The most talked-about posts of 2010

Here is a recap of this year's Common Sense Family Doctor posts that received the most comments from readers (here or on other blogs such as Healthcare Headaches or KevinMD.com), in chronological order. Happy holidays and see you all in 2011!

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1. The decline of VBAC: hearing hoofbeats, thinking zebras (3/10/10) - Why women in the U.S. undergo far too many Cesarean sections, and the numbers are still climbing.

2. Shining Knights and heroic family doctors (4/1/10) - The heroism of primary care clinicians will always be underrated.

3. The cost-conscious physician: an oxymoron? (4/13/10) - Maximizing value in health care needs to be taught in medical school and residency.

4. Where will new primary care docs come from? (6/4/10) - Analyzing recent research on how to attract students more likely to pursue primary care careers.

5. What soft drinks and cigarettes have in common (7/21/10) - My critique of the controversial AAFP-Coca-Cola "consumer alliance" and the mixed message it sends to our patients.

6. Spain: an unlikely primary care model for the U.S. (8/14/10) - The successful transformation of Spain's primary care system provides a guide for how to do the same in the U.S.

7. Health reform: 4 changes to expect at your doctor's office (8/23/10) - An excerpt from my U.S. News blog post on how health reform legislation could change the patient's experience.

8. Quality assessment in primary care: an imperfect science (9/6/10) - How can we objectively measure "good" primary care in order to raise its quality nationwide?

9. The meeting that wasn't, and a surprise announcement (11/1/10) - Why I no longer work at the Agency for Healthcare Research and Quality.

10. Direct primary care: health reform's missing piece? (11/18/10) - Highlighting a primary care payment model that hasn't received nearly enough attention in Washington, DC.

Guest Blog: Family medicine's influence: let's talk!

Pat Jonas, MD is the president and medical director of Family Health Connections, Inc., a family-focused and holistic medical practice in Dayton, Ohio. He produces a weekly Blog Talk Radio show on Tuesdays from 8-9 PM Eastern on his blog, Dr Synonymous, where the following post was first published.

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FAMILY MEDICINE: INFLUENTIAL WITH PATIENTS, HOSPITALS, AND EMPLOYERS: LET'S TALK!

"You are a scarce, valuable resource," I told my colleague about 20 years ago when he felt rejected by the local hospital when bumped out of the practice he had served since proudly joining the family physician who had delivered him and cared for his family. He was inspired by the man who had served the community so well, eventually for over fifty years, and became a family doctor, just like his role model and mentor. Now, he saw the practice, in the neighborhood where he grew up, that he inherited at his mentor's retirement and merged into the hospital network to help with recruitment and management, redirected away from his philosophy of care toward hospital corporate values. What happened? Why did they close the office and order him to take the patients and practice where another recently trained family physician had been placed in practice two years ago in another retired physician's office in another neighborhood?

Hospital administrators think differently than physicians. Family physicians may even think differently than many other physicians. We care about our patients and their well-being. We haven't taken the time to verify our thought processes and our differences with hospital managers and other physicians. We need to clarify our similarities and differences now, though. We have to find our areas of mutual interest and mutual misalignment. We have to agree to disagree on many issues because of differing philosophies and business models. A creative tension between family physicians and hospital leadership benefits patients and the local economy.

Hospitals need to fill beds, CT scanners and cardiac cath labs. Patients don't want to fill them unless there is a clear need. If there are excessive medical resources such as CT scanners and cath labs, there will be a push to fill them by changing decision thresholds to use them. The creative tension between family physicians and hospital leaders can serve to find a balance in use of resources. As the family physician becomes a more scarce, valuable resource, their influence in hospitals is needed even if their presence is diminished. We are one of the keys to decreasing re-admissions of patients. We are key influencers of how our patients use health care resources, e.g. which hospital they relate to and where they go for physical therapy. We are key translators of healthcare system intentions to our patients. We are important communicators with small employers and some large employers in communities. We are trusted.

Let's get some better communication going between family physicians, hospitals and employers. It will better serve our patients and communities.

