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.

Guest Post: Medical schools are no place to train physicians (Part 1 of 2)

Dr. Josh Freeman is Professor and Chair of the Department of Family Medicine at the University of Kansas. His research interests include medical education, faculty development and curricular innovation, and health care for underserved populations. This is the first of two guest posts that were originally published on his blog, Medicine and Social Justice. Part 2 is available here.

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Doctors have to go to medical school. That makes sense. They have to learn their craft, master skills, and gain an enormous amount of knowledge. They also, and this is at least as important, need to learn how to think and how to solve problems. And they need to learn how to be life-long learners because new knowledge is constantly being discovered, and old truths are being debunked. Therefore, they must learn to un-learn, and not to stay attached to what they once knew to be true but no longer is. They also need, in the face of drinking from this fire-hose of new information and new skills, to retain their core humanity and their caring, the reasons that (hopefully) most of them went into medicine.

Medical students struggle to acculturate to the profession, to learn the new language replete with eponyms, abbreviations, and long abstruse names for diseases (many are from Latin, and while they are impressive and complicated, they are also sometimes trite in translation, e.g., “itchy red rash”). They have to learn to speak “medical” as a way to be accepted into the guild by their seniors, but must be careful that it does not block their ability to communicate with their patients; they also need to continue to speak English (or whatever the language is that their patients speak). “Medical” may also offer a convenient way of obscuring and temporizing and avoiding difficult conversations (“the biopsy indicates a malignant neoplasm” instead of “you have cancer”). But there needs to be a place for them to learn.

So what is wrong with the places that we are teaching them now? Most often, allopathic (i.e., “MD”) medical schools are part of an “academic health center” (AHC), combined with a teaching hospital. They have large biomedical research enterprises, with many PhD faculty who are, if they are good and lucky, are externally funded by the National Institutes of Health (NIH). Some or many of them spend some of their time teaching the “basic science” material (biochemistry, anatomy, physiology, microbiology, pharmacology, pathology) that medical students need to learn.

By “need to learn” we usually mean “what we have always taught them” or “what they need to pass the national examination (USMLE Step 1) that covers that material.” This history goes back 100 years, to the Flexner Report of 1910. Contracted by the AMA, educator Abraham Flexner evaluated the multitude of medical schools, recommended closing many which were little more than apprenticeship programs without a scientific basis, and recommended that medical schools be based upon the model of Johns Hopkins: part of a university (from the German tradition), grounded in science, and based in a core curriculum of the sciences. This has been the model ever since.

However, 100 years later, these medical schools and the AHCs of which they are a part have grown to enormous size, concentrating huge basic research facilities (Johns Hopkins alone receives over $300 million a year in NIH grants) and tertiary and quarternary medical services – high tech, high complexity treatment for rare diseases or complex manifestations of more common ones. They have often lost their focus on the health of the actual community of which they are a part.

This was a reason for two rounds of creating “community-based” medical schools, which use non-university, or “community”, hospitals: the first in the 1970s and the second in the 2000s. Some of these schools have maintained a focus on community health, to a greater or lesser degree, but many have largely abandoned those missions as they have sought to replicate the Hopkins model and become major research centers. The move of many schools away from community was the impetus for the “Beyond Flexner” conference held in Tulsa in 2012 and for a number of research studies focused on the “social mission” of medical schools.

The top ten Common Sense posts of 2013

The past year has been a productive one for me professionally. I became an Associate Professor at Georgetown, completed my Master of Public Health degree, made national television and radio appearances to discuss lung cancer screening on NBC News and NPR, and was appointed to a four-year term as a member of the American Academy of Family Physicians' Commission on Health of the Public and Science. My most rewarding professional activity, however, continues to be writing for Common Sense Family Doctor. Below are links to and excerpts from the ten posts in 2013 that have received the most page views, with the top post viewed 6443 times to date.

1. PSA testing: excerpts from a roundtable discussion  (January 5)

Even if people don’t follow the U.S. Preventive Services Task Force recommendations and discontinue prostate screening, I hope that we will have improved the quality of discussions patients are supposed to be having with their physicians about what their risk is, what outcomes they value, and what they are willing to endure to make sure that they don’t develop late stage prostate cancer.

2. Why don't clinicians discuss cancer screening harms? (November 3)

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

3. Guest Post: Why the Direct Primary Care Model would benefit poor patients (September 6)

With direct pay models, actual health care costs can be kept much lower and made much more affordable. Also, since direct pay models typically care for smaller patient panels, patients have more time with their primary care team to address the myriad of life issues that affect their health.

