The importance of caring for caregivers

Mr. B, the patient who first stirred my interest in family medicine, was a spry former World War Two fighter pilot who came to the ER complaining of an irregular heart beat. I remember him regaling me with stories about the Battle of Britain while his wife dutifully stood by his side in the chaos of the crowded emergency room at a private hospital affiliated with my medical school. It was just my third clinical rotation.

Early the next morning, Mr. B suffered a stroke, a common complication of atrial fibrillation. As a result, he lost the use of most of the left side of his body and sank into a deep depression. Later, after there was nothing more to do in the way of acute care, my medical team transferred Mr. B to a rehabilitation facility down the street. There, I continued to monitor and encourage his slow and painful progress for several more weeks. Later that year, when I applied to family medicine residency programs, my care for Mr. B became the core story of my application essay. I had decided to join a medical specialty that cared for the "whole person," rather than a single body part or organ system, and in my mind, helping Mr. B recover from his complex illness was the perfect example of what family doctors do best.

The essay worked - I was accepted to my first choice residency program. But looking back on that episode now, more than a decade later, I realize that I missed a crucial piece of the story. I never thought to ask Mr. B's wife, his primary caregiver, how she was faring. What personal trials must she have gone through in caring for her formerly independent husband and coming to terms with this permanent change in his health and its effect on their daily lives? I can only guess, but I'll never know.

Two recent magazine pieces written by caregivers describe how hard it is to support a loved one suffering from chronic illness. In "Letting Go of My Father," reporter Jonathan Rauch tells the story of struggling to care for a father with a rapidly progressive neurological condition, and his belated discovery that many friends and colleagues were encountering the same challenges with an elderly parent. In "On Caregiving," psychiatrist and medical anthropologist Arthur Kleinman relates how caring for a spouse with Alzheimer's disease taught him more about "the moral core of caregiving" than a lifetime of patient care and academic research. Kleinman observes:

Caregivers protect the vulnerable and dependent. To use the experience-distorting technical language: they offer cognitive, behavioral, and emotional support. And because caregiving is so tiring, and emotionally draining, effective caregiving requires that caregivers themselves receive practical and emotional support.

Such support can be offered by family physicians and a variety of other professionals. It would have helped a great deal if as a medical student I'd known that there were established office tools for assessing "caregiver burden," including emotional and physical health. An article in this week's Los Angeles Times provides useful advice and resources for caregivers, including practical tips on confirming the diagnosis, financial and legal planning, and elder care support services. The author's most important tip: "don't go it alone." To that, I'd add that primary care clinicians should do everything we can to recognize and address the needs of caregivers, not only for the well-being of patients like Mr. B, but to sustain the health of their families and communities.

VBAC and home birth: evaluating the evidence

Thanks to a recent pronouncement from the American College of Obstetricians and Gynecologists, my two-year old daughter, who arrived via a vaginal birth after Cesarean section (VBAC), may not be a medical rarity for much longer. In a previous post, I discussed possible causes for the steep 15-year decline in the percentage of U.S. women who have delivered a child vaginally after a previous Cesarean birth (currently fewer than 1 in 10). In March, at a conference held at the National Institues of Health in Bethesda, Maryland, an expert panel concluded that the scientific evidence did not support ACOG's existing recommendation that surgical and anesthesia personnel be "immediately available" during a trial of labor. However, they found evidence that this restrictive requirement had caused many hospitals without 24-hour availability of these services to discontinue VBAC entirely.

To its credit, last week ACOG released an updated version of the guideline that states that a trial of labor is a reasonable option for the vast majority of women who desire a vaginal delivery after a previous Cesarean, including those who have had more than one prior Cesarean and those carrying twins. While continuing to assert that mothers and babies are best served by access to emergency resources, they add: "Respect for patient autonomy also argues that ... [an institutional no-VBAC policy] cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery." Amen.

Now I'll to turn to another controversial maternity care topic: home birth. The subject of a widely viewed 2008 documentary and Time Magazine story, out-of-hospital births represented less than 1 percent of all births in the U.S. in 2005, according to government researchers. A recent meta-analysis of previous studies comparing planned home and planned hospital births that concluded that the former was "associated with a tripling of the neonatal mortality rate" elicited a variety of reactions from health professionals in the U.S. and abroad, ranging from ACOG's reiterating its opposition to home births to calls for more research by the American College of Nurse Midwives and the UK's Royal College of Obstetricians and Gynecologists.

