Meet FOFM Authors on Dr. Anonymous Show!

Thank you to all of our readers who listened to The Dr. Anonymous Show - Episode 201!

For those who could not make it live, you can listen to the show in its entirety at the link above!  Sebastian calls in after a safe trip to Houston towards the end of the show.  Enjoy!



The following description, from The Doctor Anonymous Blog, describes the episode.  We hope you enjoy learning about our pathway towards family medicine in addition to learning more about our blog and other issues in family medicine and healthcare!  Thanks Dr. A!!

"Hope you can join us this week for Doctor Anonymous Show 201 when our guests will be the authors of the blog called "Future of Family Medicine." This unique blog is written by medical students and the topics vary from health policy, to concepts like the Patient Centered Medical Home, and today's post called "The New Deal for Primary Care in Community Health Centers." Join us on Thursday, January 20, 2011 at 9pm Eastern Time on BlogTalkRadio. Also, check out the video promo above. See you for the show!"

The New Deal for Primary Care in Community Health Centers

(Image of Codman Square CHC's proposed expansion under the new federal grants. Founded in 1974, Codman Square is a FQHC located in Dorchester, MA)

2011 marks the 46th anniversary of the creation of community health centers (CHCs), which were originally created as part of the "war on poverty" in 1975. The importance of CHCs has continued to grow over the past 46 years and CHCs have continued to receive increased federal support, in large part due to bipartisan support.

One of the primary aims of community health centers is to provide good, comprehensive primary care to members of the community that it serves. CHCs disproportionately serve low-income, minority populations. 89.4% of physicians at CHCs nationally are primary care physicians and, of PCPs, 53.8% are family physicians (Rosenblatt et al, 2006). Family medicine's service model is uniquely fitted to the aims of community health centers since both aim to provide comprehensive, community-oriented care.

The large role that family medicine plays in CHCs means that the new funding and planned expansions for CHCs in the health care reform bill brings new opportunities for the specialty of family medicine! In the Patient Protection and Affordable Care Act (PPACA) passed in March 2010, $11 billion were appropriated for Community Health Center capital development grants. $9.5 billion are allocated for creation of new CHCs and expansion of existing CHCs. $1.5 billion are allocated to renovation and upkeep of existing aging CHC facilities. Currently, CHCs serve 20 million patients nationwide. By 2015, they are projected to serve twice that number, 40 million patients nationwide.

Since CHCs predominately provide for underserved populations, this increase will expand access to care to many uninsured patients and also insured patients who have been unable to find a regular primary care physician.

The expansion, while bringing increased opportunities for family physicians and other primary care doctors, also brings another question. Will there be enough FM doctors and PCPs to fill the provider positions that will become available at these new and expanded CHCs? Already, in 2006, a study showed that the average CHC has 13.3% of its family physician positions unfilled. This percentage is even larger in rural areas. This number will only increase if current trends in the primary care workforce shortage continue.

What are some effective recruitment techniques that CHCs are using?

• loan repayment: the National Health Service Corps (NHSC) and some state programs provide student loan repayment to physicians who are willing to work at CHCs. The PPACA adds $1.5 billion to NHSC funding and will add an estimated 15,000 PCPs in shortage areas.
• J-1 visa exemptions: popular among IMGs who do not have legal residency in the US as a means of staying in the USA after residency training (IMGs who come on a J-1 visa for GME training typically have to return to their home country for 2 years following residency unless they receive a J-1 visa exemption; one of the means of receiving a J-1 visa exemption is by serving at a CHC following residency)

These methods of recruitment and other movements within primary care fields provide hope for provider shortages at community health centers. However, we will need to continue to find solutions to recruit PCPs to CHCs and, more importantly, to retain those we already have, if we are to continue to provide quality care and increased access to care through the community health center model.

References:

Rosenblatt RA, Andrilla CHA, Curtin T, Hart LG. Shortages of Medical Personnel at Community Health Centers. JAMA 2006;295:1042-1049.

National Association of Community Health Centers. Community Health Centers and Health Reform: Summary of Key Health Center Provisions. http://www.nachc.com/client/Summary%20of%20Final%20Health%20Reform%20Package.pdf

Ku et al. Using Primary Care to Bend the Curve: The Effect of National Health Reform on Health Center Expansions. Geiger Gibson/RCHN Community Health Foundation. June 30 2010. Policy Research Brief No. 1.

A Medical School That Stays True To Its Mission For Primary Care

"Mercer medical school receives $1.5 million gift"

"Mercer University announced Tuesday the school has received one of its largest-ever anonymous donations that will endow a chair at the university’s School of Medicine...

"The Rufus Harris Chair will direct the medical school’s Center for Rural Heath and Health Disparities...

"According to the news release, a recent study showed the Mercer School of Medicine is one of the most successful schools in the nation at producing physicians who practice in rural areas, shortage areas and low-income areas. The study ranked Mercer second in percentage of graduates who practice in low-income areas in Georgia."

According to the Mercer University School of Medicine, their mission is:

To educate physicians and health professionals to meet the primary care and health care needs of rural and medically underserved areas of Georgia

Utilizing the Graham Center's Med School Mapper Tool, Mercer places 26% of its graduates into rural areas, 54% into HPSA shortage areas, with about 65% remaining in state and 56% into primary care. Of its graduates going into family medicine, 68% go into shortage areas and 39% into rural areas.

This is definitely an example of a medical school trying to stay true to its mission. This grant is not only going to amplify their efforts, but will really benefit the residents of Georgia.

With that being said, when looking at other medical schools, not many are willing to take on a commitment to help their communities with primary care, especially where I go to school within the urban and suburban areas in the northeast. Whose responsibility is it as we move forward to produce physicians that are needed in communities with shortages? Why is Mercer able to do this successfully, where other schools fall short?

Once 2014 hits (pending repeal/replace/laziness), will schools alter their mission statements for the sake of our nation's public health? My initial prediction - not likely but there is always hope!

Keep it up Mercer! You truly are an example of where medical schools should be focusing their efforts in producing the workforce our country truly needs.

Complementary/Alternative Medicine in the Family

I generally spend the week between Christmas and New Year's catching up with many of my old friends from home - it's one of the few times when we're all in Toronto (where I'm from). Yesterday, as I was catching up with 2 old friends, several topics of conversation led me to ponder more deeply about the relationship between family medicine and complementary/alternative medicine (CAM).

One friend told me that he was thinking about applying to a Doctorate program in Traditional Chinese Medicine (TCM). As he shared more about it, I realized the irony of myself, an ethnic Chinese and incidentally an allopathic medical student, being told about TCM by a Caucasian and traditional Chinese medicine student-hopeful.

Later, my other friend shared her ongoing struggle with depression and her attempts to explore CAM. In her ongoing relationship with her family doctor, she had repeatedly discussed CAM potential treatments only to have them ignored by her doctor.

Personally, I have often found a range of physician attitudes from disengagement to active hostility towards complementary-alternative treatment modalities. What brings this attitude?

Is it lack of knowledge leading to this attitude whether hostile or dismissive?

Is it because there lacks evidence in many cases regarding the efficacy of CAM?

Or is part of it from racist and superior attitudes (whether consciously recognized or not) that Western, white medicine must necessarily be better than anything that could come from other cultures, whether Chinese, Ayurvedic or others?