4. Concerns about calcium supplements (February 8)

Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence do we need?

5. Breast cancer and the Angelina Jolie effect (May 15)

Will the Angelina Jolie effect turn out to be a spike in the rates of women being tested for the mutations in their BRCA genes? If so, it's likely that many more women will be harmed than helped. BRCA mutations are rare, affecting 2 to 3 per 1000 women. The vast majority of women who develop breast cancer do not carry these mutations and will not benefit from testing.

6. Should you be screened for lung cancer? Maybe not, and here's why (July 29)

For lower-risk patients, for whom the potential lifesaving benefits of CT scans are very small, the downsides of the screening test become considerably more important. Screening tests have harms just like any other medical procedure, and it's important for your doctor to thoroughly review those harms with you if you are considering screening.

7. Screening-illiterate physicians may do more harm than good (July 13)

The Institute of Medicine has identified low levels of health literacy as a major obstacle to ensuring optimal health and quality of care. But how can physicians expect our patients to make informed decisions regarding screening tests when large numbers of us are functionally illiterate regarding basic screening concepts?

8. The future of medicine is low-tech and high-touch (May 8)

Yes, robots and smartphones can and will play vital roles in the future of medicine. But if we really want sick patients to have the best chance to get better - and healthy patients to avoid getting sick in the first place - then we should do everything in our power to support low-tech and high-touch interventions too.

9. Unintended consequences of "pregnancy prevention" (February 5)

Defining pregnancy as a disease to be prevented is not just a matter of semantics. An overly interventionist approach to pregnancy is largely responsible for the current U.S. rate of one in 3 babies being born by Cesarean section, and predictions that it may soon approach 50 percent.

10. $10 billion per year to train the wrong physicians (June 18)

Where physician production is concerned, you get what you pay for. Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

Very best wishes for a happy and healthy 2014!

Two types of "scut work"

When I was an acting Medicine intern in Manhattan's Bellevue Hospital at the turn of the century, all employees who provided the hospital's "ancillary services" went home between the hours of 5 PM and 8 AM. It was the job of the on-call interns to fill in. If a patient needed a stat blood draw or IV line replacement in the middle of the night, his nurse paged the intern to do it. If I wanted a vial of blood to reach the lab before the morning, the only way to accomplish this was to carry it there myself. If a patient needed an urgent x-ray or CT scan, I personally navigated his or her stretcher from room to elevator and through the corridors to Radiology. (Even during daytime hours, this was often the most efficient way to complete this task.) In those days when x-rays and scans were actually printed on sheets of transparent plastic and stored in file folders, it was also the intern's job to hunt down images needed for morning rounds.

Generations of doctors-in-training have given the name "scut work" to these kinds of tedious, often disagreeable chores that do not require a doctor's degree but are nonetheless essential to patient care. More than a decade later, interns and residents continue to toil at similar unrewarding tasks in hospitals all over the U.S. and around the world.

But scut has evolved in the era of electronic medical records to mean more than late-night blood draws and transporting patients and medical records. Scut work is now performed by physicians with decades of post-residency experience, at all hours, in outpatient and inpatient practice. It goes by important-sounding names: "Stage 2 Meaningful Use" or "NCQA Certified Patient Centered Medical Home." Specific tasks involve clicking through endless series of drop-down boxes to document smoking cessation counseling, order flu shots and age-appropriate cancer screenings, and record transitions of care and receipt of referral notes. These are all things that I would have documented in a free-text or dictated note, but must now jump through electronic hoops to get credit from private and public payers who believe that primary care patients will ultimately benefit from all this clicking even as it distracts my and my colleagues' attention away from the real work of doctoring.

In a recent editorial in Annals of Internal Medicine, Drs. Christine Sinsky and John Beasley argue that "texting while doctoring" is a potential patient safety hazard:

In clinics across the country we have observed patients send signals of depression, disagreement, and lack of understanding and have witnessed kind, compassionate, and well-intended physicians missing these signals while they multitask. These physicians are concentrating not only on the patient but on typing the history, checking boxes, performing order entry, and other electronic tasks. ... Computerized order entry displaces to the physician clerical tasks once performed by others, increasing time commitment and cognitive interruptions.

The authors suggest that supporting team-based care models that rely on non-physicians to do the bulk of documentation may still save the physician-patient interaction. But this is unlikely to happen if physicians are required by federal regulators to type in orders themselves, or if new payment schemes do not rapidly supplant fee-for-service and render current billing templates obsolete.