I agree that more research is needed. But as for the analysis itself, there are at least two reasons to question whether it should cause many (or any) women to reconsider their home birth plans. First, while "tripling" in neonatal deaths sounds scary, this is a relative rather than an absolute difference in risk. Reading the fine print, neonatal death occurred in 0.15 percent for planned home and 0.04 percent for planned hospital births. That's an absolute risk difference of just 0.11 percent, or about 1 extra death for every 1000 births. This difference is very close to the small increased risk of neonatal death during attempted VBAC versus repeat Cesarean section (0.8 extra deaths for every 1000 births), which ACOG has acknowledged should be a mother's choice.

Second, all but 3 of the 12 studies included in the meta-analysis were conducted prior to the year 2000, in populations with much lower Cesarean rates than in the U.S. Overall, only 9.3% of women in the planned hospital birth groups had Cesarean deliveries - a far cry from the 32% that currently occur in the U.S. So while this study's results are most applicable to countries in other parts of the world that have Cesarean rates of 10% or less, it's not clear if it captured the maternal complications that invariably result from doing 3 times as many surgeries.

The bottom line? The available evidence indicates that planned home birth is no riskier for babies, compared to planned hospital birth, than is attempting VBAC compared to choosing a repeat Cesarean delivery.

Common Sense Family Doctor celebrates its first birthday

Exactly one year ago, on July 24, 2009, I posted the first entry in this blog. I'd like to thank instructor David A. Taylor and my science writing classmates at The Writer's Center in Bethesda, Maryland, for encouraging me to channel my creative energies in this way. 124 entries later, Common Sense Family Doctor is still going strong! In case you've missed any, below are links to a compilation of my favorite pieces.

July and August 2009

September and October 2009

November and December 2009

January and February 2010

March through May 2010

Adverse Effects in Pulse Magazine, May 2010

Family Health Guide, May through July 2010

As always, thank you all for reading, commenting, and otherwise expressing your support.

- Kenny Lin

What soft drinks and cigarettes have in common

Judging by the outrage sparked by the American Academy of Family Physicians' agreement with Coca-Cola to produce patient education materials about obesity, and the respected ScienceBlogs website's brief flirtation with a nutrition blog sponsored by PepsiCo, many health professionals consider soda to be nothing less than the "new tobacco." There are many good reasons to think so. The average American consumes approximately 50 gallons of soda each year, which is thought to be a major contributor to our current epidemic of obesity, the details of which I discussed in a previous post. In 2004, the Centers for Disease Control estimated that obesity killed almost as many people in the U.S. per year (about 400,000) as tobacco did, and predicted that it would soon surpass it as the number one cause of death.

Taxes on cigarettes have proven to be very effective at discouraging their use, and early versions of the U.S. health reform bill sought to do the same by taxing sugar-sweetened beverages. In addition to reducing soda consumption, the penny-per-ounce tax would have raised billions of dollars to expand coverage for the uninsured and fund public health campaigns targeting other lifestyle behaviors that lead to obesity, such as physical inactivity.

Using time-tested tactics borrowed from Big Tobacco a generation ago (when Phillip Morris and other tobacco companies openly attacked and distorted the science linking smoking to lung cancer, heart disease, and other causes of death), the beverage industry quickly flooded Washington, DC with lobbyists and challenged research linking soda consumption to obesity. As reported in the Los Angeles Times, an industry-funded coalition calling itself "Americans Against Food Taxes" spent millions of dollars in key states to discourage Congress from including the tax in the bill - and won. State governments lost, too. Earlier this year in New York State and in Washington, DC, websites and airwaves were blanketed with "anti-tax" messages that were so effective at generating political opposition that neither of these proposals even came to a vote.

I admit that connecting soft drinks with obesity and premature death isn't quite as instinctive as knowing that inhaling a burning carcinogen-delivery system is bad for you. After all, the beverage industry argues, extra calories can come from many sources other than what people drink. But sugar-sweetened beverages are unique among junk foods in that their calories don't make us feel "full." We just keep on drinking, adding empty calories in 40-ounce Big Gulp containers or going back to the dispenser for free refills.

