Finding good primary care: beyond "best doctors" lists - Part 1 of 2

Every year, I receive a survey in the mail from Washingtonian Magazine asking me to nominate local primary care and specialty physician colleagues for the honor of being named one of Washington, DC's "Top Doctors." I usually send in a few names, and more often than not at least one of them ends up making the list. As a fellow family physician recently noted on his blog, these "top docs" lists are misleading at best, and useless at worst. By polling doctors about their opinions of colleagues, rather than the doctor's own patients, the list generators virtually guarantee that qualities other than name recognition - bedside manner, diagnostic ability, and knowledge of current research, for example - will have little impact on the rankings. (Incidentally, rankings of "Top Hospitals" also rely on reputation above all else, as a recent study reported in the Annals of Internal Medicine.)

Numerous websites now offer patients the opportunity to give and read about the true inside scoop on the "best" and "worst" doctors. These doctor review websites, however, provide little substantive information that isn't available on the website of your state's medical board, favor patients who have an axe to grind (since satisfied patients are less likely to write reviews), and as one physician columnist has noted, are stunningly easy to manipulate. Consumer Reports, they're not.

So how does a social media-savvy patient search for a new primary care physician when his or her insurance changes? Many innovative practices have launched increasingly sophisticated websites that, in addition to containing basic information such as types of insurance plans accepted, operating hours, and biographies of the doctors and staff, include links to online health risk appraisals, interactive Facebook and Twitter pages. In a future post, I will discuss some of the ways that primary care physicians are using social media to attract new patients and encourage current patients to stay healthy.

Guest Blog: First Born

John Grey is an Australian-born poet, playwright, and musician. His latest book is What Else is There from Main Street Rag. His work has appeared in The English Journal, Northeast, Pearl, and the Journal of the American Medical Association. The following poem was first published in the Bellevue Literary Review.

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FIRST BORN

You want to tell everyone
that your wife's not sick
she's having a baby.
She may not feel great
but goddammit if she's not healthier
than anyone in the entire hospital,
every doctor, every sad sack
fidgeting anxiously in a waiting room.
"It's a miracle" you want to
cry out to the woman whose husband's
downstairs having radium treatment,
the guy whose girlfriend is in a coma,
the old man whose bride of fifty years
no longer speaks his name.
You know enough that for every miracle
on this earth, there's at least three
that are grinding their marvels in reverse,
so you keep silent.
Eventually, the nurse struts down the corridor
two steps behind her smile,
declares that "It's a boy."
All heads look up.
For a moment there, a tumor,
a dead brain, a blank look,
are, each in turn, a boy.

- John Grey

The next all-natural blockbuster drug

Pharmaceutical companies and their shareholders are always looking for the next "blockbuster" drug, the label given to a drug that generates more than $1 billion of revenue per year. Blockbuster drugs don't necessarily have to save many (or any) lives - slick marketing more than compensates for marginal improvements in treatment efficacy - but they do need to target conditions that are common enough that millions of patients will buy them. In adults, such conditions include osteoporosis, high cholesterol, and arthritis.

The reason that there have been few, if any, blockbuster drugs for children is that the vast majority of children are healthy. But what if medical science discovered a drug that was proven conclusively to prevent or reduce the risk of a variety of common and uncommon childhood illnesses, including ear infections, gastroenteritis, respiratory infections, eczema, asthma, diabetes, obesity, and even sudden infant death syndrome? A recent cost analysis published in a leading pediatric research journal suggested that giving this drug to 90% of U.S. children for the first 6 months of life could potentially save the lives of more than 900 infants and $13 billion per year. How much do you think people would be willing to pay for this miracle drug? Enough that it could potentially become the first pediatric blockbuster - that is, if breast milk wasn't already free.

Although the American Academy of Pediatrics recommends that mothers exclusively breastfeed infants for the first 6 months of life, and supports continuing breastfeeding to at least one year of age, data from the 2004-2008 National Immunization Survey document that only 73% of U.S. women attempt to breastfeed after birth, and only 42% and 21% are still breasfeeding at 6 and 12 months of life. The numbers are even more discouraging for Black women: only 54% attempt breastfeeding, and just 27% and 11% are still doing so at 6 and 12 months.

Pediatricians and family physicians work diligently to convince women to breastfeed their babies and to continue as long as they can to reap the numerous health benefits (which include a reduced risk of type 2 diabetes, breast, and ovarian cancer for mom), but they are often frustrated in these efforts by health system and employment obstacles. Hospitals commonly distribute free formula or branded diaper bags (my son, who never drank a drop of infant formula, nonetheless went home with a free bag courtesy of Enfamil) and interrupt critical early attempts at breastfeeding with tests and other procedures. Upon returning to the workplace, many moms find that the only private place to pump and store breast milk is a bathroom. However, a new provision in the health reform bill will for the first time require that U.S. employers (even those with fewer than 50 employees) provide regular breaks and a private space for female employees who need to express breast milk. Small employers who may initially feel that this new requirement is an "undue hardship" should consider the lower health costs (and lower insurance premiums) that should result from more infants consuming this all-natural blockbuster drug.