From my perspective, family medicine, based on its comprehensive and holistic approach to the body, seems ideally matched to act as a partner to complementary-alternative medicine. CAM can particularly be important to offer to patients in areas where western allopathic medicine is limited. This areas often include pain management, psychiatric illnesses, quality of life management and others. If family physicians are to effectively create patient-centered medical homes, they must be educated about and open to complementary-alternative medicine since many of their patients may be using them. An open dialogue must happen between patients and their personal physicians - this starts with

(a) physicians being open to dialogue and actively asking questions about CAM, and

(b) being educated enough about CAM to engage in an effective dialogue.

There are a few problems with complementary-alternative medicine before it can be an effective partner with family medicine:

1) Evidence-based practices: much of CAM remains word-of-mouth and "expert opinion-based." If CAM is to become a credible partner and treatment, it must produce credible clinical studies for physicians to embrace it.

2) Regulation: CAM for the large part is unregulated and practitioners can vary in terms of the amount of training they receive. To receive more credibility and standardization of practices, CAM practitioners must become regulated.

As we work towards these goals, both from the CAM and physician side, it will provide better patient management and ultimately work towards caring for each and every individual in the ideal, multi-faceted manner. Happy New Year!

'Family Medicine is a Waste of Your Talent'

There are many things medical students interested in family medicine hear from other students, residents, and attending physicians when bringing up their desire to go into the specialty.

Here are some things I have heard recently

"Family Medicine is a Back-Up Plan"
"Sub-specialize until you can't specialize anymore"
"The IOM sold out on primary care & now want ARNPs to pick up the slack"
"Aww family medicine? That's so nice of you."
"You're Too Smart For Family Medicine"
"The ship may have already sailed on primary care"

First, I will start out by saying that every time I hear this or read it, I get an acidic taste in my mouth, probably signifying vomit encroaching on my pharynx (5-yard penalty on the vomit).

When I look back on reasons for going into family medicine, I would consider myself a student who was "on the fence" about the specialty. In its current state, going into primary care is a decision that my financial planner would probably strangle me over.

The primary care loan forgiveness programs provide financial relief over several years that could be made up over 1/2 to 1 year in most specialties. Nursing leaders are advocating that they can provide the same care just as good as I will while lobbying for equivalence in pay but deny they are trying to replace primary care physicians. Then there is the SGR, the RUC, hospital network/ACO-wannabes taking over private practice....

I initially wanted to go into orthopaedics - not because I wanted to hit the "ROAD" (though it must be nice), but because of my love for sports and desire to have a niche in something. It was not until my first time rotating with a family medicine physician with a CAQ in sports medicine that I realized it was possible to help athletes and non-athletes with musculoskeletal issues, not go through an ortho residency that could potentially ruin my marriage, and continue to see patients without sports medicine issues as a primary care physician.

After $280,000 of student loan debt it may seem crazy but with these past 4 years of medical school with a graduate degree thrown in-between an undergraduate degree, I feel like specializing would only hurt the non-financial gains I have made in my education. I have learned so much about pathology, disease-processes, prevention and clinical practice, that specializing would only end up wasting all of the talent I have accumulating along the way. Family medicine allows me to continue to provide healthcare to everybody - newborns, children, women regardless of hCG status... what we usually refer to as "womb-to-tomb" or "all stages and all ages".

It also allows me to "specialize" in any area at any point no matter where I am in my career. The CAQ in sports medicine is going to be a given in my case - but if one day I decide that I want to be more proficient in cardiac health, I do not need to take a pay cut to do a fellowship in cardiology to focus my attention on that area. If I want to have a niche in diabetes management, I do not need to do a fellowship in endocrinology. And even though those with fellowships are getting paid more to provide these services (note: current tense), this flexibility will keep me from burning out, maintain my interest and desire to further my education as a life-long student, and keep me from losing the huge investment I made which I will be reminded about each month as I make my student loan payments.

Family Medicine - Make the Most of Your Talent, Make the Most of Your Investment - It Is Impossible To Be Too Smart For Family Medicine

Family Medicine Rocks

On The Today Show this morning someone held up a sign at the end of this outdoor segment with Dustin Hoffman that says "Family Medicine Rocks." It is toward the end of the clip on the right hand side of the screen.

Why? Because Family Medicine Rocks.

What Is Family Medicine?

Going into medicine from a suburban community in the northeast, I never really knew exactly what family medicine was as a specialty. I had heard of it before, but did not see it in action until going to undergraduate school in the middle of Pennsylvania. It was there when I began to understand that family physicians could do a little bit of everything...

But what really is family medicine? I needed an exact definition... as one to memorize for an exam.

Before medical school began, I went to Honduras with a group of family physicians and general internists. It was there where we delivered 2 babies, sutured small wounds, treated rare infectious diseases, helped children in an orphanage, and provided acute and chronic care to people of all ages and stages. This is not something I experienced in my suburban community in the northeast. Family physicians providing comprehensive care in obstetrics, treating obscure infectious disease, all while taking care of pediatric and geriatric patients? What IS this specialty??

I searched for the truth early on in medical school - a difficult task considering I go to a school in a large city in the northeast. It was here where I learned that family medicine physicians were very undervalued, overlooked, overworked, and underfunded. Although competent in all areas, family physicians mostly taught public and community health, physical exam skills, and patient communication skills... interesting since family physicians also provided care in all of the other subject areas during the first two years of medical school, but did not give lectures in any of the core content areas. (sidebar - I would argue that the entire family medicine faculty had better presentation and communication skills than several of the proceduralists that lectured us.)

Later on during my clinical years, I traveled to family medicine conferences, networking with a variety of family physicians throughout the country. I have also spent time on a number of clinical rotations in family medicine away from the big cities, traveling to the subrural community 45 minutes away as well as venturing to the south for an away elective. It is amazing how different family physicians practice depending on the location and proximity to specialist-driven care.

One of my future colleagues, a family physician in the rural midwest, practices in a small community located more than an hour away from most of the specialists located in an academic center within a small city. He does full-scope family medicine, providing full scope care in obstetrics, performs C-Sections, colposcopy and gynecological care, performs colonoscopy, ultrasound, helps in the emergency department, rounds on patients in the hospital/taking call, takes house calls, and by the way, sees patients in the typical northeast fashion - outpatient practice. He does all of this mainly because it is too much of a hassle for the patients and specialists to get together at the specialty-driven academic center located over an hour away. Is this family medicine?

My conclusion is that you cannot really define family medicine.

Another family medicine colleague said that you, as the family physician, are defined by the needs of your patients.

Furthermore, we are defined by the number of specialists required to refer to in order to practice proper defensive medicine when involved in a malpractice case when asked

"'x' specialist was located in close proximity as an 'expert' for 'y' condition. Why did you choose to follow evidence-based medicine instead of referring your patient to 'x' specialist to follow the same evidence-based medicine?"

When it comes down to it, a family physician can do whatever they want to do, as long as they are flexible in their location for practice and are providing services that others are not willing to practice within that given area. The most important thing to remember is knowing when to refer to that academic center - inconveniently located in an area that already has at least 2 other of its kind within walking distance.

Access to care following health care reform: Lessons from Massachusetts

In March of this year, President Obama signed into law the Affordable Care Act. In 2006, Massachusetts enacted state health reform that included some similar elements to decrease the number of uninsured in the state including increased coverage and the individual mandate.

We are now 4 years status-post the passage of the health care legislation in MA. What lessons can we learn for the national health care reform from Massachusetts?