The president of the American Academy of Family Physicians recently wrote in the Annals of Family Medicine that there was nothing unethical about the organization taking hundreds of thousands of dollars from Coca-Cola in order to produce apparently unbiased educational content. She is wrong, and I would say this if a candy or fast-food company stepped forward with a fistful (okay, a briefcase-full) of cash next year. No one expects an organization of family doctors to say that soft drinks are good for you, but in taking Coca-Cola's money, what the AAFP is effectively telling patients (few of whom will ever visit the FamilyDoctor.org website) that soft drinks aren't really bad for you. That's the message that smokers were hearing a few decades ago, and most of them aren't alive today to wish that they had been told otherwise.

Guest Blog: Residency regulators are back

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 June 25, 2010.

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How many hours can a doctor work?

The residency regulators are back. About ten years ago, the national organization that accredits residency programs (ACGME) set out its first guidelines about how many hours a doctor-in-training can work. Interns and residents finally achieved the vaunted 80-hour workweek. (New York State was 15 years ahead on this, having mandated an 80-hour work week in 1989, stemming from the Libby Zion case.)

Every patient wants a doctor who is well rested and alert, but limiting residents to 80 hours per week wasn’t as simple a panacea as it seemed, as I wrote in an editorial in the Resident Hours Perspective NEJM shortly after the ACGME regulations were issued.

Practical issues abounded, mainly concerning the increased number of hand-offs required, as patients had to be cycled between teams of doctors. Less quantifiable, though no less concerning, was the inevitable progression toward “shift-mentality” and a decrease in professionalism.

In fact, the 80-hour workweek did not decrease errors and did not increase sleep time for the doctors. The ACGME has recognized this and has now issued a new report. In essence, they have admitted what all of us who teach new doctors already know, that medicine is far too complex to apply simple formulas. What really helps doctors-in-training practice good medicine, decrease errors, and maintain a high standard of professionalism is good supervision.

It might seem like stating the obvious, but fresh-off-the-boat interns need near-total supervision. These eager new doctors were medical students just an eye-blink ago, and a parchment diploma did not ratchet up their clinical skills overnight. A good supervisor needs to watch closely and teach intensively during this early period.

Over the next several years, as the residents gain skill and confidence, supervisors can ease back, offering more opportunities for independent decision-making. The overall thrust is that the quality of medicine delivered by residency training programs depends heavily on the quality and quantity of supervision provided.

The changes in this area are palpable. When I did my medical residency training almost twenty years ago, senior physicians (attendings) were barely present. The attending showed up once a day to see all the newly admitted patients during an “attending rounds” session, and then returned to his or her private practice. We were on our own for the rest of the patients’ care, even if it lasted weeks.

Now, I am an attending at the very same hospital, but the model is entirely different. When I spend a month supervising a team on the medical wards, I am there full-time. We still have that attending rounds session to talk about new admissions, but we also have the rest of the day. I don’t follow two steps behind my residents and interns every waking moment, but we talk constantly during the day. I also examine the patients independently to make my own clinical assessment. We work as a team six days per week and I can be reasonably sure that we are all on the same page with the patients’ care.

Do errors still happen? Are residents still exhausted? Yes, and yes. But I do think patient care is better for it.

The trick now is to teach them independence and to foster the do-whatever-it-takes-for-your-patients credo that suffused my training years. Not to mention the joys and rewards of medicine.
But that can be done in 80 hours, or at least I am hoping so.

- Danielle Ofri

The doctor will "tweet" you now

There’s a lot of evidence that to prevent many serious health conditions, including diabetes, obesity, heart disease, and stroke, making healthy lifestyle changes are just as good, if not better than, taking medications. Lifestyle changes may consist of stopping unhealthy behaviors such as tobacco and excessive alcohol use, or starting healthy behaviors such as moderate daily exercise and eating adequate amounts of fresh fruits and vegetables.