In contrast, Dr. Diane Chang describes old-school scut work in JAMA's "A Piece of My Mind" as "the physical, backbreaking, day-to-day work of taking care of another person." She shares scenes of doctors, nurse's aides, and other health workers debriding infected ulcers, cleaning up vomit and feces, feeding and bathing and changing beds. "Acts of caring are sacred: feeding the sick and old, cleaning them, and tending to their wounds are in some ways as intimate as you can get with another body," she writes. "In performing these acts, we bear witness to people naked and infirm, at the beginning of life or at the very end, or at the most vulnerable moments in their lives."

I don't want to go back to my days of doing scut at Bellevue. I am not nostalgic about trying repeatedly to place an 18-gauge IV in a patient with no palpable veins at four in the morning, or replacing a delirious patient's nasogastric tube for the fifth time in as many hours because he kept pulling it out. But at least that kind of scut, unlike the tedious tasks involved in electronic documentation, was work that was meaningful to patients.

New statin guidelines and other notable medical reversals

The recently published American College of Cardiology / American Heart Association cholesterol treatment guideline, which updates the National Heart, Lung, and Blood Institute's Adult Treatment Panel III recommendations that have guided clinicians for more than a decade, has generated controversy for several reasons: primary care groups did not participate in development of the guideline; several panelists had financial conflicts of interest; its cardiovascular risk calculator may substantially overestimate risk in certain populations; and the lowered risk threshold for prescribing medication, if adopted worldwide, could potentially result in more than a billion people taking statin drugs.

Family physicians who have grown comfortable with ATP III's "treat to target" paradigm for cholesterol management were likely surprised by the new guideline's "fire and forget" approach, which advises prescribing fixed doses of statins based on cardiovascular risk assessments and not routinely rechecking cholesterol levels. The latter approach is more consistent with the evidence from randomized controlled trials, but this change is, nonetheless, a significant reversal of an established medical practice. Although such reversals are surprisingly common, they can be unsettling to clinicians.

In an editorial in the December 1st issue of American Family Physician, Drs. Caroline Wellbery and Rebecca McAteer review reasons for other dramatic reversals such as hormone replacement therapy and tight glucose control in diabetes, which include poor design and small size; focus on disease-oriented evidence, application of findings to nonstudy populations; unidentified harms; and economic factors. They have several related suggestions to help physicians avoid pitfalls associated with currently accepted practices that may be vulnerable to later reversal:

To minimize the dizzying impact of changing recommendations, physicians should focus on patient-oriented evidence, and not be distracted by disease-oriented evidence. Physicians should become familiar with the basic principles of good research, and avoid drawing premature conclusions from observational studies or studies with design flaws. Physicians should also recognize the pharmaceutical industry's influence on research studies and practice recommendations.

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This post first appeared on the AFP Community Blog.

What can Rwanda teach the U.S. about primary care?

As reviewed on this blog and in many other sources, the relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world but rank near the back of the pack in key health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although economic inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I'd argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.

Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of an Atlantic headline that caught my eye earlier this year: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a recent BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to only 33% of eligible U.S. girls in 2012.

Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? (That's right, 2 dollars for an entire year. According to the Kaiser Family Foundation, the average monthly individual premium for generally healthy persons in 2010 was $215, or just over $2500 per year.)

They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:

Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.

Image courtesy of BMC Health Services Research.

The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this (apologies for my poor graphical skills):

At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.

The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's sometimes easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that probably don't require any imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.

Care transitions: 4 key questions to ask your doctor

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

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

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

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

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

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

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

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

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

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

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

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

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

Tackling the problem of too few family physicians

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

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

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

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

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

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

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This post was originally published on the AFP Community Blog.

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from August, September, and October:

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

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

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

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

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

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

Why don't clinicians discuss cancer screening harms?

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

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

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

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This post originally appeared on the AFP Community Blog.

Doctors are the biggest driver of health care costs

There are many reasons to be dismayed by the error-filled and managerially incompetent rollout of the federal health insurance exchanges that are in many ways the linchpin of President Obama's Affordable Care Act. I sympathize with commentators who have called for the resignation of Department of Health and Human Services Secretary Kathleen Sebelius. It's hard to imagine Franklin Roosevelt not firing someone in his Cabinet had Social Security stumbled this badly out of the gate, or Lyndon Johnson not causing officials' heads to roll if the launch of Medicare and Medicaid had been so mangled.

Still, I believe that throwing the baby (the ACA) out with the bathwater (government officials) would be a huge mistake. Health care costs will continue to rise with or without the law's implementation, consuming an ever greater chunk of the struggling U.S. economy and causing government budgets to run into the red regardless of any future grand bargains on taxes and spending. The status quo stinks, and doing nothing is not an option.

