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.

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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

Healthcare headaches

I'm pleased to announce that I have started writing a weekly blog on the website of US News and World Report, Healthcare Headaches. This blog will aim to inform patients about current health issues and how to navigate the health system to get the care they need. The first entry, 3 Ways to Get Your Doctor to Take Your Pain Seriously, discusses a recent study in the Journal of General Internal Medicine about doctors' misperceptions of patients' health beliefs and provides practical tips to patients on how to communicate their needs to clinicians.

US News has given me permission to excerpt or re-post Healthcare Headaches content on Common Sense Family Doctor one week after an entry goes live on their website, which I will do if it makes sense to do so (e.g. involves a primary care theme). In the meantime, please feel free to tell your friends, colleagues, and patients about my new blog. Thank you!

Guest Blog: What primary care can learn from oncology - Part 1 of 2

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 piece was originally posted on his blog, BeyondApples.org.

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Why do my patients with cancer get better care than my patients in primary care?

As the senior resident on my hospital’s inpatient leukemia service this past month, this question troubled and intrigued me daily. Despite the sheer complexity of treating leukemia (administration of chemotherapy, bone marrow biopsies, stem cell transplantation), the resources required (transplantation routinely costs $1 million), and the severity of the illness (patients with little to no functional immune system), I couldn’t help but marvel at how coordinated, integrated, and patient-centric the care was.

From the first day I saw that things in leukemia worked differently. Most inpatient ward teams consist of an attending, a senior medical resident, one or two interns, and medical students. Each member of the team is “on service” for 2-4 weeks after which they rotate to different parts of the hospital or to the outpatient or research setting. As a result, a patient admitted to general medicine today is taken care of by a completely different team than took care of her 3 months earlier when she came in for the same problem.

On leukemia, our medical team included an advanced practice nurse (APN) who did not rotate off and on service. Being on the inpatient leukemia team was her primary responsibility 365 days a year. When I wondered if a patient admitted for chemotherapy needed an interval CT scan, she would remind me that the patient had just received one a month earlier. When the patient later developed a rash that I considered getting a biopsy of, she reassured me that the rash looked no different than the one the patient had developed the last time she received chemotherapy. And when I was trying to determine which prophylactic antibiotics to discharge the patient on, she contacted the primary oncologist to get his opinion and, if necessary, arranged prior authorization for medications that her insurance company might otherwise deny coverage for. Perhaps most importantly, our APN was a constant presence for patients fighting a disease that wrecked havoc on their bodies and their lives.

Often when the medical team finished examining a patient, the patient would ask to speak to our APN privately, no doubt to receive additional emotional and psychosocial support, something that is terribly lacking in many patients with chronic disease, yet serves to reduce treatment breaks and improve adherence and identify co morbid conditions such as depression that are common but often go unnoticed.

Then there was the weekly leukemia conference I was reminded to attend. Thinking I was walking into another research lecture, I was surprised to learn that this meeting was really a “tumor board” in which new and active patients were discussed. Sitting around the expansive conference table were leukemia attendings and fellows, advanced practice nurses, social workers, case managers, and the inpatient leukemia team. We began by discussing the admitted patients with my team providing the updates and the outpatient oncologist providing context and overall direction. ... We then discussed the new patients — while multiple leukemia specialists went back and forth formulating the diagnostic plan and initial chemotherapy, the case managers and social workers figured out how to best coordinate the dozens of steps required to place a central line, draw routine blood tests at home, and schedule chemotherapy and follow up visits. Finally, everyone was encouraged to bring up concerns about any patient on the roster.

In general medicine, doctors are often left to deal with complex medical and social issues with little input from others. Though I’m in a large group practice of over 100 primary care physicians, we have no clear and formal mechanisms for asking and receiving advice from each other on individual patients. In addition, despite the fact that many of the day-to-day challenges of primary care center around not the medical but rather the socioeconomic determinants of health, I do not have access to dedicated social work and case management services.

