Thursday, July 24, 2014

"All In" as Common Sense Family Doctor turns five

Last summer around this time, I announced that I had started writing a book titled Conservative Medicine and elaborated on my ambitious book proposal in a series of blog posts. It's now a year later, but, sad to say, I haven't made much progress. I have some good excuses, though. In the past year, I:
  • Became Associate Course Director, then Course Director, of the first-year Georgetown School of Medicine course "Patients, Populations & Policy"
  • Gave three lectures and numerous interviews about the benefits and harms of CT screening for lung cancer
  • Created a searchable database of primary care relevant recommendations from the Choosing Wisely campaign
  • Was appointed to a four-year term on the American Academy of Family Physicians' Commission on the Health of the Public and Science
  • Was re-appointed to the editorial board of Family Practice Management 
  • Moved into a new home (in January)
  • Welcomed my fourth child / second daughter (in May) - in case you haven't been counting, my kids' ages are now 8, 6, 2, and 2 months
  • Re-certified as a Diplomate of the American Board of Family Medicine by passing my Board exam
  • Passed 6,500 Twitter followers and 10,000 tweets
  • Passed 525,000 blog page views and reached 475 posts

So, though it may seem to readers like I've been loafing, the reality is that my time and energy has often been needed elsewhere. And when choosing between book writing and blogging, the latter wins out. In fact, to make more time in my schedule to post to Common Sense Family Doctor, I've decided to voluntarily cut back on my American Family Physician editor duties to the tune of $1000 per month. Creating this protected time should allow me to post more often than I have been able to lately, and take chances intellectually by daring to write about topics outside of my areas of health expertise, such as educational reform.

On the fifth anniversary of my very first post, I am announcing a new investment in myself and this blog. I am going "all in" on Common Sense Family Doctor.

Monday, July 21, 2014

Nurturing the next generation of diverse family physicians

Since joining my current practice two years ago, I've noticed that I care for a disproportionate number of immigrants of Chinese and other Asian descent compared to my colleagues. Although both of my parents were born in Taiwan, I don't speak Mandarin or have special expertise on medical conditions common in Asian Americans. Nonetheless, Asian patients seem more comfortable with me anyway. Similarly, U.S. health workforce analyses show that underrepresented minority physicians (Black, Latino, and Native American) are more likely to provide primary care to medically underserved populations.

A recent Robert Graham Center Policy One-Pager examined the racial diversity of family medicine resident physicians from 1990 through 2012. It compared the proportion of residents of a particular race with the proportion of the U.S. population of the same race. The White and Native American resident to population ratio was close to 1:1, but Blacks and Latinos were present in family medicine residency programs at only 50 to 75 percent of their proportions in the population. (Asian residents have always been overrepresented compared to the population, with a current ratio of 5.1 to 1.) The good news is that family physicians are diversifying; the bad news is that Black and Latino physicians still have a long way to go to "catch up" to their numbers in the population. This means that many Blacks and Latinos will receive primary care from physicians of different races, which isn't automatically a bad thing. But it begs the question of why this situation exists in the first place.


Too many Black and Latino Americans grow up in desperately poor and crime-ridden neighborhoods with substandard public schools, and for decades resources have been poured into programs designed to give these students opportunities for educational success, from Head Start to Fairfax, Virginia's Young Scholars. It's still a rough and treacherous road, as Ron Suskind illustrated in the bestseller A Hope in the Unseen, about Cedric Jennings, an African American from Washington, DC who overcame a heartbreaking upbringing (his father was repeatedly incarcerated for dealing drugs and he and his mother were evicted from multiple homes for falling behind on rent payments) and dysfunctional schools to be admitted to Brown University. But if communities can give these kids enough K-12 support to get them accepted to four-year colleges, then a good number of them should go on to become doctors, right?

It's not that simple. In the New York Times Magazine article "Who Gets to Graduate?," Paul Tough delved deeply into the problem of college dropouts at the University of Texas at Austin, a respected public university that offers automatic admission to any Texas resident who graduates in the top 7 percent of his or her high school class. He followed Vanessa Brewer, an African American woman raised in a single-parent home who aspired to become a nurse anesthetist. Vanessa experienced a crisis of confidence after failing her first statistics test, and wondered: "Am I supposed to be here? Am I good enough?" Wrote Tough:

There are thousands of students like Vanessa at the University of Texas, and millions like her throughout the country — high-achieving students from low-income families who want desperately to earn a four-year degree but who run into trouble along the way. Many are derailed before they ever set foot on a campus, tripped up by complicated financial-aid forms or held back by the powerful tug of family obligations. ... Many are overwhelmed by expenses or take on too many loans. And some do what Vanessa was on the verge of doing: They get to a good college and encounter what should be a minor obstacle, and they freak out. They don’t want to ask for help, or they don’t know how. Things spiral, and before they know it, they’re back at home, resentful, demoralized and in debt.

