Wednesday, June 27, 2012

Family physicians and Communities of Solution

Every so often, American Family Physician reviews a public health topic, such as outdoor air pollutants, disaster preparedness and response, or reducing the effects of climate change. And occasionally we receive feedback from readers who suggest that these topics are not appropriate for a family medicine journal, since family physicians are practicing clinicians who provide direct care to individual patients, not public health professionals responsible for large populations. However, this view of the limited role of family physicians is by no means unanimous.

In response to concerns about the shrinking scope of family medicine, Dr. Joseph Scherger wrote on the Society of Teachers of Family Medicine blog that "family medicine today is more complex and expansive in some ways than ever before." Family physicians must learn advanced motivational counseling and information management skills to practice excellent preventive and chronic care. Also, the patient-centered medical home requires family physicians to take population-based approaches to managing chronic illnesses.

In March, the Institute of Medicine published a report on opportunities for integrating primary care and public health. Notably, the report did not advocate for large numbers of family physicians to obtain formal public health degrees. Just as an editorial in the Annals of Internal Medicine argued that the subspecialty of geriatric medicine would be best served by incorporating its unique resources and skills into primary care training, a group of family medicine leaders convened by the American Board of Family Medicine recently declared:

The modern primary care physician, who values “community participation, political involvement, and collective advocacy," can, in effect, be a true public health professional, forming partnerships with community-based organizations that facilitate healthy change. This paradigm shift includes the transition from treating individuals in isolation to treating people in the context of their lives in their communities, indeed, culminating in community-centered care.

In a publication in the Annals of Family Medicine, this group re-examined and updated the 1967 Folsom Report, which provided a blueprint for connecting the personal physician with community resources in "Communities of Solution." What do you think of this ambitious vision of the family physician as a public health professional? Is this a desirable goal, and if so, what would it take to achieve it?


The above post first appeared in the AFP Community Blog.

Sunday, June 24, 2012

What you could lose in the battle over health reform

Although I will refrain from predicting how the U.S. Supreme Court will rule this week on the legal challenge to the individual health insurance mandate provision of the Affordable Care Act (aka "Obamacare"), I strongly believe that striking down the entire law would do considerably more harm than good. To illustrate what could be lost in this political donnybrook, below is a post that originally appeared on my "Healthcare Headaches" blog on a few months after the law's passage in 2010.


4 Health Reform Changes to Expect At Your Doctor's Office

As a family physician, I've gotten used to attending dinner parties where relatives, friends, and sometimes complete strangers ask me about health reform, and how the new law might impact their relationship with their doctor. Unfortunately, because I'm well versed in all the complexities of the legislation, I can't come up with a simple sound bite. But a paper published in the Annals of Internal Medicine in August 2010 attempted to explain how the Affordable Care Act is likely to transform the practice of medicine and outlined what changes doctors will need to make in order to provide better care for their patients.

The authors highlighted a number of problems that exist: rates of re-admissions, medication errors, and infections are much too high at nationwide hospitals. And American patients fail to take full advantage of preventive services like counseling for smoking cessation and screening for cancer. "Physicians will need to embrace rather than resist change," the authors wrote, in order for the new legislation to successfully reverse these problems and reduce health care costs in the long term. That means doctors need to move away from a system where they're paid for ordering more tests and performing more procedures and toward one that reimburses them for coordinating care among a number of specialists and preventive health professionals like nutritionists and nurse practitioners. The goal is to keep you healthier and out of the hospital. Here's what you can expect at the doctor's office - if not now, soon.

1) You'll get the health care you need—no more, no less. It's surprising, and frankly shocking, how little doctors know about the effectiveness of the treatments they routinely prescribe for common conditions such as heart failure and diabetes. While studies are often lacking that help doctors determine which test or treatment is most appropriate for you, a new Patient-Centered Outcomes Research Institute will provide funding for studies to help doctors make more informed decisions. That should keep you from getting unnecessary medical care and provide you with care that's most effective. Since research takes time to perform and doctors are often slow to change their practices based on new research, this change may not happen immediately. While studies performed more than a decade ago showed that MRI scans provide no benefit for acute back pain and that antibiotics have no effect on acute bronchitis, doctors have only recently curtailed their use of them, and many still prescribe these costly tests and drugs when patients demand them.

2) You will receive healthcare from a team of health professionals. This "team care" will be in addition to, not subtracted from, the care you are already used to receiving from your personal doctor. The care team may include nurse practitioners, physician assistants, care managers, and nutritionists, depending on your individual health needs. The idea is that the more people who are working together to monitor your health conditions, the less likely a complication will be missed.

[Your Primary Care Team Will See You Now]

3) Your care team will reach out to you in an attempt to prevent future health problems. This may include reminding healthy people about the need for periodic health screenings, or a home visit from a nurse if you've been recently hospitalized for a chronic condition like heart failure. Rather than being paid only when patients get sick, doctors and care teams will be given financial incentives to keep patients well.

