When my three-year old son began having recurrent coughing fits and shortness of breath after exercise, my wife and I knew the probable diagnosis. We made an appointment with our family doctor who confirmed that our son, indeed, had asthma. After prescribing medications to prevent and manage the symptoms, our doctor would have—had we not been medical professionals—taken just 10 or 15 minutes to explain how to administer the medications and avoid triggers like tobacco smoke, mold, pollen, and hairy pets. She would have also had to cram in lessons on recognizing the early warning signs of an asthma attack, what actions to take to treat it, and when to call the office or go straight to the emergency room.
Our son's doctor didn't have go into detail about any of those things and, given her crowded waiting room, I suspect she was grateful. But what about the 7 million other parents whose children are diagnosed with asthma? Or those who live with chronic conditions like diabetes and heart disease who don't have the benefit of medical school training?
One solution that's becoming more widespread: care management or disease management programs now offered by many health insurance plans and some large employers like IBM to help patients manage their care between doctor's visits. Basic programs generally offer round-the-clock telephone or e-mail access to health educators and informational brochures. More intensive programs may include home visits by nurses and/or remote monitoring of pharmacy usage to keep track of prescriptions written by multiple physicians. Employers and health insurance companies hope to benefit in the long run by keeping employees on the job and defraying costs of multiple hospitalizations for poorly managed conditions.
Patients at Johns Hopkins Hospital in Baltimore can, as outpatients, enroll in the hospital's ambitious Guided Care program. A specially trained nurse in each primary care practice affiliated with Hopkins coordinates care from various specialists—for those with multiple health problems—making sense of various, sometimes contradictory, care instructions. The nurse also provides individualized counseling on diet, exercise and medications, and links the patient to nutritionists and physical activity programs. Recent studies have shown that the Guided Care program improves patients' perceived quality of health care and their satisfaction; it isn't yet known, however, whether it results in fewer emergency room visits and hospitalizations.
Unfortunately, most care management programs haven't been subjected to the same degree of scientific scrutiny, so it's not clear which components help patients most. In order for you or your loved one to get the most out of a care management program, I recommend that you do the following:
1) Make sure to tell your doctor that you've enrolled in a program and provide the name and contact information. Insurance companies and employers who provide care management programs don't necessarily keep patients' individual physicians in the loop.
2) Find out from your doctor what's unique about your condition and relay that to your care manager. Chances are you deviate somewhat from the "typical" patient with your condition. Everyone has a different mix of symptoms, concurrent health problems, and medical history, so find out where you deviate from the norm.
3) Check with your doctor about the accuracy of any educational materials you receive. Such materials are usually generic and not meant to cover every conceivable situation.
4) Peruse your local library. You'd be amazed how many health books are out there for every conceivable condition. Becoming more informed about your chronic health conditions not only helps you manage them better but also gives you the freedom to worry less about day to day complications, allowing you to live each day more fully.
**
The above post is an excerpt from "Multiple Health Problems? Try Care Management," first published on my Healthcare Headaches blog on USNews.com.
Saturday, August 28, 2010
Monday, August 23, 2010
Air, space, and primary care checklists
There is a mesmerizing - some would say hypnotic - air traffic control display at the National Air and Space Museum in Washington, DC that shows the flight paths of every airplane over the United States during a 24-hour period in 2006. At any given moment, up to 6,000 planes were in the air, and the total number of flights numbered in the many tens of thousands. Immediately after the 9/11 terrorist attacks, air traffic controllers were instructed to land every one of them at once. And miraculously, they were able to do so without a single runway collision or plane running out of fuel.
After reading Harvard surgeon Atul Gawande's bestselling book The Checklist Manifesto several months ago, I learned that a feat that seemed miraculous to an outsider really wasn't. Since the early days of aviation, when planes became too complex for even the most experienced pilots to control without making an occasional devastating error of judgment or omission, pilots have depended upon checklists to manage both routine tasks and once-in-a-lifetime emergencies, such as last year's "Miracle on the Hudson" landing of a crippled US Airways jet in the Hudson River in which every passenger was rescued. Gawande's book goes on to describe how checklists have revolutionized industries as far apart as skyscraper construction and his own studies of safety in surgery.
Since reading Gawande's book, I've thought about how checklists might be applied to improve the performance and efficiency of primary care. On one hand, we already have many checklist-type procedures in family medicine: obtaining vital signs (which can include smoking status and body mass index in addition to height, weight, temperature, and blood pressure), paper or electronic applications that help family physicians to remember recommended immunizations, screening tests, checklists for diabetes care, and so forth. And through trial and error while developing the patient-centered medical home, we've found that regular practice meetings called "huddles" can serve much the same purpose as a surgical team organizing itself for a major operation.
