Thursday, November 21, 2013

Care transitions: 4 key questions to ask your doctor

Doctors do the best they can to keep patients healthy and out of the hospital. Sometimes, though, hospitalization is necessary despite the best possible care. At the first private practice I joined after residency training, my colleagues and I admitted patients to a local hospital and took turns caring for those who needed inpatient treatment. This system ensured we'd have easy access to their previous medical records and often know them on a personal level. Arranging office appointments after discharge was almost never a problem, and we were guaranteed knowledge of what had happened to our patients in the hospital.

That's all changed. The way patients receive hospital care has transformed radically in the past 15 years. Many primary care physicians, pressured to take on more patients and exhausted from being on call too many nights, have stopped seeing their patients through a hospital stay. Instead, they now rely on "hospitalists," a relatively new breed of specialists whose exclusive responsibility is to care for hospitalized patients.

There are potential advantages to being treated by a hospitalist rather than a family doctor. Because hospitalists spend all their time on the wards rather than trying to juggle obligations to hospital and office patients, they're usually easier to reach with questions or concerns. Also, hospitalists may be more up-to-date on the latest medical research on inpatient treatments. These advantages should theoretically translate into better care and shorter stays for hospital patients. And they do, according to a 2007 study published in the New England Journal of Medicine; researchers found that patients cared for by hospitalists indeed had shorter hospital stays and lower medical costs than those cared for by primary care physicians.

But as hospitalists are replacing family doctors on hospital wards, concern is mounting that poor communication between hospital and office physicians could lead to worse health outcomes after discharge. I personally know the frustration of seeing a patient in the office after a recent hospitalization having not received critical information about what medication changes were made, what procedures he underwent, or what tests are needed to monitor his condition. Patients whose doctors don't have access to complete information during follow-up visits may be more likely to end up in the emergency room or be hospitalized yet again. (Same goes for patients who don't schedule follow-up visits at all.)

A study published in the Annals of Internal Medicine in 2011 seemed to confirm these fears. In a nationally representative sample of Medicare patients admitted to hospitals between 2001 and 2006, those who were cared for by hospitalists had slightly shorter average hospital stays and slightly lower hospital bills than those cared for by primary care physicians. However, in the 30 days after discharge, hospitalist patients were more likely to be readmitted or land in the emergency room. One possible explanation: poor communication, since hospitalist patients were significantly less likely to follow up with their primary care physicians after discharge.

To improve the quality of "care transitions" between hospitalists and family doctors, some health systems have devised programs to ensure patients get the recommended follow-up care. Two other studies published in 2011 evaluated such programs. In one study, seniors who'd been hospitalized for heart failure at Baylor Medical Center in Garland, Texas received several home visits by specially trained nurses between three days and three months after discharge. Those enrolled in the nurse-visit program were only half as likely as past heart failure patients to be readmitted within 30 days. In another study, patients at six Rhode Island hospitals were assigned health coaches (nurses or social workers) who visited them once in the hospital, once at home, and telephoned them twice to encourage follow-up with primary care physicians and ask about any worrisome signs or symptoms. Patients in that program were nearly 40 percent less likely to be readmitted within 30 days than patients who received no health coaching.

Because it's impossible to predict whether you or a loved one will need to be hospitalized, it's important to understand your doctor's policies for patients who require hospital care. You can start by asking these 4 questions:

1. Do the practice's physicians care personally for patients in the hospital, or do they rely on hospitalists?

2. If you live in a metropolitan area with multiple hospitals to choose from, which hospital does your doctor prefer?

3. If you are seen by a hospitalist, what protocols are in place to ensure timely communication between the hospital and your doctor's office about follow-up plans?

4. Are you eligible for any programs that assist patients with care transitions?

Given all of the changes that have taken place in medicine, many communities are unlikely to return to the "old days" when the same doctors were responsible for caring for their patients both in and out of the hospital. Consequently, patients need to be proactive to be sure that they receive the best post-hospital care. Being hospitalized is always stressful, but knowing that your follow-up care won't fall through the cracks may give you peace of mind.


This post first appeared on Common Sense Family Doctor in a slightly different form on August 11, 2011.

