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.

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 October and November:

1) Family medicine leadership (10/19/10)

2) Direct primary care: health reform's missing piece? (11/18/10)

3) A different perspective on screening for breast cancer (10/5/10)

4) Telemedicine: more than what the doctor ordered (11/3/10)

5) Complexities of cardiac risk assessment (10/2/10)

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

Your primary care team will see you now

In a previous post about how health reform will change your doctor's visits, I mentioned that you're likely to see your future primary care delivered by a "team" of health professionals rather than your doctor. You might be surprised to hear that "team" is a relatively new concept in family medicine. I once had a colleague who told me, only half in jest, "My definition of good teamwork is that when I tell my office nurse to do something, he or she does it." Personally, I've always favored nurses or medical assistants who excelled at anticipating my needs: those who would prepare a suture tray when a patient showed up with a laceration, for example, or open a urine specimen container for a patient complaining of flank pain and chills.

In contrast, a high-functioning health team doesn't require doctors to issue orders all the time—or expect nurses to read their boss's mind. These medical assistants can read charts and test results to determine if a patient, say, needs a referral or isn't up to date on an immunization. Medical degrees aren't required for these things, according to a 2004 commentary on health care teams that was published in the Journal of the American Medical Association. Medical teams could allow doctors to expand their practices, and also solve the time-crunch problem where appointment slots in some offices have been reduced to 12 minutes per patient. Nurse practitioners and physician assistants can set aside far more time to discuss lifestyle changes and the side effects of various medications than doctors rushing from room to room.

Effective primary care teams delegate responsibilities so that each staff member does only what he or she is trained to do, rather than wasting time and energy on tasks that can be performed with less training. I recently introduced a group of clinicians and staff to an electronic tool that uses a patient's age, gender, smoking status, and sexual activity to determine what screening tests and lifestyle counseling needs should be addressed at a preventive health visit. Under the traditional primary care model, only the doctor would use the tool, advise patients, and order tests and immunizations. Only when the doctor emerged from the examining room would other staff members—who did little more than place patients in rooms and take weight, temperature and blood pressure—have any idea what the patient needed to have done.

In the primary care team model, the receptionist or a medical assistant could ask each patient to fill out a form with the necessary information. The medical assistant could then input this information into the tool and create a customized list of preventive recommendations. A medical assistant or nurse could then counsel patients about exercise habits, dietary practices, and smoking cessation before they even saw the doctor. They could also provide basic information about screening tests and immunizations, leaving the doctor to answer any remaining questions. If a referral was needed to obtain, say, a mammogram or a colonoscopy, the assistant could start the necessary paperwork while the doctor performed the examination.

Primary care teams are already being implemented in some practices throughout the country, and they've been shown to improve patient satisfaction levels as well as a practice's efficiency and finances, according to some recently published case studies. Efforts are now underway to teach teamwork skills in medical school and residency training programs. So what does this mean for your next visit to the doctor's office? Practices will vary, of course, but as more medical groups reorganize themselves into primary care teams, you may start to have more meaningful interactions with nurses and other office staff instead of sitting alone in an exam room waiting for your doctor to arrive. And since staff will relay your specific needs and concerns to your doctor before he or she walks into the room, you may find your concerns addressed more to your satisfaction.

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The above post is an excerpt from a piece first published on my Healthcare Headaches blog on USNews.com.

The "R" word

There is a terrific two-page commentary titled "The Real Meaning of Rationing" in this week's issue of the Journal of the American Medical Association by Drs. David Meltzer and Allan Detsky. They point out that the price disconnect caused by health insurance leads insurers to attempt to allocate health "goods and services" based on actual need or effectiveness rather than the patient's desires. Of course, in contrast to the example of wartime rationing, any person who is able and willing to pay full price for an uncovered health service can typically receive it - be it a full-body CT scan, an "executive" physical, or an anti-cancer drug.

Because many Americans are deeply suspicious of the motives of government and health insurance companies, they tend to react negatively to perceived actions by "bureaucrats" to limit coverage for services, whatever the reason. "For example," the authors write, "the challenges of rational discussion of health care reform in the United States can be illustrated by typing the words 'mammography' and 'rationing' into a Google search." Noting that "deeply vested interests" often act to inflame the debate, they add:

What is needed is intelligent discourse on what approaches to rationing work best and what values Americans most wish to express as a nation to address this problem. ... Concerns about "death panels" and debates about rationing make better press than balanced discussions of who should or should not receive a mammogram, or the effects of co-payments on appropriate and inappropriate emergency department use. It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.

I agree completely, though I wonder who will be the ones to teach ordinary citizens not to be afraid of the "R" word. Certainly not politicians, or disease advocacy groups, or for the most part, our most respected physicians and scientists. After all, as Josh Freeman noted today on his Medicine and Social Justice blog, the $250 million price tag for the National Cancer Institute's recently concluded lung cancer screening study would have paid for the entire 2008 budget of the Agency for Healthcare Research and Quality or the 2010 primary care workforce programs of the Health Resources and Services Administration. Instead, a year or two from now, when the U.S. Preventive Services Task Force examines the evidence on lung cancer screening, there will probably be lots of powerful, politically-connected groups urging them to give an "A" or "B" level recommendation to CT scans for smokers so that this service will automatically receive first-dollar coverage under the prevention provisions of the Affordable Care Act. And the "R" word will once again rear its ugly head.

Guest Blog: Home glucose testing in type 2 diabetes

Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog, DrPullen.com.

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Home glucose monitoring in non-insulin treated type 2 diabetes has not been shown in controlled studies to improve either blood sugar control or prevent complications of diabetes. Still, it is commonly used by diabetics and commonly recommended by physicians to diabetics as an important aspect of their care. What is the right thing to do? The answer is not simple.

As a pretty valid rule of thumb, we should only do a test in medicine if the results are going to be used to make a decision of some sort. In diabetics who use insulin before each meal, and vary the dose of insulin based on their blood sugar prior to the meal, measuring their blood sugar before each meal is done to obtain information on which to base a decision of how much insulin to inject. This is a classic case of using diagnostic information to make a therapeutic decision. On the other extreme, a person with type 2 diabetes who is either not on medication at all, or who is on a stable dose of oral medication, and has been well controlled over the last few doctor visits, is not going to alter his or her diabetes treatment in any way based on home blood sugar monitoring, and a good argument can be made that there is no need to be measuring home blood sugars.

