Can primary care practices be "Dream Teams"?

The greatest U.S. Olympic basketball team ever assembled, dubbed the "Dream Team," dominated the rest of the world at the 1992 Summer Olympics. This team, which beat opponents by an average of 44 points en route to a gold medal, included 10 eventual NBA Hall-of-Famers, including Michael Jordan, Patrick Ewing, Karl Malone, Magic Johnson, and Larry Bird. Now that professional basketball players were eligible to represent the U.S. in world competitions, many observers predicted that the U.S. would be unbeatable for decades.

It turned out to be a single decade. At the 2002 World Championship, the U.S. team didn't even medal, finishing a shocking 6th. At the 2004 Summer Olympics, the U.S. barely managed to take home the bronze. And it wasn't as if these were teams of second-stringers; in particular, the 2004 team included perennial All-Stars Tim Duncan, Allen Iverson, LeBron James, and Dwayne Wade. But that was actually the problem - too many stars, too little teamwork. So USA Basketball changed its program, assembling a team with fewer individual stars and more role players who all committed to playing together for long stretches prior to the 2008 Olympics, where the "Redeem Team" took back the gold medal for the U.S.

In many ways, family medicine in 2010 is where U.S. basketball was in 2004. Three years ago, four major organizations representing primary care physicians agreed to an outline of "Joint Principles of the Patient-Centered Medical Home," which included this statement: "The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care." Unfortunately, this "physician-centric" approach prevents the development of true primary care teams, and instead reinforces the traditional medical hierarchy: the doctor gives orders to staff, and the staff carry out the orders without question or debate. As the evaluators of American Academy of Family Physicians' National Demonstration Project of 36 medical home practices concluded:

Becoming a PCMH requires more than just implementing sophisticated office systems: it involves adopting substantially different approaches to patient care that requires moving away from a physician-centered approach and toward a team approach shared with prepared office staff. ... The role of the primary care physician in the context of the practice and the larger health care system will continue to be important but needs to be encouraged to evolve in new and innovative ways.

Can physicians evolve from being authoritative bosses to being facilitators and players on primary care "Dream Teams"? Even recent residency graduates may be poorly prepared for these new roles, despite heroic efforts to transform residency training to prepare family doctors to work in practices of the future. However, as Atul Gawande noted in his 2009 bestseller, surgeons, pilots, and architects have managed to put aside their inner prima donnas and successfully integrate into teams in equally demanding professions. Given the right economic incentives, there's no reason why we can't, too.

Guest Blog: Depression Session

Abby Caplin, MD, MA practices mind-body medicine and counseling in San Francisco. She helps people living with chronic medical conditions to lead empowered and vibrant lives, reclaiming their wholeness despite illness (http://www.abbycaplinmd.com/). Abby also offers a weblog, Permission to Heal, for people who are "up in the middle of the night or down in the middle of the day" because of illness. The following poem was first published in Pulse Magazine.

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DEPRESSION SESSION

The chopped apple of her father's eye,
She tastes the grapes of her mother's drunken wrath
The barely visible slivers of silver-tongued almond
Needle her intestines as she savors
The seedless watermelon of fruitless friendships,
And endures the hard rind
Of a body gone awry,
To be chewed and chewed until swallowed or
Spat out. A salad of sorts
Surrounded by lemons
Home-grown, organic, bitter
And full of juice. She brings me a tough
Clear plastic bag filled with them
To our session.
"They're the last of the season," she tells me.
I pray this is true,
While at home, I pore through cookbooks,
Searching for yet another recipe.

- Abby Caplin

Obstacles to reversing the obesity epidemic

If you go to the website of the U.S. Centers for Disease Control and Prevention, you can download a colorful slide presentation that illustrates with stunning clarity how much worse the problem of obesity has become in the past twenty years. In 1990, every one of the 50 states could boast that fewer than 15 out of every 100 adults had an unhealthy weight; by 2008, more than 25 out of every 100 adults in 32 states were classified as obese. So who’s to blame, and what can be done about it?