The bottom line on national statistics on college graduation rates is that "rich kids graduate; poor and working-class kids don't." And surprisingly, graduation rates have little relationship to natural ability and much more to do with confidence, rooted in one's socioeconomic background.

A case in point: I failed my first anatomy exam in medical school. It felt terrible to see my score near the bottom of the class, but as the son of a pharmacist and a computer scientist with two Master's degrees, and the grandson of a neurologist and related to a long line of doctors, I pulled myself together and eventually earned a passing grade. Had this sort of setback happened to a student who was the first in his family to finish college, it could easily have led to that student leaving medical school entirely.

A U.T. program called the University Leadership Network (ULN) not only confirmed that a lack of confidence related to humble upbringing puts students at the highest risk of dropping out, but successfully tested an brief online intervention that measurably improved their odds of completing at least 12 credits during their first semester and staying on track to graduate in four years. Tough summarized ULN's straightforward strategy: "Select the students who are least likely to do well, but in all your communications with them, convey the idea that you have selected them for this special program not because you fear they will fail, but because you are confident they can succeed." The payoff for replicating this program at universities across the nation, Tough suggested, could be immense:

Beyond the economic opportunities for the students themselves, there is the broader cost of letting so many promising students drop out, of losing so much valuable human capital. ... Most well-off students now do very well in college, and most middle- and low-income students struggle to complete a degree. ... These two trends are clearly intertwined. And it is hard to imagine that the nation can regain its global competitiveness, or improve its level of economic mobility, without reversing them. ... A big part of the solution lies at colleges like the University of Texas at Austin, selective but not superelite, that are able to take large numbers of highly motivated working-class teenagers and give them the tools they need to become successful professionals. The U.T. experiment reminds us that that process isn’t easy; it never has been. But it also reminds us that it is possible.

Becoming a family physician isn't easy. But America's need for the next generation of diverse family physicians has never been greater, and Tough's article has convinced me that nurturing them is possible.

Monday, July 14, 2014

Now that's government waste: $10 billion per year to train the wrong physicians

Last year, the physicians at my academic family medicine practice met with two senior officials from our parent health care organization to be oriented to its new initiatives and projects. Their presentation documented the organization's ongoing investments of many millions of dollars into renovating subspecialty care suites and purchasing new radiology equipment that was likely to be highly profitable, but provide dubious benefits to patients. Two of my colleagues asked why, given the expected influx of millions of newly insured patients into primary care, and an estimated shortfall of more than 50,000 primary care physicians by 2025, the organization had not identified expansion of primary care training as a financial priority. Where exactly did they expect to find family physicians to staff all of the new community offices they planned to open? An awkward silence ensued, followed by some polite hemming and hawing about how this was a complicated issue, and that supporting generalist training would likely require additional funding that was perhaps beyond the organization's limited resources.

Additional funding required? How about $9.5 billion? That's the approximate amount that that Medicare spends each year, with no strings attached, to subsidize the cost of training physicians in U.S. residency programs. Noting that the federal government doles out these dollars without requiring any particular outcomes from the institutions that benefit from them, some have called for Medicare to hold institutions more accountable for meeting America's physician workforce needs. If we have a surplus of radiologists and a shortage of general surgeons, why not tie funding to training more of the latter and fewer of the former? Given the decentralized nature of the U.S. health system, though, that has been easier said than done. In particular, it is challenging to follow the money trail and determine which institutions end up producing which types of doctors.

A 2013 study in Academic Medicine by health services researchers at The George Washington University and the Robert Graham Center filled this information gap. Painstakingly assembling and cross-checking data from several sources on actively practicing physicians who completed their residency training from 2006 to 2008, they were able to identify residency-sponsoring institutions that were top producers of primary care physicians, that produced lower proportions relative to all physicians, and that produced none at all. Notably, they conclusively disproved "The Dean's Lie" that counts all internal medicine residents as going into primary care (when only 1 in 5 actually plan to do so), demonstrating that at some institutions fewer than 1 in 10 internists become primary care physicians. They also identified a large funding discrepancy between the top and bottom primary care producers.

The top 20 primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41.0%) and received $292.1 million in total Medicare GME payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.