In my practice I find many diabetic patients who find a good deal of comfort in checking their blood sugars more often than is needed to control their blood sugars. Some patients find daily, or even several times daily, blood sugar monitoring to be strong positive feedback that reinforces their good behavior regarding diet and exercise. Is this a good reason to do home blood sugar testing? More to the point, should third party payers, including Medicare, pay for this testing even though there is little or no evidence that it leads to better health outcomes?

I commonly am faced with non-insulin using diabetic patients who test several times daily, whose insurance companies decline to pay for this frequent testing based on lack of evidence that it is beneficial. Patients then ask me as their physician to explain to the insurer why they need to test several times a day. The reasons acceptable to the insurer usually include: insulin treatment, frequent hypoglycemia, and uncontrolled hyperglycemia. Most of these patients have none of these reasons. They just feel more confident when they know their blood sugars frequently. This can lead to patient dissatisfaction, and puts me in the awkward position of being perceived as not advocating for a patient. This issue has been a hot topic in the UK recently.

We are facing major issues regarding health care spending in America. There is great evidence that control of blood pressure, cholesterol and blood sugars in diabetes can lead to reduced health care costs. Still, with the cost of a single home blood sugar test running about $1, the cost of even once daily home blood sugar testing for a diabetic is $300 to $400 per year. There are approximately 25 million type 2 diabetics in the US. Many do not need to be testing home blood sugars. We need to do a better job of giving patients permission to test less or not at all, and yet encourage them to do the other things that do make a difference. Diabetic eye exams, blood pressure control, and lipid control all have much better evidence for morbidity and mortality prevention than does home blood sugar testing.

Direct primary care: health reform's missing piece?

Last year, in a blog post titled "the 'single payer' should be you," I profiled the innovative Seattle-based practice Qliance Primary Care, which, rather than billing private or public health insurers, charges patients a flat monthly fee for unlimited access to a broad range of primary care services:

Previous medical groups that utilized this business model often charged exorbitant fees, leading critics to label them "boutique" or "concierge" medicine, available only to the wealthy. In contrast, Qliance's fees are quite affordable: from $49 to $79 per month. This fee, combined with a catastrophic health insurance policy to protect against unexpected ER visits or hospitalizations, is significantly less expensive than traditional insurance policies - which makes sense, since 100 percent of payments go directly to the practice rather than being filtered through insurance bureaucrats. So why aren't there more advocates for a "single payer" health system in which the single payer is you?

The October 15th issue of Family Practice News featured a front-page article about Qliance and its practice model, termed "direct primary care." Although this model was absent from the "Affordable Care Act" law (which instead emphasized accountable care organizations and multi-disciplinary patient-centered medical homes), it provides benefits above and beyond simple cost savings: all in-person appointments are scheduled for at least 30 minutes.

One obvious objection to implementing the direct primary care model nationally is that there are certainly a few people for whom spending even $50 a month out of pocket for basic medical care is a hardship. But consider the comparison: at my wife's nonprofit medical clinic for uninsured patients, the monthly payroll deduction for no-frills, employer-subsidized health insurance in 2011 starts at $281.50 per month, not counting a $350 annual deductible and 20 percent co-insurance for most services. These charges amount to more than 10 percent of many employees' salaries, and has actually led some of them to seriously consider declining health insurance benefits so that they will be eligible to be seen at their own clinic.

Making more low- and middle-income people eligible for government subsidies and tax breaks so that they can afford the skyrocketing cost of traditional health insurance isn't the long-term answer to this problem. By cutting insurers out of the equation, and lowering the cost of basic health care for individuals, direct primary care models offer a real, affordable health reform solution.

VBAC redux

Several months ago, I wrote in this blog about the precipitous decline of vaginal births after Cesarean (VBAC) in the U.S., which I attributed in part to the the internalization by obstetric specialists of the medical maxim "hearing hoofbeats, thinking zebras":

Objective data support the notion that labor managed by family physicians and professional midwives is considerably more likely to result in a vaginal birth than labor managed by an Ob/Gyn, even controlling for factors such as maternal age and risk status. It isn't difficult to understand why. If an Ob/Gyn is feeling uncertain about how well a patient's labor is progressing and has an inflated estimate of the probability that something might go wrong (the zebra), it's very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically, then and there. On the other hand, if the surgeon is at least a phone call away, the family physician or nurse midwife might be more patient with the hoofbeats, betting they're hearing a horse.

In preparation for a consensus development conference on VBAC held in March at the National Institutes of Health, a team of evidence reviewers from Oregon Health and Science University prepared a comprehensive report on the factors associated with successful VBAC delivery and the benefits and harms to the mother and infant from a trial of labor. I summarize this report in the Nov. 15th issue of American Family Physician. Here are the main results:

The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). Most studies found no differences in neonatal intensive care unit admission rates.

Bottom line: "most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant." In July, the American College of Obstetricians and Gynecologists slightly relaxed their previous restrictions on access to VBAC by issuing an updated guideline. Will this guideline change and fresh re-examination of the evidence supporting a trial of labor in patients with a previous Cesarean be enough for VBAC to make a comeback in the U.S.?

Moneyball and health care quality statistics - Part 2 of 2

The Society of Thoracic Surgeons recently allowed Consumer Reports to use its national database of information about heart bypass surgeries to rate surgical groups on patient survival rates, surgical complications, and medication management. But this ranking, too, has its limitations: While about 90 percent of the approximately 1,100 cardiac surgical groups in the U.S. participate in the society's database, just 22 percent of these groups opted to include themselves in the Consumer Reports rankings. That's because they didn't want their performance data to become public. And none would allow individual surgeons to be named.

Many health insurers have begun sending confidential "report cards" to family doctors that give them feedback on their performance in managing chronic conditions such as heart failure and diabetes. These evaluations, too, have been criticized for ignoring differences in patient populations; younger patients with high-paying jobs, for example, are less likely to stop taking medications for financial reasons than older patients on fixed incomes. So a doctor with a poorer patient population might get poorer grades than one with a richer population. Still, the evaluations might be helpful in comparing two doctors who practice in the same neighborhood, if practices eventually make this information public to prospective and current patients.