At the conference we each received a roster of all the patients the group was actively managing. Each line of the roster included the patient’s name, date of birth, type of leukemia, and treatment plan – nothing surprising. But in addition, it included the name of any clinical trial or research protocol the patient was on. Flipping through the roster, I was stunned to see that virtually every patient was enrolled in a research study of one sort or another. Those who were not in a study of a new experimental chemotherapy or drug (Phase I or Phase II trial) were instead on a study to collect and track patient responses to an established leukemia treatment.

General medicine is no less cutting-edge than leukemia; many of our treatments have no good data supporting their use and new drugs come out each year. And yet, to my knowledge, I don’t have a single patient in my practice on a research protocol. Worse still, we don’t even analyze our own data. If you asked me what the average HbA1c is for my patients with diabetes, I couldn’t tell you. In comparison, the oncologists at my hospital can report their institutional survival rates for specific types of leukemia by age of diagnosis, gender, and ethnicity.

This dedication to building evidence was matched by a commitment to use the available evidence. At times it almost seemed as if they were speaking another language. Sentences often were punctuated by phrases such as “per the CALBG 10580 protocol” and frequently, recommendations were accompanied by specific citations from the oncology literature. In primary care, most of our recommendations are based on experience or habit; seldomly we may refer to a consensus guideline. It’s no wonder, then, that studies show it takes 7-10 years after a new guideline or seminal study is released for practice patterns to change. It’s not that such data doesn’t exist — it’s that often we just aren’t using it.

(to be continued later this week)

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 June and July:

1) Can primary care practices be "Dream Teams"? (6/28/10)

2) VBAC and home birth: evaluating the evidence (7/27/10)

3) What soft drinks and cigarettes have in common (7/21/10)

4) Medical school rankings are a means, not an end (6/16/10)

5) The doctor will "tweet" you now (7/15/10)

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

Where will new primary care docs come from? (Part 2)

In a previous post, I described a study that found that U.S. medical graduates from 1997 to 2006 who became primary care doctors were "more likely to be female, planned to practice in medically underserved communities, and had strong altruistic beliefs about health care and the medical profession's social responsibility." Another research group recently used the percentage of gradutes who practice primary care as one of their "social mission" criteria for ranking medical schools. But using retrospective profiles as the basis for recruiting new students, and promoting schools that have historically graduated higher proportions of primary care physicians, will not be enough to meet the basic health needs of 32 million newly insured patients by 2014, much less those of patients whose family doctors are now nearing retirement.

As if we need another example of how hard it is to prime the primary care pipeline, The Commonwealth Medical College (TCMC), a school in northeastern Pennsylvania that opened its doors in August 2009 with a stated emphasis on training primary care physicians to address the state's widespread workforce shortages, reported in the July/August issue of Family Medicine that the career preferences of its inaugural class changed dramatically between medical school acceptance and matriculation:

In contrast to our students' often-stated primary care proclivity before matriculation, results of the orientation survey just 3–6 months after medical school acceptance and before their first class disclosed that seven (12.5%) students cited general surgery and orthopedic surgery, respectively, as their first career choice, and four (6.2%) students listed emergency medicine. Only 15 (23%) students indicated a preference for general internal medicine (eight students), obstetrics-gynecology (four), family medicine (two), or pediatrics (one). Graduating medical students who are focused on a career in primary care is difficult, and our experience indicates that even accurately identifying medical school candidates with this interest can be fraught with error.

Students change their minds about specialty choice multiple times during medical school, and there is obviously plenty of time left to persuade members of this class of the benefits of a career in primary care. I also hope that TCMC's innovative community-based training curriculum provides students with a more balanced perspective on population health problems than does the average tertiary care-focused academic medical center. A great deal is riding on the outcome of this program, not only for the residents of Pennsylvania, but the entire nation. If it succeeds, perhaps medical schools around the country will follow suit. But if it fails ... what then?

Guest Blog: Would modern medicine have helped our early patriots?

Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA. The following post was previously published on July 4, 2010 in The Health Care Blog and DrPullen.com.

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WOULD MODERN MEDICINE HAVE HELPED OUR EARLY PATRIOTS?