4) Technology will improve the efficiency of your health care. Gone will be the days when illegibly written prescriptions or blurry faxes of handwritten hospital progress notes led to thousands of medical errors each year. Doctors will be expected not only to exchange their paper charts for electronic medical records, but to use them meaningfully; that means improving the accuracy of the information in your health record and making sure these records will be accessible to you and the various professionals participating in your care. Of course, this transition will probably result in glitches at first. If doctors' early experiences with electronic health records are any indication, different computer systems may not be able to transfer information to each other, and enterprising hackers will no doubt try to breach the security of online health records, which could threaten your privacy.

[Electronic Medical Records: No Cure-All for Medical Errors]

Of course, it isn't possible at this early date to know how many of these hopes for health reform will actually happen. The ultimate goal, though, is something that I believe all doctors desire: for the health system of the future to give us the tools to provide you with the highest quality experience every time you need to seek health care.

Friday, June 8, 2012

Family medicine is "total medicine"

A terrific article in today's Huffington Post by two of my colleagues, Dr. Ranit Mishori and Family Medicine Education Consortium executive Larry Bauer, argues that family physicians need to "get out of the shadows" and advocate for a larger role in fixing America's health care problems. Instead of subdividing patients by age or body system, family medicine is the specialty trained to handle "diagnostic complexity," which requires a broad and varied skill set:

Every day we treat children, mend bones, manage chronic diseases, deal with hypertension, diagnose intestinal conditions, carry out eye exams, deliver babies, help control diabetes, take skin biopsies, inject aching joints, evaluate stroke victims, monitor depression and in some cases perform minor surgeries. And yes, this range of skills, while broad, does constitute a genuine and focused medical specialty -- the specialty of knowing your patient inside out and over years. We are meant to be experts as much in the person who comes to see as we are in the medical procedures we employ, to build a shared trust with our patients, to be partners with them toward the lifelong goal of staying healthy -- enough, by the way, to avoid too often the need for one those other specialists, whose practices often depend on people being very sick in the first place.

There is an odd logic that diminishes the status of family doctors. It is also faulty logic. People think that the more a physician knows about a specific medical problem or body part and the higher that physician's salary, the better care they will receive. Leaving aside whether that's actually true, it sets up a phony reverse corollary -- the belief that a doctor whose knowledge is more generalized, and whose pay scale is lower, is therefore providing inferior care. This is just wrong. As generalists, we believe the ability to see the patient's big picture; knowing "enough" about most problems; and understanding the preferences, past medical history and the resources of the person seeking care is far more important in most situations than narrow expertise.

Mishori and Bauer go on to ask whether family medicine (which not that long ago was called "family practice") should be renamed "total medicine" to better represent everything that family physicians do. But I think that family medicine needs more than a simple re-branding. When 1/3rd of the U.S. physician work force consists of generalists and 2/3rds consists of subspecialists, patients not only receive less value for their money (since subspecialists have higher salaries), but poorer health outcomes to show for it. A 50/50 ratio, which is the norm in much of the world, would not only save health care dollars, but likely result in fewer illnesses and deaths from preventable conditions. So let me say this as clearly as possible to those who are predicting a vast physician shortage in the upcoming years: America does not need more physicians, it needs more family physicians.

Thursday, June 7, 2012

How would you rate your health care team?

Two recent commentaries in the Annals of Family Medicine and the New England Journal of Medicine argue that the performance of modern family doctors can only be as good as their practice teams. In "The Myth of the Lone Physician: Toward a Collaborative Alternative," George Saba and colleagues explain why the myth that a primary care physician can do it all alone is dysfunctional and outdated, and should be replaced with the paradigm of a "highly functioning health care team":

What will be the roles and responsibilities of each team member? What systems and skills are needed to ensure effective communication? How will decisions be shared? How will conflict be resolved? How will the team foster trust and respect? How will the team promote the development of meaningful healing relationships? How will the team evolve over time? The specific answers to these questions define the roles and tasks of each team member, and the collaborative process of working through these challenges strengthens team relationships.

Similarly, in "Sharing the Care to Improve Access to Primary Care," Amireh Ghorob and Thomas Bodenheimer assert that the only way for physicians to meet the health care needs of a burgeoning and increasingly complex patient population is to delegate many of their traditional responsibilities - such as "patient education, lifestyle counseling, medication titration, and medication-adherence counseling" - to other health professionals:

The paradigm (culture) shift transforms the practice from an “I” to a “we” mindset. Unlike the lone-doctor-with-helpers model, in which the physician assumes all responsibility, makes all decisions, and delegates tasks to team members, but the capacity to see more patients does not increase, the “we” paradigm uses a team comprising clinicians and nonclinicians to provide care to a patient panel, with a reallocation of responsibilities, not only tasks, so that all team members contribute meaningfully to the health of their patient panel. Non-clinician team members must add capacity in order to bring demand and capacity into balance.