Why screening for colorectal cancer shouldn't be a hard sell

Breast and prostate cancer screening tests may dominate headlines, but in terms of the quality of the scientific evidence that early detection saves lives, there are no better cancer screening tests than those for colorectal cancer, or cancer of the large intestine. One in 20 adults will develop colorectal cancer during his or her lifetime, and detecting it before symptoms occur substantially improves a patient’s chances of survival. Nevertheless, 57,000 people in the United States still die from colorectal cancer every year; in fact, more men under age 75 will lose their lives this year to colorectal cancer than to prostate cancer.

Given these facts, I am often perplexed at why colorectal cancer screening is such a hard sell to my patients in practice. Women and men over 50 who diligently come back for annual mammograms and PSA tests politely decline when I bring up three effective and widely available colorectal cancer tests: yearly fecal occult blood testing (checking for microscopic evidence of blood in stool samples); flexible sigmoidoscopy (visualizing the lower third of the large intestine) every five years; or colonoscopy (visualizing the entire large intestine, a procedure typically performed under anesthesia) every 10 years. Nationally, other family doctors encounter similar resistance. The Centers for Disease Control and Prevention estimates that about two in five adults older than 50 is overdue for a colorectal cancer screening. As a result, patients may suffer and die needlessly from advanced cancers that, having spread to other organs, offer little hope of survival.

Why the resistance? One problem may be that patients are confused by having to choose between more than one colorectal screening test, each of which has pros and cons that are difficult to explain in a five-minute conversation. Another issue is that many patients who have had rectal examinations in doctor's offices as part of physical exams are misled into thinking that's all they need. (According to a recent national survey whose results were published in the Journal of General Internal Medicine, nearly a quarter of primary care clinicians are unaware that testing a single stool sample obtained during a rectal exam misses 95 percent of colorectal cancers and precancerous polyps.) And there's no denying that at least some of the resistance to testing stems from the "ick" factor and fears about pain, which apparently weren't completely overcome by the example of former Today show host Katie Couric, who got a colonoscopy on national television after her husband died of colorectal cancer.

The problem of low adherence to colorectal cancer screening recommendations was concerning enough that the National Institutes of Health organized a state-of-the-science conference in February to recommend ways to ramp up the use of these tests. An expert panel reviewed the available evidence and concluded that effective strategies to increase screening rates include improving patients' access to the tests, one-on-one counseling sessions with physicians or health educators, and sending reminders to patients who are due for screenings.

Two studies recently published online in the Archives of Internal Medicine provide additional proof that reminders and targeted messages can prod reluctant patients into complying. The first study, led by researchers at Harvard Medical School and Washington University School of Medicine in St. Louis, tested the effectiveness of sending an electronic reminder message via a Web-based personal health record to patients who were overdue for a colorectal cancer screening. Those who received the reminder were provided with a link to an online tool that allowed them to calculate their personal colorectal cancer risk. After one month, patients who received the message were statistically more likely to have gotten screened than patients who did not; however, by 4 months there was no difference between the two groups.

The second study was done by researchers at Northwestern University's Feinberg School of Medicine. Patients who'd been advised to get a colonoscopy but hadn't followed up within three months of the order being placed in their electronic health record were randomly assigned to either receive a personal reminder letter from their physician and an educational brochure and DVD, or usual care. Patients who received the letter were statistically more likely than patients who did not to undergo screening three and six months later, though the effect was small; even after six months, more than four out of five patients in both groups hadn't gotten a screening test.

As I mentioned in a previous blog post, electronic health records will only improve outcomes for patients if doctors use them to make patients aware when their healthcare isn't meeting proven guidelines. Even though the interventions in these two studies produced less-than-dramatic improvements in screening rates, they illustrate the importance of doctors having systems in place to identify who is or isn't up-to-date on screening. If your doctor doesn't have an easy and/or automated way to figure out if you need a test, you probably won't know, either. So the next time you visit your family doctor, consider asking him or her what tools the practice uses to communicate with patients outside of office visits about preventive health needs. Receiving these important messages could mean the difference between getting—or skipping—a test that could save your life.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Healthy lifestyle counseling challenges

I once used to see patients in a clinical practice located next door to a popular fast food restaurant. My office hours usually began in the early afternoon and ended about 9 p.m.. Whenever I was pressed for time or hadn't packed a dinner, I'd run over to the restaurant to grab a burger, french fries, and soda, and many of my colleagues did the same. As we exchanged guilty looks while sneaking in through the back entrance of the office, I'd often find myself wondering if my counseling patients to eat healthier foods was actually making any difference.

