Common Sense Family Doctor in 2012: a preview

I thought about titling this post "All I Wanted For Christmas was Common Sense Family Doctor," but decided that it was presumptuous to assume you would prefer reading a collection of my blog posts to receiving, say, a new IPad, Nook, or Kindle Fire. (For readers who want both types of gifts, I hope to make Common Sense Family Doctor available on those e-readers at some point in the future, as well as in a more traditional book format.)

Here is a sneak preview of a few topics that I plan to write about after the New Year:

1) Costs and charges of health care - As you may know if you have been reading this blog from the beginning, the hospital bill for my second child (a normal spontaneous vaginal delivery) was $8,569.27, a staggering sum of money that the hospital couldn't begin to explain in an itemized bill, and of which our then-health insurance company ultimately wrote off more than 40 percent and we paid $100. Now that my wife is covered by health insurance with a 20 percent deductible on all medical services other than preventive care (alas, though the Institute of Medicine has decreed that pregnancy prevention counts as preventive care, bringing a new life into the world does not), we're naturally very interested in what the bill for our soon-arriving third child might be. I'll detail our extensive efforts to pin down the same hospital on  its usual maternity care charges, and explain why it's so hard in the current health financing environment for patients to get any straight answers about health care costs.

2) Dissecting American Health Care - I first met former Assistant Surgeon General and current RTI International Chief Scientist Doug Kamerow, MD while precepting Family Medicine residents at the Fort Lincoln Family Medicine Center seven years ago, and since then he's written dozens of short essays for National Public Radio and BMJ on a variety of health care-related topics, now collected into a terrific book that was recently reviewed by patient advocate Jessie Gruman at the Prepared Patient Forum. I'll review highlights from my favorite Kamerow commentaries and explain how his perspectives point the way toward future reforms of our broken health system.

3) Cancer and the media - Building on a cancer screening talk that I gave to reporters at the National Press Foundation a few weeks ago, I will explore the pitfalls of reporting on cancer news and ways to improve communication about the latest research findings on screening tests and treatments to the public. Gary Schwitzer's recently renamed Health News Watchdog Blog has covered much of this territory already, but I hope to add some unique contributions to the dialogue from my experiences as a practicing family physician, teacher, researcher, and consumer health blogger.

My very best to you and yours for a happy and healthy 2012!

Kenny Lin, MD

23 1/2 hours

That's the title of this thoroughly enjoyable and informative lecture on the benefits of regular exercise by Canadian family medicine educator Mike Evans, MD. It's definitely worth 9 minutes of your time.

Guest Blog: My BHAG for Family Medicine

Jennifer Middleton, MD is a family physician and residency faculty member with whom I recently gave a social media presentation at the Family Medicine Education Consortium's annual Northeast meeting. The following post originally appeared on her blog, The Singing Pen of Doctor Jen.

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I have a BHAG (Big Hairy Audacious Goal).

I want people to hear "Family Medicine" and know that it refers to a medical specialty dedicated to providing relationship-based, patient-centered health care.

I want people to know that family docs take care of a lot of complicated, challenging diseases - and not usually in isolation. Our patients have high blood pressure, complications from type 2 diabetes, congestive heart failure, depression, chronic kidney disease, emphysema, anxiety, asthma, and coronary artery disease, to name a few; treating each of those conditions individually is nothing like treating them in relation to each other.

I want people to know that I trained for three years to become an expert in my specialty. During my Family Medicine residency, I learned about providing preventive care. I learned how to treat a multitude of acute problems - colds, fractures, lacerations, rashes, etc. I learned how to deliver babies, resuscitate victims of cardiac arrest, and drop a central line into a coding patient. I can take off your moles, skin tags, and warts. I can remove your ingrown toenail and treat your acne. I can obtain your pap smear, discuss your birth control options, and treat your STDs.

I want people to know that I can care for your kid and your grandparent. I routinely counsel teens about sex, drugs, and rock 'n' roll. I am comfortable in offices, hospitals, maternity wards, newborn nurseries, intensive care units, nursing homes, and even patients' homes.