In the current issue of Family Practice Management, Berdi Safford and Cynthia Manning discuss "Six Characteristics of Effective Practice Teams," which include shared goals; clearly defined roles; shared knowledge and skills; effective, timely communication; mutual respect; and an optimistic, can-do attitude. How many of these characteristics does your doctor's office embody? Would you say that they currently function as an effective health care team?


A slightly modified version of the above post was first published on the AFP Community Blog.

Monday, June 4, 2012

Changing unhealthy habits requires changing environments

New York City Mayor Michael Bloomberg's recent proposal to ban sales of sugary beverages larger than 16 ounces has encountered opposition not only from soda manufacturers, but many others who are skeptical that such a ban would make any difference in the explosion in obesity rates. According to the Centers for Disease Control and Prevention, in 2010 the percentage of state residents classified as being obese ranged from 21% (Colorado) to a staggering 34% (Mississippi). By comparison, in 1990 no more than 15% of residents of ANY state were obese! But will banning the sale of extra-large sodas address this problem, the way that public smoking bans have helped to drive down smoking rates? In "Why Americans Need Bloomberg's Big Gulp Ban," TimeIdeas columnist Shannon Brownlee argues that the answer is yes:

When I was a kid, Coca-Cola came in 6-ounce glass bottles, and that seemed like plenty. It wasn’t all that long ago that a 12-ounce soda was considered perfectly sufficient—even large. But walk into any pizzeria or deli these days and you’ll have a very hard time even finding 12-ounce cans of anything. 20-ounce plastic bottles are now considered the standard single-serving size. ... As a result, we can no longer gauge what’s an appropriate amount of calories we should be drinking. The average American guzzles 52 gallons of soda, sweetened fruit juices, sports drinks, energy drinks, and sweetened tea and coffee per year. These drinks account for a third of the 156 pounds (pounds!) of added sugar each of us consumes on average each year. The ban on large drinks, on the other hand, could reset our notion of what a normal beverage serving looks like, and that could make all the difference. 

On the Washington Post's WonkBlog, Sarah Kliff reviews Bloomberg's accomplishments as a self-styled "public health autocrat": making NYC the first city to ban smoking in restaurants and bars, ban trans-fats in restaurant foods, and require chain restaurants to prominently post calorie count information. Numerous cities and states have since followed Bloomberg's lead, and the Affordable Care Act, if not struck down by the Supreme Court, will require calorie labeling at chain restaurants all over the country.

Critics argue that these well-intentioned initiatives infringe on freedom of choice and haven't been shown to improve health-related habits. For example, one study found that low-income people in NYC were no more likely to choose lower-calorie foods after the policy went into effect. This and other studies suggest that it takes more than data to affect food choices. After all, you may not know that a Big Mac with Cheese packs 704 calories and 44 grams of fat, but unless you're from another planet, you probably knew that it isn't good for you. On the other hand, when the Massachusetts General Hospital redesigned its cafeteria by implementing a simple color-coded scheme (red for unhealthy, yellow for less healthy, and green for healthy) and making healthy foods easier to see and reach, sales of healthy items (especially beverages) rose substantially. Changing the environment accomplished what calorie labeling couldn't.

Kudos to Mass General, but outside of deep-pocketed Harvard, where will the money come from to redesign hundreds of thousands of cafeterias? In the June issue of The Atlantic, David Freedman argues that obese and overweight people can change their microenvironments - and successfully change unhealthy eating and exercise behaviors - with the help of mobile technologies:

Today, for absolutely nothing, would-be weight-losers can download many of the key elements of a Skinnerian behavior-modification program directly to their phones and computers. One of the most popular options is Lose It, an app and Web site that allows users to pick a goal weight and a time line for reaching it, and then formulates a daily calorie count accordingly. Lose It then lets users track their eating and physical activity, which they can do by holding their phones up to a food package’s barcode, or by tapping the screen a few times at the start and end of a walk (the app offers a range of activity categories, including guitar strumming, household walking, and sex). Lose It uses this data to provide clear, graphic feedback on users’ daily progress—you might see at a glance that having dessert will send your numbers into the red, but that if you walk for 20 minutes after dessert, you’ll go back into the green.

As yet it remains uncertain if weight-loss apps will be able to replicate the results of more traditional, labor-intensive weight-loss interventions. And it's still reasonable to assume that strategies to stabilize, and eventually, reverse, national obesity rates will need to change obesity-promoting environments on the individual and community levels. The first step to a healthy weight may be disappointment at the inability to buy one's usual big sugary soda; the second one may be deciding, on second thought, not to purchase a soda at all.

Friday, June 1, 2012

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 the past few months:

1) How much does it cost to have an appendectomy? (4/24/12)

2) Electronic health records: medical progress, not panacea (5/16/12)

3) My take on state health insurance exchanges (3-part series) (4/16/12)

4) Counterintuitive findings on quality incentives and patient satisfaction (4/20/12)

If you have a personal favorite that isn't on this list, please let me know. TGIF and thanks for reading!