Some of my physician colleagues have argued that the major problem in medicine today is that restrictive insurance companies and armies of utilization reviewers have curtailed our independence. Return decision-making power to doctors, they argue, and the system will run more efficiently. When surveyed recently about who had "major responsibility" to control health care costs, U.S. doctors called out trial lawyers, insurance companies, hospitals, drug and device manufacturers, and patients. Only one in three pointed the finger at themselves.

In an editorial in the New England Journal of Medicine, family physician Cheryl Bettigole takes the opposite point of view. Observing how a $20 to $30 Pap smear can be transformed into a battery of tests (some unnecessary) that cost hundreds or even a thousand dollars, she argues that physicians have the primary responsibility to protect patients from financial harm and be good stewards of health care resources:

So how do all these tests come to be ordered for healthy women who come in only for an annual gynecology exam? The answer is that someone ... checked off all those boxes on the order form. When I was in training, our attendings would ask a standard quiz question: “What is the biggest driver of health care costs in the hospital?” Answer: the physician's pen. A mouse or a keyboard, rather than a pen, now drives the spending, but we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.

Yes, the U.S. health care non-system provides physicians with numerous incentives to "do the wrong thing" in patient care. The more services we provide, the more money we make. Pharmaceutical representatives persuade us to prescribe expensive new brand-name drugs instead of more affordable (and often, more effective) generics. Indecipherable medical bills and insurance statements prevent patients from knowing how much their care costs until they've already received it. But these challenges should not be excuses for inaction on the part of practicing physicians or those in training. As Dr. Bettigole writes:

We need to teach medical students and residents to see [good financial stewardship] as an important aspect of their responsibility to their patients. Furthermore, we need to advocate for a system in which information about the cost and benefit of diagnostic tests is readily available to patients and providers at the point of care. If we fail to do so, we risk not only our patients' pocketbooks but also the gains we have made against cervical cancer and many other conditions. We contribute to spiraling health care costs and are doing real harm.

Shining Knights and heroic family doctors

Not long ago, I attended the Shining Knight Gala, a fundraising dinner that benefited the trauma surgery and injury prevention programs at Virginia Commonwealth University Medical Center. The highlight of the evening was the dramatic presentation of the story of a young man who had suffered severe, life-threatening injuries in a car accident and, through the skill and dedication of first responders and the VCU trauma and rehabilitation professionals, was stabilized and over several months gradually restored to health. In recognition of their extraordinary efforts, all of the clinicians involved in this young man's care were awarded the "Order of the Shining Knight." As fire fighters, emergency medical technicians, emergency room physicians and nurses, trauma surgeons, and rehabilitation specialists trooped on to the stage to shake Virginia Governor Bob McDonnell's hand and pose for photos with their award (while their patient looked on happily from a nearby table), it was impossible not to be deeply moved.

It struck me later that there is no primary care analogy for what I witnessed that evening. General internists will not have the satisfaction of being recognized for the patients who didn't have heart attacks or strokes because of the blood pressure medications or aspirin they prescribed; family physicians and pediatricians won't be given awards of merit for all the children they "saved" from measles, mumps, polio, and a host of other vaccine-preventable diseases. While primary care physicians certainly provide acute care services for a variety of ailments, the greatest impact of our work is ultimately unmeasurable: all of the poor health outcomes that might have happened, but didn't.

Does this mean that there are no heroic family doctors? Far from it, but recognizing our behind-the-scenes efforts - and reinforcing the appeal of the primary care specialties to medical students - is certainly more challenging. But I'm cautiously optimistic that the past few years' Residency Match results, which showed modest increases in the numbers of U.S. graduates choosing residency programs in family medicine, general internal medicine and pediatrics, represent a turning of the corner. With the millions of people expected to gain health insurance over the next year, this country will need every primary care clinician it can get.

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This post originally appeared on Common Sense Family Doctor on April 1, 2010. I am re-posting it in belated recognition of National Primary Care Week, which Georgetown is celebrating with a series of Family Medicine Interest Group events led by several outstanding physician colleagues.

Rethinking the war on drugs

A few years ago, I served for several weeks on a grand jury for the Superior Court of the District of Columbia. Mine was designated a RIP (Rapid Indictment Protocol) jury, assigned to efficiently hand down indictments for small drug-related offenses. These cases usually involved undercover officers posing as customers making purchases from street dealers, or uniformed police stopping suspicious vehicles and searching them for drugs. Although rarely we heard testimony about defendants caught with thousands of dollars of contraband, the vast majority of offenses were possession of small amounts of marijuana, heroin, or cocaine for "personal use." Many of the latter defendants had multiple such offenses, which had resulted in probation, "stay away" orders (court orders to avoid certain neighborhoods where drugs were highly trafficked), or brief stints in jail. Few, if any, had received medical treatment for their addictions.

