medical conditions. Two states -- Colorado and Washington -- have taken things even further, legalizing marijuana for recreational use.
Of course, none of this changes how marijuana is viewed by federal authorities. The Department of Justice has issued guidance to federal prosecutors, reiterating the agency's commitment to the Controlled Substance Act. The FDA has not approved marijuana as a safe and effective drug for any indication.
Legislators are again impacting the care of patients and the health care delivery system. So where does that leave us as physicians? WebMD polled physicians last year and nearly 70 percent of respondents agreed that medical marijuana can help patients with certain conditions. But physicians were less enthusiastic about making the drug available. Half of the doctors polled in states where medical marijuana is legal supported its legality. In those states still debating medical marijuana laws, 52 percent of doctors supported it.
Hence, although an overwhelming majority of U.S. physicians understand the potential benefits of medical marijuana, roughly half oppose it.
In my home state of Illinois, legislators have legalized medical marijuana. Many patients are asking for it; many have valid reasons, such as cancer or chronic pain. For those who do not, the discussion explaining the reason for denial is lengthy. Illinois, like many states, used model legislation to create its medical marijuana program, and physicians are not required to write prescriptions. Rather, we certify which patients meet conditions that allow them to legally buy the drug at a dispensary.
Sadly, conversations with my patients have highlighted some obvious problems with medical marijuana. I have had patients suffering from chronic pain ask for medical marijuana because they fear becoming addicted to prescription narcotics. They, like many others, don't understand that marijuana can also be addictive. According to the 2013 National Survey on Drug Use and Health, marijuana use accounted for more than 4 million of the 7 million Americans who are dependent on or abusing illicit drugs.
In short, many patients don't know the harmful effects of marijuana. So although there are limited health benefits to medical marijuana, we must also ensure that patients understand the risks.
At last year's Congress of Delegates, the AAFP adopted policy stating that decisions about medical marijuana should be based on evidence-based research and called for further studies into the use of medical marijuana and related compounds. But with new studies being published regularly, it can be hard to keep up on what the latest evidence tells us.
The AAFP can help. The March edition of FP Audio has a clinical topic that will help physicians evaluate current evidence on the use of medical marijuana for the treatment of multiple sclerosis and severe childhood epilepsy. Another edition exploring the topic further is scheduled for July.
The Academy will offer two sessions related to medical marijuana Sept. 29-Oct. 3 at FMX in Denver. An interactive lecture will cover what family physicians need to know about medical marijuana. And during an "Out and About" -- an offsite CME session -- a family physician and a patient will discuss legalized marijuana from the physician and patient perspectives. That session will be followed by a tour of CannLabs, an advisor to commercial, governmental and educational entities focused on the cannabis industry.
State chapters also can play a role. The Illinois AFP is offering its second webinar on medical marijuana and its implications for physicians on April 27. Registration is limited to the first 100 participants, but an archived version will be available. (The event is not limited to Illinois AFP members.)
The bottom line is that medical marijuana is becoming available in a growing number of states. There is a tremendous economic advantage to a state’s economy. Consumer advocacy groups have formed to urge the federal government and the FDA to ease federal restrictions and fund marijuana research. When patients come to us for help, we should know the law governing our actions and what liabilities may exist. And, we should have an informed conversation with our patients about the potential risks and benefits of a drug for which long-term safety for adults and children is not yet truly known. The laws are changing rapidly. Family physicians should become knowledgeable of the laws in our own states regarding the use of medical marijuana. Consult your state medical boards and/or departments of professional regulation for guidance where necessary. The train has left the station.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
Rx for Success: PBS Film Shines Light on Health Care Triumphs
I recently watched a documentary that put a song in my heart and left me inspired by people who decided to take control and make a difference in the world around them -- for their patients, their teams and their communities. I heard stories of family physicians doing what we do best, despite the many hurdles we all face in a fragmented system. I want you to see what is possible.