The standard answer, that obesity results from a failure in willpower, is reinforced by popular television shows such as “The Biggest Loser,” where overweight contestants are removed from their natural environments and placed on super-intensive dietary and exercise regimens that lead to, in some cases, hundreds of pounds of weight loss over several weeks. But as Atlantic correspondent Marc Ambinder noted in a recent magazine article, this type of program is out of reach for all but the wealthiest individuals who can afford celebrity personal trainers.

Family doctors can certainly provide support and assistance to patients who want to lose weight, but there are limits to what we can do, given the time we have to devote to counseling and the extremely limited training we receive on practical strategies to assist with weight loss. For an increasing number of obese people (including Ambinder himself), bariatric (weight loss) surgery has achieved what medicine can’t – but even the recent explosion of bariatric surgery centers can’t possibly come close to treating one quarter of the adult population.

Obesity is as much a public health problem as a medical problem. Obstacles to living a healthy lifestyle include rising serving sizes and television screen time, combined with a lack of access to nutritious foods and safe places to be physically active in many towns and cities. The announced intention of U.S. First Lady Michelle Obama to tackle obesity in children shows how difficult and sustained an effort will be necessary to reverse the overall obesity epidemic. In May, the President’s Task Force on Childhood Obesity made a series of recommendations for wide-ranging action in institutions such as hospitals, restaurants, schools, grocery stores, and parks. Most of these changes will require more than just exhortation, but policy changes in local and national levels.

So I encourage you think about this question: what can you do to fight obesity in your family, friends, and community?

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This post was first published on my CommonSense MD blog at Family Health Guide.

Guest Blog: Two steps forward for America's health

Danielle Ofri, MD, PhD is the author of three books about her experiences as a general internist at NYU School of Medicine and serves as editor-in-chief of the Bellevue Literary Review. The following post originally appeared on her blog on May 27, 2010.

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TWO STEPS FORWARD FOR AMERICA'S HEALTH

The fine print of the 2010 Health Care Reform bill is still being analyzed. Shortcomings and limitations are being uncovered. But a new report from the Commonwealth Fund showed that there will be immense and immediate gains for young adults.

Most young adults “fall off” of their parents’ health insurance plans once they complete their education (graduating from college or high school). Many get jobs without benefits. Many lose public health benefits like Medicaid when they turn 19. Most young adults can’t afford to purchase health insurance.

Nearly 14 million people aged 19-29 have no insurance. This represents fully a third of the uninsured of America. That’s an awful lot of people who are doing without medical care, paying exorbitant out-of-pocket costs, or relying on emergency rooms.

Starting in September of 2010, insurance companies will be required to allow children to stay on their parents’ plans until they turn 26. Beginning in 2014, Medicaid eligibility will be expanded to include all adults earning less that 133% of the poverty line.

These two provisions, plus the other key elements of the law—ban on lifetime limits and on discrimination based on health status—could serve to extend health insurance to nearly all young adults. The main group that will be left out will be undocumented immigrants. (Unfortunately, this group represents too much of a political lightening rod to allow any intelligent consideration of options.) Beyond that, it will be people who opt out of eligible plans, and choose to pay the fine instead.

What about that fine? The main premise of the reform act is that everyone needs to have insurance in order to eventually lower costs. For all the huffery and puffery about this mandate, two-thirds of all young people support this. As expected, young Democrats were stronger supporters than young Republicans. But what might be surprising is that young adults with lower incomes—those for whom this might be a hardship—were strongly in favor of this mandate. More so than those with upper incomes, for whom this would not be a big deal.

Many people predicted that the world would come to an end when this bill was passed, that there was some sort of nefarious government takeover in the works. Getting the young adults in our society—the next generation who will be contributing to our country—to have adequate health insurance? Doesn’t sound so nefarious to me.

I wonder how many of those opponents have college-age children. They are probably mighty eager to see September roll around.

From one blog to three

As Common Sense Family Doctor approaches its first anniversary, I am pleased to announce that I will soon be writing and moderating two new blogs that you are more than welcome to visit. Common Sense MD, hosted by the U.K.'s Family Health Guide, offers my take on important family health issues such as obesity, depression, cancer screening, and pregnancy concerns. After recently helping to launch the online feature "AFP By Topic: Editor's Choice of Best Current Content" for the journal American Family Physician, I'm planning to roll out an AFP Blog later this summer, featuring expanded perspectives on clinical issues from the journal and guest blogs from leading family doctors.