After a few weeks of hearing these cases, my fellow jurors and I grew increasingly frustrated with this state of affairs. We felt like cogs in a bureaucratic machine, fulfilling a required service but making little difference in anyone's lives. A young man or woman caught using drugs would inevitably return to the street, violate the terms of his or her probation or "stay away" order, and be dragged before our grand jury again for a new indictment. We openly challenged the assistant district's attorneys about the futility of the process. They would just shrug their shoulders and tell us that was the way things were, and it wasn't our job to come up with a better strategy for dealing with illegal drug use. True enough, but then again, whose job was it?

An article by Michael Specter in the October 17, 2011 issue of the New Yorker reported on the recent experience of Portugal in decriminalizing personal drug use. To an American physician accustomed to our endless war on drugs, what Portuguese authorities did was hard to imagine: "For people caught with no more than a ten-day supply of marijuana, heroin, ecstasy, cocaine, or crystal methamphetamine - anything, really - there would be no arrests, no prosecutions, no prison sentences. Dealers are still sent to prison, or fined, or both, but, for the past decade, Portugal has treated drug abuse solely as a public-health issue." Rather than being paraded before grand juries for ritual convictions, people caught using drugs in Portugal are instead summoned before a 3-person panel (a judge, doctor, and psychologist or social worker) and assigned to counseling and medical treatment for their addictions.

Did this new policy result in an explosion in the number of Portuguese drug users, no longer cowed by the prospect of criminal prosecution? Hardly. In the words of a chief police inspector who initially resisted the change in tactics:

In the last years before the law, consumers were arrested by police. ... They were fingerprinted and made statements and took mug photos and were presented to court. And always, always, always released. It was a waste of everyone's time. It didn't stop drug use or slow down the dealers. So the idea that somehow people are getting away with what they did not get away with before is silly.

A public health approach to the consequences of illegal drug use in the U.S. might include increasing support for needle exchange programs, which have been banned from receiving federal funding for years but have been repeatedly shown to reduce rates of HIV transmission in controlled studies. Unfortunately, our inherent discomfort with such "permissive" interventions often gets in the way of recognizing the evidence that our current punitive approach to drug use is more harmful than beneficial to drug users and society in general. As Specter concludes:

It is common in the U.S. to judge drug addiction morally rather than medically, and most policy flows from that approach. ... Yet one has only to look at the American health-care system to be reminded that neither science nor evidence necessarily drives public-policy decisions. ... While it would make no sense to base American policy [toward drug use] on a decade-long Portuguese experiment, it seems even more foolish to ignore results that call so clearly for an increased focus on treatment, not jail time.

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A slightly different version of this post first appeared on Common Sense Family Doctor on November 8, 2011.

Upcoming Event: Affordable Care Act 101

This Thursday, October 10th, from 3-4 PM Eastern, I will be participating as an invited panelist in a Google Hangout sponsored by Voto Latino. Please join me and representatives from the National Hispanic Medical Association, National Council of La Raza, Young Invincibles, and Enroll America as we discuss the implications of the Affordable Care Act for the health and health care of Latino Americans.

Learning from primary care in Canada and Europe

What can family medicine in the U.S. learn from the organization of primary care in other Western countries? In this month's Georgetown University Health Policy Seminar, we explored two recent studies that shed light on successes and challenges of primary care reforms in Ontario, Canada and the European Union.

Starting in 2000, policymakers in Ontario implemented a primary care reform strategy based on five national objectives, which are strikingly similar to many proposed U.S. reforms: "1) increasing access to primary care organizations that would provide a defined set of services to a defined population; 2) increasing emphasis on health promotion, disease and injury prevention, and chronic disease management; 3) expanding all-day, every-day access to essential services; 4) establishing interdisciplinary primary care teams; and 5) facilitating coordination and integration with other health services." As a result, an almost entirely fee-for-service primary care system was gradually replaced with a mixture of salary-based, capitation-based, and blended fee-for-service payment models by 2012. Far from being demoralized by the rapid changes, Ontario primary care physicians actually reported increasing satisfaction during this transition period.

Another study in the same issue of Health Affairs analyzed associations between the strength of primary care systems in 31 European countries, national health expenditures, and measures of population health. The study found that countries with more robust primary care had lower hospitalization rates and less socioeconomic inequality in self-rated health, in addition to better chronic disease outcomes. However, these advantages came at the cost of higher baseline health care spending, though spending growth appeared to be slower in countries with a comprehensive primary care bedrock.

