From 2012 to 2018, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommended not screening for prostate cancer, based on evidence that the then-widespread practice produced no net benefit. As a result, fewer family physicians subsequently screened their patients with the PSA test, and fewer men were diagnosed (or overdiagnosed) with localized prostate cancer. However, the USPSTF's recent change to a more permissive approach to PSA-based screening has increased the likelihood that more men will need to make difficult decisions regarding what to do about a prostate cancer diagnosis.
As I discussed in a previous AFP Community Blog post, surveyed men with newly diagnosed localized prostate cancer expected to gain a whopping 12 years of life expectancy by undergoing surgery or radiation. In fact, two randomized, controlled trials found no gains in prostate cancer-specific or all-cause mortality. After nearly 20 years of follow-up, the U.S. Prostate Cancer Intervention versus Observation Trial (PIVOT) reported in 2017 that radical prostatectomy reduced the likelihood of treatment for asymptomatic, local, or biochemical (PSA) disease progression compared to observation, but caused more urinary incontinence, erectile dysfunction, and limitations in activities of daily living. Similarly, the U.K. Prostate Cancer for Testing and Treatment (ProtecT) trial found that active surveillance was comparable to radiotherapy or prostatectomy, with a slightly greater likelihood of clinical progression and metastatic disease in the active surveillance group.
A 2018 article reviewed the evolving National Comprehensive Cancer Network guidelines for treatment of localized prostate cancer, which recommend incorporating comorbidity-adjusted life expectancy into screening and treatment decisions:
The comorbidity-adjusted life expectancy is particularly important because the number of comorbid diseases is among the most significant predictors of survival after prostate cancer treatment. Prostate cancer is usually slow growing, and the survival benefit of treatment may present only after 10 years. Therefore, patients with low-risk or very low-risk prostate cancer should be treated only if the patient has a comorbidity-adjusted life expectancy of at least 10 years.
An older Swedish randomized trial comparing radical prostatectomy to watchful waiting in men with predominantly clinically-detected (rather than PSA-detected) localized prostate cancer found that radical prostatectomy was associated with less than 3 years of life gained after 23 years of follow-up. Altogether, the evidence suggests that curative treatments may be worthwhile for selected men with symptoms, but that there is little or no benefit to looking for prostate cancer in men who feel well.
**
This post first appeared on the AFP Community Blog.
Wednesday, January 30, 2019
Monday, January 21, 2019
When deprescribing is the best medicine
Physicians who care for older adults or others with multiple chronic conditions understand that deprescribing unnecessary or inappropriate therapies is central to providing high-quality care and improving patient safety. An editorial by Drs. Barbara Farrell and Dee Mangin in the January 1 issue of American Family Physician reviewed the health risks associated with polypharmacy (taking five or more chronic medications) and provided a table of resources for each step of the deprescribing process, including several evidence-based guidelines co-written by the authors. AFP's Practice Guidelines department summarized their guideline on deprescribing antipsychotics for dementia and insomnia last year and reviewed how to taper benzodiazepine receptor agonists for insomnia in adults in the January 1 issue.
A 2018 systematic review in the British Journal of General Practice reviewed data from 27 randomized, controlled trials of deprescribing a range of drug classes in adults aged 50 years or older in primary care settings. In 19 studies, at least half of patients in the intervention groups were able to stop their medications completely, and adverse effects were uncommon. However, the risk of "relapse" (needing to resume the drug after completely discontinuing it) ranged from 2 to 80 percent.
Patient expectations, medical culture, and organizational constraints can present barriers to deprescribing. A qualitative study of New Zealand primary care physicians in the Annals of Family Medicine described deprescribing as "swimming against the tide." Study participants recommended several practice and system-level interventions to support deprescribing that could also be applied to practices in the U.S.:
- Targeted funding for annual medicines review
A 2018 systematic review in the British Journal of General Practice reviewed data from 27 randomized, controlled trials of deprescribing a range of drug classes in adults aged 50 years or older in primary care settings. In 19 studies, at least half of patients in the intervention groups were able to stop their medications completely, and adverse effects were uncommon. However, the risk of "relapse" (needing to resume the drug after completely discontinuing it) ranged from 2 to 80 percent.