In the next few years, more information should become available on the quality of care provided to patients. The government is working to compile national numbers on hospital complication rates, which would add to patient safety data already being collected such as how often incisions reopen after surgery. The new data that will soon be offered on the Hospital Compare tool will, in my opinion, be a game changer. First and foremost, it will include information on infection rates. Nearly 90,000 U.S. patients die every year from hospital-acquired infections, and about a third of those deaths are due to preventable bloodstream infections caused by the insertion of a catheter, according to the Centers for Disease Control and Prevention.

It would be nice to know how often the hospital you pick for surgery takes precautions proven to prevent these infections, like covering patients with sterile drapes and swabbing their skin with an antiseptic before a catheter is inserted and making sure doctors who do the insertion wash their hands and wear a sterile mask, hat, gown and gloves. Hospital Compare will also provide data on surgical mistakes due to foreign objects left in the body; severe pressure ulcers from not turning bed-ridden patients, falls and other accidents that occur in the hospital; blood transfusions with the wrong blood type; and signs of diabetes mismanagement.

As more reliable statistics about the quality of care provided by doctors and hospitals become available, it's important to consider what factors matter most to you as a patient. For example, clean bathrooms are nice, but most people would place a higher value on surviving the hospitalization and not needing to return after being discharged. A heart surgeon's brusque bedside manner may not matter nearly as much to you as the percentage of her patients who develop postoperative infections. And family doctors who are willing to share their numbers—and work to improve them—are likely to go the extra mile to manage your chronic condition appropriately.

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The above post (continued from a previous post) first appeared on my Healthcare Headaches blog at USNews.com.

Moneyball and health care quality statistics - Part 1 of 2

At a recent conference, Harvard surgeon and best-selling author Atul Gawande told the audience of health professionals and policy makers that he always assigns his medical students a book about baseball called Moneyball: The Art of Winning an Unfair Game. It's the story of how the 2002 Oakland Athletics, which had one of the lowest payrolls in professional baseball, were able to consistently out-compete better financed teams due to their general manager's unrivaled ability to evaluate and appropriately value players. Oakland took advantage of the tendency of other teams to overvalue players based on word-of-mouth assessments of talent or commonly measured statistics—such as batting averages and number of stolen bases—that had little relationship to winning games.

Gawande's point was that many of the Moneyball lessons can be applied to medical care when it comes to evaluating the performance of doctors and hospitals. Since I have a policy of not accepting close friends and family members as patients, I refer them to doctors with whom I've worked in the past or have met through medical conferences. My loved ones may be reassured by my recommendation, and I assume I'm pointing them to a good doctor.

But I also have a nagging worry that my gut instincts about a doctor I'm acquainted with may not correlate with the quality of care that doctor provides. I have no way of knowing if my friends and family members will get better or worse care from my referral than if they had randomly selected a name from a list. In fact, a recent study published in the journal Archives of Internal Medicine found that publicly available data on physicians such as medical school attended, malpractice lawsuit history, and specialty board certification are poor predictors of their adherence to accepted standards of medical care such as checking cholesterol levels in patients with diabetes and performing Pap smears in adult women at least every 3 years.

Take the well-known U.S. News & World Report "Best Hospital" Rankings. Whether a hospital is ranked in a particular specialty depends on its score, almost a third of which comes from its reputation with specialists. There may be a good argument for doing that, but to me it's too much like my physician recommendations. The website of the federal Centers for Medicare and Medicaid Services features a Hospital Compare tool that allows patients to search for and compare up to three hospitals at a time based on statistics such as the percentage of patients with heart failure who receive appropriate discharge instructions, medications, and smoking cessation counseling. It tells you if readmission and death rates for patients with heart attacks, heart failure, or pneumonia are better, the same as, or worse than the national average. (Higher rates of readmission could indicate that the hospital didn't do a good job of treating the patient in the first place or provided inadequate instructions for follow-up care.) It also provides subjective measures like patient surveys about the responsiveness of nurses and doctors, the cleanliness of rooms and bathrooms, and how well pain was controlled.

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The above post (to be continued in a few days) originally appeared on my Healthcare Headaches blog at USNews.com.

Guest Blog: The IOM report on the future of nursing

Stephen Ferrara, NP is a family nurse practitioner at Montefiore Medical Center in New York City. The following post originally appeared in his blog, A Nurse Practitioner's View.

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The big news this week in the world of nurse practitioners and health care was the release of the Institute of Medicine's (IOM) Report, "The Future of Nursing: Leading Change, Advancing Health." It's a logical read and echoes what NPs, patients, and some other professions have been saying for years: let NPs do the work they are already educated and trained to do without arbitrary and archaic state and/or federal barriers. This is not a "scope of practice" issue; it is allowing us to practice to the full extent of our educations.

For example, when I reflect back on my NP education, there was no course entitled, "How to sort of take care of chronic conditions but when you get in over your head, make sure you have your collaborating physician's number on speed dial." We were taught to function as primary care providers that included acquiring the knowledge base to evaluate, diagnose and treat our patients and their conditions using the skill sets and tools needed to care for our patients. NPs don't practice witchcraft or voodoo - we are providing high-quality, cost-effective and culturally congruent care.

Predictably, organized medicine is playing the "patient safety" and "quality of care" card. Bad outcomes occur when there are breakdowns in communication and from care that is uncoordinated - not usually because the clinician is incompetent.

The bottom line is (at least in New York where I practice), without a collaborating physician on record, the 14,000 or so NPs are unemployed and can't legally do anything that we were trained or educated to do. It is time to remove these non-evidence based barriers and retrospective reviews and allow us to function as true partners on the health care team. Collaboration among providers would still continue to happen, and I promise pigs wouldn't start to fly. Fourteen states have already transitioned to to an autonomous model of practice model for NPs. Lawmakers must not cave to special interests and, instead, make the tough decisions that will enable greater access to care.

Telemedicine: more than what the doctor ordered

Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure had risen dangerously. I'd adjust blood pressure medications only to find her short of breath with swollen legs—a sign of worsening heart failure—at her follow-up appointment. The trouble was, I had no idea how well she followed my instructions in between visits which occurred every month or two. Had her blood pressure been soaring at home for the past few weeks or only during the hour she was in my office? I had no way of knowing.

Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.

Given this unacceptable situation, family doctors need to adopt a new model of care that includes more frequent contacts with patients and adjustment of medications based on blood pressure monitoring at home, stress the authors of the AJMC paper who are affiliated with the University of California at San Francisco. They suggest that hypertensive patients receive home monitors to check their blood pressure on a daily basis and record the readings in a paper or electronic log. Nurses, medical assistants, or other "health coaches" should call patients every two weeks in between office visits to check on their blood pressure readings and provide counseling on lifestyle changes, such as starting an exercise program or reducing dietary sodium. If a patient's home blood pressure readings are too high, a medication dose can be increased using standard protocols that are pre-approved by the doctor. This model is supported by research: A 2008 study published in the Journal of the American Medical Association found that patients who received home blood pressure monitors and regular contacts from a pharmacist through a secure Web site were significantly more likely to achieve blood pressure control after one year compared to patients who weren't monitoring themselves.

Of course, remote monitoring or telemedicine for chronic health conditions has applications beyond blood pressure management. Remote devices can send the results of blood sugar readings or body weight measurements, in addition to blood pressure readings, from your home directly to your doctor's office. Studies conducted by the Veterans Health Administration have demonstrated that daily body weight measurements on scales remotely linked to doctor's offices can help reduce re-admission rates for heart failure patients, a major factor in reducing ballooning health care costs. In fact, 12 states now require that health insurance plans cover telemedicine services, and 25 states reimburse doctors for telemedicine services through their Medicaid programs.

Even in states that don't mandate coverage for home health monitoring, many health insurers are introducing pilot programs that provide free equipment to selected patients, provided that their doctors show they're utilizing the data to improve care. If you have high blood pressure or another chronic health condition that might benefit from monitoring in between office visits, it's worth checking with your doctor and insurance provider about options that could be available to you at little or no cost.

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

The meeting that wasn't, and a surprise announcement

Although I normally arrive at work around 9 AM on Mondays, today would have been an important exception. This was to be the first day of the third U.S. Preventive Services Task Force meeting of 2010, and about now, outgoing Task Force Chairman Ned Calonge would be calling the meeting to order and asking every person in the room, including staff, observers, and the medical transcriptionist, to introduce themselves by name, position, and one interesting personal fact that changed from meeting to meeting. One meeting it was birthplaces; another meeting it was our favorite vacation spots; another, our favorite quotations. Even though this process often consumed half an hour or more, Dr. Calonge believed that getting to know each other a little bit better was crucial to the success of dissecting volumes of scientific evidence and making recommendations that would affect primary care clinicians and patients throughout the United States, if not the world.

As reported in this article in the Wall Street Journal's Health Blog, however, there is no USPSTF meeting today. And while the question of why the meeting was cancelled is perhaps easily answered by looking at the calendar, in my mind it is much less apparent how to repair the damage that this setback did to the Task Force, medicine, and the fragile public trust.

This leads me to an announcement that may come as a surprise to some: in less than three weeks, I will be leaving the support team of the USPSTF and resigning from the Agency for Healthcare Research and Quality. I am looking forward to having more time to spend writing this blog and Healthcare Headaches, as well as expanding my medical editing roles at American Family Physician and returning to patient care. But I will miss my colleagues at AHRQ and the Task Force very much. To borrow a line from a farewell message I sent to many of them last week, they deserve all our thanks for everything they do (and will continue to do) to make the U.S. health care "system" a little bit more rational, despite the many obstacles and challenges. Politics trumped science this time, as it has in the past, and may at times in the future. On the bright side, though, in a few more weeks the growing force of private sector allies of the USPSTF and evidence-based medicine will have one more member, and I'm ready and willing to speak my mind.

No Common Sense Family Doctor post this week

I will be busy preparing a presentation on blogging and using social media tools for the Family Medicine Education Consortium's Northeast Region Meeting in Hershey, PA and also laying the groundwork for a big announcement early next week (how's that for a teaser)? If you can't wait that long to get your blog fix, there will be a new post on my Healthcare Headaches blog on USNews.com tomorrow or Wednesday. See you all in November!

Improving care with electronic health records

For most of my career, I kept track of my patients' health histories by scribbling hand-written notes in a paper chart. For a healthy child, I'd include dates when vaccines were given; for an adult with, say, diabetes, I'd make sure to jot down a recommended schedule of blood and urine tests as well as foot and eye exams. A majority of primary care physicians, in fact, still use this kind of tracking system—despite research suggesting that these handwritten flowsheets aren't just inefficient, but extremely vulnerable to errors. Some say the solution lies in simply switching to electronic medical records.

After all, paper charts don't automatically update themselves when, say, the Centers for Disease Control and Prevention makes a new vaccine recommendation. An electronic medical record system can do that and can also allow test results to be emailed or transferred automatically into a patient's chart; paper charts rely on office administrators to input them by hand, which can lead to mistakes. I, myself, have occasionally forgotten to record that a vaccine was administered during the chaos of a busy work day. Nor did I have any systematic way of knowing how many of my patients were actually receiving the preventive and chronic care they needed.

But the latest research suggests that electronic health records don't necessarily improve care unless they include interactive features: They should make it easier for doctors to implement proven guidelines for good care, providing the necessary shots and screenings, follow-up exams and treatments to help patients live longer with chronic diseases or to prevent these diseases altogether. Ideally, these records should include a software tool that periodically culls through patients' records looking for gaps in care such as who is overdue for a cholesterol screening or flu vaccine. The system would then send out reminders to patients to come in for a test or appointment.

Kaiser Permanente added such a tool to their electronic medical record system several years ago and found that it works to improve care. A study published last month in the American Journal of Managed Care found that the support tool brought more diabetes and heart disease patients in for health screenings, vaccinations and medication adjustments. After three years, for patients with diabetes, the percentage of care recommendations met every month increased from 68 percent to 73 percent; for heart disease patients, the percentage rose from 64 percent to 71 percent. Another study found that the tool helped more healthy patients get recommended screening and exams for preventive care. Bottom line: This support tool lowers the rate of skipped appointments and gaps in care.