What lessons should U.S. policymakers take home from this research?

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This post first appeared on The Health Policy Exchange.

I oppose Obamacare; I support the Affordable Care Act

Tomorrow, more than three years after being signed into law, and more than a year after surviving a Supreme Court challenge, the Affordable Care Act, more commonly known as Obamacare, finally begins to fulfill its promise. Most of this country has long since taken sides, despite appalling gaps in popular understanding of what the law means, what it does, and what it doesn't do.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy is a mess. The trillions in debt that the U.S. has run up over the past 5 years will hurt my generation and future generations, and if Republicans can be faulted for their fantasy that the federal budget can be balanced exclusively through spending cuts, Obama has sustained the Democratic fairy tale that raising taxes on "millionaires and billionaires" is all that is necessary to pay the skyrocketing bills. On multiple occasions during my time in government, the President had no qualms about squashing science and scientists for political convenience. He is a perpetual campaigner, preferring theatrical gestures to the backstage grunt work of governing. And for all of his rhetorical gifts when preaching to the choir, he's been one of the least effective persuaders-in-chief to have held the office.

And so, naturally, I oppose Obamacare. I oppose a government takeover of health care that includes morally repugnant death panels staffed by faceless bureaucrats who will decide whose grandparents live or die and make it impossible for clinicians to provide compassionate end-of-life care. I oppose the provision in Obamacare that says that in order for some of the 50 million uninsured Americans to obtain health insurance, an equal or greater number must forfeit their existing plans or be laid off from their jobs. I oppose the discarding of personal responsibility for one's health in Obamacare. I oppose Obamacare's expansion of the nanny-state that will regulate the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories, doesn't exist and never will.

Instead, the Affordable Care Act (which I support) is based on a similar law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieves the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discourages irresponsible health care "free riders" and provides support for people of modest means to purchase private health insurance in regulated open marketplaces. It tells insurers that in exchange for new customers, they can no longer discriminate against the old and sick and make their profits off the young and healthy. Finally, the ACA rewards physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may or may not improve health.

The ACA has flaws. Since it doesn't do much to narrow the income discrepancy between different types of physicians, it may overwhelm the capacity of primary care as millions of uninsured patients look for family doctors for the first time. The ACA's provisions to discourage overuse of unnecessary medical services are limited and probably inadequate to the scope of the problem. But it's worth noting that these problems all predated the law. We don't have enough family physicians and other primary care clinicians, specialists make too much money in comparison, and overdiagnosis and overtreatment are already rampant today. That the ACA takes on these issues at all is a small victory of sorts.

It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the 2008 Republican Presidential nomination and then narrowly defeated Hillary Clinton, who was the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed 1994 reform plan that makes right-wing objections to the ACA look insignificant by comparison. Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? Perhaps. But it underlines the need for people of all political persuasions to set aside the overheated rhetoric about Obama and Obamacare and focus on making the ACA work, starting tomorrow.

Guest Post: Why clinical questions are only a starting point

Dr. Robert Bowman is a Professor of Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona. He blogs at Basic Health Access and Clinician Specific Medical Education.

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People come to family physicians with some indication or faith that we can help them. As the learned “high priests” of medicine, we can answer their questions in various ways. The following 5 ways that Christians perceive that God answers prayers also provide a framework for how we address clinical questions.

"No, I love you too much."

Daily we see patients who already have answers to their questions. They come to us for many reasons. One reason is so that we can confirm their impression. If we do so wrongly, we contribute to their problem. We also know that what some people are asking is wrong. For this and for other presentations, we have to say “No, I love you too much.” This can be difficult for physicians who want to please all of their patients or improve their “patient satisfaction” scores.

"Yes, but you will have to wait."

We gather information and then do exams, tests or sometimes treatments. Haste can help answer a clinical question, but a hasty answer can be wrong. Hundreds of hasty diagnoses or treatments have been proven wrong in later years. For 20 years we were pushing an unproven test for prostate cancer screening when we should have been saying: “You will have to wait.”

Those on the front lines of care recognize that some diseases and conditions go away. Patience is needed. When people come in with fever, chills, and headache within 24 to 48 hours, chances are that this will resolve with little consequence. Deciding who can wait or not is a clinical decision, but one that does not necessarily lead to a diagnosis. We fail to measure much of clinical decision making. Those who measure immediately will find many clinical questions unanswered. This is about the patient, physician, interaction, the state of the science, and limitations in each of these areas. Immediate diagnosis and treatment can be wrong and harmful – but sometimes delays can be harmful. Outside players (legal, payers, practice pressures, daily situations) exert influences that can impede optimal decisions and care.