Patient expectations, medical culture, and organizational constraints can present barriers to deprescribing. A qualitative study of New Zealand primary care physicians in the Annals of Family Medicine described deprescribing as "swimming against the tide." Study participants recommended several practice and system-level interventions to support deprescribing that could also be applied to practices in the U.S.:
- Targeted funding for annual medicines review
- Computer alerts to prompt physicians’ memories
- Computer systems to improve information sharing between prescribers
- Improved access to non-pharmaceutical therapies
- Research to build the evidence base in multimorbidity, education and training
- Ready access to expert advice and user-friendly decision support
- Updating guidelines to include advice on when to consider stopping medicines
- Tools and resources to assist in the communication of risk to patients
- Activating patients to become more involved in medicines management and alert to the possibility that less might be better
Along those lines, the AFP editorial also provided a Table of examples of language that family physicians can use to discuss deprescribing with patients and facilitate shared decision-making.
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This post first appeared on the AFP Community Blog.
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This post first appeared on the AFP Community Blog.
Thursday, January 17, 2019
Birthday reflections: envisioning my third act
I'm celebrating my 43rd birthday today, and nearly a decade of blogging at Common Sense Family Doctor. Although 2018 was the first year in which I wrote fewer than one post per week (46 total), I haven't slowed my writing output overall, authoring or co-authoring ten journal articles or textbook chapters last year and kicking off 2019 with a new study in the Journal of the American Board of Family Medicine on conversations on Twitter about women and Black men in medicine. I am grateful to my longtime colleague Dr. Ranit Mishori (@ranitmd) for coming up with this novel research idea and inviting me to join the team.
The changing of the calendar prompts me to reflect more on my career arc as a family physician, researcher, educator, and author. I have been thinking of my career thus far as an ongoing series of "acts," each lasting for several years. The first act began in 2004 with a year-long editing and faculty development fellowship at Georgetown, continued through my time as a medical officer at AHRQ, followed by a year working in urgent care, and concluded with my re-joining the family medicine department as a full-time faculty member and associate deputy editor of American Family Physician and earning my Master of Public Health degree from Johns Hopkins.
In the second act, beginning around 2012-2013, I gradually built my outpatient primary care practice in northwest DC (a handful of patients found me first through my blog); developed and enhanced medical school courses and a fellowship program involving population health, health policy and advocacy; and was promoted to professor of family medicine and deputy editor of AFP. To be sure, there have been setbacks along the way, including, recently, the disappointment of not advancing to the interview stage in my application for the open editor position at the Annals of Family Medicine.
2019 feels to me like the start of Act 3, although I can't fully articulate why. Maybe it's because in my 15th year of practice I have clearly entered mid-career. My patients are getting older, and more of them now struggle with chronic diseases and chronic pain and are spending time in various local hospitals. With my paths to editorial leadership of prominent family medicine journals closed off for at least the next decade (barring the unexpected), I have turned my energies toward developing new features such as AFP's Lown Right Care department and, together with collaborators at Lown, Georgetown, and in Louisiana, am working on a systematic review for the first time in years. My public speaking continues to focus on overuse, particularly of screening tests whose benefits are overvalued and harms are underappreciated. My four kids (ages 4 through 12) keep growing, my wife's house calls practice and nonprofit are thriving, and our family has no plans to leave the DC area anytime soon - again, barring the completely unexpected.
Act 3. The curtain rises. What does this next act have in store for me?
The changing of the calendar prompts me to reflect more on my career arc as a family physician, researcher, educator, and author. I have been thinking of my career thus far as an ongoing series of "acts," each lasting for several years. The first act began in 2004 with a year-long editing and faculty development fellowship at Georgetown, continued through my time as a medical officer at AHRQ, followed by a year working in urgent care, and concluded with my re-joining the family medicine department as a full-time faculty member and associate deputy editor of American Family Physician and earning my Master of Public Health degree from Johns Hopkins.
