Every so often, American Family Physician reviews a public health topic, such as outdoor air pollutants, disaster preparedness and response, or reducing the effects of climate change. And occasionally we receive feedback from readers who suggest that these topics are not appropriate for a family medicine journal, since family physicians are practicing clinicians who provide direct care to individual patients, not public health professionals responsible for large populations. However, this view of the limited role of family physicians is by no means unanimous.
In response to concerns about the shrinking scope of family medicine, Dr. Joseph Scherger wrote on the Society of Teachers of Family Medicine blog that "family medicine today is more complex and expansive in some ways than ever before." Family physicians must learn advanced motivational counseling and information management skills to practice excellent preventive and chronic care. Also, the patient-centered medical home requires family physicians to take population-based approaches to managing chronic illnesses.
In March, the Institute of Medicine published a report on opportunities for integrating primary care and public health. Notably, the report did not advocate for large numbers of family physicians to obtain formal public health degrees. Just as an editorial in the Annals of Internal Medicine argued that the subspecialty of geriatric medicine would be best served by incorporating its unique resources and skills into primary care training, a group of family medicine leaders convened by the American Board of Family Medicine recently declared:
The modern primary care physician, who values “community participation, political involvement, and collective advocacy," can, in effect, be a true public health professional, forming partnerships with community-based organizations that facilitate healthy change. This paradigm shift includes the transition from treating individuals in isolation to treating people in the context of their lives in their communities, indeed, culminating in community-centered care.
In a publication in the Annals of Family Medicine, this group re-examined and updated the 1967 Folsom Report, which provided a blueprint for connecting the personal physician with community resources in "Communities of Solution." What do you think of this ambitious vision of the family physician as a public health professional? Is this a desirable goal, and if so, what would it take to achieve it?
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The above post first appeared in the AFP Community Blog.
Wednesday, 27 June 2012
Sunday, 24 June 2012
What you could lose in the battle over health reform
Although I will refrain from predicting how the U.S. Supreme Court will rule this week on the legal challenge to the individual health insurance mandate provision of the Affordable Care Act (aka "Obamacare"), I strongly believe that striking down the entire law would do considerably more harm than good. To illustrate what could be lost in this political donnybrook, below is a post that originally appeared on my "Healthcare Headaches" blog on USNews.com a few months after the law's passage in 2010.
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4 Health Reform Changes to Expect At Your Doctor's Office
As a family physician, I've gotten used to attending dinner parties where relatives, friends, and sometimes complete strangers ask me about health reform, and how the new law might impact their relationship with their doctor. Unfortunately, because I'm well versed in all the complexities of the legislation, I can't come up with a simple sound bite. But a paper published in the Annals of Internal Medicine in August 2010 attempted to explain how the Affordable Care Act is likely to transform the practice of medicine and outlined what changes doctors will need to make in order to provide better care for their patients.
The authors highlighted a number of problems that exist: rates of re-admissions, medication errors, and infections are much too high at nationwide hospitals. And American patients fail to take full advantage of preventive services like counseling for smoking cessation and screening for cancer. "Physicians will need to embrace rather than resist change," the authors wrote, in order for the new legislation to successfully reverse these problems and reduce health care costs in the long term. That means doctors need to move away from a system where they're paid for ordering more tests and performing more procedures and toward one that reimburses them for coordinating care among a number of specialists and preventive health professionals like nutritionists and nurse practitioners. The goal is to keep you healthier and out of the hospital. Here's what you can expect at the doctor's office - if not now, soon.
1) You'll get the health care you need—no more, no less. It's surprising, and frankly shocking, how little doctors know about the effectiveness of the treatments they routinely prescribe for common conditions such as heart failure and diabetes. While studies are often lacking that help doctors determine which test or treatment is most appropriate for you, a new Patient-Centered Outcomes Research Institute will provide funding for studies to help doctors make more informed decisions. That should keep you from getting unnecessary medical care and provide you with care that's most effective. Since research takes time to perform and doctors are often slow to change their practices based on new research, this change may not happen immediately. While studies performed more than a decade ago showed that MRI scans provide no benefit for acute back pain and that antibiotics have no effect on acute bronchitis, doctors have only recently curtailed their use of them, and many still prescribe these costly tests and drugs when patients demand them.
2) You will receive healthcare from a team of health professionals. This "team care" will be in addition to, not subtracted from, the care you are already used to receiving from your personal doctor. The care team may include nurse practitioners, physician assistants, care managers, and nutritionists, depending on your individual health needs. The idea is that the more people who are working together to monitor your health conditions, the less likely a complication will be missed.
[Your Primary Care Team Will See You Now]
3) Your care team will reach out to you in an attempt to prevent future health problems. This may include reminding healthy people about the need for periodic health screenings, or a home visit from a nurse if you've been recently hospitalized for a chronic condition like heart failure. Rather than being paid only when patients get sick, doctors and care teams will be given financial incentives to keep patients well.