430,000 uninsured Massachusetts residents have now been granted insurance since 2007 when the law came into effect. However, access to primary care remains a huge problem in Massachusetts especially in the more rural areas of Western Massachusetts. Data published by the Massachusetts Medical Society in October show that 54% of Family Physicians and 49% of General Internists in the state are not accepting new patients. The average wait time for an appointment with a new primary care provider is 44 days.

Anecdotally, as a medical student in Massachusetts, I have witnessed the family medicine clinic attached to the main teaching hospital (incidentally, where my personal PCP is) cut evening and weekend hours due to a shortage of physicians. Earlier this year when I called to make an appointment for an acute problem, I was offered a visit in 2 weeks. [Side note: I grew up in Canada and, when I was sick, I frequently called at 9 am when my family doctor's office opened to receive an appointment later that same morning. ]

I emailed my physician instead... but, how many people in the same situation, would go to the Emergency Room?

In Massachusetts, we have witnessed an increase in emergency room and urgent care utilization following the passage of health care reform. This not only increases costs but also undermines doctor-patient continuity and fragments care. This situation is even more acute in the rest of the nation. Massachusetts has the 3rd highest PCP to population ratio with 107.8 PCPs per 100,000 vs. an average of 79.4 per 100,000.

So, what can we do?

Can we rely on IMG grads to provide where US grads will not? How can we collaborate with other medical staff like nurses, MAs, and PAs, to increase efficiency and provide better care to more? Are PCMHs or ACOs the answer? We are increasing PCP payment and increasing PCP and underserved residency slots but is this enough and is it timely (given that it takes almost a decade to train a physician)? These are all questions we need to answer if national health care reform is to be effective...

Incorporating PCMH/Patient-Centered Medical Education During Non-Clinical Years

Medical education, although increasing in price, is evolving to meet the demands of the Patient Protection and Affordable Care Act. The model most frequently referenced in the law to effectively carry out this legislation is a concept known as the Patient-Centered Medical Home - a model that is not a new concept. The PCMH was introduced by the American Academy of Pediatrics in 1967 and eventually reinvigorated in the past decade by the AAP, the American Academy of Family Physicians through TransforMED, and the American College of Physician as the Advanced Medical Home model. What does this mean for medical students?

Is this possible? Don't we already have enough to learn about during medical school?

The Pennsylvania State University College of Medicine at Hershey received a $1.46 million grant to incorporate PCMH training during the 3rd year of medical school. Other schools receiving grants to incorporate PCMH into clinical education include Tulane and Alpert Medical School of Brown University. When reading the details of these grants, it seems like they are going to implement a majority of PCMH training into the last 2 years of medical school.

Enter EVMS. They also received a grant, though their vision seems a bit different. The grant of $2.1 million over 5 years is intended to develop a project called Predoctoral Education for Advancing Community Health (PEACH). They plan to "create a simulated community-health center where medical students will learn how to manage complicated cases effectively within a busy practice."

The goal is to teach not just primary-care medicine, but to teach primary-care practice systems that are necessary to achieve success for the patients. Every week they're going to be going to their simulated medical office and taking care of patients as if they were interns in a family-medicine residency.

It's getting them ready for 21st-century primary care. If they go into primary care, they'll be better prepared. If they go into a specialty, they'll be better prepared to interact with the primary-care physicians that are in their community

A curriculum that allows for longitudinal training while incorporating the use of the PCMH seems like a no-brainer. Having a panel of patients of all ages, male and female, with a wide variety of biopsychosocial issues to "take care of" and coordinate care for during non-clinical years would really bring the basic science foundations learned concurrently to life. Providing clinical relevance is something that most medical students enjoy during the non-clinical years.

Imagine sitting in lecture during your first year of medical school and receiving an email from one of your "patients" from your longitudinal panel of patients asking for your opinion on an acute or chronic condition. Should they go to the hospital or see you at their "medical home" that is conveniently open after they are finished with work. Between lecture, you log onto your medical home's EMR and access your patient's information to figure out what should be done and promptly email them back to see you in the office. Later that day, a standardized patient is waiting for you at the clinical skills center to discuss their current issue. You are unsure about a few things during that patient encounter, so you "tweet" a question to your professors and classmates that follow you on your professional Twitter account. Later that evening, you also receive a video with commentary by faculty about your encounter....

Imagine setting up a video-chat with other students in nursing, physician assistant, nutrition, behavioral health, and future social workers that are part of your medical home to discuss your patient panel's coordination of care.

Suppose one of your patients were to have a procedure or surgery - the student would go to their school's simulation center to learn how to "drive the camera" and use other laparascopic tools as well as learn how to suture. Maybe one of your patients are in labor? - Back to the simulation center for a simulated birth. You then see the standardized patient for follow-up care with their "simulated newborn" to learn the newborn well-child exam.

The possibilities of revolutionizing medical education are endless. By learning how to use the PCMH concept with simulation centers, standardized patients, EMR, social media, and coordinating with other future members of our medical homes, we will develop the communication and coordination of care necessary to breed quality physicians. This does not only help our future primary care physicians, but also those who specialize, so that they understand the amount of communication and coordination they will also need to have with their primary care counterparts to improve the care of our patients.

Newsflash: Medical Students Assist in Medical Care at Teaching Facilities

About a week and a half ago, The Dallas Morning News published an unfortunate case of medical mismanagement, mainly dealing with a lack of oversight from attending physicians over residents and medical students.

"Even students – who have yet to graduate from medical school – provide key care, sometimes without direct supervision....
...(the) surgical consent form had warned that (the patient) could face 'blood vessel or nerve injury' complications. It also noted that students might be involved in (their) 'surgery and surgical care'."

They also released a spin-off article stating that ethicists generally feel that patients around the country are not made aware of medical student involvement in their care.

Many hospital patients don't know who's caring for them at any given moment, said Dr. Lisa Soleymani Lehmann, a Harvard Medical School assistant professor who runs the Center for Bioethics at Brigham and Women's Hospital. Many don't distinguish between residents, who are degreed doctors getting paid, on-the-job training, and students, who are unlicensed and still in medical school.

"There's a tremendous amount of confusion," Lehmann said.

She has surveyed about 200 Boston-area patients who underwent operations in which students participated. Half of the patients didn't even realize that medical students had been in the operating room, she said.

Lehmann said many hospitals' consent forms have improved in recent years and now tell patients that medical students will be "involved" in their care. But patients "don't know what that means," and many don't even read the forms, she added.

Over the past week and a half, I have had an internal struggle about what to write about this event. The specifics of this case are quite tragic and should never happen anywhere. At first I was rather annoyed that the author of the original article happened to release the spin-off right away while generalizing all medical students and implying a general lack of communication around the country. Could the author use such an unfortunate case as a stepping block to create generalized anxiety throughout the nation?

As previously mentioned in my burnout blog post, our medical education is already compromised by a feeling of uneasiness from our attending physicians with their practice of defensive medicine. If we place further restriction on our medical training because of a select number of medical mismanagement cases, will we continue our travel down the slippery slope and overall loss of educational opportunities? Will intern year be the new 3rd and 4th year of medical school? (not to mention the possibility of increasing the number of years of residency!?)

Take a look at AMA Opinion 8.087 - Medical Student Involvement in Patient Care. It basically states that medical students need to be identified and patients need to be disclosed as to how the students will be involved in their care, whether it is in the community health center taking an H&P or simply "driving the camera" in surgery.

After taking some time to settle down and think about my own medical training experiences, I have realized that there are definitely ways to improve communication with all members of the team towards patients.