On the other hand, primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so? I'd love to hear your ideas.
After reading Harvard surgeon Atul Gawande's bestselling book The Checklist Manifesto several months ago, I learned that a feat that seemed miraculous to an outsider really wasn't. Since the early days of aviation, when planes became too complex for even the most experienced pilots to control without making an occasional devastating error of judgment or omission, pilots have depended upon checklists to manage both routine tasks and once-in-a-lifetime emergencies, such as last year's "Miracle on the Hudson" landing of a crippled US Airways jet in the Hudson River in which every passenger was rescued. Gawande's book goes on to describe how checklists have revolutionized industries as far apart as skyscraper construction and his own studies of safety in surgery.
Since reading Gawande's book, I've thought about how checklists might be applied to improve the performance and efficiency of primary care. On one hand, we already have many checklist-type procedures in family medicine: obtaining vital signs (which can include smoking status and body mass index in addition to height, weight, temperature, and blood pressure), paper or electronic applications that help family physicians to remember recommended immunizations, screening tests, checklists for diabetes care, and so forth. And through trial and error while developing the patient-centered medical home, we've found that regular practice meetings called "huddles" can serve much the same purpose as a surgical team organizing itself for a major operation.
On the other hand, primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so? I'd love to hear your ideas.
Thursday, August 19, 2010
Welcome to the blogosphere, American Family Physician
In addition to blogging for Common Sense Family Doctor and Healthcare Headaches, starting today I will also be writing and moderating a new blog for the journal American Family Physician (where I am an associate medical editor). The AFP Community Blog will be a weekly forum for exchanging thoughts and opinions about clinical topics published in the journal and other important issues relevant to the practice of family medicine. Please visit this blog to see what it has to offer.
Tuesday, August 17, 2010
Does your doctor understand your health beliefs?
As a family physician, I've found that patients' individual health beliefs often play a big role in important decisions such as starting a new medication or undergoing an invasive test or procedure. Some patients were more willing to endure potentially risky procedures in order to learn their diagnosis quicker, for example, while others preferred "watchful waiting," or monitoring symptoms that were unlikely to be a sign of anything serious. Unfortunately, in a typical 15-minute office visit, I barely had enough time to establish a friendly rapport with my patients, much less probe them deeply about their beliefs. As a result, I'd often find myself making assumptions about the care they preferred.
Unfortunately, it turns out my assumptions, and those of other doctors, were more likely to be wrong than right. In a recent study published in the Journal of General Internal Medicine, researchers found that physicians' and patients' beliefs about conditions and treatments often diverge. Patients typically assume that they're somehow to blame for a disease, like diabetes or heart failure, and that the disease can be managed with non-pharmaceutical treatments; they also assume that they'll partner with their doctors in making treatment decisions. Doctors, on the other hand, often see the conditions they diagnose as unavoidable and requiring a prescription to treat with little input necessary from the patient.
The study's surprising finding was that when physicians were asked to fill out surveys expressing their own beliefs and what they thought their patients' beliefs were, they gave pretty much the same answers. In other words, doctors thought that their patients' beliefs were basically the same as their own.
So how can you, as a patient, avoid misunderstandings with your doctor? Here are three communication tactics I try with my doctor when I'm the one being examined.
1. Speak up. The authors of the study found that doctors were more likely to be aware of their patients' individual health beliefs when their patients "asked questions, expressed concerns, and stated their opinions." I might start a conversation by saying something like "let me make sure I understand correctly what you're recommending…" because I know when I hear these words from my own patients, it's a clue for me to step back and make sure that I understand the patient's point of view. The aim is to be polite but persistent in making sure your doctor understands your personal preferences.
2. Don't be afraid to disagree. If your doctor seems to be shrugging off your symptoms as "all in your head" or suggesting what seems to be an unreasonable course of action, make sure you fully explain why you disagree. Perhaps this pain feels different or lasts longer than the usual aches, or perhaps you can't comprehend how your doctor reached a particular diagnosis based on your medical history. Sometimes challenging your doctor can reveal mistakes. And doctors, like everyone else, make them from time to time.