This is great news if you use Kaiser Permanente for medical care, but what if you don't? Well, you can probably expect to see some significant changes at your doctor's office over the next three to five years. Physicians who take advantage of government financial incentives to set up electronic medical record systems must prove they're making "meaningful use" of the data from the health records, meaning that they've improved patient care as a result.

But now is a good time to ask your doctor about how your records will be handled in the future. Will a fail-safe system be implemented to ensure that you don't miss crucial office visits or screenings? If you see more than one doctor on a regular basis, find out if your primary care clinician—the one responsible for coordinating all of your care—uses a system that's compatible with the systems your specialists use. This will make it far easier to transfer test results and updates to prescriptions back and forth between various offices. Otherwise, the responsibility for keeping your medical chart up to date will fall on your shoulders. If you're not satisfied that your doctor is staying abreast of all these technological changes, you might want to consider switching to another practice.

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

Family medicine leadership

A recent commentary in the New England Journal of Medicine by family physicians Thomas Bodenheimer and David West examines how the city of Grand Junction, Colorado has managed to provide above-average quality health care with Medicare costs that are 24% lower than the national average. The explanation that Grand Junction residents are simply healthier that residents of other U.S. jurisdictions doesn't hold water. So what differences in the health care system of this community can be credited for its remarkable results - and applied to other communities across the country? Bodenheimer and West answer:

We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adapted elsewhere. These are

leadership by the primary care community;

a payment system involving risk sharing by physicians;

equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients;

regionalization of services into an orderly system of primary, secondary, and tertiary care;

limits on the supply of expensive resources, including specialists, beds, and equipment;

payment of primary care physicians for hospital visits; and

robust end-of-life care.

Although these innovations are mostly common sense, the perverse financial and political incentives that drive the U.S. health system (before and after the implementation of this year's reforms) present obstacles to many of them, from equalization of physician payment (requiring fresh infusions of dollars from tight state and federal budgets) to the appallingly inaccurate portrayal of end-of-life care as "death panels" (see my previous posts here and here).

We're just two weeks away from a midterm election that will likely alter the national political landscape, but no matter which party ends up with a legislative majority, patients and physicians can't look to the parties for sensible health policy solutions. To improve population health in this country, the professionals who care for the "folks" - family physicians and other primary care clinicians - need to lead the way by advocating for changes that will give every community a fighting chance to replicate the successes of Grand Junction.

Guest Blog: Advocating for change at community health centers

Dr. Keisa Bennett is a family physician in Lexington, Kentucky who previously saw patients at a community health center in Washington, DC while completing a fellowship in primary care health policy. The following piece was originally posted on her blog, Ruminations of a Family Doctor.

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I had a bright spot listening to the head of DC Primary Care Association criticize community health centers, the very entities her organization exists to support (in a way). Sharon Baskerville's beef with the CHC model (and she makes it well known, so I'm not "outing" her here), is its arrogance and self-righteousness. "We're doing good things for poor people," we say, but what we mean is: "We're doing better than nothing for people no one else cares about." We who reject a "cush" job in the 'burbs with a well-educated, well-insured patient population are sure we're saints. And to be sure, many people who work in CHC's have indeed made great personal sacrifices to work with and advocate for their patients.

The danger in this arrogance, however, is the "better-than-nothing" mindset. It makes us work hard and feel justified, even if our patients wait for hours to see us only to be turned away or told they need to go to the emergency room. Even if our clinic looks dingy and has folding chairs and no toys or magazines during those waits. Even if we skimp on using phone translation because it's so darn slow and seeing more patients must mean we're doing "better".

We get so caught up in doing better care for the indigent, we excuse the fact that we don't question why medical indigence even exists. We doctors don't want to admit that a few trained community health workers could do at least half of the services we're doing more efficiently. No one wants to ask the patients what they really want because we already know the answer. They want what we want, and we wouldn't want to travel by bus and by foot for 30 minutes just to sit in a dingy waiting room all day only to be told that our baby's horrible, scary cough doesn't need any treatment and then be scolded for not using the thermometer correctly.

We would want a trusted person or persons we could call on when we were afraid of a symptom or unsure whether to go to the doctor. Someone who would gather community members together to help everyone figure out how to make the whole environment healthier. When we did need a doctor, we would want to go to a warm, welcoming place where the staff greeted us as a friend and enjoyed serving us and we were happy to pay for their care in one way or another. We want a relationship with at least one person in this office who we can trust to be our advocate. We want these people to communicate well with any higher-level or specialty care we might need.

And if some of us deserve this, all of us deserve it. Shouldn't we all work for it? We would have to give up a system of "better than..." The trouble with trying to make things good for everyone is that a lot of better than disappears. Martyrdom and crusades have to be let go of, given up. We crusaders don't think we are holding up change, but as long as we work for CHCs existing in their present form, we are part of the inertia.

- Keisa Bennett

Challenging conventional clinical wisdom

Over the past few years, I've been invited to speak twice at Lancaster General Hospital (PA) about studies of the effects of screening for colorectal and prostate cancer. Recognizing the need to further explore the controversies surrounding the evidence for these tests, Dr. Larry Bonchek kindly asked me to write a scientific commentary about these topics for the Journal of Lancaster General Hospital, which he edits. The result was the article "Challenging the Conventional Wisdom on Colorectal and Prostate Cancer Screening," just published in the journal's Fall 2010 issue. You are more than welcome to read the full article online, but here are my bottom-line conclusions for clinicians and patients:

The decision to perform screening for colorectal or prostate cancer can be complex, and should take in account evidence-based recommendations, the implications of recent studies, and patient preferences. In order to give patients accurate information on the benefits and limitations of cancer screening tests, physicians should discard “conventional wisdom” that has not been supported by scientific evidence. To briefly review:

1) Collecting a fecal occult blood sample for screening during the digital rectal examination is not “better than nothing at all.”

2) FOBT and flexible sigmoidoscopy have comparable benefits and fewer harms than screening colonoscopy.

3) Benefits of PSA screening on mortality are likely small to none.

4) Overdiagnosis and overtreatment of PSA-detected prostate cancers cause substantial harms.