From attending physicians to medical students, it is quite helpful to know the extent of our involvement, especially in surgery. This is not an easy task, as some attending physicians may provide student opportunities during procedures on the fly at their own discretion. Again, this is a difficult task as there is always a first time for doing something and assessing ability is impossible unless the task actually occurs in real-time.

When is it appropriate to drill a pin into a broken bone? How do we know when a student is ready to suture? Are students more prepared to advance their skills on the last rotation of 4th year or as a resident during the first week of internship?

From attending physicians, residents, and medical students, we all need to communicate better towards patients in regards to our role in patient care. Consent forms that are vague and do not provide specific detail are not adequate for patient satisfaction or overall patient safety. We need to identify ourselves to our patients and not just disclose the side effects of medication or the risk of infection and bleeding, but each of our roles in providing safe and effective care.

The correlation between research and policy: not statistically significant

For years, research has shown us that more primary care physicians per capita leads to better population health outcomes. As a corollary, more subspecialists in a given geographic area leads to poorer health outcomes. A perfunctory look at specialty choice by medical students shows that decreasing numbers of students are choosing primary care.

Likewise, research shows that team based, patient-centered care creates better health outcomes and potentially higher patient satisfaction. We also know that this approach can decrease ER visits and ultimately decrease costs.

Then, why haven't we enacted policies and laws to support these and many other findings? Reporting live from the North American Primary Care Research Group Conference (NAPCRG) this week, I have attended seminars and seen posters with outstanding research in chronic disease management, health delivery/services, medical education, you name it. Early yesterday afternoon, I was in the paper session for Health Care Delivery/Health Services Research and it was standing room only. One of the co-authors to a paper couldn't even get into the room because it was so full. Then, I attended a workshop on "Advocacy Skills for the Primary Care Researcher." 10 people in attendance (not counting the 5 workshop leaders and 3 organization staff members in the room).

This disconnect is the fundamental problem with why our research doesn't translate into policy. Researchers do research; the majority never set foot in a legislator's office, don't understand and shun politics, and focus on the statistics. On the other hand, legislators generally don't make evidence-based decisions; most legislators don't understand what a p-value is (forget picking up "Health Affairs" or "NEJM"). They base their decisions on what their constituents want, personal stories, interest groups and media reports.

In my Community and Consumer Organizing class at Harvard School of Public Health, we learned about Kingdon's Open Window Model for change. People generally sit in 1 of 3 streams:

1. Problem Stream: identifying and validating problems through research
2. Policy Stream: identifying and narrowing down solutions to short list of technically feasible policies
3. Political Stream: enacting laws during favorable political climate for solutions

In this model, those who are able to get things done are those who sit at the borders of the streams and can align the streams to create an open window of opportunity.

So, how can we get our researchers more interested in advocacy and politics? How can get legislators excited about the policy implications of research? Addressing these issues and creating more translational research will be fundamental as we pursue reform in primary care, in chronic disease management, in health systems... as we pursue a healthier and better America.

Advocates of Independent Nurse Practitioner Practice Losing Focus Within Current Scope of Practice

One of the hot topics occurring in the health care debate deals with figuring out appropriate leaders of the Patient Centered Medical Home (PCMH). With the recent report by the IOM advocating for independent practice by nurse practitioners, many physician groups, including the AAFP and AMA, have come forth with strong statements advocating against the IOM report and independent practice by CRNPs.

A recent editorial by the AAFP, titled "Nurse Practitioners Are Team Members, Not Leaders, in the PCMH" points out some very disturbing numbers and trends. It begins by pointing out that the IOM and nursing organizations are correct in their analysis that there is a primary care physician shortage and that the role of CRNPs and the medical team could be increased to help with this shortage. However, it provides numbers produced by the American Association of Colleges of Nursing (AACN) that the IOM, CRNP advocates, and the media fail to mention when talking about the expansion of the current scope of practice and independent practice:

"the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025...U.S. nursing schools turned away 54,991 qualified applicants from baccalaureate and graduate nursing programs in 2009 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. In addition, almost two-thirds of nursing schools say faculty shortages are the reason they cannot accept more entrants into their programs."

When thinking about faculty shortages as a medical student, we look to attending physicians as our faculty to help us along our pathway in becoming physicians. In turn, nursing students look towards nursing leaders to help in their training to ultimately become nurses at all levels of nursing education. What better nursing leaders to help in this shortage than CRNPs? Better yet, the Doctor of Nursing Practice (DNP) was originally developed for nurses to have a PhD for academic and faculty purposes to educate future nurses. Are DNPs solely practicing academic nursing as faculty to the extent at which this degree was originally developed?

Why focus so much effort on increasing scope of practice when there are such deficiencies within the current scope of practice? One of the issues that a CRNP or DNP faces by going into academic nursing is a pay decrease and that may keep potential academic nurses away from becoming faculty. I hope that is not the case, especially when encountering all of the physicians that are faculty at academic medical centers that take large decreases in salary to remain in academic medicine instead of private practice.

Let me offer a different and possibly refreshing argument against the independent practice of CRNPs which goes against the usual argument pointing out disparities in education and standardized training/certification.

Medical students, nursing students, physician assistants, physicians, nurses... the entire medical team can agree that patient care comes first. A lot of focus goes into resident working hours and sleep deprivation but what about the bedside nurses that take on extra shifts and patients all the time because there are not enough nurses for coverage?

Expanding the scope of practice for nursing without addressing the current shortage of nurses within the current scope of practice will only spread the nursing workforce even thinner - and in my opinion, will only compromise patient care further than it already does. Increasing advocacy efforts for independent practice and encouraging current nurses to pursue higher education to provide outpatient primary care in the PCMH without increasing the amount of resources and faculty to contribute to a larger nursing workforce will lead to adverse unintended consequences.

Medical Student Burnout and Unprofessional Conduct

Recently, AAFP News Now released an article titled

Unprofessional Conduct Among U.S. Medical Students Linked to Burnout

It focused on an article recently released in JAMA entitled

Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students

I had the opportunity to be interviewed for this article and was featured on an inset within the article that shared a minority of my interview. As I am currently rotating on inpatient medicine at a local community hospital, I am once again experiencing our health care system at its finest - a lot of wasteful spending and unnecessary testing. I am taking a look back at what I had wrote down for the interview and decided to paraphrase the majority of my response into the following blog post regarding the health care system and medical education.

When looking at the advances we have made in biochemistry, genetics, and molecular biology, we are being asked to know so much more information in much greater detail – and still within these 4 years worth of medical school.As more requirements are created and more scientific advances are brought forth, more time is needed in lecture and studying for tests like the USMLE and shelf exams. Most traditional programs are 4 years with 2 years of foundational science and 2 years of
clinical experience.

For one, I believe that medical school admissions do not do a good job
at identifying candidates that will provide an adequate workforce and/or will be good for medicine. It must be extremely difficult to screen applicants to figure out who is genuine about the profession – who is going into medicine because they truly want to go into medicine... on the other hand, who is going into medicine because they test well, and/or because their parents forced them into it throughout childhood. This is definitely a minority of students but nevertheless, takes away seats from other potential medical students who may choose to serve a better purpose and population within our health care system's needs.

Maybe we are not bringing enough students into medicine that come from
underserved areas; maybe we are not screening correctly in the
admissions process to accept students who display genuine altruistic views
and who do not fabricate an artificial personality in an interview
and/or on a personal statement. The 40 MCAT, 3.9 pre-med GPA and 5
publications may look good on paper but may fail miserably at
developing into an altruistic and compassionate physician.