In short, where physician production is concerned, you get what you pay for. In this case, Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

That's the big picture. Since all politics is local, policymakers who want to know what types of physicians their teaching hospital or health system is training can use the Graham Center's free GME Outcomes Mapper tool to find out. And if enough of them do so, maybe we can all have a serious national conversation about moving beyond guaranteed health insurance coverage to ensuring that the care (and the workforce) that coverage is paying for will actually help us to live longer or better.

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This post originally appeared on Common Sense Family Doctor on June 18, 2013.

Wednesday, July 9, 2014

"Choosing Wisely makes me happy"

Thanks to The BMJ for alerting me to this terrific 4-minute YouTube video. I also recommend checking out this article about the spread of the Choosing Wisely campaign worldwide.

Saturday, July 5, 2014

Skip the annual pelvic examination? How about the whole checkup?

An American College of Physicians practice guideline has garnered attention for recommending against clinicians performing screening pelvic examinations in asymptomatic, nonpregnant women. Although the new guideline has been called "controversial," its findings should not be a surprise to readers of American Family Physician. An editorial and blog post published in AFP early in 2013 argued that this longstanding tradition is "preventive time not well spent," since the pelvic examination doesn't actually prevent anything (screening for ovarian cancer does more harm than good and accurate testing for chlamydia and gonorrhea can be done on urine samples) and is associated with increased cost, inconvenience, and patient discomfort. With Pap smears only recommended every 3 to 5 years in most women, it also seems prudent to redirect time saved from not performing extra pelvic exams to effective preventive services such as counseling for tobacco and alcohol misuse.

But why stop at the pelvic examination? Last September, the Society of General Internal Medicine included the following item in its Choosing Wisely Top 5 List of potentially unnecessary tests or procedures: "Don't perform routine general health checks for asymptomatic adults." They cited a Cochrane review of 14 randomized controlled trials that found that the annual physical increases new diagnoses but "do not decrease total, cardiovascular-related, or cancer-related morbidity or mortality."

The physical examination may not improve outcomes in asymptomatic patients, but what about the cardiovascular risk assessment and lifestyle counseling that goes along with it? A randomized trial published this year in BMJ casts doubt on the benefits of this preventive service. In nearly 60,000 residents of Copenhagen, Denmark between the ages of 30 and 60 years, four or more sessions of individual lifestyle counseling over a 5-year period produced no effect on rates of coronary artery disease disease, stroke, or mortality after 10 years of followup. In an accompanying editorial, the Cochrane review authors state flatly: "General health checks don't work. It's time to let them go."

As the U.S. faces a worsening shortage of primary care clinicians, are today's family physicians prepared to abandon annual pelvic examinations and well-adult checkups in general? If not, why not?

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The post originally appeared on the AFP Community Blog.

Thursday, June 26, 2014

Guest Post: Why you should care about how family physicians are measured

The following post consists of lightly edited excerpts from several e-mail exchanges among members of the Family Medicine Education Consortium between May 20-26, 2014.

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Colleagues,

We recently published an article documenting family physicians' frustrations with the Centers for Medicare & Medicaid Services' documentation, coding, and billing rules we are forced to work under by CMS and private insurance companies. Plenty of stories have mentioned the income disparity between primary care docs and procedural subspecialists. I have never read an article that asked why this disparity even exists in the first place. They talk about salary differences or first salaries out of residency, as if the only factor at play was competitive market forces. No journalist has cracked the code (that I've read) that understands that the root of this discrimination is the CMS billing system, which over 90% of insurance companies use. [Editor's note: this Washington Monthly article explains why Medicare's price-fixing always undervalues the work of primary care physicians.]

I don't understand why non-physicians seem so indifferent to this aspect of our work lives. Their attitude always seems to be some version of "the details of the rules are boring, you're a rich doctor, so quit complaining." These awful rules affect their patient experience. Patients complain about their doctor being rushed and not listening to them. CMS rules often cause us to behave this way.

Richard Young

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I wonder if this group would want to try to submit something to CMS about what we should really measure with patient outcomes like quality of life. Not sure who could take the lead, but having a lot of names on such a document would be a strong statement to them at least.

Hugh Silk

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Be careful what you ask for. The whole quality movement in family medicine has led us astray: it assumes there is one right answer for a medical issue, e.g., antibiotics one hour prior to major surgery. Because of the complexity of what we do, often there is no one right answer, so what do we measure?

The quality improvement (QI) movement is largely unable to risk adjust. If we propose measures for quality of life (QOL) outcomes for constructs such as energy levels, sleep quality, shortness of breath, then we create incentives for family physicians to "dump" the sickest patients, which is exactly the opposite of what this country needs. Up to now, QI has assumed that more is better, which is anti-family medicine. None of the criteria measure things we don't do to patients. The Choosing Wisely campaign offers hope for a more balanced portfolio.