I want people to know that Family Medicine residents learn about using the best medical evidence and the latest medical technology to guide decision-making conversations with patients. They can intelligently sift through the tremendous reams of medical studies that are published daily to pull out the information most relevant to their patients.

I want people to know that those residents learn how to work within a healthcare team. Nurses, medical assistants, pharmacists, care managers, social workers, administrative staff - it takes all of us to provide outstanding care. These incredibly important people are my hands, eyes, and ears into the thousands of little tasks that must get done every day in the office and at the hospital.

I want people to know that no medical specialty is as devoted to medical education as Family Medicine. The Society of Teachers of Family Medicine holds an annual meeting devoted solely to medical student education. We are one of only a handful of medical specialties with an entire fellowship (post-residency training) devoted to faculty development - training the next generation of academic Family Medicine teachers, researchers, and leaders.

Lastly, I want people to know that family docs do everything that they do in the context of our patients' belief systems, families, and communities. Our specialty is the only one that mandates dozens of hours of educational time during residency about the doctor-patient relationship. How to help folks quit smoking/over-eating/whatever, how to tell someone that the biopsy did show cancer, how to mediate family disagreements about end-of-life wishes - this behavioral instruction is just as important to a Family Medicine resident as the pathophysiology, treatment, and prevention of disease.

If you're not a family doc, I bet you didn't know all of those things. And the blame for that truth lies squarely with us as family docs. Frankly, other specialties have been better than us at promoting themselves. You all likely know what a dermatologist or a cardiologist is, even if you're not working in the medical field. Family docs can learn a lot from how other specialties have advanced the interests of their patients by advancing their specialty's cause; it's something we have failed to recognize the importance of until now.

Because of that failure, Family Medicine is not understood - and thus not valued - by the public, by politicians, by health plan administrators, and by too many of the other people who make decisions about health care in this country.

We need to show them what Family Medicine is all about.

My BHAG is to share Family Medicine with the people who don't know about us yet. I hope that this blog does that in some small way; certainly, many of the Family Medicine bloggers and tweeters out there are doing it in a bigger way.

But, I don't think that's enough. We need more. We need an #FMRevolution. I have to believe that there's something even bigger, hairier, and more audacious that we could do. I wish that I knew just what that that big, hairy, audacious thing was. Fortunately, though, I am but one of many.

It will take all of us to get the chorus of Family Medicine to echo across our nation.

Striking back at the true rationers of health care

In February, I predicted that Don Berwick would not survive the partisan politics surrounding his recess appointment as administrator of CMS (Centers for Medicare and Medicaid Services), and regrettably, Dr. Berwick indeed stepped down from that position last week despite a number of notable accomplishments in his too-short tenure. Speaking yesterday at the annual national forum of the Institute for Healthcare Improvement, which he led for nearly two decades, Dr. Berwick struck back fiercely at politicians who have used the myth of "death panels" to oppose health reform efforts, and others who he called the "true rationers" of health care. In his own words:

Cynicism grips Washington. It grips Washington far too much, far too much for a place that could instead remind us continually of the grandeur of democracy. ... Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels” – the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas.

The truth, of course, is that there are no “death panels” here, and there never have been. The truth is that, as our society has aged and as we have learned to care well for the chronically ill, many of us face years in the twilight our lives when our health fades and our need for help grows and changes. Luckily, palliative care – care that brings comfort, company, and spiritual and emotional support to people with advanced illness and their families – has grown at its best into a fine art and a better science. The principle is simple: that we can and should offer people the very best of care at all stages of their lives, including the twilight.

The truth is, furthermore, that patient-centered care demands that the ways in which a person is cared for ought always to be under his or her control. The patient is the boss; we are the servants. They, not others, should direct their own care, and the doctors, nurses, and hospitals should know and honor what the patient wants. ... It is one of the great and needless tragedies of this stormy time in health care that the “death panel” rhetoric has denied patients the care that they want, denied caregivers the information they need to give that care, and denied our nation access to a mature, open, informed, and balanced discussion of the challenge of advanced illness and the commitment to individual dignity. It is a travesty.

If you really want to talk about “death panels,” let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say a senior citizen of marginal income, “I am sorry you cannot afford your medicines, but you are on your own?” What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins?