Guest Blog: Improving access to preventive services for seniors

Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA and blogs at DrPullen.com.

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A nice surprise buried in the health care reform bill is that starting next year, Medicare patients will be able to receive annual preventive care exams that are paid for by the program. It may come as a surprise to those of you with private insurance plans who think of coverage of an annual exam as routine, but up until now Medicare has only covered a “Welcome to Medicare” exam in the first year after turning 65. Also, many preventive services like colonoscopy and mammography were either not covered, or subject to high co-payments and deductibles. This situation has always seemed backwards to me. I can make a pretty good argument that an annual physical exam for a 27 year old man is not needed, but it is almost always a covered benefit in any plan the young insured patient has through an employer. Older adults, on the other hand, are far higher risk for cancer, heart disease, diabetes, hypertension, depression, and safety at home issues than are young adults. So I am pleased that preventive services for older and more vulnerable adults will be covered starting in 2011. Leslie Alderman nicely discussed the details of this new coverage in a recent New York Times article.

Starting Sept 23, 2010, all new insurance plans, or current plans which make certain changes, will be required to provide coverage for preventive services recommended by the U.S. Preventive Services Task Force as category "A" or "B" ratings (moderate or high certainty of at least a moderate net health benefit). Beginning Jan. 1, 2011, Medicare will also cover these services with no co-payment or deductible.

This is good news, and should make it much easier for primary care physicians to convince older patients, some of whom currently choose between purchasing shelter, food, or medicine on fixed incomes, to receive evidence-based preventive care.

The cost-conscious physician: an oxymoron?

Several years ago, when my wife directed the third-year Family Medicine clinical clerkship at a highly ranked medical school, she developed a popular workshop on the cost of health care that presented students with scenarios of patients who were either uninsured or underinsured and challenged them to provide cost-conscious health care by selecting medications and tests that were clinically appropriate and financially affordable. Many students remarked that it was the only time during their two years of clinical rotations when they were required to consider costs in decision-making.

Now that the U.S. health reform bill is law, and over 95 percent of Americans (as opposed to today's 84 percent) are expected to have health insurance by 2014, many physicians may be tempted to think that they can ignore the costs associated with prevention, diagnosis, and management of patients' health conditions and just focus on doing what's "right" for the patient, since somebody else is footing the bill. But contrary to popular opinion, that "somebody else" isn't an insurance company or the government; ultimately, it's the patient, in the form of higher insurance premiums (or taxes) to pay for an ever-expanding range of tests or treatments of questionable or zero benefit.

In response to Dr. Howard Brody's challenge to the medical profession to identify lists of unnecessary tests and treatments, physicians have suggested antibiotics for colds, coronary calcium scans, PSA and thyroid tests in well patients, drugs for high blood pressure that are more expensive and offer fewer benefits than older drugs, MRIs and spinal fusions for low back pain. If it's so easy to come up with a list, then why is it so hard to eliminate the waste? According to a recent Newsweek article, the problem is that many of the items on the list are physicians' financial "bread and butter." "We doctors are extremely good at rationalizing," says Brody in the article. "Somehow we manage to figure out how the very best care just happens to be the care that brings us the most money." Other concerns voiced by physicians are that patients have come to expect (if not demand) much of the aforementioned unnecessary care because it's been going on for so long.

But if health care reform is to have any hope of slowing the extraordinary growth in the cost of health care in the U.S., doctors can't keep looking to patients, hospitals, pharmaceutical and medical device companies, and insurers for solutions. In an editorial in the New England Journal of Medicine, Dr. Molly Cooke argues convincingly that cost-consciousness must be systematically incorporated into medical and continuing education:

First, we should be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care.

"Value" isn't about saving money, but means getting the maximum health benefit for our enormous investments in health care. This wake-up call needs to be delivered and reinforced to students, residents, and health professionals at every level - starting today.

Guest Blog: Writing Poems on Antidepressants

Nikki Moustaki is the author of The Complete Idiot's Guide to Writing Poetry and is a recipient of a National Endowment for the Arts grant. She has taught at New York University, Indiana University, and the New School. The following poem was first published in the Bellevue Literary Review.

