Here is a recap of this year's Common Sense Family Doctor posts that received the most comments from readers (here or on other blogs such as Healthcare Headaches or KevinMD.com), in chronological order. Happy holidays and see you all in 2011!
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1. The decline of VBAC: hearing hoofbeats, thinking zebras (3/10/10) - Why women in the U.S. undergo far too many Cesarean sections, and the numbers are still climbing.
2. Shining Knights and heroic family doctors (4/1/10) - The heroism of primary care clinicians will always be underrated.
3. The cost-conscious physician: an oxymoron? (4/13/10) - Maximizing value in health care needs to be taught in medical school and residency.
4. Where will new primary care docs come from? (6/4/10) - Analyzing recent research on how to attract students more likely to pursue primary care careers.
5. What soft drinks and cigarettes have in common (7/21/10) - My critique of the controversial AAFP-Coca-Cola "consumer alliance" and the mixed message it sends to our patients.
6. Spain: an unlikely primary care model for the U.S. (8/14/10) - The successful transformation of Spain's primary care system provides a guide for how to do the same in the U.S.
7. Health reform: 4 changes to expect at your doctor's office (8/23/10) - An excerpt from my U.S. News blog post on how health reform legislation could change the patient's experience.
8. Quality assessment in primary care: an imperfect science (9/6/10) - How can we objectively measure "good" primary care in order to raise its quality nationwide?
9. The meeting that wasn't, and a surprise announcement (11/1/10) - Why I no longer work at the Agency for Healthcare Research and Quality.
10. Direct primary care: health reform's missing piece? (11/18/10) - Highlighting a primary care payment model that hasn't received nearly enough attention in Washington, DC.
Monday, 27 December 2010
Wednesday, 22 December 2010
Guest Blog: Family medicine's influence: let's talk!
Pat Jonas, MD is the president and medical director of Family Health Connections, Inc., a family-focused and holistic medical practice in Dayton, Ohio. He produces a weekly Blog Talk Radio show on Tuesdays from 8-9 PM Eastern on his blog, Dr Synonymous, where the following post was first published.
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FAMILY MEDICINE: INFLUENTIAL WITH PATIENTS, HOSPITALS, AND EMPLOYERS: LET'S TALK!
"You are a scarce, valuable resource," I told my colleague about 20 years ago when he felt rejected by the local hospital when bumped out of the practice he had served since proudly joining the family physician who had delivered him and cared for his family. He was inspired by the man who had served the community so well, eventually for over fifty years, and became a family doctor, just like his role model and mentor. Now, he saw the practice, in the neighborhood where he grew up, that he inherited at his mentor's retirement and merged into the hospital network to help with recruitment and management, redirected away from his philosophy of care toward hospital corporate values. What happened? Why did they close the office and order him to take the patients and practice where another recently trained family physician had been placed in practice two years ago in another retired physician's office in another neighborhood?
Hospital administrators think differently than physicians. Family physicians may even think differently than many other physicians. We care about our patients and their well-being. We haven't taken the time to verify our thought processes and our differences with hospital managers and other physicians. We need to clarify our similarities and differences now, though. We have to find our areas of mutual interest and mutual misalignment. We have to agree to disagree on many issues because of differing philosophies and business models. A creative tension between family physicians and hospital leadership benefits patients and the local economy.
Hospitals need to fill beds, CT scanners and cardiac cath labs. Patients don't want to fill them unless there is a clear need. If there are excessive medical resources such as CT scanners and cath labs, there will be a push to fill them by changing decision thresholds to use them. The creative tension between family physicians and hospital leaders can serve to find a balance in use of resources. As the family physician becomes a more scarce, valuable resource, their influence in hospitals is needed even if their presence is diminished. We are one of the keys to decreasing re-admissions of patients. We are key influencers of how our patients use health care resources, e.g. which hospital they relate to and where they go for physical therapy. We are key translators of healthcare system intentions to our patients. We are important communicators with small employers and some large employers in communities. We are trusted.
Let's get some better communication going between family physicians, hospitals and employers. It will better serve our patients and communities.
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FAMILY MEDICINE: INFLUENTIAL WITH PATIENTS, HOSPITALS, AND EMPLOYERS: LET'S TALK!
"You are a scarce, valuable resource," I told my colleague about 20 years ago when he felt rejected by the local hospital when bumped out of the practice he had served since proudly joining the family physician who had delivered him and cared for his family. He was inspired by the man who had served the community so well, eventually for over fifty years, and became a family doctor, just like his role model and mentor. Now, he saw the practice, in the neighborhood where he grew up, that he inherited at his mentor's retirement and merged into the hospital network to help with recruitment and management, redirected away from his philosophy of care toward hospital corporate values. What happened? Why did they close the office and order him to take the patients and practice where another recently trained family physician had been placed in practice two years ago in another retired physician's office in another neighborhood?
Hospital administrators think differently than physicians. Family physicians may even think differently than many other physicians. We care about our patients and their well-being. We haven't taken the time to verify our thought processes and our differences with hospital managers and other physicians. We need to clarify our similarities and differences now, though. We have to find our areas of mutual interest and mutual misalignment. We have to agree to disagree on many issues because of differing philosophies and business models. A creative tension between family physicians and hospital leadership benefits patients and the local economy.