Recent evidence on low-carbohydrate diets

I first heard of the Atkins diet back in medical school 12 years ago when one of my classmates abruptly began eating steak without potatoes and hamburgers without the bun. I was skeptical that this odd regimen would work, but his experience and subsequent research has shown that low-carbohydrate diets are as effective as traditional low-calorie, low-fat diets for losing weight.

A more important question is whether a low-carbohydrate diet, which includes higher amounts of protein and fat than the typical higher-carb diet, is as good for your heart in the long run. Two recent studies published in the journal Annals of Internal Medicine seem to provide conflicting answers. In the first study, researchers randomly assigned 307 overweight adults to a low-carbohydrate or a low-fat diet, in addition to exercise counseling. After 2 years, participants in both groups had lost an average of about 15 pounds, but the low-carbohydrate group had a significantly greater increase in HDL "good" cholesterol.

The second study, though, found that all low-carbohydrate diets aren't created equal. This one followed 100,000 male and female health professionals over a period of 20 years or more to see whether the amount of carbohydrates, fat and protein they ingested had any impact on their health. Participants whose diets were classified as the lowest in carbohydrates were 12 percent more likely to die during the study than those who consumed the highest amount of carbohydrates. But it was the low-carb, meat-loving folks who had the highest risk of death from heart disease and cancer compared to low-carb dieters whose protein sources were mostly vegetables.

So which study should you believe? Unfortunately, neither provides a definitive answer about whether low-carb diets are good or bad in the long run. Although the first study confirms that low-carb diets lead to weight loss and an increase in HDL cholesterol, that doesn't mean followers of these diets will wind up with less heart disease down the road. Also, participants in the first study had access to trained health counselors who met with them 37 times over two years to make sure that they rigorously adhered to the diet and exercise plan—a valuable resource that most people can't afford. While the second study provides more long-term data on low-carb diets, the researchers couldn't control for every factor that might affect a person's risk of dying such as, for example, exposure to air pollution. Rural folks might be more likely to eat more plant proteins like soybeans, while also having less exposure to air pollution than urban folks who might gravitate towards meat-based meals. So the type of protein people ate may not have been completely responsible for the difference in death risk.

If you're thinking of trying a high-protein, low-carb diet to lose weight or improve your health, consider the following factors based on the latest research.

1) You have a good chance of losing weight if you follow the diet faithfully, and you will most likely find it easier to stick with than a low-fat diet.

2) In order to keep off any weight you lose, you need to increase your physical activity. Aerobic exercise (walking, jogging, swimming) produces better results for weight maintenance than strength-building exercises (pushups, lifting weights), though a combination of both types may offer additional health benefits, such as prevention of injuries.

3) Although low-carb diets have been shown to improve cholesterol in some people, we don't know if they protect against heart problems in the long run. One thing I do know: If a diet sounds too good to be true, it probably is. In this case, current research is consistent with common sense. Replacing carbs with tofu and steamed vegetables is likely to be better for your health than baby-back ribs and pork loins.

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

A different perspective on screening for breast cancer

A nurse practitioner and writer living in Washington, DC, Veneta Masson contributed a guest post to Common Sense Family Doctor earlier this year. This month, she published a thought-provoking piece in the journal Health Affairs, titled "Why I Don't Get Mammograms." Explaining her decision to stop receiving yearly mammograms after age 56, she eloquently articulates her perspective as a patient informed by clinical experience and syntheses of scientific evidence regarding the benefits and harms of screening for breast cancer. In doing so, she challenges the public and medical consensus that routine mammography is an unqualified societal good. Ms. Masson concludes:

I accept that sooner or later, I’ll die of something. It could be breast cancer. It’s also possible that I’ll die with cancerous changes in my breast (or some other location) that never progressed enough to cause harm. ... It’s been ten years since my last mammogram. I don’t have to wonder whether this will be the year for a false alarm, false reassurance, or discovery of a cancer that might or might not require treatment. I accept the fact that life is uncertain.

I’m grateful for the gift of good health, recognizing that that’s what it is: a gift. I will always mourn my sister’s untimely death, which took place three years after her [breast cancer] diagnosis despite state-of-the-art treatment. If it were in my power, I’d honor her by redirecting the $5 billion this country spends each year on screening mammography to other purposes. I’d direct those sums instead to the study of how breast cancer starts, and what we can do to treat it more effectively.

This piece is especially timely in light of a recent study in the New England Journal of Medicine that suggested that nearly two-thirds of the reduction in breast cancer mortality observed after the implementation of routine screening mammography in Norway was actually the result of advances in treatment, rather than earlier detection. Both articles are must-reads for clinicians and patients who want to better understand the limitations and tradeoffs associated with breast cancer screening and screening for cancer in general.

Complexities of cardiac risk assessment

One of the most powerful patient education tools I've used in practice is the Framingham Heart Study's coronary risk calculator, which estimates the 10-year risk of having a heart attack using age, sex, smoking status, cholesterol and blood pressure levels. I've frequently used this calculator to illustrate that quitting smoking is far more effective at lowering one's heart attack risk than taking drugs to lower cholesterol and blood pressure to recommended levels.

It turns out, though, that not all risk calculators are created equal. A recent study published in the Journal of General Internal Medicine found that many online heart risk calculators, including the one on the American Heart Association's website, use a simplified algorithm (a point-based tool, rather than an equation) that ends up estimating an artifically high risk for 10% of adults and an artificially low risk for 5%. Worse, using the faulty calculator, 39% of patients with high cholesterol would have met criteria for more intensive therapy (either a higher drug dose or the addition of a new drug) than necessary. Since most doctors are unaware of differences between the calculators, it's possible that millions of patients might be misclassified and subjected to more treatment than they really need.

While the solution to this problem is fairly obvious - toss the point-based tool, which was created to help docs do pen-and-paper calculations in the days before widespread Internet access - the solution to another problem of estimating cardiac risk is much less clear. As it is with many other health conditions, socioeconomic status (i.e., being poor) is an independent risk factor for heart attacks that isn't counted by the Framingham calculator.

But it's clearly impractical (and ethically questionable) to practice primary prevention of heart disease on the basis of an individual patient's family income. So a group of researchers publishing in the current issue of Annals of Family Medicine suggested a somewhat more workable alternative: substituting individual incomes with residential income quartiles derived from census areas, since people of similar income levels tend to live in the same neighborhoods. They suggest that electronic health records might be programmed to automatically incorporate the patient's street address into the coronary risk calculation, or conversely, lower the risk thresholds for cholesterol-lowering treatments.