"Yes, but not what you expected."

This is always a tough situation as people have already moved their minds down one path. It takes time and effort on our part to erase this path so that they can move down another. Our treatments often do not work and some are harmful. Even with correct diagnosis and treatment, some patients find that our treatments are too inconvenient or expensive to continue and may or may not tell us.

"Yes, and here’s more."

Family physicians have more to offer than just diagnosis and treatment. Because of our tens of thousands of patient care experiences, we have experienced the impacts upon others and how they responded and what helped. The context of neighborhood, family, and individual past experiences is a rich database. Teaching of medical students and residents adds to the reflection, discussion, learning, and management. Ideally we have experienced the disease and condition and can speak with regard to practical matters, with evidence as a foundation. It helps to have access to pharmacists, behavioral professionals, and nurse educators who can step in and connect patients to needed care. But adding more can be difficult with financial margins so thin, with penalties for serving patients in settings where margins are thin, with fast rising costs of delivery, and with stagnant reimbursement. 

"Yes, and I thought you would never ask."

This is what we tend to focus on too much. People come in and we make the diagnosis and treatment together and have great agreement and all are pleased about expectation, diagnosis, treatment, and outcome. We like to measure this outcome since it is easy to measure. Much of what we do in family medicine, though, is in the first four answers rather than this last one. Saying no, getting people to wait patiently, or redirecting wrong impressions is often more important to individual outcomes than is the clinical question. Unfortunately, current designs for training and practice support make responding "Yes, and here is more" difficult unless we personally sacrifice to provide more care.

Family physicians generally do not experience the immediate rewards of diagnosing an inflamed appendix with confirmation during removal at surgery. But we do see the negative consequences of focusing on short-term outcomes at the expense of long term approaches to health, where the "clinical question" may only be a convenient starting point.

Conservative Medicine: Who needs to read it?

"Don't just do something, stand there." This deliberate rephrasing of "don't just stand there, do something" reminds me that the typical impulse of a physician to take immediate action in the face of clinical uncertainty can sometimes lead to a worse outcome than exercising patience, collecting more information, and waiting for any harmful conditions (if present) to declare themselves in time.

However, as I explained in this week's MD Global Health podcast, powerful monetary and psychological incentives present throughout the health care industry push physicians, advocacy groups, and medical institutions to aggressively seek out and treat persons with "underdiagnosed" diseases, expand the definitions of existing diseases (e.g., pre-osteoporosis, or low bone density), and sometimes, create new diseases (e.g., restless legs syndrome) out of whole cloth. Recognizing that these issues are often exacerbated by expert consensus recommendations of dubious quality, a distinguished international working group recently proposed a short list of questions that, if properly implemented, could permit clinicians and patients to evaluate financial conflicts of interest in clinical guidelines.

Conservative Medicine will not only outline a list of problems that result from overtesting and overtreatment, but offer a set of solutions in the areas of medical education, public policy, regulation, and patient advocacy. Who needs to read it? I believe that my book will appeal to a broad audience of health professionals, journalists, policymakers, and ordinary people with and without defined health problems who wonder if they actually need "preventive health care," and if so, how much.

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This is the sixth and final entry in a series of brainstorming posts about a book that I am writing titled Conservative Medicine.

Mindful communication, physician burnout, and patient satisfaction

Are mindful clinicians happier clinicians, and do they communicate better with patients? A pair of studies published this month in Annals of Family Medicine aimed to answer one or the other of these questions. Mindfulness, defined as "purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings," is being increasingly recognized as having a protective effect against clinical burnout. In the first study, an abbreviated mindfulness intervention in 30 primary care clinicians was associated with reduced burnout and improved measures of mental health 9 months later. In the second study, clinicians with higher self-rated mindfulness were found to engage in more patient-centered communication and have higher patient satisfaction scores.

These studies are particularly important to family physicians like me because other surveys have shown that we (and general internists and emergency physicians) are at much greater risk of experiencing early career burnout than other medical specialists. This isn't only a professional issue, it's a public health issue; since the U.S. primary care shortage is expected to worsen over the next decade due to low student interest, health insurance expansion, and population growth, we need "all hands on deck" now more than ever. (I'll tackle the issue of credentialing primary care nurse practitioners in a future post, but for now suffice to say that at best this is only part of the solution.)