David Loxterkamp, M.D., is the son of a physician. For two decades, he was a small-town, small-practice family physician much like his father, a general practitioner, had been. About 10 years ago, however, Loxterkamp decided he needed to make a change.
"I realized medicine is too difficult to do it alone," he said. "This is a really hard, emotionally draining job. You really need someone else to help you out."
Loxterkamp assembled a team to help him care for his small community in Maine, where he still makes house calls. His practice now includes other physicians, nurses, a psychiatrist, a psychologist, a pharmacist, a physician assistant, a medical assistant and a physical therapist.
It's hard to argue with their results. The practice's ER visits have fallen 40 percent in the past four years. One-third of the patients enrolled in a smoking cessation program have actually quit, and the blood sugar level of patients with previously uncontrolled diabetes has dropped dramatically.
David Grubin also is the son of a general practitioner, but he did not follow in his father's footsteps. Grubin is a filmmaker whose documentary, Rx: The Quiet Revolution, makes its debut tonight in many markets on PBS. Grubin said his father had lost faith in the U.S. health care system by the time he retired. Physicians, his father said, didn't have enough time for their patients, and he didn't know how to change a system that valued volume over quality.
Grubin's father, however, had never met anyone like Loxterkamp, one of the four examples the film provides of physicians and systems that have found a way to succeed in a dysfunctional, fragmented health care system.
The film, which will be repeated in most markets and also can be viewed online, delivers a powerful message: It is possible to succeed in our flawed, fee-for-service system. Although Loxterkamp practices in a recognized patient-centered medical home, these success stories didn't depend on the kind of incentives often provided in practice transformation pilots.
For example, Grubin visited On Lok, a San Francisco-based program for the elderly, that has been around since the 1970s. Like Loxterkamp's practice, On Lok takes a team-based and patient-centered approach to care.
The innovative program provides care and social activities for the elderly during the day yet allows patients to remain in their homes at night. In addition to medical care, the program provides services like grocery shopping and cleaning to patients who likely would otherwise be in a nursing home.
According to the film, patients in the program are less likely to visit ERs and hospitals and are less likely to be readmitted than those who live in nursing homes.
With the number of Americas older than 65 expected to double in the next 20 years, such services could be in high demand in the near future. And this film could help more patients be aware of -- and expect -- high quality, patient-centered care.
Grubin's travels also took him to Alaska, where native Alaskans were so dissatisfied with an Indian Health Service program that relied on emergent care that the community took control of the local hospital and built a new system with a strong primary care foundation. Team-based care is again a central theme in this story as is telemedicine, which the system uses to connect remote communities with physicians and pharmacists.
Teams and telemedicine also play prominent roles in the success of a program in Mississippi, which has the nation's lowest median household income and the highest rate of obesity. The state, which has one of the nation's highest rates of diabetes, is trying to address these health problems with a program that provides patients a tablet-based monitoring program that allows them to provide a blood sample each morning.
The program goes beyond monitoring with physicians, nurses, dieticians, physical therapists and more providing care and counseling. As one patient told the filmmaker, "You need somebody that cares."
Clearly, Grubin has succeeded in finding such people. It is critical to point out again that these practices were created in the setting of a flawed, fee-for-service, volume-driven, fragmented and dispassionate system. Individuals, sometimes a family physician and sometimes another team member, took control of their lives and situations. They made changes, big and small, with the most important one being that they would remember to care. They have reclaimed their joy of practice by embracing the essence of team-based, patient-centered care. And now they have shared their stories in this film.
These stories give us hope and show us what is possible.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Dear Payers: Unnecessary Visits Waste Patients' Time
One of the biggest health care challenges we face in this country is the combination of fragmented care and the siloing of different systems. I recently was reminded how important this issue continues to be.