I was attracted to family medicine partly out of a desire to reduce health disparities, but I honestly hadn't imagined that doing so would potentially involve prescribing more cholesterol-lowering drugs to people just because they happened to live in poor neighborhoods. On the other hand, it seems unethical to expose poorer patients to higher heart attack risks just because I feel uneasy about differentiating patients based on socioeconomic status. I'd very much enjoy hearing other clinician and patient perspectives on this issue.

Self-management support doesn't help in heart failure

Heart failure is the most common reason seniors wind up in the hospital, and many patients are hospitalized again and again. They find it's just too difficult to properly manage their condition with its complex drug regimens, dietary restrictions, and frequent monitoring—all of which have been shown in studies to reduce their risk of severe disability and even death. As a family doctor, I've always had a hard time getting my patients to adhere to my advice on managing their heart failure and assumed that any additional one-on-one counseling would be beneficial. Turns out, though, that may not be the case. A study published in a recent issue of JAMA finds that patients with heart failure who receive customized support are no less likely to suffer from disabling symptoms, be hospitalized, or die prematurely than patients receiving standard educational materials.

Self-management support has been shown to improve blood sugar control and quality of life in patients with diabetes. It differs from traditional patient education in that it enables patients to better monitor their own conditions, set personal goals, and overcome any physical or psychological impediments that prevent them from controlling their disease. Rather than, say, simply handing a patient a brochure about the disease and its treatments, a doctor would help patients implement problem-solving strategies and tap into community resources. For example, clinicians might help patients sketch out exercise plans or help them join a local YMCA or neighborhood walking group. They would also check in with patients every week or two to see if those exercise promises were being kept.

The researchers in the JAMA study, which included more than 900 patients with mild to moderate heart failure, randomly assigned participants to either receive face-to-face counseling with educational materials or just the materials without any counseling. Those who received counseling attended two-hour meetings 18 times over the duration of a year to learn skills in monitoring their condition, reducing stress, altering their diets and calling on family and friends for support with their changes. Unfortunately, the study found that these intensive efforts were no better than basic educational materials.

I prefer, though, to look at this from a positive perspective. Those patients in the study who received just the educational materials were actually quite successful at reducing their sodium intake and reported less depression and improved confidence in their ability to manage their disease. These patients had 18 tip sheets mailed to them over a year and received followup phone calls to make sure they'd received each one; the caller also answered any questions patients had about the sheets. This type of support that the control group received, frankly, goes above and beyond the normal standard of care for most heart failure patients. What's more, it was just as good as 36 hours of face-to-face meetings—and far less expensive.

For me, the take-home message of this study is that if you have heart failure, you should learn as much as you can about things you can do to manage your condition, and the way you get that information doesn't seem to matter. Perhaps face-to-face counseling with a doctor or nurse works best for you. Maybe you'd rather take home some handouts to read on your own or look up information online from reputable health sites run by the government or university health centers. Or you may choose to turn to social networking tools such as blogs, Twitter or smart phone apps that have supportive and educational messages. While these technologies weren't included in the JAMA study, I'd be surprised if they don't turn out to be effective too.

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The above post is excerpted from "Heart Failure Treatment: Counseling Not Necessary," first published on my Healthcare Headaches blog on USNews.com. (By the way, I don't write the headlines. In this case I would not have chosen those words. Counseling is necessary and good - but more counseling may not be better.)

One month until the FMEC NorthEast Region meeting

For those of you who are family physicians or teach family physicians-in-training, I want to make sure you're aware of the Family Medicine Education Consortium (FMEC) and their upcoming Northeast Region meeting ("Family Medicine Innovations: Blueprints for Redesigning Health Care") in Hershey, PA at the end of October. Along with accepting an award for creative nonfiction, I will also be participating in a panel discussion on the uses of social media for personal and professional purposes. Plenary speakers will include Paul Grundy, President of the Patient-Centered Primary Care Collaborative; and Roland Goertz, President-Elect of the American Academy of Family Physicians. You can learn more about this exciting conference by checking out its unofficial blog or watching the professionally produced YouTube video below.

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 August and September:

1) Spain: an unlikely primary care model for the U.S. (8/14/10)

2) Air, space, and primary care checklists (8/23/10)

3) Primary care and health disparities (9/16/10)

4) Care management for chronic health conditions (8/28/10)

5) Quality assessment in primary care: an imperfect science (9/6/10)

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

Money-saving medication tips

When you purchase a new item of clothing, television set, or a car, as a general rule you can assume that the higher-quality items are the newest and/or those with the highest price tags, even if you know little about the products themselves. But this approach is often a poor guide to purchasing medications, where the newest and most costly drugs are often no better than, and occasionally inferior to, older and less expensive ones.

Most family practices have a "sample closet" stocked with free samples of brand-name prescription drugs for common conditions. When I was in training, I often gave financially needy patients who were starting a new medication a one month supply of samples instead of a prescription. Although it seemed like a money-saving idea at the time, it wasn't long before the samples ran out, and my patients were left with the choice of paying for an unnecessarily expensive medication or switching to a less expensive drug that they hadn’t tried before. In fact, a 2006 study in the Journal of the American Board of Family Medicine found that practices that distributed free drug samples actually cost their patients an average of $7 more per prescription per month than practices that did not give out samples.

This added cost might have been worth it if patients were paying for higher-quality medications, but most new drugs offer no clinical advantages. The Food and Drug Adminstration requires only that new drugs be superior when compared to a placebo, not to the best drug already on the market. Also, in order to maintain patent protection and prevent competitors from offering cheaper versions, pharmaceutical companies often develop “new” drugs with trivial differences from the originals. For example, prescription Clarinex for seasonal allergies is more expensive, but no more effective than, over-the-counter Claritin, and prescription Nexium for acid reflux is more expensive, but no more effective than, generic omeprazole.