Maybe a real death panel is a group of people who tell health care insurers that it is okay to take insurance away from people because they are sick or are at risk for becoming sick. Enough of “death panels”! How about all of us – all of us in America – becoming a life panel, unwilling to rest easy, in what is still the wealthiest nation on earth, while a single person within our borders lacks access to the health care they need as a basic human right? Now, that is a conversation worth having.

And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.

When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of Seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.

Managing symptoms in end-of-life care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of American Family Physician, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane systematic review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care.

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The above post was first published on the AFP Community Blog.

The vital role of guideline narratives

A few weeks ago, I presented Family Medicine Grand Rounds at Georgetown University School of Medicine on resolving conflicts between screening guidelines. During the question and answer session, Department Chair James Welsh, MD asked how evidence from carefully conducted clinical trials can possibly overcome powerful emotional stories of "saved lives." I answered that evidence-based medicine's supporters must fight anecdotes with anecdotes. For every person who believes his or her life was extended by a PSA test or a mammogram, statistics show that many more are temporarily or permanently injured as a result - and their stories matter too. As blogger Kevin Pho, MD wrote about the USPSTF's recent prostate cancer guideline, "Task Force advocates will need to put a human face on the complications stemming from prostate cancer screening" in order to convince physicians and patients that it's okay to stop. Indeed, news stories about PSA test-related complications such as this one by Associated Press writer Marilynn Marchione will go a long way in balancing the scales.

An insightful commentary published in JAMA last month took this point one step further by asserting that narratives deployed to support evidence-based guidelines should include not only patients' stories, but the story of the guideline developers themselves:

Typically, experts present a “clean” version of their findings without any narrative about how they made sense of the data. This fulfills the scientific virtues of objectivity, coherence, and synthesis. When the USPSTF released its report on screening mammography to much controversy, it included no narrative about the process. Only later was the story of the task force deliberations revealed. This narrative, with multiple characters operating within the context of historical precedents, timing mandates, and a messy political milieu, created a substantially more compelling perspective. But the account came too late to engage a confused and angry public with the task force's conclusions.

Guideline developers could include as part of their reports the narrative of their internal workings: We started with what we knew, we looked at the evidence, we revisited our hypotheses, we argued about the findings, and ultimately we acted here and now because it was prudent, but there are more data to come, and here is what we plan to do as we learn more. Such stories could increase trust and therefore improve the translation of evidence for individual use and public policies.

I attended both of the Task Force's 2008 meetings when screening mammography was debated, and the difference between them spoke volumes. During the first meeting, the panel deadlocked multiple times over whether to recommend for ("B") or recommend against routinely ("C") mammograms for women in their 40s. Both sides made impassioned arguments in favor of their points of view, and after running hours beyond the time allotted for discussion, they finally admitted that they were unable to reach a consensus. In contrast, at the second meeting when the results of a new decision analysis were presented, there was - to everyone's great relief - near-unanimity that the benefits and harms of screening were closely balanced in this age group. (Incidentally, the Canadian Task Force on Preventive Health Care recently concurred with the USPSTF's 2009 recommendations.)

Given the potential for narratives to humanize guidelines for the public, it was disappointing that the USPSTF's first Report to Congress offered a thoroughly sanitized description of the lengthy and challenging process by which it identified and prioritized research gaps in clinical preventive services. This process, which I participated in as a medical officer, consisted of a series of spirited debates over more than two years about thorny questions such as: 1) Is there an objective, defensible way to prioritize certain preventive services more than others? 2) Is it more important to support research on services with insufficient evidence that are already in widespread practice (e.g., PSA tests), or less commonly provided services with potentially large benefits (e.g., CT scans for lung cancer)? Unfortunately, the Report doesn't even begin to hint at how we grappled with these and other contentious issues, much less the multiple impasses that were reached and eventually overcome.

Consequently, I couldn't agree more with the elegantly stated conclusion of JAMA commentators Drs. Zachary Meisel and Jason Karlawish:

Stories help the public make sense of population-based evidence. Guideline developers and regulatory scientists must recognize, adapt, and deploy narrative to explain the science of guidelines to patients and families, health care professionals, and policy makers to promote their optimal understanding, uptake, and use.