Thursday, November 14, 2013

Tackling the problem of too few family physicians

Researchers at the American Academy of Family Physicians' Robert Graham Center have estimated that the U.S. will require 52,000 additional primary care physicians by 2025 due to the effects of population growth, aging, and insurance expansion. Since it takes at least eleven years of post-secondary education to train a family physician, even a renewed surge of student interest in primary care careers is unlikely to meet this anticipated need. Another recent Graham Center study concluded that expanding the scope of practice of nurse practitioners and physician assistants would still result in an overall shortage of primary care clinicians.

This month's issue of Health Affairs contains several proposals to expand the capacity of the existing primary care workforce. Scott Shipman and Christine Sinsky review effective strategies for reducing waste and improving efficiency in office practice: delegating clerical and administrative tasks, using medical assistants as work "flow managers," establishing non-physician protocols for routine chronic care and test ordering, and moving some types of acute care visits online. If each practicing primary care clinician could free up capacity to see one more patient each working day, that would translate into 30 to 40 million additional visits per year.

Another review by Jonathan Weiner and colleagues projects increases in efficiency and reductions in future demand for office visits from expansion of health information technology and e-health applications. Based on the published literature, they estimate that even incomplete implementation of existing technologies could increase physician visit capacity by up to 21 percent.

Finally, Arthur Kellermann and colleagues propose creating the new occupation of "primary care technician," analogous to the existing profession of emergency medical technicians (EMTs), who provide the vast majority of first-contact emergency medicine in the field. This is their job description:

What we need are primary care extenders with local ties and cultural competence of community health care workers, the procedural skills of PAs, and ready access to the knowledge of NPs and primary care physicians. They should be easy to train, inexpensive to employ, and capable of working miles apart from their supervising providers. ... Primary care technicians could be quickly trained to deliver basic preventive, minor illness, and stable chronic disease care to populations that currently lack access to care.

Are these proposals, taken individually or in combination, adequate solutions to the problem of too few U.S. family physicians?


This post was originally published on the AFP Community Blog.

Friday, November 8, 2013

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, September, and October:

1) I oppose Obamacare; I support the Affordable Care Act (9/30/13)

2) Conservative Medicine: Why am I the best person to write it? (8/27/13)

3) Doctors are the biggest driver of health care costs (10/29/13)

4) Conservative Medicine: Why is now the right time for it? (9/4/13)

5) Mindful communication, physician burnout, and patient satisfaction (9/22/13)

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

Sunday, November 3, 2013

Why don't clinicians discuss cancer screening harms?

Recently, I attended a conference that included an exercise where attendees were asked how many patients they thought it was acceptable to diagnose and treat needlessly (or "overtreat") in order to prevent one death from cancer. We stood at various points along a wall that represented different thresholds: at one end, 100 persons overtreated for every 1 life saved; at the other, 1 person overtreated for every 1 life saved. Not surprisingly, attendees held a wide range of opinions (I stood somewhere in the middle), but the exercise illustrated the tradeoff inherent in effective screening tests for breast, colorectal, and cervical cancer: for every person who benefits from screening, others will be harmed. This fact has led many physicians to advocate that shared decision-making be used more widely to integrate patients' preferences and values with the decision to accept or decline a screening test.

How often do physicians take the time to explain the harms of cancer screening to their patients? A research letter published in JAMA Internal Medicine explored this question in an online survey of 317 U.S. adults between 50 and 69 years of age. 83 percent of participants had attended at least 1 routine cancer screening; 27 percent had undergone 3 or more. However, less than 10 percent of participants had ever been informed by their physicians of the risk that the screening test(s) could lead to overdiagnosis and overtreatment. The few physicians who did attempt to quantify this risk generally provided information that was inconsistent with the medical literature.

If the results of this survey are representative of the practices of U.S. primary care clinicians, then more than 90 percent aren't telling patients that there are downsides to undergoing routine mammograms, colonoscopies, and Pap smears. Why not? Is it because they aren't familiar enough with the data to accurately describe these harms? Or is it because they fear that patients who receive information about cancer screening harms will choose to decline these tests?


This post originally appeared on the AFP Community Blog.