In the second act, beginning around 2012-2013, I gradually built my outpatient primary care practice in northwest DC (a handful of patients found me first through my blog); developed and enhanced medical school courses and a fellowship program involving population health, health policy and advocacy; and was promoted to professor of family medicine and deputy editor of AFP. To be sure, there have been setbacks along the way, including, recently, the disappointment of not advancing to the interview stage in my application for the open editor position at the Annals of Family Medicine.
2019 feels to me like the start of Act 3, although I can't fully articulate why. Maybe it's because in my 15th year of practice I have clearly entered mid-career. My patients are getting older, and more of them now struggle with chronic diseases and chronic pain and are spending time in various local hospitals. With my paths to editorial leadership of prominent family medicine journals closed off for at least the next decade (barring the unexpected), I have turned my energies toward developing new features such as AFP's Lown Right Care department and, together with collaborators at Lown, Georgetown, and in Louisiana, am working on a systematic review for the first time in years. My public speaking continues to focus on overuse, particularly of screening tests whose benefits are overvalued and harms are underappreciated. My four kids (ages 4 through 12) keep growing, my wife's house calls practice and nonprofit are thriving, and our family has no plans to leave the DC area anytime soon - again, barring the completely unexpected.
Act 3. The curtain rises. What does this next act have in store for me?
Monday, January 7, 2019
Guest Post: How the medical profession can help heal divisions as well as diseases
- Richard Gunderman, MD, PhD, Indiana University
Medicine need not be confined to the role of cultural bellwether, a sheep with a bell on its neck that reveals where the whole flock is headed. Along with other professions such as law, clergy and education, medicine can and should play the leadership role of a shepherd, helping our society to develop more thoughtful, balanced and generous approaches to the challenges that face us. After all, the word doctor means teacher, and our culture needs the best instruction we can offer. The dawn of a new year makes the time ripe for such a shift in medicine’s role.
Popular culture has reflected an erosion of the doctor as teacher and role model. In the 1960s and 70s, television doctors such as Dr. Kildare and Marcus Welby epitomized virtues such as dedication and compassion. Then along came “M.A.S.H.” and “St. Elsewhere,” which adopted a more irreverent attitude toward medicine and the people who practice it. By 2004’s “House,” which ran for eight seasons, the doctor had degenerated into a clever but deeply misanthropic opioid addict.
This principle does not imply that doctors should never harm. After all, no surgeon could ever operate and no oncologist could ever administer chemotherapy if they rigorously adhered to it. It means instead that risks and harms must always be balanced against benefits, and that where the balance is too uncertain or unfavorable, it is better to do nothing. More broadly speaking, we should avoid saying things or acting in ways that cause needless injury.
What would “Do no harm” look like in our popular culture? First, it would mean eschewing personal attacks, which seek to label people as unworthy, disgusting, or evil. In public discourse, our goal should be to understand different points of view, to educate one another, and to take the interests of others into account in arriving at decisions. Physicians are expected to take good care of even patients they find disagreeable, and this an outlook sorely deficient in the U.S. today.
In popular culture, complex matters are often reduced to highly simplified dichotomies, in which the two sides are portrayed as sporting white and black hats. It seems as though all Americans need to know is whether a person is a Democrat or Republican, a conservative or a liberal, or a reader of The Washington Post or The Wall Street Journal. In fact, however, making good choices requires an understanding far deeper than which side of a political divide a person is on.
Good doctors learn quickly that a cursory inspection can be deeply misleading, as a story once told by a colleague reveals. An elderly, disheveled, incoherent woman was brought to the emergency room with a broken arm. The staff took her for a homeless person. Later, however, she started to make sense, and provided her phone number. When her family came to pick her up, they arrived in a chauffeured limousine. In this as in so many cases, what first met the eye turned out to be quite deceptive.