It would be interesting to figure out specific determinants that make
students less altruistic and less likely to serve the medically
underserved. As medical students, we are molded by the experiences we
are faced with during clinical rotations. Were these students who had more
contact with patients who manipulate the health care system for
primary or secondary gain? In most cases, our attitude in respect to
patient populations trickles down from our attending physicians,
residents and interns.

With defensive medicine taking precedence in many situations, medical students take notice of the frustrations felt by our superior members of the team. Are these attitudes more likely to occur in underserved areas? If so, medical students are not only discouraged, but definitely overwhelmed at the amount of follow-up
required of the large volume of unnecessary testing that occurs. We spend so much time trying to cover our back that the amount of quality learning that actually occurs is dramatically reduced.

If we took just half the amount of time we waste on defensive medicine
and documentation and shifted that towards more time for teaching
rounds and instructional time by attending physicians and residents, I
believe medical students would feel more satisfaction with their
education and clinical experiences. As it is, medical students spend
most of their time trying to help the interns and residents with
non-educational work (what we refer to as “scut work”) so that we may
eventually have time at some point for educational purposes.

Additionally, because there is so much more hand-holding by attending
physicians towards the residents and all the way down to the medical
students, it is difficult for medical students to convince themselves
that they are actually contributing to the care of patients. Taking
all of this together, it does not surprise me that studies are showing
that medical students are burning out, documenting non-factual
clinical findings, lacking altruism and altogether becoming
unprofessional throughout the process.

The medical community as a whole needs a “face-lift” in regards to everybody’s attitude towards health care delivery. I do not think this will be possible until the health care system undergoes a much more meaningful reform to address the issues that attending physicians, residents, and medical students face due to the current clinical environment. The current political environment is not going to alleviate any of these issues because nobody is willing to commit to long-term changes in health care delivery and tort law.

Without meaningful tort reform, proper emphasis and payment for primary care, and population education about meaningful health care reform and personal responsibility, we will not peel through the layers and fix any of the intended and unintended consequences that have accumulated throughout years of failed policy and legislation.

Understanding the impact of 2010 mid-term elections

Yesterday during the mid-term elections, the Republicans gained the majority in the House of Representatives and increased representation in the Senate (where they are still in the minority). As the Obama Administration spent ~1.5 yrs of the past 2 yrs implementing health care reform, the Affordable Care Act is (ACA) sure to be targeted. Here are some of the ways family medicine and health care reform may be affected:

One of the campaign promises that Republicans ran on was repealing health care reform, i.e. the Affordable Care Act. The full repeal of the ACA is unlikely since:
(a) any legislation that is introduced and passed in the House by a Republican majority would not pass the Senate and even if it did would be vetoed by the President.
(b) many Republicans were supported financially during the campaign and continue to be supported by special interest groups such as insurers and pharmaceutical companies who stand to benefit from the ACA since there will be increased numbers of individuals insured under ACA

Likely actions to affect the bill:

• repeal of individual sections of bill that are unpopular with Republicans, moderate Democrats, independents
  
• attempts to block funding for new programs and provisions of the ACA
• attempts to delay implementation of parts of ACA
  

Other actions that may occur with the new House are:

• attempt to pass comprehensive tort reform legislation (as promised during campaigning)
• subpoenaing Don Berwick of CMS and Kathleen Sebelius, HHS Secretary to testify about health care reform process
  
• implementing budget cuts to primary care research such as Title VII, NIH and AHRQ funding (Republicans have pledged to cut $100 billion from discretionary spending)
  

Many of my projections are informed by discussion in my Community Organizing Health Policy class at HSPH; my discussion with Bob Blendon, a health policy analyst; and a memo to members of the Academic Family Medicine Advocacy Committee (AFMAC).

What do other people think? Thoughts or predictions?

Impact of 2010 Elections on Health Care Reform

Check out this webcast on Friday, November 5 from 1:30-2:30 pm EST as three experts discuss the impact that this week's elections will have on health care reform.

Discussing will be:

• Douglas Holtz-Eakin, President of American Action Forum and former Director of Domestic and Economic Policy for the John McCain Presidential Campaign
• David Cutler, Harvard Professor of Applied Economics and former Senior Health Advisor to Obama's presidential campaign
• Bob Blendon, Professor of Health Policy and Political Analysis at Harvard School of Public Health and Executive Director of the Harvard Opinion Research Program
  

Doctor Anonymous: Med Students at #fmecnet

Doctor Anonymous interviews us at the FMEC NE Region Meeting in Hershey, PA. The panel on social media inspired us to start a family medicine blog for medical students interested in family medicine. We hope that you enjoy our blog and that we can provide a location for medical students to respectfully discuss issues related to medical school leading up to residency.

Doctor Anonymous: Med Students at #fmecnet: "It's always great talking with med students at the Family Medicine Education Consortium NE region meeting. At the 2010 meeting in Hershey, ..."

Too much testosterone therapy

If the ubiquitous television advertisements are to be believed, there is an epidemic of low testosterone (or “low T” for short) sweeping America. Men of all ages have been instructed in these advertisements to “ask their doctor” if they have any one of a list of nonspecific symptoms that could be improved with testosterone therapy. Although hypogonadism is the only widely recognized indication for testosterone supplementation, recent research suggests that substantial numbers of men without testosterone deficiency are receiving prescriptions.

Concerns about excessive testosterone therapy led the Endocrine Society and the American Urological Association to recommend in the Choosing Wisely campaign that clinicians not prescribe it to men without biochemical evidence of testosterone deficiency, including men with erectile dysfunction and normal testosterone levels. In addition to having questionable benefits for these patients, supplementation is potentially harmful. Recent studies have linked testosterone therapy to an increased risk of cardiovascular events in men over age 65 and in younger men with heart disease.

The Endocrine Society recently recommended that physicians talk with patients about these potential risks and avoid prescribing testosterone to men without hypogonadism. In the meantime, the U.S. Food and Drug Administration is re-evaluating the risk of stroke, heart attack, and death associated with testosterone products. Given well-documented efforts of pharmaceutical companies to expand the market for testosterone therapy by ghostwriting articles for lay and scientific publications, physicians would be wise to steer clear of commercially-sponsored educational offerings and restrict prescriptions of testosterone to patients with FDA-approved indications.

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This post originally appeared on the AFP Community Blog.

"Pure Custer": our obsession with the flawed PSA test

In the face of accumulating evidence and a U.S. Preventive Services Task Force finding that prostate-specific antigen (PSA) screening for prostate cancer does more harm than good, the most frequent response I hear from physicians who continue to defend the test is that PSA is all we have, and that until a better test is developed, it would be unethical to not offer men some way to detect prostate cancer at an asymptomatic stage. (However, these physicians for the most part don't question the ethics of not offering women screening for ovarian cancer, which a recent randomized trial concluded provides no mortality benefit but causes considerable harms from diagnosis and treatment.)