Politicians, regulators, and industria-crats don't want to hear this, but a lot of the value of our services simply can't be measured. Many of our decisions have no evidence base to declare one right answer. To even accept simple disease-specific measures as an overall assessment of care quality implies that our decisions are simple and straightforward, when nothing could be further from the truth.

This is not to say that physicians and their practices should not reflect on their own performance and measure internal processes to improve local care delivery systems. There is value to performance improvement, just not as a summative evaluation of a physician or practice. So let's all sign a document that tells CMS to abandon the folly of measuring family physician quality with simplistic electronic medical record- or billing-based measures. Our worlds are too complex for the computers to keep up with.

Richard Young

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I agree what we do is very, very subjective. But the alternative is to wait to see what they decide on and be forced to practice that way. Someone, somewhere is going to hold us to something; we should decide what that is. Maybe it is relationships. Maybe it is intent to change behavior. Maybe it is QOL but with wiggle room - a movement of QOL in the right direction counts as much as better QOL.

This is the kind of conversation we need where we offer something that we think we could be measured by, not just what we don't want to be measured by.

Hugh Silk

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Submit to, or occupy CMS? Only the latter will have any meaningful impact.

Michael Fine

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I think this is a challenge for the Family Medicine community. We have a talented core group of researchers who understand both quantitative and qualitative measurement methods. Also, Direct Primary Care can remove the control of those who juggle the carrots and place the measurement that matters in the hands of the patient.

Larry Bauer

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I will be attending a symposium in about two weeks to talk about future research directions concerning behavioral change. One of the most important things we do in family medicine is to help patients make decisions around, and commitments toward, change. What can we measure that makes a difference? What is it about family medicine that helps patients in that process?

David Loxterkamp

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David, this probably comes as no surprise, but I disagree with your "most important things" statement. The most important thing we do is not to cause patients to change their behavior, but to non-judgmentally accept them as they are and to foster a lifelong conversation with them about their options and trade-offs for every health-related concern they have. How much impact do we have on causing smokers to quit long-term? About 5%. How much do we affect weight loss? Essentially none at all. We should tell our patients to go to Weight Watchers and not waste their time or society’s resources trying to "educate" them into lower weights. These outcomes are not what is so valuable about family physicians.

This is another example of why industrial QI thinking doesn’t work for much of family medicine. QI assumes there is a discrete outcome that can be declared as success or failure within a relatively short time frame: over a few Plan, Do, Study, Act cycles. One of the ways we deliver better care at a lower cost is to foster an endless series of negotiations with patients over a lifetime, constantly adjusting the options and goals as the natural history of the disease evolves and all of the other changes in their lives affect their health: births, deaths, job loss, job gain, bouts of depression, bouts of elation, and everything in between.

This is the message CMS needs to hear. Maybe a measure about how much time your family physician talked to you about your options would be valid. Of course, this shouldn’t be measured until CMS agrees to pay us to take the time to implement it.

Richard Young

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Richard, as a patient who wants a doctor to work WITH, not to be harangued by, your point is spot on. I love my family doctor because he assumes I am an intelligent individual who wants to be healthy and live a happy long life -- not a bag of organs in need of fixing.

Shannon Brownlee

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Friends, this is an interesting series of comments. I've noticed after about 177,000 patient encounters many similarities and differences. One of my responsibilities as a Family Physician is to make sure that each patient knows that he or she matters - sort of a human validation and often a role validation (father, mother, patient, guardian, etc.). AND, know that I matter, too.

Could we have a measurable energy that when combined with our context and the patient's context, delivers wholeness? The human energy field of patient and physician engaged in dyadic sharing and mutual interdependence may be measurable as technology evolves (probably with a cell phone). Their fear of short or long term loss, or that we won't connect to their reality and further mis-align them with their potential, combined with our fear that their problem might exceed our skills or our coding skills or our employer's mandates for our scope of practice and time allotment may suddenly (or over time) melt into a mutually beneficial human dance of meaning, enhancing organ and system and spiritual unction for both. Can the creative tension of this dyadic dance show merit of a financial sort to someone who might pay?

I love what I get to do. I love being a Family Physician. I'm blessed to get a close look at the human condition in the context of meaningful relationships that enable humans to better align with their values, goals and dreams. And measurable or not, my values, goals and dreams are included in the outcomes of doing Family Medicine.

Pat Jonas