The founders of the U.S. knew that human beings are not angels, but they also believed that people can look beyond narrow self-interest and do what is best for others and the larger whole. They knew that serving a purpose beyond self is one of the surest ways to find meaning and purpose in life, and that those who contribute the most often lead the fullest lives. They bet their own lives on the proposition that Americans could answer the call of their better selves.
By serving as exemplars of what a life of service looks like in communities across the country, doctors and other professionals can remind Americans of all ages what human beings at their best are really capable of. To look out only for number one is to lose hope in neighbors, communities and society. To get to know others, to take an interest in their stories, and to reach out and serve when they need help and support is one of the signs of a hopeful, thriving culture.
The idea of medicine as a cultural beacon of goodness may seem profoundly counter-cultural. Our appetite seems much greater for stories of doctors whose financial or sexual misconduct has disgraced themselves and the profession. Yet for the professions to play a role in reshaping our habits of mind and heart, their members must act courageously, not waiting until the cultural winds have shifted but letting their better voices speak even when no one else seems to be listening.
This article is republished from The Conversation under a Creative Commons license. Read the original article.
Medicine need not be confined to the role of cultural bellwether, a sheep with a bell on its neck that reveals where the whole flock is headed. Along with other professions such as law, clergy and education, medicine can and should play the leadership role of a shepherd, helping our society to develop more thoughtful, balanced and generous approaches to the challenges that face us. After all, the word doctor means teacher, and our culture needs the best instruction we can offer. The dawn of a new year makes the time ripe for such a shift in medicine’s role.
Doctors as teachers
In serving as educators, doctors have many resources to draw on. They are among the best educated groups in our society, having pursued one of our the longest and most intense courses of study. In practice, they regularly participate in moments that help to clarify what life is all about – birth and death, growth and aging, suffering and relief. And they serve as trusted confidantes and counselors to patients and families at some of life’s most meaningful moments.Popular culture has reflected an erosion of the doctor as teacher and role model. In the 1960s and 70s, television doctors such as Dr. Kildare and Marcus Welby epitomized virtues such as dedication and compassion. Then along came “M.A.S.H.” and “St. Elsewhere,” which adopted a more irreverent attitude toward medicine and the people who practice it. By 2004’s “House,” which ran for eight seasons, the doctor had degenerated into a clever but deeply misanthropic opioid addict.
First, do no harm
As a physician and educator, I think that, for medicine to help heal our culture, doctors must embrace their role as advocates for principles that have long represented the core of the healing professions. Although “Primum non nocere, or ”First, do no harm,“ does not appear in the writings of the "father of medicine” Hippocrates, it is often cited as medicine’s first principle. And the idea that doctors should avoid harm is part of the modified Hippocratic Oath that most doctors take when they graduate from medical school.This principle does not imply that doctors should never harm. After all, no surgeon could ever operate and no oncologist could ever administer chemotherapy if they rigorously adhered to it. It means instead that risks and harms must always be balanced against benefits, and that where the balance is too uncertain or unfavorable, it is better to do nothing. More broadly speaking, we should avoid saying things or acting in ways that cause needless injury.
What would “Do no harm” look like in our popular culture? First, it would mean eschewing personal attacks, which seek to label people as unworthy, disgusting, or evil. In public discourse, our goal should be to understand different points of view, to educate one another, and to take the interests of others into account in arriving at decisions. Physicians are expected to take good care of even patients they find disagreeable, and this an outlook sorely deficient in the U.S. today.
Get the whole story
A second habit deeply ingrained over the course of medical training is to recognize that there are usually more than two sides to any question. Suppose a patient complains of pain in the right lower quadrant of the abdomen, a classic symptom of appendicitis. Only poor physicians would confine their attention to the question, “Is it appendicitis or not?” The real issue at hand is to determine what is causing the pain and what needs to be done about it.In popular culture, complex matters are often reduced to highly simplified dichotomies, in which the two sides are portrayed as sporting white and black hats. It seems as though all Americans need to know is whether a person is a Democrat or Republican, a conservative or a liberal, or a reader of The Washington Post or The Wall Street Journal. In fact, however, making good choices requires an understanding far deeper than which side of a political divide a person is on.