Even worse, a few drugs that are commonly stocked in sample closets turn out to be downright dangerous to your health, since rare and potentially fatal side effects often don't become evident until a drug has been on the market for several years. I remember (and regret) giving out countless samples of Vioxx instead of over-the-counter ibuprofen to patients with arthritis pain; this drug was withdrawn from the market in 2004 after studies showed that it increased the risk of heart attacks and strokes. Avandia, an expensive diabetes drug that has been a fixture in sample closets for years, is the subject of an ongoing FDA safety review about its potential to increase the risk of heart attacks and heart failure.

There are a few easy things that you can do to avoid paying too much for your medications. When your doctor suggests that you need a new medication, ask if it’s possible to prescribe a less costly or generic alternative. Many pharmacies and discount chains offer one month supplies of generic medications for $4 or 90-day supplies for $10. If you are taking more than one medication for a condition (high blood pressure, for example), generic pills may be available that combine two drugs in one. If you don’t have insurance coverage for prescription drugs, some pharmaceutical companies and local and state government agencies often offer sizeable discounts on frequently prescribed drugs for people who meet certain financial requirements. (Here are more details on the Together Rx Access program offered by drug companies.)

Finally, after you have been on a stable dose of a medication for three months or more, consider buying several months’ supply in bulk via mail order. The Pharmacy Checker website provides a useful tool for comparing drug prices among reputable online pharmacies. I have usually advised patients to check with me before doing this, in case I anticipate making a change in their dose or frequency.

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The above post is adapted from "Drug Discount: 5 Ways to Save at the Pharmacy," first published on my Healthcare Headaches blog on USNews.com.

Patient-centered primary care: easier said than done

Two months ago, surgeon and New York Times columnist Pauline Chen observed that primary care demonstration projects have spent most of their efforts building components of the "medical home" - such as proactive, team-based care and health information technology - without necessarily making it "patient-centered":

Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.

It's welcome news, then, that a pair of insightful, accessible analyses of the potential and challenges of the patient-centered medical home model were published last week. The first article, a Health Policy Brief from the Robert Wood Johnson Foundation, succinctly explains the key elements of the medical home, provisions in U.S. health reform legislation designed to spread its adoption in primary care, and remaining questions, including:

1) What does it mean to be a patient-centered medical home?
2) How will we know whether they work?
3) Are patients and physicians ready?
4) Are they for everybody?
5) Do we have the necessary political and financial resources?

The second article on the PCMH, published in the September issue of Family Practice Management, bears the appropriate subtitle "Still a Work in Progress." It describes the variety of pilot projects that are ongoing across the nation, involving "over 14,000 physicians in nearly 5,000 practices caring for nearly 5 million patients."

For these projects to be successful, those 5 million patients need to experience being at the center of their primary care. What does that mean, exactly? In the August issue of Health Affairs, several prominent family medicine researchers defined a patient-centered approach as one that "fosters interactions in which clinicians and patients engage in two-way sharing of information; explore patients' values and preferences; help patients and their families make clinical decisions; facilitate access to appropriate care; and enable patients to follow through with often difficult behavioral changes needed to maintain or improve health."

It's hard for me as a family physician to read those words and not think that patient-centered primary care is stuck in a sort of chicken-and-the egg scenario. In order to "earn" more time per patient visit, we've been asked to prove to insurers, payers, and government officials that the patient-centered medical home provides additional value beyond traditional primary care. But in order to do all of the things that constitute patient-centered care, we first need to be able to spend more time with patients. Therefore the subtitle of this post: easier said than done.

Primary care and health disparities

One of the ugliest incidents in my career occurred during my faculty development fellowship year, when I spent two days each week seeing patients at several federally qualified community health centers in inner city Washington, DC. Midway through the year, I was transferred from a health center that served an African-American population to one serving a mostly Spanish-speaking clientele. Nearly all of the permanent primary care clinicians at this health center spoke fluent Spanish, and I saw it as a sign of the center's desperate need for clinicians that they willingly accepted a family physician who had never managed to learn enough Spanish to ask any questions more complex than "where does it hurt?"

The plan had been for me to be paired with a Spanish-speaking medical assistant who could also function as an interpreter, but due to staffing changes and the reality that medical assistants have many responsibilities, that never worked out. So I found myself spending hours using awkward telephone translation services, pressing patients' relatives and children into service as translators (a big no-no), or as a last resort, deliberately avoiding picking up the medical charts of patients who knew no English.

None of these actions endeared me to the other clinicians, but one in particular, a short-tempered Latino family doctor who had worked at the health center for many years, seemed offended by my presence from the outset. After weeks of giving me the silent treatment, one day he literally exploded and told me in no uncertain terms that I had absolutely no business seeing patients there (especially "his" patients) when I couldn't speak the language, and that the constant influx of temporary physicians from academic medical centers like me who moved on to other things was what gave health centers for the underserved a reputation for poor quality.

Several years removed from that professionally and personally distressing incident, I came across a study in the Archives of Internal Medicine that examined the relationship between proportions of minority patients served by 96 U.S. primary care clinics and elements of their workplace and organizational environments. Consistent with my experience, clinics that served at least a 30% minority population reported that their patients often spoke little or no English, had lower health literacy, and had more complex and chronic medical problems such as depression, pain syndromes, and substance abuse. To address these challenges, these clinics had access to fewer resources (medical supplies, referral specialists, pharmacy services, and examination rooms) and were more likely to have "chaotic" work environments and low job satisfaction than clinics serving less than 30% minorities. The authors concluded that primary health care for minority populations in this country is both "separate and unequal," and suggested that health disparities may be due as much to disadvantages built into the provision of care as to patient-centered factors.

And last week, JAMA published an important analysis of Health Plan Employer and Data Information Set (HEDIS) performance measures of 162 primary care physicians in a practice-based research network in eastern Massachusetts. The authors concluded: "Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary care physicians."

My hat is off to family physicians and other primary care clinicians who care for underserved patients. Every day, you make do with less, manage more challenging clinical problems, and to add insult to injury, apparently are now getting dinged on the quality of care you provide. There is no excuse for the way I was treated in that clinic many years ago, but I have come to understand my antagonist's "us versus them" mentality as a coping mechanism. Making a real dent in health disparities will require more than expanding Medicaid coverage and building new community health centers. Creative programs are also needed to attract top-flight family physicians to practices for the underserved and keep them there by providing the necessary support for them to thrive, professionally and emotionally.