A few years ago, I read historian Stephen Ambrose's dual biography of Oglala Sioux leader Crazy House and Civil War cavalry general George Armstrong Custer, whose troops were routed by the Sioux at the famous Battle of Little Bighorn in 1876. One premise of the book is that the same aggressive instincts that served Custer so well during the Civil War - to always attack, even when the strength and disposition of his enemy was unknown - became fatal flaws when he became an "Indian fighter." For most of his post-Civil War career, Custer and his men wandered the Great Plains looking for someone to fight, and not particularly caring if the Indians he engaged in battle were actually at war with the U.S. Army. In one telling description of Custer's first major Western engagement, Ambrose writes:

Here was audacity indeed. ... Custer had no idea in the world how many Indians were below him, who they were, or where he was. His men and horses were exhausted. ... He was going to attack at dawn from four directions at once. He had made no reconnaissance, held nothing back in reserve, was miles away from his wagon train, and had ordered the most complex maneuver in military affairs, a four-pronged simultaneous attack. It was foolish at best, crazy at worst, but it was also magnificent and it was pure Custer.

If readers of American Indian descent will kindly forgive my making this analogy with their 19th century ancestors, this passage is strikingly similar to the way we diagnose and manage prostate cancer. The vast majority of American Indians by this time had either signed peace treaties or were content to leave settlers alone. Under pressure to "do something" about a few troublesome tribes, however, the U.S. Army sent the overaggressive Custer out to do battle with whatever "warriors" he could find, assuming that in the process he would either kill, capture, or scare off those who aimed to do them harm.

That's pretty much what we do by deploying the PSA test to screen for prostate cancer. We cast as wide a net as possible, doing harm at every step of the way: false positives, adverse effects of prostate biopsies, and overdiagnosis and overtreatment of abnormal-appearing cells that we identify - usually inaccurately - as potentially lethal. For every man whose life may be extended by treatment, 30 to 50 will be treated for no benefit, and 10 to 20 will sustain permanent physical harm. And our continuing obsession with this flawed screening test not only flies in the face of evidence, it's pure Custer.

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This post first appeared on Common Sense Family Doctor on November 18, 2011.

Of impersonal statements and meaningless use

Since becoming a full-time medical school faculty member again, I've volunteered to interview about two applicants each month from September through March. When I first started doing this, I was surprised that the admissions office did not provide me with a copy of the applicant's resume and essay until the time of the interview, carried in a manila folder by the applicant. But I quickly realized that it wasn't necessary to receive this paperwork in advance; reading it afterwards added very little to the sense of the applicant's personal qualities that I got from talking with him or her for half an hour or less.

In fact, the "personal" essays, which should be the most original parts of applications, are usually pretty formulaic. I don't doubt that a few students are called to medicine after falling in love with biology (or physiology, or organic chemistry) in a lonely laboratory but then realizing that they thrive around people (while changing soiled hospital bedsheets, or reading to kids in an emergency waiting room), leading to a eureka! moment when they decide to pursue medicine. The rest of them are likely playing it safe rather than sharing more complicated stories. (Here's mine.)

Writing in Annals of Internal Medicine, internal medicine residency director Turi McNamee bemoaned the the impersonal nature of so-called personal statements:

The overwhelming majority of personal statements are excruciatingly boring. It seems that our standardization of the medical school curriculum has led to a generation of physicians who feel the need to be standardized people as well, even when making statements that are by their very title intended to be personal. [Good personal statements] demonstrate a feature that is still key to being a doctor: humanity. How else are we to know about this side of our candidates if not for their personal statements?

It isn't just medical school and residency curricula that are being standardized. So is clinical practice, via the transformation of guidelines (emphasis on "guide") into performance measures that can be extracted from electronic medical records, if physicians are trained to standardize their office notes in EMR-friendly ways. At my practice, we always collaborate with patients about treatment plans (even if only one option makes any sense); we always examine at least 10 organ systems during a moderately complex initial visit (even if there's no reason to examine most of those regions); we always provide voluminous patient education handouts (desired or not); and we always, always, ask about tobacco use and document counseling smokers to quit (even if the patient has expressed no interest in doing so).

Perhaps these electronic exercises collectively known as "meaningful use" will someday improve care and outcomes. Until then, I know it's only a matter of time before I read a personal essay from an earnest medical school applicant who once aspired to be a professional coder but decided he could have his nonsensical documentation requirements and treat patients, too.

Oh, the humanity!

Screening mammography: growing costs, shrinking benefits

Providing preventive services is a core responsibility of family physicians, and, consequently, American Family Physician devotes many pages to keeping readers up-to-date with the latest studies and recommendations on breast cancer screening. There has been much news of note in the past few years, beginning with the U.S. Preventive Services Task Force's 2009 statement that clinicians should engage women in shared decision-making discussions about the relative benefits and harms of beginning screening mammography before age 50, and perform screening only every other year.

Other groups, such as the American College of Obstetricians and Gynecologists, recommend annual mammography starting at age 40. As reviewed in a recent article, the conflicting USPSTF and ACOG guidelines agree that mammography appears to lower breast cancer mortality, but dispute how to value the harms: false positive results, anxiety, biopsies, overdiagnosis, and unnecessary treatment. To further complicate matters, as adjuvant therapies for breast cancer continue to improve, researchers have speculated (with some supporting data) that mammography may not be nearly as useful at preventing deaths from breast cancer today as it seemed to be a generation ago.

But could the mortality benefit of mammography in younger women actually be as low as zero? That was the startling conclusion of the Canadian National Breast Screening Study, which published its 25-year follow-up report in BMJ earlier this month. Beginning in the early 1980s, this randomized trial evaluated the effect of 5 years of annual mammography in nearly 90,000 women between the ages of 40 and 59 and found no difference in breast cancer mortality between the intervention and control groups. (It's important to note that women age 50 and older in the control group received annual clinical breast examinations.) The study's findings also suggested that more than 1 in 5 breast cancers detected in the mammography group would not have become clinically evident during a patient's lifetime in the absence of screening.

The American College of Radiology labeled the BMJ study "incredibly flawed and misleading" and advised that clinicians and patients disregard its findings. The Incidental Economist blogger Aaron Carroll countered that this study's well-documented limitations (e.g., older mammography technology) were no more disqualifying than those of other (even older) studies that found screening reduced breast cancer deaths: "If you’re not going to be swayed at all by a randomized controlled trial of 90,000 women with 25 year follow up, excellent compliance, and damn good methods, it might be time to consider that there’s really no study at all that will make you change your mind [about the effectiveness of screening mammography]."

Researchers recently estimated that the total cost of mammography screening in the U.S. in 2010 was $7.8 billion, not including costs of missed work or subsequent treatments. If 85% of women between the ages of 40 and 85 were screened annually as recommended by ACOG, the cost would have been $10.1 billion. In contrast, if the same proportion of women adhered to USPSTF screening guidelines (biennial mammography between 50 and 74, with the option of starting earlier or ending later based on a woman's preferences and health status), the cost would have been $3.5 billion. Even though the Affordable Care Act requires insurers to pay for annual screening mammography in women over 40 without any out-of-pocket costs, are patients really getting their money's worth in improved health?

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This post originally appeared on the AFP Community Blog.

Tapping the potential applications of mHealth

Mobile health, or "mHealth" for short, describes technology that allows clinicians or public health professionals to monitor and/or deliver health-related messages to patients via cellular phones, tablets, or other wireless devices. mHealth applications can complement and expand care provided at traditional face-to-face visits, and exploring their untapped potential to improve health in the U.S. and abroad was the topic of a recent Georgetown University Health Policy Seminar.

One popular mHealth initiative is the text4baby program, a public-private partnership launched in 2010 that sends free text messages to expectant and new mothers containing appointment reminders, safety alerts, and general prenatal and postpartum health advice. Smartphone apps now include a variety of self-management tools for weight loss, physical activity, and chronic diseases such as hypertension and diabetes. The U.S. Food and Drug Administration recently moved to regulate health apps that act as medical devices (e.g., electrocardiogram) and would pose safety risks to patients if they malfunctioned. However, the vast majority of health apps used by consumers will not require FDA approval.