Good doctors learn quickly that a cursory inspection can be deeply misleading, as a story once told by a colleague reveals. An elderly, disheveled, incoherent woman was brought to the emergency room with a broken arm. The staff took her for a homeless person. Later, however, she started to make sense, and provided her phone number. When her family came to pick her up, they arrived in a chauffeured limousine. In this as in so many cases, what first met the eye turned out to be quite deceptive.
Put service before self
To become really good doctors, medical students need to learn something: Patients do not exist to provide careers to physicians; instead, physicians exist to care for patients. Like other professionals, doctors need to put the interests of their patients first. The overarching goal is not to advance the physician’s career, to generate more income, or to secure the business interests of a medical practice or hospital. The goal is to care well for the patient.The founders of the U.S. knew that human beings are not angels, but they also believed that people can look beyond narrow self-interest and do what is best for others and the larger whole. They knew that serving a purpose beyond self is one of the surest ways to find meaning and purpose in life, and that those who contribute the most often lead the fullest lives. They bet their own lives on the proposition that Americans could answer the call of their better selves.
By serving as exemplars of what a life of service looks like in communities across the country, doctors and other professionals can remind Americans of all ages what human beings at their best are really capable of. To look out only for number one is to lose hope in neighbors, communities and society. To get to know others, to take an interest in their stories, and to reach out and serve when they need help and support is one of the signs of a hopeful, thriving culture.
The idea of medicine as a cultural beacon of goodness may seem profoundly counter-cultural. Our appetite seems much greater for stories of doctors whose financial or sexual misconduct has disgraced themselves and the profession. Yet for the professions to play a role in reshaping our habits of mind and heart, their members must act courageously, not waiting until the cultural winds have shifted but letting their better voices speak even when no one else seems to be listening.
**
This article is republished from The Conversation under a Creative Commons license. Read the original article.
Thursday, December 20, 2018
My favorite public health and health care books of 2018
For the fourth year running, here is a list of the top 10 health-related books I read, ordered alphabetically. Although most were published within the past year, a few older books made it in as well. If you have already read these, feel free to peruse my lists from 2017, 2016, and 2015 for other worthwhile health and medicine reads for the holidays.
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1. Bad Blood: Secrets and Lies in a Silicon Valley Startup, by John Carreyrou
What amazed me about this sordid tale wasn't the degree of corporate malfeasance involved, but how a charismatic college dropout managed to dupe so many investors and reporters (except for the author, notably) for so long.
2. Called for Life: How Loving Our Neighbor Led Us Into the Heart of the Ebola Epidemic, by Kent Brantly
Although there have been many excellent profiles of Dr. Brantly, a Texas family physician who survived an infection with Ebola virus during the 2014 outbreak in Liberia, nothing compares to hearing the story in his own words.
3. The Comeback: Greg LeMond, the True King of American Cycling, and a Legendary Tour de France, by Daniel de Vise
Though you'll likely find this biography in the sports section of your local bookstore, it is as much about medicine as cycling: LeMond's remarkable recovery from a nearly fatal hunting accident, as well as the pharmaceutical doping practices that spread through the rest of the peloton in the early 1990s and led to his premature retirement from the sport.
4. The Fears of the Rich, The Needs of the Poor: My Years at the CDC, by William Foege
The compelling memoir of a public health legend who tacked infectious disease threats from Legionnaires disease to smallpox.
5. The Fever: How Malaria Has Ruled Humankind for 500,000 Years, by Sonia Shah
What is by far the deadliest creature in human history? The mosquito.
6. In Shock: My Journey From Death to Recovery and the Redemptive Power of Hope, by Rana Awdish
A critical care doctor became a critical care patient, and after multiple near-death experiences emerged on the other side a more compassionate and capable physician.
7. Next in Line: Lowered Care Expectations in the Era of Retail and Value-based Health, by Timothy Hoff
A management professor explores, through patient and physician interviews, how efforts to standardize and improve primary care quality have instead created an environment that is toxic to the therapeutic relationships that make family medicine effective in the first place.