Hospitals need to fill beds, CT scanners and cardiac cath labs. Patients don't want to fill them unless there is a clear need. If there are excessive medical resources such as CT scanners and cath labs, there will be a push to fill them by changing decision thresholds to use them. The creative tension between family physicians and hospital leaders can serve to find a balance in use of resources. As the family physician becomes a more scarce, valuable resource, their influence in hospitals is needed even if their presence is diminished. We are one of the keys to decreasing re-admissions of patients. We are key influencers of how our patients use health care resources, e.g. which hospital they relate to and where they go for physical therapy. We are key translators of healthcare system intentions to our patients. We are important communicators with small employers and some large employers in communities. We are trusted.
Let's get some better communication going between family physicians, hospitals and employers. It will better serve our patients and communities.
Monday, 20 December 2010
Why screening for colorectal cancer shouldn't be a hard sell
Breast and prostate cancer screening tests may dominate headlines, but in terms of the quality of the scientific evidence that early detection saves lives, there are no better cancer screening tests than those for colorectal cancer, or cancer of the large intestine. One in 20 adults will develop colorectal cancer during his or her lifetime, and detecting it before symptoms occur substantially improves a patient’s chances of survival. Nevertheless, 57,000 people in the United States still die from colorectal cancer every year; in fact, more men under age 75 will lose their lives this year to colorectal cancer than to prostate cancer.
Given these facts, I am often perplexed at why colorectal cancer screening is such a hard sell to my patients in practice. Women and men over 50 who diligently come back for annual mammograms and PSA tests politely decline when I bring up three effective and widely available colorectal cancer tests: yearly fecal occult blood testing (checking for microscopic evidence of blood in stool samples); flexible sigmoidoscopy (visualizing the lower third of the large intestine) every five years; or colonoscopy (visualizing the entire large intestine, a procedure typically performed under anesthesia) every 10 years. Nationally, other family doctors encounter similar resistance. The Centers for Disease Control and Prevention estimates that about two in five adults older than 50 is overdue for a colorectal cancer screening. As a result, patients may suffer and die needlessly from advanced cancers that, having spread to other organs, offer little hope of survival.
Why the resistance? One problem may be that patients are confused by having to choose between more than one colorectal screening test, each of which has pros and cons that are difficult to explain in a five-minute conversation. Another issue is that many patients who have had rectal examinations in doctor's offices as part of physical exams are misled into thinking that's all they need. (According to a recent national survey whose results were published in the Journal of General Internal Medicine, nearly a quarter of primary care clinicians are unaware that testing a single stool sample obtained during a rectal exam misses 95 percent of colorectal cancers and precancerous polyps.) And there's no denying that at least some of the resistance to testing stems from the "ick" factor and fears about pain, which apparently weren't completely overcome by the example of former Today show host Katie Couric, who got a colonoscopy on national television after her husband died of colorectal cancer.
The problem of low adherence to colorectal cancer screening recommendations was concerning enough that the National Institutes of Health organized a state-of-the-science conference in February to recommend ways to ramp up the use of these tests. An expert panel reviewed the available evidence and concluded that effective strategies to increase screening rates include improving patients' access to the tests, one-on-one counseling sessions with physicians or health educators, and sending reminders to patients who are due for screenings.
Two studies recently published online in the Archives of Internal Medicine provide additional proof that reminders and targeted messages can prod reluctant patients into complying. The first study, led by researchers at Harvard Medical School and Washington University School of Medicine in St. Louis, tested the effectiveness of sending an electronic reminder message via a Web-based personal health record to patients who were overdue for a colorectal cancer screening. Those who received the reminder were provided with a link to an online tool that allowed them to calculate their personal colorectal cancer risk. After one month, patients who received the message were statistically more likely to have gotten screened than patients who did not; however, by 4 months there was no difference between the two groups.
The second study was done by researchers at Northwestern University's Feinberg School of Medicine. Patients who'd been advised to get a colonoscopy but hadn't followed up within three months of the order being placed in their electronic health record were randomly assigned to either receive a personal reminder letter from their physician and an educational brochure and DVD, or usual care. Patients who received the letter were statistically more likely than patients who did not to undergo screening three and six months later, though the effect was small; even after six months, more than four out of five patients in both groups hadn't gotten a screening test.
As I mentioned in a previous blog post, electronic health records will only improve outcomes for patients if doctors use them to make patients aware when their healthcare isn't meeting proven guidelines. Even though the interventions in these two studies produced less-than-dramatic improvements in screening rates, they illustrate the importance of doctors having systems in place to identify who is or isn't up-to-date on screening. If your doctor doesn't have an easy and/or automated way to figure out if you need a test, you probably won't know, either. So the next time you visit your family doctor, consider asking him or her what tools the practice uses to communicate with patients outside of office visits about preventive health needs. Receiving these important messages could mean the difference between getting—or skipping—a test that could save your life.
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The above post was first published on my Healthcare Headaches blog at USNews.com.
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