In the developing world, "mHealth projects are launching at an exponential rate," declared a recent issue of Johns Hopkins Public Health Magazine. Cellular phones have made real-time communication with field workers routine and allowed teams of nurses and midwives to attend births in rural Bangladesh. However, the field of mHealth is hampered by a lack of evaluations of health outcomes and concerns about sustainability of successful interventions:

Using phones to advance public health isn’t as simple as it seems. Researchers are grappling with complex questions that have already doomed hundreds of mHealth projects: How do you know whether mHealth projects are really working and worth the investment? How do you conquer the phenomenon known as “pilotitis,” and scale effective strategies into health systems that have regional or national impacts? And how do you make sure these projects are long-lasting additions, instead of the public health equivalent of a dropped call?

We debated the types of policies that would be most likely to encourage innovations that make a positive difference for individuals and populations. How can we avoid creating "digital divides" that could worsen health disparities? Should state and local governments provide direct grants or tax relief to promising startups? Or should the central planners get out of the way and trust free market forces to produce the future of mHealth?

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This post is being published simultaneously on The Health Policy Exchange.

Movings and dislocations in life and medicine

A little over a month ago, my family of five moved to a more spacious and modern house in the same neighborhood. I'm slowly getting adjusted to our new place - the locations of the light switches, how to operate the refrigerator's automatic ice maker, which cycle to choose among the dozen different options displayed on our high-end washing machine. It still takes me a few minutes longer to get ready in the morning, while groping through unfamiliar dresser drawers in novel locations. (We purchased a new bedroom set after we moved in.)

There are undeniable advantages to our new home, including central air conditioning, larger appliances, and energy-efficient windows that don't require covering with plastic when the outside temperature plummets. But it may be a while before I can think of it as home, and overcome my automatic instinct to take the turn that leads to our old house when returning from work. I know in my heart that this move is forward progress, but now it feels more like a dislocation.

Our country's health care system is experiencing a similar sort of dislocation, driven not only by the error-plagued implementation of the Affordable Care Act, but trends that have been in motion for decades. Soaring medical technology costs and physician subspecialization have bloated health care spending to nearly one-fifth of the U.S. economy. An employment-based health insurance system that made sense when many people worked for a single company for their entire adult lives is gradually collapsing under its own weight. The ACA's requirement that insurers pay for a minimum set of "essential health benefits" and remove lifetime coverage limits has driven up premiums and shrunk provider networks for millions of people, even as state Medicaid expansions have made millions of others eligible for health insurance for the first time in their adult lives.

Based on the number of new patients I'm seeing in my office because "my new insurance plan won't cover visits to my old doctor," I would not be surprised if more Americans end up changing doctors this year than in any year before. But will they then settle comfortably into permanent patient-centered medical homes? Will newly formed alliances of clinicians and hospitals succeed in organizing themselves to provide accountable care that improves population health outcomes? In other words, is this seemingly inexorable movement toward a brave new health system forward progress, or a temporary dislocation?

Welcoming health centers to the medical neighborhood

Early in my career, I provided patient care at several community health centers in Washington, DC, and more recently, my wife served as the medical director for two area health centers. In fact, for several years we saw our own family doctor in a community health center. Despite the Supreme Court ruling that made the Affordable Care Act's expansion of Medicaid coverage optional for the states, health centers are expected to continue to play a big role in providing affordable primary care to millions of patients. And one of the many challenges that health centers encounter on a daily basis is how to arrange for patients to see subspecialists for diagnostic or therapeutic interventions (e.g., colonoscopy, surgery, cardiac stress testing) that their clinicians don't offer.

In a study published in Health Affairs, Katherine Neuhausen and colleagues asked directors of 20 community health centers in all parts of the U.S. how they addressed this challenge. The authors analyzed their responses to identify six distinct models that health centers use to obtain subspecialty care: Tin Cup, Hospital Partnership, Buy Your Own Subspecialists, Telehealth, Teaching Community, and Integrated System. As one might expect, health center directors who used the Tin Cup (i.e., begging subspecialists for charity care) model were least satisfied with their ability to access subspecialty care, while the most satisfied directors used the Integrated System model, which "features community health centers that are completely integrated with a local government health system or a safety-net hospital that has a comprehensive network of specialists." If a high-functioning community health center can provide its patients with a medical home, then the Integrated System represents the next essential step to meet all of their health care needs: the medical neighborhood.

In that neighborhood, it's important to recognize that the exchange of services can and should be a two-way street. Hospitals and large specialty practices have financial and material resources, while community health centers have the experience and know-how to manage care for high-risk patients with chronic conditions (the so-called "hot spotters" in Atul Gawande's widely read New Yorker article) who generate a disproportionate share of health care costs. The state of Maryland has been particularly innovative in encouraging these two types of organizations to combine forces through a matchmaking project whose results were outlined briefly in a JAMA article and further described in an innovations database maintained by Maryland's Department of Health and Mental Hygiene.

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This post appeared on Common Sense Family Doctor in slightly different form on August 22, 2012.

Will Choosing Wisely change the way family physicians practice?

As phase 3 of the Choosing Wisely campaign draws to a close, it's time to start assessing its impact. Family physicians have been at the forefront of this clinician-led movement to reduce waste and prevent harm from unnecessary medical interventions, beginning with Dr. Howard Brody's call for organized medicine to develop "Top Five" lists of such services:

I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty's “Top Five” list. ... The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.

The American Academy of Family Physicians responded to the Choosing Wisely campaign by participating in all three phases, ultimately contributing 15 clinical recommendations that span the full scope of the specialty of family medicine. However, Dr. Nancy Morden and colleagues observed in a recent New England Journal of Medicine editorial that some societies avoided selecting services that are major contributors to their incomes:

The American Academy of Orthopaedic Surgeons, for example, named use of an over-the-counter supplement as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.

Although patient advocacy groups such as Consumer Reports are also participating in Choosing Wisely, the ultimate success or failure of the campaign will depend on how well physician societies can convince their members to curtail commonly accepted but nonbeneficial services, such as the annual physical examination in healthy adults. Earlier this month, American Family Physician unveiled an online tool that allows readers to search for primary care-relevant recommendations by keyword and topic area. We hope that family physicians and other primary care clinicians will bookmark this tool and use it often to Choose Wisely with their patients.

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This post first appeared on the AFP Community Blog.

Who needs intensive primary care?

In almost every large hospital in this country, there are at least two types of patient beds: regular and intensive care. Intensive care beds are designed for the sickest of the sick - patients who require continuous monitoring, specialized respiratory or cardiovascular support, the most knowledgable consultants, the most powerful drugs. Intensive care units (ICUs) have long been accepted as a necessary innovation in inpatient care, leading to better outcomes for patients than would have otherwise occurred if they were treated with a hospital's "ordinary" resources.

In his oft-cited New Yorker article, "The Hot Spotters," Harvard surgeon Atul Gawande reviewed medical outreach programs to the sickest, costliest five percent of outpatients, programs that he termed "intensive outpatient care." It was the first time I had seen this term, and it got me thinking. While hospital ICUs have become the domains of subspecialist critical care physicians (often called "intensivists"), intensive outpatient care's natural leaders are primary care clinicians. So when Gawande described family physician Jeffrey Brenner's innovative program to improve care coordination and reduce hospitalizations in Camden, New Jersey, what he was describing was really intensive primary care:

If he [Dr. Brenner] could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs. And, if the stats approach to crime was right, targeting those with the highest health-care costs would help lower the entire city’s health-care costs. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients.