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WRITING POEMS ON ANTIDEPRESSANTS

Writing poems on antidepressants
is hard. You can appreciate the difficulty
by reading the previous two lines.
Metaphors are easy
to come by when you're aching
or pining or wounded in love,
which scientists have proven is a type of madness
and madness can be cured with a pill.
Not everyday
is Paris. Not everyday
does a bird come winging
out of a carpet to give you a free metaphor,
especially if there are oranges on the table
and you're on your meds.
Each day offers some little irony or a dream
or a blind albino woman
sitting next to you on the train
with eyelashes like white silk threads
attached like broom-straw to her one closed eye
as she taps her cane against the window
and you, the poet on antidepressants,
thinks: look at that, hmmm, interesting.
Did I buy dog food? Here's my stop.

- Nikki Moustaki

The Girl in the Well

While this blog takes every opportunity to champion the essential role of family physicians in reforming our broken health system, I readily admit that the ability of primary care to affect the most important health problems in the U.S. pales in comparison to the impact of public policies. Restricting tobacco advertisements, raising cigarette taxes, and banning smoking in public places has done more for the health of Americans than thousands of clinicians advising their patients to quit. Laws that encourage the construction of sidewalks, parks, and supermarkets in low-income neighborhoods are more effective at increasing physical activity and healthful eating than armies of dedicated health counselors. Reducing highway speed limits and enacting seat belt and bicycle helmet laws has saved far more lives than injury prevention counseling from thousands of well-meaning pediatricians.

Why is it, then, that so much of our national conversation on improving health has focused on health care rather than public health measures? Why are we captivated by the interaction between a single clinician and his or her patient (the inviolate "doctor-patient relationship") rather than overwhelming evidence about interventions that could better the health of communities? The answer is that statistics are, by themselves, underwhelming. Most people are moved to action by anecdotes, a fact that politicians know very well. This is why there are always a few "special guests" sitting with the First Lady at every State of the Union Address for the President to use as props, and why speaker after speaker at February's health reform summit began their long-winded addresses with stories about individual citizens whose lives would be (depending on their political perspective) improved or worsened by the proposed legislation.

Dr. Alfred Somner, former dean of the Johns Hopkins Bloomberg School of Public Health, calls this the "girl in the well" phenomenon:

The world will watch with bated breath through a four-day rescue ordeal, while at the same time hundreds of millions of people go to bed hungry each night ... We accept the problems of the masses as just so much background noise; but it is background noise that causes immense, entirely unnecessary misery the world over and contributes in our own country to spiraling health-care costs.

For primary care to be most effective at improving health, it must work hand-in-hand with public health departments and community organizations, which themselves must be adequately resourced and funded. A case in point: the Communities Putting Prevention to Work Initiative, launched by the U.S. Department of Health and Human Services last September to target physical inactivity, nutrition, obesity, and smoking, takes the critical step of looking beyond the girl in the well, and in doing so, promises to make the one-on-one work of family doctors just a little bit easier.

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Disclosure: I am employed by the U.S. Department of Health and Human Services.

Shining Knights and heroic family doctors

Not long ago, I attended the Shining Knight Gala, a fundraising dinner that benefited the trauma surgery and injury prevention programs at Virginia Commonwealth University Medical Center. The highlight of the evening was the dramatic presentation of the story of a young man who had suffered severe, life-threatening injuries in a car accident and, through the skill and dedication of first responders and the VCU trauma and rehabilitation professionals, was stabilized and over several months gradually restored to health. In recognition of their extraordinary efforts, all of the clinicians involved in this young man's care were awarded the "Order of the Shining Knight." As fire fighters, emergency medical technicians, emergency room physicians and nurses, trauma surgeons, and rehabilitation specialists trooped on to the stage to shake Virginia Governor Bob McDonnell's hand and pose for photos with their award (while their patient looked on happily from a nearby table), it was impossible not to be deeply moved.

It struck me somewhat later that there is no primary care analogy for what I witnessed that evening. General internists will not have the satisfaction of being recognized for the patients who didn't have heart attacks or strokes because of the blood pressure medications or aspirin they prescribed; family physicians and pediatricians won't be given awards of merit for all the children they "saved" from measles, mumps, polio, and a host of other vaccine-preventable diseases. While primary care physicians certainly provide acute care services for a variety of ailments, the greatest impact of our work is ultimately unmeasurable: all of the poor health outcomes that might have happened, but didn't.

Does this mean that there are no heroic family doctors? Far from it, but recognizing our behind-the-scenes efforts - and reinforcing of the appeal of the primary care specialties to medical students - is certainly more challenging. But I'm cautiously optimistic that the 2010 Residency Match results, which saw a 9% increase in the number of U.S. graduates choosing family medicine residencies and modest increases in interest in general internal medicine and pediatrics, represents a turning of the corner. With the millions of people expected to gain health insurance over the next several years, this country will need every primary care clinician it can get.