Medical homes and the meaning of "P.C." - Part 1 of 2

In this week's issue of Annals of Internal Medicine, Dr. Adam Goldstein writes about a disabled elderly man who died from a metastatic colorectal cancer that may have been prevented had one of his physicians referred him for a screening test at one of several preceding office visits. Dr. Goldstein blames this omission on breakdowns in communication and coordination of care between multiple clinicians. He feels that a primary care team (which I discussed in a recent blog post) would have served this patient far more effectively:

With a team approach to care, 1 or more members of the team is more likely to notice when something seems amiss rather than relying on 1 team member alone. ... In addition to traditional concepts, the new medical home also focuses on integrating health care technology, quality measures, and feedback on performance - all critical aspects of a care planning process that can lead to improved systems of care for severely disabled patients.

The term "medical home" was first used by the American Academy of Pediatrics in 1967 to refer to a physician-led practice that integrated and coordinated the health care of children with chronic medical conditions. All of the primary care physician organizations, as well as the American Medical Association, now seem to agree that the PCMH is the answer to many of the ills of our fragmented, specialist-oriented health care system. But what does the "PC" in this acronym stand for? Primary care? Politically correct? And does it really improve the experience and health of patients?

A recent review of state and federal legislation related to the medical home found "a lack of a clear operational definition," and widely varying ideas about its key components. The failure of the American Academy of Family Physicians' 2-year National Demonstration Project to yield better patient satisfaction or health outcomes in practices that attempted to transform themselves into medical homes has elicited doubt among many observers that the PCMH idea will ever be successful in more than a handful of highly motivated practices.

In my next post, I'll share a more optimistic view of the implications of the AAFP's report for the PCMH, and why being a "patient-centered medical home" is about more than simply technological innovations.

Is Vitamin D vastly overrated?

Vitamin D seems to be all the rage in medicine these days. A family physician colleague commented to me last week that the laboratory test for vitamin D deficiency is becoming the most frequently ordered test in his practice. This clinical bandwagon is likely a response to data from multiple recent studies that found low vitamin D levels in the majority of children and adults of all ages. While vitamin D has always been thought to play an important role in keeping bones strong, researchers are suggesting that low levels may increase one’s risk for a variety of diseases, including cancer and cardiovascular disease.

Before you go out to your local drugstore to buy mega-doses of vitamin D supplements, though, there are at least two good reasons to proceed with caution. First, association does not always translate into causation. In other words, just because people with a low (or high) level of a nutrient are more likely to suffer from a particular illness doesn’t mean that the abnormal level caused the illness, nor does it mean that restoring a normal level will cure it. For example, studies have showed that high homocysteine levels are associated with an increased heart attack risk. When I was in residency training, cardiologists routinely prescribed folate supplements to patients who had had heart attacks in order to lower their homocysteine levels and reduce their risk of having another heart attack. However, subsequent studies determined that lowering homocysteine levels does absolutely nothing for these patients.

The second reason to be wary of the vitamin D hype is that we’ve been down this road before, with vitamins A, B, C, and E. An editorial published recently in the American Journal of Epidemiology provides a sobering summary of initial high hopes placed in each “anticancer vitamin du jour” that were subsequently dashed by randomized controlled trials. In the case of vitamin E, high doses actually appear to be harmful.

There’s a lot we don’t know about vitamin D, as an exhaustive review of the evidence for the U.S. Institute of Medicine concluded last year. Although most studies suggest that vitamin D supplements reduce the risk of fractures and falls in older adults, it’s not at all clear what the best dose should be; in a recent study, older women taking a single large dose of vitamin D each year suffered more fractures and falls than women who didn’t. In the meantime, there are many other things that you can do to keep your bones healthy, including regular weight-bearing exercise, not smoking, and eating a balanced diet that includes two to three servings of dairy products each day.

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This post was first published on my CommonSense MD blog at Family Health Guide.

Guest Blog: The Disabled Boat

Steve Gunther-Murphy works in IT Healthcare at Kaiser Permanente in Oakland, California. He's been writing poetry since the seventh grade, has had works published in a variety of magazines and poetry journals, and has given poetry readings in Hawaii, Colorado and California. The following poem, first published in Pulse Magazine, is dedicated to his friends Teresa Harris and Ellen Case.

THE DISABLED BOAT

Drifting on the sea of disease
in a cardboard boat,

never knowing when the slash
of a spinal eel
will lunge from its coral-bone cave
and cut through
the threads
of a once dancing ankle
or the push of a thigh
singing race or run.

Waiting without wanting--
as the slap of a wave
against the paper-thin stern
then bow
brings on the storm
that pummels every movement
until you slip into a coma of the wind;

your sails ripped from the mainstay
and the tar between the rails
yelling like the death of a two-year-old child.

You wake weeks
later
and notice
that your keel is gone;

your body shakes like a rock cod against
the pith of the boat's floor
with the hook deep in your gill;
making you talk in slow motion
and without air.

Who wants to live this life
of a shadow fish,
pulled from the depths of who you were
and gutted of simple motions
or the ability to sing glee from your gullet?

This is not the space I am.

This is not the blue snap of yesterday
that burst forth from my mother's womb
like an iris
on an island of moss rock.

- Steve Gunther-Murphy