As Josh Freeman pointed out on his blog Medicine and Social Justice, the reason that attempts to constrain health care spending by increasing co-payments for drugs and other services (described by supporters as giving patients more "skin in the game") inevitably fail is that these interventions target the 90 percent of patients who hardly utilize the health care system at all. Meanwhile, the 5 to 10 percent whose illnesses drive health care expenditures - the sickest of the sick - cut back on essential care, their conditions spiral rapidly out of control, and hospitalizations and costs keep rising.

The programs described in Gawande's New Yorker article aren't the only models of intensive primary care out there. Some have been around for quite a few years, mostly targeting elderly patients with multiple chronic conditions and funded through Medicare. These include the national Program for All-Inclusive Care for Elderly (PACE), covering more than 23,000 people in 29 states; Johns Hopkins University's Guided Care nurse-coordinator program; and old-fashioned house calls, which family physician Steven Landers has dubbed "The Other Medical Home" and believes are key to revitalizing the specialty of family medicine.

Intensive primary care isn't for everyone, of course. For one thing, it costs too much. And for most patients with acute or simple health conditions, the 15-minute office visit model still works just fine. Intensive primary care should be reserved for the sickest of the sick - patients who require frequent monitoring, specialized social support, the most knowledgable consultants, the most complicated drugs. So how can we design criteria to identify patients who should be transferred from regular to intensive primary care - criteria that will improve the health of the sickest patients, be acceptable to payers, and result in lower health care costs?

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This post originally appeared on Common Sense Family Doctor on February 24, 2011.

Are drugs the best medicine for children with ADHD?

Data from the Centers for Disease Control and Prevention document a steady rise in diagnoses of attention deficit hyperactivity disorder (ADHD) since its first national survey in 1997. Since stimulant medications are widely considered to be first-line therapy for ADHD, it is not surprising that by 2011, more than 3.5 million U.S. children were taking these medications. Guidelines for ADHD, such as one from the American Academy of Pediatrics, prefer prescription drugs over behavioral interventions due in part to the results of an influential 1999 study sponsored by the National Institute of Mental Health that compared these treatments and declared drugs to be superior.

However, a recent article published in the New York Times reported that some of the original study investigators are now openly questioning this conclusion. Since the primary outcomes were short-term impulsivity and inattention symptoms, rather than academic and social outcomes that may be affected more by behavioral skills training, the study's design inherently favored drug therapies. And the manufacturers of these drugs were happy to promote the results to boost sales:

Just as new products ... were entering the market, a 2001 paper by several of the study’s researchers gave pharmaceutical companies tailor-made marketing material. For the first time, the researchers released data showing just how often each approach had moderated A.D.H.D. symptoms: Combination therapy did so in 68 percent of children, followed by medication alone (56 percent) and behavioral therapy alone (34 percent). Although combination therapy won by 12 percentage points, the paper’s authors described that as “small by conventional standards” and largely driven by medication. Drug companies ever since have reprinted that scorecard and interpretation in dozens of marketing materials and PowerPoint presentations. They became the lesson in doctor-education classes worldwide.

There are, of course, practical challenges to providing behavioral therapy for ADHD, including a lack of resources in many communities and high costs, which, unlike drug therapies, are often not paid by health insurance. One way family physicians may facilitate therapy is to integrate behavioral health specialists into their practices.

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This post first appeared on the AFP Community Blog.

Guest Post: Medical schools are no place to train physicians (Part 2 of 2)

This is the second of two guest posts by Dr. Josh Freeman. Part 1 is available here.

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The fact is that most doctors who graduate from medical school will not practice in a tertiary academic health center (AHC), but rather in the community, although the other fact is that a disproportionate number of them will choose specialties that are of little or no use in many communities that need doctors. They will, if they can (i.e., if their grades are high enough) often choose subspecialties that can only be practiced in the high-tech setting of the AHC or the other relatively small number of very large metropolitan hospitals, often with large residency training programs. As they look around at the institution in which they are being educated, they see an enormously skewed mix of specialties. For example, 10% of doctors may be anesthesiologists and there well may be more cardiologists than primary care physicians. While this is not the mix in world of practice, and still less the mix that we need to have for an effectively functioning health system, it is the world in which they are being trained.

The extremely atypical mix of medical specialties in the AHC is not “wrong”; it reflects the atypical mix of patients who are hospitalized there. It is time for another look at the studies that have been done on the “ecology of medical care”, first by Kerr White in 1961 and replicated by the Robert Graham Center of the American Academy of Family Physicians in 2003, and represented by the graphic reproduced here. The biggest box (1000) is a community of adults at risk, the second biggest (800) is those who have symptoms in a given month, and the tiny one, representing less than 0.1%, is those hospitalized at an academic teaching hospital. Thus, the population that students mostly learn on is atypical, heaving skewed to the uncommon; it is not representative of even all hospitalized people, not to mention the non-hospitalized ill (and still less the healthy-but-needing-preventive care) in the community.

Another aspect of educating students in the AHC is that much of the medical curriculum is determined by those non-physician scientists who are primarily researchers. They not only teach medical students, they (or their colleagues at other institutions) write the questions for USMLE Step 1. They are often working at the cutting edge of scientific discovery, but the knowledge that medical students need in their education is much more basic, much more about understanding the scientific method, and what constitutes valid evidence. There is relatively little need, at this stage, for students to learn about the current research that these scientists are doing. Even the traditional memorization of lots of details about basic cell structure and function is probably unnecessary; after 5 years of non-use students likely retain only 10% of what they learn; even if they need 10% -- or more – in their future careers, there is no likelihood that it will be the same 10%.

We have to do a better job has of determining what portion of the information currently taught in the “basic sciences” is crucial for all future doctors to know and memorize, and we also need to broaden the definition of “basic science” to include the key social sciences of anthropology, sociology, psychology, communication, and even many areas of the humanities such as ethics. This is not likely to happen in a curriculum controlled by molecular biologists.

Medical students need a clinical education in which the most common clinical conditions are the most common ones they see, the most common presentations of those conditions are the most common ones they see, and the most common treatments are the ones they see implemented. They need to work with doctors who are representative, in skills and focus, of the doctors they will be (and need to be) in practice. Clinical medical education seems to work on the implicit belief that ability to take care of patients in an intensive care unit necessarily means one is competent to take care of those in the hospital, or that the ability to care for people in the hospital means one can care for ambulatory patients, when in fact these are dramatically different skills sets.

This is not to say that we do not need hospitals and health centers that can care for people with rare, complicated, end stage, tertiary and quarternary disease. We do, and they should have the mix of specialists appropriate to them, more or less the mix we currently have in AHCs. And it is certainly not to say that we do not need basic research that may someday come up with better treatments for disease. We do, and those research centers should be generously supported. But their existence need not be tied to the teaching of medical students. The basic science, and social science, and humanities that every future doctor needs to learn can be taught by a small number of faculty members focused on teaching, and does not need to be tied to a major biomedical research enterprise.

Our current system is not working; we produce too many doctors who do narrow rescue care, and not enough who provide general care. We spend too much money on high-tech care and not enough on addressing the core causes of disease. If we trained doctors in the right way in the right place we might have a better shot at getting the health system, and even the health, our country needs.