On Independence Day, I thought it would be interesting to look at the causes of death of some of our famous Revolutionary era patriots. When I started researching this, I anticipated early deaths from infections and untreatable chronic diseases like diabetes and hypertension. Interestingly, many of the famous early Americans lived to a ripe old age, and died of causes that even today may well have been their demise.

George Washington: Washington is an exception to the comment above. Washington died at age 67, likely of a pharyngeal infection, possibly streptococcal disease. Today he would likely have received antibiotic treatment and survived this illness.

Thomas Jefferson: Jefferson really died of old age, living to age 83 and dying on July 4, 1826. He survived to be the third-to-last signer of the Declaration of Independence to pass. He had uremia, nephropathy, and may have died of dehydration from amoebic dysentery. The most interesting thing I found about his death was the he wrote his own epitaph, and insisted that it include “not a word more.” It did not mention his governorship of Virginia, vice-presidency or presidency:

“HERE WAS BURIED THOMAS JEFFERSON
AUTHOR OF THE DECLARATION OF AMERICAN INDEPENDENCE
OF THE STATUTE OF VIRGINIA FOR RELIGIOUS FREEDOM
AND FATHER OF THE UNIVERSITY OF VIRGINIA.”

John Adams: Fittingly died on July 4, 1826, just hours after Jefferson, at age 88 making him the next-to-last Declaration of Independence signer to die. He also died of old age, suffering from congestive heart failure and likely coronary disease. At age 88 he may have lived longer with the excellent heart failure treatments of today, but he certainly lived a long life. When told it was July 4th, it is rumored in his last hour of life he said: “It is a great day. It is a good day.” His last words have been reported as “Thomas Jefferson survives” (not knowing that Jefferson had died hours earlier).

Benjamin Franklin: Although famous for having syphilis, Franklin likely died of empyema, an infection of the space between the lung and the chest wall. He was bedridden for the last year of his life, and likely contracted pneumonia. Empyema sometimes complicates pneumonia, and though we are often able to treat pneumonia and empyema successfully today, at age 84 pneumonia is still often the “old man’s friend.”

John Hancock: Hancock died at age 56, reportedly of gout. Most likely the gout led to him being bedridden, and he died of complications of bed rest. Today we are very good at treating gout, so he would likely have lived both a better quality and longer life with modern medicine. Of note, Hancock’s funeral was the most lavish in the new America as of his death on October 8, 1793.

Samuel Adams: Samuel Adams lived to age 81, dying on October 2, 1803. He suffered from what is now felt to be essential tremor, making him unable to write in his last decade. This is a condition we have pretty good success with treating today, and he would have likely had a better quality of life with modern medical help for this condition. I’m unable to find information about his cause of death, but he certainly did not die prematurely.

James Madison: Madison was the last of our Founding Fathers to die on June 26, 1836, at the age of 85. As the primary author of our Constitution, a major contributor to the Federalist Papers, and a key early legislator and later President, he had a brilliant mind. He seemed to struggle in his later years with anxiety and dementia, and may well have benefited from an SSRI. At times his anxiety, and probably depression, left him essentially bedridden. He died at an old age, at the time simply called “debility.”

John Paul Jones: The naval hero of the Revolutionary war is famous for saying, “I have not yet begun to fight,” during the engagement with the British ship Serapis in the North Sea in 1779. He died of a brain tumor at age 45. The big advantage Jones would have had today would have been a long US military career, with military health care. We still often are not terribly successful at treating brain tumors, so he may still have died at a young age.

Alexander Hamilton: Hamilton, felt by some to be our greatest Secretary of the Treasury, died after a well known duel with Aaron Burr. The bullet apparently entered in the right lower abdomen, ricocheting off the pelvis and causing liver, diaphragm, other internal organ damage and also spinal cord injury at about the L2 level, leaving Hamilton paralyzed. He died the next day. The bullet wound may have still killed him today, although duels are thankfully a thing of the past. With modern surgery he may well have survived as a paraplegic.

- Ed Pullen