During a recent clinic, most of my patients were logged in with notes related to their insurance rather than a medical need for a visit. Some of them were there for health maintenance per insurance, one was for a "diabetic check per insurance," and so on. Oddly, this was a group of patients that I had seen only a few months ago.
I asked these patients why they had come in, noting that I had not expected to see them so soon. (In fact, I had not planned to see them for a year, assuming they weren't ill.) Most of them said they had received phone calls from their insurance companies stating they needed to be seen for a health maintenance visit, but in reality, no such need existed.
Family physicians provide health maintenance during every visit, but we must make sure we code appropriately because, unfortunately, insurance companies often pay more attention to codes than to the actual care being provided.
As I reviewed their records, I realized that in my efforts to care for my patients, I had neglected to care for their charts by indicating an ICD-9 "V" code (e.g., V70.0, "Routine general medical examination at a health care facility") within the timeframe of the insurance calendar. However, each of these patients had indeed had health maintenance evaluations. When I had seen them in November, we had gone through the management of their chronic diseases, any acute issues, their biopsychosocial issues, and we had also addressed their individualized preventive services aspects -- all of the things that we routinely address.
Each patient had Physician Quality Reporting System measures checked and recorded, and I reviewed health maintenance and documented it clearly in the chart; however, as this was just a routine part of what I did, I was billing based on their medical disease management.
Despite their efforts, my patients had been unable to convince the insurance representatives on the phone that they had actually covered all of these issues. In fact, one patient who came to me for a diabetic check per insurance does not even have diabetes, and so this was another issue I documented.
Rather than calling patients -- who reported that they felt "harassed" by the payers -- it would make more sense in a nonfragmented system for insurance companies to call physicians so we can review what care has and has not been offered and provide any necessary information. My hope and ideal would be that all payers look for ways to connect with physician offices or, better yet, implement a system that would note the checkboxes that indicate the appropriate health maintenance measures were indeed done without the V code.
Better and easier communication with payers would benefit patients and physicians and help payers avoid unnecessary costs. Several of the affected patients had Medicare, but when I tried to call that payer I was unable to get a real person on the phone. The patients did not have any related paperwork with them, so I couldn't identify a direct help phone number. So, we covered whatever clinical issues needed some attention. Then, without really requiring anything specifically for the health maintenance, I diligently coded V70.0s and documented the previous discussions in their charts.
The sustainable growth rate formula legislation that passed the House last week includes steps to consolidate performance measures in an effort to decrease administrative burdens. It would be helpful if interoperability existed that would allow immediate tracking when such measures were done anywhere in the health care system. Although we have made some progress, there is still a great deal of work to be done.
One of my favorite quotes lately is, "It is not patient-centered until the patient says that it is patient-centered." Forcing patients to make unnecessary office visits certainly misses the mark.
Reid Blackwelder, M.D., is Board chair of the AAFP.
FP Recommendation Key to Boosting Colorectal Cancer Screening Rates
Each year, more than 130,000 U.S. adults are diagnosed with colorectal cancer, the nation's second-leading cause of cancer deaths. Despite those stark statistics, nearly one-third of adults ages 50 to 75 aren't getting screened as recommended.
In an American Cancer Society survey of unscreened patients, one of the leading reasons respondents gave for not being screened was that they had not received a screening recommendation from a physician. Family physicians are positioned to make a huge difference in closing this gap because we provide roughly 200 million office visits each year to a vast spectrum of patients.
A physician discusses care options with a patient. An American Cancer Society patient survey indicates that a physician recommendation can make a big difference in whether or not patients are screened for colorectal cancer.
So it was no surprise last year when the National Colorectal Cancer Roundtable (NCCRT) -- chaired by family physician Richard Wender, M.D. -- sought the AAFP's support for its 80% by 2018 initiative, which seeks to increase the percentage of adults ages 50 and older who get screened for colorectal cancer to 80 percent by 2018.
It's been estimated that achieving that goal would prevent more than 200,000 deaths because colorectal cancer can be detected early -- when treatment is more likely to be successful -- and even prevented through the removal of precancerous polyps.