3. Write out your questions in advance. It's common to forget what you wanted to discuss while you're undergoing a quick exam. If possible, try to write out some questions before your appointment concerning your preferences for follow-up and treatment. If you don't know what kinds of questions to ask or how to ask them, check out the Agency for Healthcare Research and Quality's website. The bottom line: While your doctor's knowledge of medicine may trump yours, you have a vaster knowledge of your own beliefs and preferences—and satisfying care requires a knowledge of both.
**
The above post is an excerpt from "3 Ways to Get Your Doctor To Take Your Pain Seriously," first published on my Healthcare Headaches blog on USNews.com.
Unfortunately, it turns out my assumptions, and those of other doctors, were more likely to be wrong than right. In a recent study published in the Journal of General Internal Medicine, researchers found that physicians' and patients' beliefs about conditions and treatments often diverge. Patients typically assume that they're somehow to blame for a disease, like diabetes or heart failure, and that the disease can be managed with non-pharmaceutical treatments; they also assume that they'll partner with their doctors in making treatment decisions. Doctors, on the other hand, often see the conditions they diagnose as unavoidable and requiring a prescription to treat with little input necessary from the patient.
The study's surprising finding was that when physicians were asked to fill out surveys expressing their own beliefs and what they thought their patients' beliefs were, they gave pretty much the same answers. In other words, doctors thought that their patients' beliefs were basically the same as their own.
So how can you, as a patient, avoid misunderstandings with your doctor? Here are three communication tactics I try with my doctor when I'm the one being examined.
1. Speak up. The authors of the study found that doctors were more likely to be aware of their patients' individual health beliefs when their patients "asked questions, expressed concerns, and stated their opinions." I might start a conversation by saying something like "let me make sure I understand correctly what you're recommending…" because I know when I hear these words from my own patients, it's a clue for me to step back and make sure that I understand the patient's point of view. The aim is to be polite but persistent in making sure your doctor understands your personal preferences.
2. Don't be afraid to disagree. If your doctor seems to be shrugging off your symptoms as "all in your head" or suggesting what seems to be an unreasonable course of action, make sure you fully explain why you disagree. Perhaps this pain feels different or lasts longer than the usual aches, or perhaps you can't comprehend how your doctor reached a particular diagnosis based on your medical history. Sometimes challenging your doctor can reveal mistakes. And doctors, like everyone else, make them from time to time.
3. Write out your questions in advance. It's common to forget what you wanted to discuss while you're undergoing a quick exam. If possible, try to write out some questions before your appointment concerning your preferences for follow-up and treatment. If you don't know what kinds of questions to ask or how to ask them, check out the Agency for Healthcare Research and Quality's website. The bottom line: While your doctor's knowledge of medicine may trump yours, you have a vaster knowledge of your own beliefs and preferences—and satisfying care requires a knowledge of both.
**
The above post is an excerpt from "3 Ways to Get Your Doctor To Take Your Pain Seriously," first published on my Healthcare Headaches blog on USNews.com.
Saturday, August 14, 2010
Spain: an unlikely primary care model for the U.S.
When U.S. health reformers were looking abroad last year, the health systems of Canada and the United Kingdom were the most commonly mentioned. In this blog, I've also compared our primary care to better-functioning systems in more out-of-the-way places: the former Soviet republic of Kazakhstan and the tiny island nation of Taiwan.
An article in the August issue of the journal Health Affairs took a closer look at the reform of the primary care system in Spain that began in the mid-1970s. Following the end of the Franco dictatorship, Spain moved rapidly to reorganize the way it provided health care to its citizens. Not only did it formally recognize family medicine as a distinctive medical specialty, Spain's central government dedicated public funds to guarantee primary care access within "Basic Health Zones" that were "organized around a single primary care team ... [to] coordinate prevention, promotion, treatment, and community care activities." They set a goal to establish a primary care center within a 15-minute drive of any residence in the country, and in 2007, 97 percent of all primary care visits were recorded on electronic health records.
The resulting health gains were impressive. Spain's life expectancy in 2007 was 84.3 years for women and 77.8 years for men, both considerably better than the U.S.'s 80.7 years for women at 75.4 years for men. And like other nations that have organized their health systems around primary care, Spain spends a much smaller fraction of its gross domestic product on health care than does the U.S.: just 8.5 percent compared to 16 percent.
Can lessons learned from the transformation of Spain's primary care system be applied to the U.S.? My answer is yes and no. We have made some recent, though comparatively modest, investments in strengthening the training of primary care physicians, and there are new incentives for physicians to accelerate their adoption of health information technology. In terms of access, it may always be difficult to recruit and retain talented physicians in rural underserved areas, as a recent Washington Post story illustrates. But improving the health of the country certainly won't happen if political leaders don't make universal primary care access - distinct from universal insurance coverage - a high priority over the coming decades.