The answer, it turns out, is both yes and no. In this week's issue of the Annals of Internal Medicine, Jennifer Lin (no relation) and her colleagues at Kaiser Permanente's Center for Health Research in Portland, Oregon reviewed the latest scientific evidence on how effective medical counseling really is in terms of getting patients to improve their eating and exercise behaviors. Their analysis, which included data from 73 studies, found that counseling does, in fact, help patients make changes that lead to modest improvements in their health. They were able to lose excess weight, increase their activity, and improve their blood pressure and cholesterol levels. While few studies followed patients for more than a year, one long-term study indicated that those with mildly elevated blood pressure who were extensively counseled on switching to a low-sodium diet had a reduced risk of heart attacks and heart failure 10 to 15 years later.

There is, though, a catch: The researchers found that in order to achieve these changes, patients needed far more counseling time than doctors or nurses can offer in our current healthcare system. "Low-intensity" counseling—a total of 30 minutes or less which is typical for most patients—appeared in the study to have no beneficial effect. Only "medium" (totaling up to six hours) and "high" intensity (more than six hours) counseling made a significant difference, and these sessions were typically led by specially trained health educators rather than the patients' own physicians who may not be as well trained in dispensing specialized nutrition or fitness advice. While study participants got these services for free, those patients in the real world often find that their health insurance will only pay for counseling if they have diabetes or heart disease.

In the absence of sweeping health insurance reforms—that were, unfortunately, not included in the Affordable Care Act—some people have suggested that closer monitoring of at-risk patients could potentially substitute for one-on-one interactions with health counselors. As I mentioned in a previous blog post, remote monitoring technology that transmits information such as blood pressure readings and weight measurements from the patient's home to the doctor's office has been shown in some studies to reduce hospitalizations for heart failure—but in others, it hasn't been found to help. In a multi-center randomized trial of more than 1600 heart failure patients recently published in the New England Journal of Medicine, patients who were instructed to use an interactive telephone voice-response system to provide daily information to their physicians about heart failure symptoms and weight were just as likely to die or be re-admitted to the hospital within 6 months than similar patients who received the usual care.

One explanation for these disappointing results is that nearly 1 in 7 patients who were instructed to use the monitoring system never made a single telephone call, and little more than half of the patients were still calling the system at least three times per week by the end of the study. It's possible that perhaps the outcomes could have been improved if the doctors in the study kept closer tabs on patients who weren't calling into the system. But maybe not, since these particular patients may have been just as reluctant to change their health habits in response to their worsening condition.

The bottom line is that there is no one-size-fits-all solution to changing health-related behaviors. What causes you to quit smoking, have a salad instead of a steak with all the trimmings, or start walking for 30 minutes a day, might not have any effect on someone else. As a family doctor, I see it as my job not only to advise my patients about what sorts of behaviors are good or bad for their health, but to work with them to learn what it will take to motivate them to make beneficial lifestyle changes. If there's a fast food restaurant next door to where they work, for example, I'd tell them to consider choosing what I finally did: Leave all their cash at home and force themselves to pack a meal instead.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Guest Blog: a taste of Canada on Chicago's South Side

Shantanu Nundy, MD is an internal medicine physician at the University of Chicago and the author of Stay Healthy at Every Age: What Your Doctor Wants You to Know. The following is an excerpt from a previous post on his blog, BeyondApples.org.

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When I volunteered to start seeing patients at a nearby free clinic, I had little idea what I was signing up for. The term “free clinic” conjured up memories as a medical student in East Baltimore tending to patients at a local homeless shelter with severe frostbite or at a student-run clinic rummaging through the storage room for anti-hypertensive medications. I expected our patients to be terribly poor, the clinic to be little more than a warehouse, for supplies and medications to be few and far between, and for the care we provided to be more about putting out fires than delivering high-quality primary care.

But the place I have come to cherish working at is none of these things. A surprising number of our patients have stable lives and regular jobs – it’s just that their jobs don’t offer health insurance (including some who work in health care!). Patients call for appointments. When they arrive they are triaged by a nurse who takes their vitals and asks about their chief complaint before putting them in an exam room. We provide comprehensive primary care complete with routine lab tests for cholesterol and diabetes, age appropriate vaccinations, and referrals for mammograms and colon cancer screening.