As anyone who has ever tried to quit smoking or make radical changes to their physical activity or dietary routines will be quick to tell you, though, making healthy lifestyle changes is hard! Family physicians do our best to support patients trying to make these changes. Unfortunately, with the exception of smoking cessation (where a few minutes of advice from your doctor can make a difference), doctors can’t provide nearly enough counseling in the limited time available at a typical visit. Patients trying to change their lifestyles for the better are most likely to succeed when they receive supportive messages again and again and feel that they aren’t alone in their efforts.

Social media tools such as blogs and Twitter offer a new venue to promote healthy and discourage unhealthy lifestyle behaviors. In addition to receiving regular supportive and educational messages, patients can share their own stories with a community of people undergoing the same types of struggles. Smokers who are seeking support to quit the habit can exchange tips with thousands of fellow nicotine addicts at http://www.twitter.com/quitsmoking123; patients with alcohol problems can join a “virtual AA group” at http://www.twitter.com/alcoholicsanony; and anyone interested in improving their physical fitness can find virtual lifestyle coaches and trainers at http://wefollow.com/twitter/exercise.

In addition, as recently reported in the Los Angeles Times, there has been a recent explosion in the number of consumer healthcare applications for smart phones. Many of these free or low-cost apps are designed to help improve physical fitness or encourage weight loss. Although their track records are slim, and none have yet been proven to be effective in changing behaviors, it’s probably worth giving them a try. I would recommend checking with your family doctor first to make sure that an app that you are considering provides reliable information.

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

Medical homes and the meaning of "P.C." - Part 2 of 2

In my last post, I discussed the high hopes many have for improving health care through the medical home and the sobering results of the AAFP's National Demonstration Project, which fell short of fulfilling those hopes. The "PC" in PCMH stands for "patient-centered," which means changing primary care practice to better meet the needs of patients rather than allowing patients access to care only when convenient for the practice (which I'd call a "practice-centered" approach). Some ways that the AAFP's demonstration practices did this were to offer same-day scheduling and phone or electronic mail consultations in lieu of face-to-face visits.

The potential of primary care teams will not be achieved if medical homes are too "physician-centered." This point requires some clarification. Physicians have the most education and training of any person in the practice, and they should be doing primary care tasks commensurate with their training and ability, and no more. But the primary care team that succeeds will expect the same from all of its members, including the nurse practitioner, the physician assistant, the health educator, the medical assistant, etc. and just as importantly, be responsive to their input about improving inefficient or inadequate processes of care.

Reflecting in the Annals of Family Medicine on the lessons from the AAFP's attempt at creating a sustainable patient-centered medical home model, my friend and colleague Dr. Larry Green from the University of Colorado, Denver makes several valuable observations:

The PCMH is useful, even galvanizing, but limited, as a political construct and is best understood as the rallying point for robust, modernized primary care that now necessitates a new mind model from all of medicine, policy makers, and especially those wonderful clinicians and staff members taking care of most of the folks in the US today. PCMH is really not a thing, a collection of techniques; it is presently a journey toward a destination not yet crystal clear. ...

I am not at all concerned about all the "hoopla" around patient experience getting worse during a 26 month period and small effect sizes. ... What would one expect from a traffic survey of travelers on a road under repair if asked, "Does this ride delight you? Are you getting exactly what you want from this road the way you want it when you want it?" And to lament small effect sizes is akin to lamenting less than gorgeous blossoms on roses planted in a desert, with the gardener having only a cup of water each day.

Well said, Larry.

Medical homes and the meaning of "P.C." - Part 1 of 2

In this week's issue of Annals of Internal Medicine, Dr. Adam Goldstein writes about a disabled elderly man who died from a metastatic colorectal cancer that may have been prevented had one of his physicians referred him for a screening test at one of several preceding office visits. Dr. Goldstein blames this omission on breakdowns in communication and coordination of care between multiple clinicians. He feels that a primary care team (which I discussed in a recent blog post) would have served this patient far more effectively:

With a team approach to care, 1 or more members of the team is more likely to notice when something seems amiss rather than relying on 1 team member alone. ... In addition to traditional concepts, the new medical home also focuses on integrating health care technology, quality measures, and feedback on performance - all critical aspects of a care planning process that can lead to improved systems of care for severely disabled patients.