Meanwhile, you will continue to find original commentary on primary care, as well as occasional creative writing pieces, on this website. On occasion, I may cross-post content that I think would be of interest to the readers of more than one blog, but will be sure to identify it as such. (You may have also noticed that this blog has become a regular source of guest posts on KevinMD.com.)

Although keeping up with multiple blogs will be a challenge, I'm looking forward to continuing to provide an ample supply of common sense thoughts on health and health care. As always, thank you for reading!

Medical school rankings are a means, not an end

Two weeks ago, I asked, "Where will new primary care docs come from?" A group of researchers from George Washington University has provided an answer in this week's issue of the Annals of Internal Medicine. In response to the U.S. News and World Report rankings of medical schools, which place a high value on research funding and reputation, Dr. Fitzhugh Mullan and colleagues at the Medical Education Futures Study devised a "social mission" ranking score consisting of the percentage of graduates from 1999 through 2001 who currently practice primary care medicine; who work in federally-designated health professional shortage areas; and who are underrepresented minorites.

The result of applying this score was that the U.S. News rankings have been turned virtually upside down, with publicly funded and otherwise unheralded schools dominating selective private schools. The study's "social mission" criteria that have already come under fire from officials at multiple lower-ranked institutions, including New York University (where I completed medical school) and Johns Hopkins University (where I am a part-time instructor and public health graduate student). Their criticisms have some merit. Primary care physicians aren't the only providers of health care for urban underserved populations, and graduating more underrepresented minorities won't automatically translate into better care for minority populations.

On the other hand, I commend Dr. Mullan and colleagues for shining a light on a dark truth that isn't well known outside of medicine: at the "top" medical schools, physicians are subtly and not-so-subtly discouraged from pursuing careers in primary care fields such as family medicine (I was no exception) and encouraged to go into higher-paid, more "prestigious" subspecialty fields. And right now, the U.S. doesn't need more subspecialty physicians - it needs primary care physicians, it needs physicians willing to practice in areas where doctors are scarce, and it needs more physicians of color who identify with and are willing to serve their communities.

Rankings are a means, not an end. It remains to be seen if this study will do more than just cause a short-lived media controversy and actually lead medical school deans to think seriously about new strategies to recruit and nurture students who will meet the social mission needs of this country. For the sake of your health and mine, let's hope that it does.

Are the humanities valuable in medical school?

Personal experience tells me that the answer to this question is "yes, of course!" As the editor of a popular science magazine and an occasional poet in college, I looked forward to the "touchy feely" humanities courses and activities during the first two years of medical school that many of my classmates ridiculed as, well, too touchy feely. Sandwiched in between dry, rote basic science classes such as Pathology and Anatomy, humanities subjects were my window to a richer world. Among other things, I wrote a heartfelt essay that described my first patient interview as an "empathic intrusion," discussed cross-cultural issues raised by Anne Fadiman's The Spirit Catches You and You Fall Down, took a four-week medical ethics elective, and co-founded a short-lived student literary magazine.

So it was with more than a little trepidation (and perhaps even some disdain) that I read a systematic review of the literature on the effect of the humanities in medical education in this month's issue of Academic Medicine that concludes: "Evidence on the positive long-term impacts of integrating humanities into undergraduate medical education is sparse." After carefully searching the literature for articles published between 2000 and 2008, the researchers found that only 9 articles out of 245 included in the study actually attempted to measure the positive impact of humanities curricula on professional behavior, clinical practice, or specialty choice. And even these few studies didn't find much to brag about. It seems that the evidence-based answer to the question posed in the title of this post is: Insufficient Evidence.

This study is a good example of taking a quantitative approach to medicine too far. If medicine is an art as well as a science, this approach is analogous to creating an algorithm for beauty. We know beautiful art when we see it. Similiarly, there are at least some qualities in a "humane" or "caring" doctor that can't be quantified, but patients know when they see (or experience) them. Clearly, we also want our physicians to learn and be evaluated on the science of health and disease, but to require that long-term benefits of humanities education be proven beyond a shadow of a doubt is to miss the point: this assessment can never be entirely objective, but will depend on the eye of the beholder. Subjectively, you validate the positive - but unmeasurable -value of my medical school humanities experience just by reading this blog.