Not long ago, to fulfill the requirements for a Master of Public Health degree, I reviewed the limited literature on interventions to reduce burnout and improve well-being in primary care physicians. The structured abstract is below, full paper available upon request.

Background: Burnout in primary care physicians may have negative effects on personal health and patient care.

Purpose: To review the prevalence of burnout in primary care in the U.S. and other Western countries; causes, determinants, and negative effects of burnout in primary care physicians; and interventions to reduce burnout.

Data Sources: Electronic searches of PubMed (2003-present) and hand searches of reference lists of key studies and reviews. The full text of 48 citations was reviewed for randomized controlled trials, cohort and cross-sectional studies, and descriptive studies relevant to one of the content areas. 17 studies were included: 4 on prevalence, 6 on causes, determinants, or negative effects, and 7 on interventions.

Data Synthesis: Burnout consists of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. The risk of burnout is higher in the presence of work overload and perceived lack of control over one’s workload. 46 percent of surveyed U.S. physicians reported at least one symptom of burnout; primary care physicians had among the highest rates. Family physicians from 12 European countries commonly reported emotional exhaustion (43%), depersonalization (35%), and reduced personal accomplishment (32%), with higher rates in younger and male physicians. Burnout was associated with a higher frequency of self-reported difficult patient encounters, but was not associated with medical errors, lower quality of care, or patient dissatisfaction.

Descriptive studies of physicians with reputations for “resilience” identified several themes that may prevent burnout. A multi-component intervention to improve physician control over work environment, staff efficiency, and patient care satisfaction was associated with a statistically significant reduction in emotional exhaustion. Limited evidence exists for the effectiveness of individual-level interventions to reduce burnout. A yearlong continuing medical education course in mindful communication was associated with decreases in all 3 burnout dimensions. Short-term cognitive behavioral interventions reduced emotional exhaustion and general psychological distress.

Patient-centered health care means sometimes saying "no"

Many commentators on U.S. health care, including me, have written that our existing models of care are far from patient-centered. In a 2009 Health Affairs piece, former CMS Administrator and Institute for Healthcare Improvement president Donald Berwick took this one step further by observing that instead of revolving around the needs and wants of patients, health systems are generally designed to meet the needs of clinicians. He related an episode during which a close friend who was having chest pain requested that he accompany her to the cardiac catheterization laboratory for emotional support and to help explain the procedure's results afterwards. The nurse and cardiologist both rejected his friend's request, giving no explanation other than "it's just not possible." (And I remember, with dismay, hearing these exact words from a physician when I wanted to accompany my newborn daughter to the hospital nursery for her first bath.)

After tracing the recent history of "patient-centeredness" as an aim of various groups devoted to improving health care quality, Berwick proposed what he called an "extremist" definition of patient-centered care:

The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one's person, circumstances, and relationships in health care.

To me, this definition sounds hardly revolutionary, and more like common sense. The sticking point for most clinicians, of course, is "without exception." Does this mean that clinicians should be required to fulfill patients' all-too-common requests for tests and procedures that have little clinical benefit or are likely to lead to harm? Well, in many cases, such as antibiotics for colds or imaging for acute low back pain, most of us already do, despite knowledge of potential adverse consequences. But perhaps these seemingly irrational requests occur because the health professional hasn't done enough to explain the risks and benefits of various options, or more importantly, understand what those risks and benefits mean from the patient's perspective.

This topic leads me a study about getting to "no" published in JAMA Internal Medicine, in which trained actors posing as patients visited the offices of internists and family physicians, and, after complaining of vague symptoms of fatigue, requested a specific medication for depression that they said they had learned about in an advertisement. In the majority of these encounters (111 out of 199), doctors simply fulfilled the request, even though the information that the actors gave clearly did not meet criteria for the diagnosis of depression. Of the 88 who did not, 31 either gave no reason for saying no or deflected the request by ordering (unnecessary) tests or prescribing a sleep aid. In the remaining 53 encounters, the doctor attempted to further explore the content of the request or suggested a referral to a mental health counselor to accomplish the same end.

Although the study's authors did not explicitly endorse a particular approach to saying "no," it seems to me that the last one, which one might call the "patient-centered" strategy, is the most likely to benefit the physician-patient relationship and prevent harm in the long run. I'm not saying that this negotiation is easy, and it certainly isn't the sort of thing that is routinely taught in medical school or residency (which explains why more than half of the doctors in this study found themselves unable to say "no" to an inappropriate request). It's only what family physicians do, day in and day out - and like many other aspects of primary care practice, we need to learn how do it better.

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This post is slightly revised and updated from a post that was originally published on Common Sense Family Doctor on February 22, 2010.