So where do we stand? The percentage of U.S. adults who have been screened increased from 56 percent in 2002 to 65 percent in 2010. And as the screening rate has risen in recent years, cancer incidence has dropped in this age group.
Still, much work remains to reach the initiative's goal. College graduates are screened at a rate of more than 80 percent, but disparities exist for many other populations. Patients with less education and income, the uninsured, underinsured and certain minority groups have dramatically lower screen rates and higher cancer rates.
So how do we reach these populations? I recently participated in an event hosted by the American Cancer Society and the NCCRT that looked at the progress made during the first year of the 80% by 2018 initiative. We heard from some of the more than 200 groups that have pledged to help boost the screening rate. Those groups range from individual physician practices to national physician organizations and also include payers, public health groups, national retailers and others. In some communities, family physicians, gastroenterologists, public health officials and others are working to identify unscreened patients and direct them to affordable care.
For example, John Allen, M.D., M.B.A., president of the American Gastroenterological Association, said during the event that a grant from Walgreens had helped physicians in Connecticut identify and screen more than 300 patients. Of those, 46 percent had precancerous polyps.
In Arizona, the state department of health is working with one payer to provide screening information to 200,000 patients, as well as providing related CME to physicians.
Earlier this month -- which happens to be Colorectal Cancer Awareness Month -- Mississippi announced a statewide program that aims to increase screening rates in that state to 70 percent by 2020. Although that goal is lower than the NCCRT's objective, it would be a giant leap for Mississippi, which has the nation's highest mortality rate -- and one of the lowest screening rates -- related to colorectal cancer.
What can we do in our own practices? We can make that all-important recommendation during visits with patients ages 50 to 75, and we can follow up with reminders through mail or email.
We also can be sensitive to what type of test patients are willing to do because although some may be hesitant to have a colonoscopy, they may agree to do a take-home test. Remember that a typical series of take-home stool tests does qualify as screening and should be done annually. However, a single, one-time, in-office stool test does NOT adequately screen for colorectal cancer.
In my federally qualified health center, we are helping eligible patients get coverage through the health insurance marketplace. Although screening is a covered preventive service, follow-up care could require a copay in some health plans.
Family physicians build relationships and trust over time. By making a recommendation and providing reminders, we can help achieve this important, life-saving goal.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
The Folly of Judging Physicians Based on Patients' Foibles
Physicians write nearly 4 billion prescriptions each year in the United States, yet roughly half the patients who come to us for help fail to take their medications as directed. Among older patients, the proportion could be as high as 75 percent.
Patients often suffer the consequences when they don't take their medications as directed, but so, too, do physicians when reimbursement is tied to outcomes and community metrics. This can create an adversarial relationship between a prescriber and a "noncompliant" patient, which is antithetical to the kind of relationship family physicians want to have with their patients.
I recently attended a presentation about minimally disruptive medicine, which means simply health care that is designed to meet the goals of the patient while also considering the capacity of the patient to meet those goals.
This overall concept gets at the issue of noncompliance and whether we should even use that term. Noncompliant conjures up an image of a patient who disregards our advice because he or she doesn't value it, but the truth is that any number of factors can prevent a person from adhering to a prescribed regimen, including insurance coverage, out-of-pocket costs, health literacy, cognitive issues, social problems, transportation and more.
The speaker gave the example of a 55-year-old man who had several chronic conditions, including diabetes, high cholesterol, hypertension and obesity. Due to his multiple conditions, his physician advised him to exercise, but the man had a blue-collar job that caused him back pain. That pain rendered him largely sedentary at home, which exacerbated his chronic conditions.
In addition to his physical health concerns, the man's chemically dependent daughter had moved into his home along with her children to escape an abusive relationship. And on top of everything else, the man was suffering from depression.