8. The Public Health Crisis Survival Guide, by Joshua Sharfstein
Dr. Sharfstein, currently Vice Dean and director of the Bloomberg American Health Initiative at Johns Hopkins University (where I earned my Master of Public Health degree), relates war stories and lessons learned from his days as a city, state, and federal health official.
9. Surgeon General's Warning: How Politics Crippled the Nation's Doctor, by Mike Stobbe
As this book illustrates, past U.S. Surgeon Generals have struggled with the high-profile but low-authority nature of the position and the political considerations that shadowed their every public utterance. I'm a fan of the current SG, Dr. Jerome Adams, whose recent declaration that teenage vaping has now reached "epidemic" proportions reminded me of his predecessor, Dr. C. Everett Koop.
10. What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City, by Mona Hanna-Attisha
Dr. Hanna-Attisha's crusade to protect the children of Flint, Michigan from lead-poisoned drinking water represented a rare triumph of the disenfranchised over racial and social injustices. Her family's interweaved immigration story serves as a reminder of what America stands to lose from policies that seek to close our borders.
**
1. Bad Blood: Secrets and Lies in a Silicon Valley Startup, by John Carreyrou
What amazed me about this sordid tale wasn't the degree of corporate malfeasance involved, but how a charismatic college dropout managed to dupe so many investors and reporters (except for the author, notably) for so long.
2. Called for Life: How Loving Our Neighbor Led Us Into the Heart of the Ebola Epidemic, by Kent Brantly
Although there have been many excellent profiles of Dr. Brantly, a Texas family physician who survived an infection with Ebola virus during the 2014 outbreak in Liberia, nothing compares to hearing the story in his own words.
3. The Comeback: Greg LeMond, the True King of American Cycling, and a Legendary Tour de France, by Daniel de Vise
Though you'll likely find this biography in the sports section of your local bookstore, it is as much about medicine as cycling: LeMond's remarkable recovery from a nearly fatal hunting accident, as well as the pharmaceutical doping practices that spread through the rest of the peloton in the early 1990s and led to his premature retirement from the sport.
4. The Fears of the Rich, The Needs of the Poor: My Years at the CDC, by William Foege
The compelling memoir of a public health legend who tacked infectious disease threats from Legionnaires disease to smallpox.
5. The Fever: How Malaria Has Ruled Humankind for 500,000 Years, by Sonia Shah
What is by far the deadliest creature in human history? The mosquito.
6. In Shock: My Journey From Death to Recovery and the Redemptive Power of Hope, by Rana Awdish
A critical care doctor became a critical care patient, and after multiple near-death experiences emerged on the other side a more compassionate and capable physician.
7. Next in Line: Lowered Care Expectations in the Era of Retail and Value-based Health, by Timothy Hoff
A management professor explores, through patient and physician interviews, how efforts to standardize and improve primary care quality have instead created an environment that is toxic to the therapeutic relationships that make family medicine effective in the first place.
8. The Public Health Crisis Survival Guide, by Joshua Sharfstein
Dr. Sharfstein, currently Vice Dean and director of the Bloomberg American Health Initiative at Johns Hopkins University (where I earned my Master of Public Health degree), relates war stories and lessons learned from his days as a city, state, and federal health official.
9. Surgeon General's Warning: How Politics Crippled the Nation's Doctor, by Mike Stobbe
As this book illustrates, past U.S. Surgeon Generals have struggled with the high-profile but low-authority nature of the position and the political considerations that shadowed their every public utterance. I'm a fan of the current SG, Dr. Jerome Adams, whose recent declaration that teenage vaping has now reached "epidemic" proportions reminded me of his predecessor, Dr. C. Everett Koop.
10. What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City, by Mona Hanna-Attisha
Dr. Hanna-Attisha's crusade to protect the children of Flint, Michigan from lead-poisoned drinking water represented a rare triumph of the disenfranchised over racial and social injustices. Her family's interweaved immigration story serves as a reminder of what America stands to lose from policies that seek to close our borders.