In short, to the untrained eye, our clinic is less a free clinic than it is simply a community-based primary care clinic that happens to be free. While this is largely true, subtle yet important differences between the care I provide at the free clinic and my hospital clinic suggest that being free is more than just happenstance – it fundamentally changes the way we deliver health care and in ways that are largely for the better.

Though I can only prescribe medications on our clinic formulary, I take comfort in knowing that my patients have their medications in hand. In my hospital clinic, I can write for any prescription I want but I’m never sure whether the prescription gets filled or how much the medication costs. Sometimes I write a prescription for one type of cholesterol-lowering agent only to find out a month later my patient had to pay hundreds of dollars for it or more commonly because of the price didn’t fill it at all, or get a notice from their insurance company telling me that I should write for a different medication or requesting pre-authorization. Less obviously, handing patients their medications has changed the doctor-patient dialogue. It’s less transactional and more didactic. Often as I hand patients their pill bottles, I find myself telling them about what side effects to look out for and how and when to take the medication.

Another important difference is in our charting. In my hospital clinic, medical documentation is an ordeal. We spend hours filling out billing sheets, dictating complete physical exams and review of systems, often with little benefit to patient care. Charts become unmanageably large, with low signal-to-noise ratios and “meaning-less” use health information. I can easily find a patient’s insurance information but have to wade through sheets of paper to find out when their last mammogram was. At the free clinic, I document what actually matters. The chart is meant to support high-quality patient care – any information that detracts from this goal is not included.

Clearly the clinic is constrained by its finite resources. But within those bounds, they offer services that they feel will fulfill their mission. At my hospital clinic we offer services based on reimbursement and margins. It’s no surprise then that my uninsured patients at my free clinic have access to weight loss counseling and general nutrition counseling while my insured patients at my hospital clinic do not.

Like the rest of us, specialists offer their time on a voluntary basis and routine referrals for dental care or GI specialists may take a few months. But these delays, while inconvenient, have not negatively impacted clinic outcomes.

Overall, the differences between my hospital clinic and free clinic parallel the differences between the American fee-for-service health care system and a single payor health system like Canada’s. In the American system, ... patients receive services that are paid for by insurance companies, not necessarily those that are best for their health. Those with expansive health insurance plans often get “more” health care (though not necessarily better care) than those with less or no insurance. In the Canadian system, patients are offered services that are made available by the government based on national guidelines and individual patient-doctor decision-making. Services including medications are free, and everyone receives the same care regardless of socioeconomic status. At the risk of being political, which system do I prefer? Using the litmus test, which clinic do I prefer working in and which clinic would I prefer to be a patient? On both accounts I’ll take the free clinic down the street.

A 12-step approach to pacifier cessation

Most infant and toddler milestones - starting solid foods, sleeping through the night, and toilet training, to name a few - are the topic of an abundance of self-help books crowding the "Parenting" sections of bookstores. But a few years ago, family doctor Sumi Sexton, child psychologist Rudy Andrew, and stay-at-home mom Liza Draper noticed a somewhat surprising omission: even though nearly three-quarters of children in the U.S. use a pacifier at some point, and 1 in 5 don't discard their precious "paci" until after age 3, there was little accessible, scientifically based information for parents on how to help their kids through this commonly challenging transition.

So these three moms got together and decided to fill this void by integrating their own experiences, a survey of de-pacifying "success stories" from other parents, and the latest clinical research. The result, the recently published volume Pacifiers Anonymous: How to Kick the Pacifier or Thumb Sucking Habit, is a gem of a book. At a slim 116 pages, it is short enough to be read in a few sittings, but is packed with enough facts and helpful advice to serve as a handy reference to return to time and time again.

Unlike many self-proclaimed parenting "experts," the authors of Pacifiers Anonymous scrupulously avoid promoting a one-size-fits-all approach to pacifier or thumb weaning. Instead, they offer thoughtful, balanced discussions of the benefits and harms of pacifier use and a catalog of weaning techniques that have worked for others in the past. Their relaxed, tongue-in-cheek style includes headings such as "Sucking Secrets" interspersed with charts, pie graphs and cartoons (my favorite showing a woman behind a bar presenting two infants with a selection of pacifiers, with the punch line: "Silicone or latex?") Pacifiers Anonymous is an entertaining and valuable addition to any parenting library.