An article in the August issue of the journal Health Affairs took a closer look at the reform of the primary care system in Spain that began in the mid-1970s. Following the end of the Franco dictatorship, Spain moved rapidly to reorganize the way it provided health care to its citizens. Not only did it formally recognize family medicine as a distinctive medical specialty, Spain's central government dedicated public funds to guarantee primary care access within "Basic Health Zones" that were "organized around a single primary care team ... [to] coordinate prevention, promotion, treatment, and community care activities." They set a goal to establish a primary care center within a 15-minute drive of any residence in the country, and in 2007, 97 percent of all primary care visits were recorded on electronic health records.
The resulting health gains were impressive. Spain's life expectancy in 2007 was 84.3 years for women and 77.8 years for men, both considerably better than the U.S.'s 80.7 years for women at 75.4 years for men. And like other nations that have organized their health systems around primary care, Spain spends a much smaller fraction of its gross domestic product on health care than does the U.S.: just 8.5 percent compared to 16 percent.
Can lessons learned from the transformation of Spain's primary care system be applied to the U.S.? My answer is yes and no. We have made some recent, though comparatively modest, investments in strengthening the training of primary care physicians, and there are new incentives for physicians to accelerate their adoption of health information technology. In terms of access, it may always be difficult to recruit and retain talented physicians in rural underserved areas, as a recent Washington Post story illustrates. But improving the health of the country certainly won't happen if political leaders don't make universal primary care access - distinct from universal insurance coverage - a high priority over the coming decades.
Thursday, August 12, 2010
Guest Blog: What primary care can learn from oncology - Part 2 of 2
This is the second of two guest posts by Shantanu Nundy, MD. You can find the first part of this piece here.
**
Perhaps the best evidence in support of the care we provided our leukemia patients came from my most startling observation: nearing the end of my 4-week rotation, I have yet to admit a single patient from the emergency room. In general medicine, by contrast, well over 90% of admissions come from the ER.
ER admissions are undesirable for a number of reasons. For one, everything in the ER costs more. Though I have never verified this myself, it is rumored that ERs routinely charge $200 for a single dose of aspirin. Furthermore, because ER doctors are trained to address the worst-case scenario and often know little about the patients besides what is written in the medical record, patients often get unnecessary and expensive tests and procedures in the emergency room. Finally, because leukemia is so super-specialized, leukemic patients are also at risk for substandard care from ER physicians who are generalists by nature.
How are inconvenient, costly, and potentially suboptimal ER stays avoided in leukemia? At diagnosis and frequently thereafter, patients with leukemia are educated about the signs and symptoms of serious complications such as infection. When fever or another acute issue arises, they have a clear care plan. They know who to call and can often reach their primary oncologist directly. Physicians that receive the call triage patients over the phone. If the patient needs to be admitted, he or she will be told to come into the hospital directly, where an inpatient bed will have already been arranged and where the resident on call (e.g., me) will have already been made aware of the oncologist’s concerns and given an initial plan and workup. Patients who need to be seen urgently but not necessarily admitted will be scheduled for a same day or next day appointment. Because every doctor in the group knows each patient (thanks to the weekly leukemia conference), even if the patient’s provider does not have a clinic spot available, the patient can be seen by another provider.
So why do my primary care patients not get as good care as my patients on leukemia? It’s not that primary care doctors are bad and leukemia doctors are good. Clearly it’s not that simple. Reimbursement in oncology is higher than in primary care, and in general oncology has a higher proportion of commercially insured rather than publicly insured patients. This gives oncologists resources primary care physicians can only dream of – outpatient laboratory services, IV infusion suites, advanced practice nurses, and dedicated case managers. Oncology also receives greater NIH funding, which supports research of new and existing treatments, and funding from philanthropic institutions and charities (think “Live Strong” and breast cancer awareness). It is also a more narrow field that requires fellowship training, compared to primary care which spans three different specialities (internal medicine, pediatrics, and family medicine) and includes general and subspecialty trainees.
But some of it is cultural as well. When I asked one of my leukemia attendings to explain why there were so few ER admissions, his answer was that leukemia specialists viewed inpatient and outpatient care as part of the same continuum of care and took responsibility for patients over the full cycle of care. Comparatively, in general medicine, outpatient and inpatient care are treated quite separately, a reality that has been formalized by the growing hospitalist movement, in which patients admitted to the hospital are taken care of by a group of physicians wholly separate from their outpatient providers.