Monday, December 17, 2018
Family medicine and the value of long-term therapeutic relationships
A commentary in the November 22 issue of the New England Journal of Medicine titled "Beyond Evidence-Based Medicine" received much well-deserved criticism for not only mis-characterizing EBM, but advocating for a novel approach, "interpersonal medicine," that was explicitly codified in the recognition of the U.S. specialty of Family Practice nearly 50 years ago. Here's what the authors wrote about this practice of medicine that is, apparently, new to them but well-known to the rest of us:
Interpersonal medicine would recognize clinicians’ influence on patients and informal caregivers and the relationships among them. It would be anchored in longitudinal, multidirectional communication; broach social and behavioral factors; require coordination of the care team; and constantly evaluate and iterate its own approach.
It was one of the few times in recent memory that other physicians were eager to jump on the #FMRevolution bandwagon, as geriatricians, general internists, and general pediatricians tweeted that their generalist fields provide "interpersonal medicine" too. I agree. But I draw the line there. No matter how excellent one's beside manner, a subspecialist whose job description revolves around treating a specific a body part, organ system, or disease state, or intermittent contacts during specific periods of illness (e.g., emergency medicine, hospitalists) is not using the generalist approach described by longtime Annals of Family Medicine editor Kurt Stange in a 2009 editorial:
A generalist approach involves working on the parts while paying attention to the whole; being connected by sustaining relationships; having a broad base of knowledge while being grounded in specific information; scanning and prioritizing, then focusing on what is most meaningful; moving back and forth between the universal and the particular. The generalist approach is rooted in recognizing connection to person, community, and cosmos.
The skills of generalist physicians - and family physicians in particular - have long been devalued by our health system's mechanisms of measuring and paying for clinical work in discrete tasks, rather than for caring for the whole person. The movement toward "paying for performance" has not helped. As Dr. Dhruv Khullar and colleagues observed in a recent JAMA Viewpoint, "because these programs are disconnected from the needs of patients and physicians within organizations, they often result in erroneous metrics, gaming of the system, and unidirectional assessments that emphasize meeting thresholds over open dialogue."
In other words, never mind that I carefully reviewed with my 65 year-old patient of the past 5 years with a recent blood pressure of 145/92 the pros and cons of intensifying his medication regimen, the limitations of the evidence, and his personal values and preferences; 140/90 is my practice's non-negotiable cutoff for poor quality. This is hardly surprising, since quality management has rarely accounted for what makes a difference to patients in primary care - particularly, as Dr. Justin Mutter and colleagues suggested in "Core Principles to Improve Primary Care Quality Management," prioritizing therapeutic relationships over time. Reflecting on changes in the role of the personal physician since the dawn of the specialty, a group of senior leaders in academic family medicine has observed:
We have watched our patients age with us. They beg us not to retire. For our patients, we are caregivers, healers, advisors, friends, and navigators through a complex system. Our patients are admirable human beings who taught us our craft, offering clinical challenges and providing us with the gratification that makes practicing medicine worthwhile. A principal challenge for the present and future ... is to be able to establish and maintain the long-term trusting relationships that have characterized family doctors and our role in health systems and society.
In a similar ode to continuity of care, Dr. Adam Cifu, a general internist who has cared for the same patient panel for more than 20 years, wrote in JAMA Internal Medicine: "In our own practices and in our roles engineering health care systems, we should prioritize the maintenance of these relationships. We are losing much more than easy clinic days as we foresake long-term physician-patient relationships." This assertion is not merely anecdotal, but supported by evidence: a recent analysis of Medicare data by Dr. Andrew Bazemore and others at the Robert Graham Center found that higher primary care physician continuity is associated with lower costs and hospitalizations. At the same time, one of my colleagues notes that insurers are paying five times as much for patients to have a video or telephone visit with a "teladoc" than with their family physician.
Enough with "interpersonal medicine"! EBM is not the problem, and it never has been. Rather, the patient experience in the U.S. will not improve without first recognizing that family physicians and other generalists have expertise in whole person care, grounded in long-term therapeutic relationships. Then, policymakers must create conditions that support providing generalist care from the continuum of medical training through clinical practice.