The term "medical home" was first used by the American Academy of Pediatrics in 1967 to refer to a physician-led practice that integrated and coordinated the health care of children with chronic medical conditions. All of the primary care physician organizations, as well as the American Medical Association, now seem to agree that the PCMH is the answer to many of the ills of our fragmented, specialist-oriented health care system. But what does the "PC" in this acronym stand for? Primary care? Politically correct? And does it really improve the experience and health of patients?

A recent review of state and federal legislation related to the medical home found "a lack of a clear operational definition," and widely varying ideas about its key components. The failure of the American Academy of Family Physicians' 2-year National Demonstration Project to yield better patient satisfaction or health outcomes in practices that attempted to transform themselves into medical homes has elicited doubt among many observers that the PCMH idea will ever be successful in more than a handful of highly motivated practices.

In my next post, I'll share a more optimistic view of the implications of the AAFP's report for the PCMH, and why being a "patient-centered medical home" is about more than simply technological innovations.

Is Vitamin D vastly overrated?

Vitamin D seems to be all the rage in medicine these days. A family physician colleague commented to me last week that the laboratory test for vitamin D deficiency is becoming the most frequently ordered test in his practice. This clinical bandwagon is likely a response to data from multiple recent studies that found low vitamin D levels in the majority of children and adults of all ages. While vitamin D has always been thought to play an important role in keeping bones strong, researchers are suggesting that low levels may increase one’s risk for a variety of diseases, including cancer and cardiovascular disease.

Before you go out to your local drugstore to buy mega-doses of vitamin D supplements, though, there are at least two good reasons to proceed with caution. First, association does not always translate into causation. In other words, just because people with a low (or high) level of a nutrient are more likely to suffer from a particular illness doesn’t mean that the abnormal level caused the illness, nor does it mean that restoring a normal level will cure it. For example, studies have showed that high homocysteine levels are associated with an increased heart attack risk. When I was in residency training, cardiologists routinely prescribed folate supplements to patients who had had heart attacks in order to lower their homocysteine levels and reduce their risk of having another heart attack. However, subsequent studies determined that lowering homocysteine levels does absolutely nothing for these patients.

The second reason to be wary of the vitamin D hype is that we’ve been down this road before, with vitamins A, B, C, and E. An editorial published recently in the American Journal of Epidemiology provides a sobering summary of initial high hopes placed in each “anticancer vitamin du jour” that were subsequently dashed by randomized controlled trials. In the case of vitamin E, high doses actually appear to be harmful.

There’s a lot we don’t know about vitamin D, as an exhaustive review of the evidence for the U.S. Institute of Medicine concluded last year. Although most studies suggest that vitamin D supplements reduce the risk of fractures and falls in older adults, it’s not at all clear what the best dose should be; in a recent study, older women taking a single large dose of vitamin D each year suffered more fractures and falls than women who didn’t. In the meantime, there are many other things that you can do to keep your bones healthy, including regular weight-bearing exercise, not smoking, and eating a balanced diet that includes two to three servings of dairy products each day.

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

Guest Blog: The Disabled Boat

Steve Gunther-Murphy works in IT Healthcare at Kaiser Permanente in Oakland, California. He's been writing poetry since the seventh grade, has had works published in a variety of magazines and poetry journals, and has given poetry readings in Hawaii, Colorado and California. The following poem, first published in Pulse Magazine, is dedicated to his friends Teresa Harris and Ellen Case.

THE DISABLED BOAT

Drifting on the sea of disease
in a cardboard boat,

never knowing when the slash
of a spinal eel
will lunge from its coral-bone cave
and cut through
the threads
of a once dancing ankle
or the push of a thigh
singing race or run.

Waiting without wanting--
as the slap of a wave
against the paper-thin stern
then bow
brings on the storm
that pummels every movement
until you slip into a coma of the wind;

your sails ripped from the mainstay
and the tar between the rails
yelling like the death of a two-year-old child.

You wake weeks
later
and notice
that your keel is gone;

your body shakes like a rock cod against
the pith of the boat's floor
with the hook deep in your gill;
making you talk in slow motion
and without air.

Who wants to live this life
of a shadow fish,
pulled from the depths of who you were
and gutted of simple motions
or the ability to sing glee from your gullet?

This is not the space I am.

This is not the blue snap of yesterday
that burst forth from my mother's womb
like an iris
on an island of moss rock.

- Steve Gunther-Murphy