The patient said he was simply overwhelmed, was unable to exercise and had little time to make the office visits his physician recommended to keep his conditions in check.
We've all had patients like this. They are aware of their health problems and would like to address them but feel unable to do so. Some are merely treading water. That leaves the physician with the unenviable choice of "firing" patients or continuing to try to help them under the very real threat of financial penalties.
Payers would like patients to fit neatly into a single mold but the reality is that patients need an individualized plan that fits their needs. Progress in addressing chronic conditions -- even if it's just baby steps -- should be valued rather than discounted, and physicians should not be penalized for being unable to force a patient with multiple chronic conditions to make miraculous improvements in the face of a litany of obstacles.
I had a patient whose hemoglobin A1c was 14. We were able to bring that number down to 10, which is a significant improvement. But from a payer's perspective, it wasn't good enough because my community metric is 8.
Using these types of quality measures across the board has unintended consequences, and physicians are being punished unfairly for failing to live up to these expectations. Drawing a line in the sand and saying, "Meet this number," fails to recognize the value of the work primary care physicians are doing to reduce the burden of illness and costs to the health care system if a patient happens to land slightly outside an ideal target area.
Being sick is emotionally, physically and financially hard on patients. We need to look at how we can partner with patients and individualize their therapies so they can make progress toward health goals that make sense for them -- not just for us and certainly not for payers.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
Curbing Childhood Obesity Requires Moving Beyond the Exam Room
A concerned parent recently brought her child to see me, worried that the child was underweight. A check of the patient's height and weight confirmed what I suspected -- the child's body mass index was normal. The problem likely is that so many of the child's peers are overweight or obese that the parent's sense of normal was skewed.
Our state, North Carolina, has the fifth-highest rate of childhood obesity in the nation, affecting nearly 20 percent of children ages 10-17 years. Nationally, more than one-third of all children and adolescents are overweight or obese.
|More than one-third of U.S. children and adolescents are overweight or obese.|
The White House recently marked the fifth anniversary of the first lady's Let's Move campaign, an ambitious national program to combat childhood obesity that the AAFP has supported. But efforts to address this epidemic have shown mixed results. In the first two years after the program launched, the obesity rate among children ages 2-5 years dropped nearly 4 percent, but the rate among those 12-19 increased more than 2 percent during the same period. Overall, the rate of childhood obesity was steady at nearly 17 percent.
The Robert Wood Johnson Foundation recently doubled down on its investment in childhood obesity programs, matching the $500 million commitment it made in 2007 with a pledge for another $500 million during the next 10 years.
But what can we as family physicians do in our own communities? When I was president of the North Carolina AFP, our chapter partnered with the state agricultural extension agency to provide nutrition education in family medicine practices. We identified children who were overweight or obese and provided education for entire families in large-group visits. We also worked with the extension office to develop a Web-based resource that included the menus of the popular fast food restaurants in our region. The database allowed users to compare nutrition information of various menu items so that they could make healthier choices when they ate out.
Both of those programs were funded by the state's Health and Wellness Trust Fund, which provided grants with money from the Tobacco Master Settlement Agreement. Although those funds are long gone, family physicians can still find creative ways to help families eat better and increase physical activity. And we can help families beyond the work we do in our exam rooms.
For example, Tommy Newton, M.D., of Clinton, N.C., created a program that rewards elementary students for achieving certain fitness goals. The 10-year-old program, used in schools across the county, has more than 3,500 students enrolled and has been shown to improve children's fitness and self-esteem.
One of the challenges many families face is the lack of a safe place for children to play. Gone are the days (in most communities) when parents felt comfortable allowing their kids to ride their bikes around town -- or even play outside in their own neighborhoods -- without supervision. One of our local communities has addressed that by completing a bike trail that stretches from one end of the city to the other, providing a safe place for families to exercise.
What is your community doing to address this crisis?
Mott Blair, M.D., is a member of the AAFP Board of Directors.
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