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from March, April, and May:

1) The decline of VBAC: hearing hoofbeats, thinking zebras (3/10/10)

2) Shining Knights and heroic family doctors (4/1/10)

3) The Presidential Physical (3/1/10)

4) Why I'm a doctor and not a pharmacist (5/25/10)

5) The cost-conscious physician: an oxymoron? (4/13/10)

If you have a personal favorite that isn't on this list, please let me know. As always, thank you for reading!

Where will new primary care docs come from?

There is widespread consensus that the upcoming increase in the numbers of people who will gain health insurance as a result of the Patient Protection and Affordable Care Act will require a corresponding increase in the numbers of primary care physicians trained to care for them, even if new practice models eventually redistribute physicians' workloads and health insurers' policies change to accomodate these new models (by paying for medical advice dispensed over e-mail, for example). I've previously mentioned in this blog that researchers at the American Academy of Family Physicians' Robert Graham Center have been hard at work for the past several years figuring out what besides salary attracts medical students to careers in family medicine, general internal medicine, and pediatrics.

This month, a study in the journal Academic Medicine provides additional perspective on the steps that policymakers and academic leaders need to take to revitalize the pipeline for primary care training. This analysis of more than 100,000 medical school graduates from 1997 through 2006 who completed a questionnaire administered by the Association of American Medical Colleges (this must have included me, though possibly not - only 65% of all graduates during these years actually completed the survey) studied statistical associations between choice of a primary care specialty and a slew of other factors.

The study's major findings aren't terribly surprising: in terms of percentage of medical school graduates entering their fields, primary care has been losing ground to internal medicine and pediatrics subspecialties for more than a decade. Students who chose primary care were more likely to be female, planned to practice in medically underserved communities, and had strong altruistic beliefs about health care and the medical profession's social responsibility.

If we believe the findings from this study - and there's no reason not to, given that they are largely consistent with those from previous studies - it makes sense for medical schools to respond by targeting recruitment efforts for women and college graduates who already plan to practice in underserved areas and who see health care as a basic human right, rather than a privilege provided for those who can afford it. It also makes sense for schools to take a more active role in promoting the whole-person (or "holistic," if you prefer) philosophy that underlies the primary care specialities from day one, rather than misleading students that the segmented, organ-system organization of the typical academic medical center is a sensible approach to improving population health.

But will medical schools actually do any of these things, and more importantly, will it really matter if the primary care-speciality income gap persists?

Guest Blog: The medical writer's Ten Commandments

Although I'm relatively new to the blogosphere, starting Common Sense Family Doctor in July 2009, I've been a medical editor for American Family Physician since 2004. Many thanks to my editor, Jay Siwek, MD, and members of the World Association of Medical Editors (better known by its acronym, WAME, pronounced "whammy") for passing on this terrific list of scientific writing shalt-nots.

THE MEDICAL WRITER'S TEN COMMANDMENTS

1. Thou shalt not, unless circumstances be extraordinary, release for publication a paper that neither contains anything new nor sheds new light on something old.

2. Thou shalt not allow thy name to appear as a co-author unless thou hast some authoritative knowledge of the subject concerned, hast participated in the underlying investigation, and hast labored on the report to the extent of weighing every word and quantity therein.

3. Thou shalt not fail to place within quotation marks the words of another, nor shalt thou fail to verify the accuracy of thy quotations.

4. Thou shalt not consider that to alter the words of another frees thee from the obligation to credit that other with an idea that thou hast borrowed from him.

5. Thou shalt not publish a reference in such manner that the reader will think thou hast read a certain article if thou hast read only an abstract or paraphrase thereof.

6. Thou shalt not write to please thyself but to meet the needs of thy reader.

7. Thou shalt not publish, as if thou were sure of it, that of which thou art not sure.

8. Thou shalt not allow one part of thy paper to disagree with another part thereof.

9. Thou shalt not mix categories. [Translation: data in tables must be consistent with their row and column headings.]

10. Thou shalt not fail to verify, again and yet again, thy arithmetic.

- Richard M. Hewitt
Associate Professor of Medical Literature
University of Minnesota and the Mayo Foundation, 1957