Interpersonal medicine would recognize clinicians’ influence on patients and informal caregivers and the relationships among them. It would be anchored in longitudinal, multidirectional communication; broach social and behavioral factors; require coordination of the care team; and constantly evaluate and iterate its own approach.
After reading these sentences via a tweet from Dr. Eric Topol, I quickly added my perspective on "interpersonal medicine," which, judged by the volume of likes and retweets, was greeted enthusiastically by other primary care clinicians and their allies:
It was one of the few times in recent memory that other physicians were eager to jump on the #FMRevolution bandwagon, as geriatricians, general internists, and general pediatricians tweeted that their generalist fields provide "interpersonal medicine" too. I agree. But I draw the line there. No matter how excellent one's beside manner, a subspecialist whose job description revolves around treating a specific a body part, organ system, or disease state, or intermittent contacts during specific periods of illness (e.g., emergency medicine, hospitalists) is not using the generalist approach described by longtime Annals of Family Medicine editor Kurt Stange in a 2009 editorial:
A generalist approach involves working on the parts while paying attention to the whole; being connected by sustaining relationships; having a broad base of knowledge while being grounded in specific information; scanning and prioritizing, then focusing on what is most meaningful; moving back and forth between the universal and the particular. The generalist approach is rooted in recognizing connection to person, community, and cosmos.
The skills of generalist physicians - and family physicians in particular - have long been devalued by our health system's mechanisms of measuring and paying for clinical work in discrete tasks, rather than for caring for the whole person. The movement toward "paying for performance" has not helped. As Dr. Dhruv Khullar and colleagues observed in a recent JAMA Viewpoint, "because these programs are disconnected from the needs of patients and physicians within organizations, they often result in erroneous metrics, gaming of the system, and unidirectional assessments that emphasize meeting thresholds over open dialogue."
In other words, never mind that I carefully reviewed with my 65 year-old patient of the past 5 years with a recent blood pressure of 145/92 the pros and cons of intensifying his medication regimen, the limitations of the evidence, and his personal values and preferences; 140/90 is my practice's non-negotiable cutoff for poor quality. This is hardly surprising, since quality management has rarely accounted for what makes a difference to patients in primary care - particularly, as Dr. Justin Mutter and colleagues suggested in "Core Principles to Improve Primary Care Quality Management," prioritizing therapeutic relationships over time. Reflecting on changes in the role of the personal physician since the dawn of the specialty, a group of senior leaders in academic family medicine has observed:
We have watched our patients age with us. They beg us not to retire. For our patients, we are caregivers, healers, advisors, friends, and navigators through a complex system. Our patients are admirable human beings who taught us our craft, offering clinical challenges and providing us with the gratification that makes practicing medicine worthwhile. A principal challenge for the present and future ... is to be able to establish and maintain the long-term trusting relationships that have characterized family doctors and our role in health systems and society.
In a similar ode to continuity of care, Dr. Adam Cifu, a general internist who has cared for the same patient panel for more than 20 years, wrote in JAMA Internal Medicine: "In our own practices and in our roles engineering health care systems, we should prioritize the maintenance of these relationships. We are losing much more than easy clinic days as we foresake long-term physician-patient relationships." This assertion is not merely anecdotal, but supported by evidence: a recent analysis of Medicare data by Dr. Andrew Bazemore and others at the Robert Graham Center found that higher primary care physician continuity is associated with lower costs and hospitalizations. At the same time, one of my colleagues notes that insurers are paying five times as much for patients to have a video or telephone visit with a "teladoc" than with their family physician.
Enough with "interpersonal medicine"! EBM is not the problem, and it never has been. Rather, the patient experience in the U.S. will not improve without first recognizing that family physicians and other generalists have expertise in whole person care, grounded in long-term therapeutic relationships. Then, policymakers must create conditions that support providing generalist care from the continuum of medical training through clinical practice.
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