Primary care doctors often argue that we need more resources, better compensation, and greater reimbursement. I agree on all fronts, and in fact many of my observations above only support this notion. But I think even with the resources at hand, there is much we can improve upon. We must become more scientific in our methods, more integrated in our care, and more patient-centric in our approach. We need not wait for change in Washington, DC to get started. We can begin by taking a closer look at our peers and learning from their successes, starting (at least at my institution) with leukemia. This will provide useful answers to the important question of why the care of oncology patients seems to be better than that of general medicine patients.
As I leave the world of oncology and return to general medicine, I can’t help but ask myself another question: what would happen if my primary care patients benefited from the same systems of care as my patients in oncology? How much better off would they be? I’m not sure of the answer, but given what I observed this past month, I would love to find out.
- Shantanu Nundy, MD
**
Perhaps the best evidence in support of the care we provided our leukemia patients came from my most startling observation: nearing the end of my 4-week rotation, I have yet to admit a single patient from the emergency room. In general medicine, by contrast, well over 90% of admissions come from the ER.
ER admissions are undesirable for a number of reasons. For one, everything in the ER costs more. Though I have never verified this myself, it is rumored that ERs routinely charge $200 for a single dose of aspirin. Furthermore, because ER doctors are trained to address the worst-case scenario and often know little about the patients besides what is written in the medical record, patients often get unnecessary and expensive tests and procedures in the emergency room. Finally, because leukemia is so super-specialized, leukemic patients are also at risk for substandard care from ER physicians who are generalists by nature.
How are inconvenient, costly, and potentially suboptimal ER stays avoided in leukemia? At diagnosis and frequently thereafter, patients with leukemia are educated about the signs and symptoms of serious complications such as infection. When fever or another acute issue arises, they have a clear care plan. They know who to call and can often reach their primary oncologist directly. Physicians that receive the call triage patients over the phone. If the patient needs to be admitted, he or she will be told to come into the hospital directly, where an inpatient bed will have already been arranged and where the resident on call (e.g., me) will have already been made aware of the oncologist’s concerns and given an initial plan and workup. Patients who need to be seen urgently but not necessarily admitted will be scheduled for a same day or next day appointment. Because every doctor in the group knows each patient (thanks to the weekly leukemia conference), even if the patient’s provider does not have a clinic spot available, the patient can be seen by another provider.
So why do my primary care patients not get as good care as my patients on leukemia? It’s not that primary care doctors are bad and leukemia doctors are good. Clearly it’s not that simple. Reimbursement in oncology is higher than in primary care, and in general oncology has a higher proportion of commercially insured rather than publicly insured patients. This gives oncologists resources primary care physicians can only dream of – outpatient laboratory services, IV infusion suites, advanced practice nurses, and dedicated case managers. Oncology also receives greater NIH funding, which supports research of new and existing treatments, and funding from philanthropic institutions and charities (think “Live Strong” and breast cancer awareness). It is also a more narrow field that requires fellowship training, compared to primary care which spans three different specialities (internal medicine, pediatrics, and family medicine) and includes general and subspecialty trainees.
But some of it is cultural as well. When I asked one of my leukemia attendings to explain why there were so few ER admissions, his answer was that leukemia specialists viewed inpatient and outpatient care as part of the same continuum of care and took responsibility for patients over the full cycle of care. Comparatively, in general medicine, outpatient and inpatient care are treated quite separately, a reality that has been formalized by the growing hospitalist movement, in which patients admitted to the hospital are taken care of by a group of physicians wholly separate from their outpatient providers.
Primary care doctors often argue that we need more resources, better compensation, and greater reimbursement. I agree on all fronts, and in fact many of my observations above only support this notion. But I think even with the resources at hand, there is much we can improve upon. We must become more scientific in our methods, more integrated in our care, and more patient-centric in our approach. We need not wait for change in Washington, DC to get started. We can begin by taking a closer look at our peers and learning from their successes, starting (at least at my institution) with leukemia. This will provide useful answers to the important question of why the care of oncology patients seems to be better than that of general medicine patients.
As I leave the world of oncology and return to general medicine, I can’t help but ask myself another question: what would happen if my primary care patients benefited from the same systems of care as my patients in oncology? How much better off would they be? I’m not sure of the answer, but given what I observed this past month, I would love to find out.
- Shantanu Nundy, MD
Subscribe to:
Posts (Atom)