4) Technology will improve the efficiency of your health care. Gone will be the days when illegibly written prescriptions or blurry faxes of handwritten hospital progress notes led to thousands of medical errors each year. Doctors will be expected not only to exchange their paper charts for electronic medical records, but to use them meaningfully; that means improving the accuracy of the information in your health record and making sure these records will be accessible to you and the various professionals participating in your care. Of course, this transition will probably result in glitches at first. If doctors' early experiences with electronic health records are any indication, different computer systems may not be able to transfer information to each other, and enterprising hackers will no doubt try to breach the security of online health records, which could threaten your privacy.
[Electronic Medical Records: No Cure-All for Medical Errors]
Of course, it isn't possible at this early date to know how many of these hopes for health reform will actually happen. The ultimate goal, though, is something that I believe all doctors desire: for the health system of the future to give us the tools to provide you with the highest quality experience every time you need to seek health care.
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4 Health Reform Changes to Expect At Your Doctor's Office
As a family physician, I've gotten used to attending dinner parties where relatives, friends, and sometimes complete strangers ask me about health reform, and how the new law might impact their relationship with their doctor. Unfortunately, because I'm well versed in all the complexities of the legislation, I can't come up with a simple sound bite. But a paper published in the Annals of Internal Medicine in August 2010 attempted to explain how the Affordable Care Act is likely to transform the practice of medicine and outlined what changes doctors will need to make in order to provide better care for their patients.
The authors highlighted a number of problems that exist: rates of re-admissions, medication errors, and infections are much too high at nationwide hospitals. And American patients fail to take full advantage of preventive services like counseling for smoking cessation and screening for cancer. "Physicians will need to embrace rather than resist change," the authors wrote, in order for the new legislation to successfully reverse these problems and reduce health care costs in the long term. That means doctors need to move away from a system where they're paid for ordering more tests and performing more procedures and toward one that reimburses them for coordinating care among a number of specialists and preventive health professionals like nutritionists and nurse practitioners. The goal is to keep you healthier and out of the hospital. Here's what you can expect at the doctor's office - if not now, soon.
1) You'll get the health care you need—no more, no less. It's surprising, and frankly shocking, how little doctors know about the effectiveness of the treatments they routinely prescribe for common conditions such as heart failure and diabetes. While studies are often lacking that help doctors determine which test or treatment is most appropriate for you, a new Patient-Centered Outcomes Research Institute will provide funding for studies to help doctors make more informed decisions. That should keep you from getting unnecessary medical care and provide you with care that's most effective. Since research takes time to perform and doctors are often slow to change their practices based on new research, this change may not happen immediately. While studies performed more than a decade ago showed that MRI scans provide no benefit for acute back pain and that antibiotics have no effect on acute bronchitis, doctors have only recently curtailed their use of them, and many still prescribe these costly tests and drugs when patients demand them.
2) You will receive healthcare from a team of health professionals. This "team care" will be in addition to, not subtracted from, the care you are already used to receiving from your personal doctor. The care team may include nurse practitioners, physician assistants, care managers, and nutritionists, depending on your individual health needs. The idea is that the more people who are working together to monitor your health conditions, the less likely a complication will be missed.
[Your Primary Care Team Will See You Now]
3) Your care team will reach out to you in an attempt to prevent future health problems. This may include reminding healthy people about the need for periodic health screenings, or a home visit from a nurse if you've been recently hospitalized for a chronic condition like heart failure. Rather than being paid only when patients get sick, doctors and care teams will be given financial incentives to keep patients well.
4) Technology will improve the efficiency of your health care. Gone will be the days when illegibly written prescriptions or blurry faxes of handwritten hospital progress notes led to thousands of medical errors each year. Doctors will be expected not only to exchange their paper charts for electronic medical records, but to use them meaningfully; that means improving the accuracy of the information in your health record and making sure these records will be accessible to you and the various professionals participating in your care. Of course, this transition will probably result in glitches at first. If doctors' early experiences with electronic health records are any indication, different computer systems may not be able to transfer information to each other, and enterprising hackers will no doubt try to breach the security of online health records, which could threaten your privacy.
[Electronic Medical Records: No Cure-All for Medical Errors]
Of course, it isn't possible at this early date to know how many of these hopes for health reform will actually happen. The ultimate goal, though, is something that I believe all doctors desire: for the health system of the future to give us the tools to provide you with the highest quality experience every time you need to seek health care.
Friday, 8 June 2012
Family medicine is "total medicine"
A terrific article in today's Huffington Post by two of my colleagues, Dr. Ranit Mishori and Family Medicine Education Consortium executive Larry Bauer, argues that family physicians need to "get out of the shadows" and advocate for a larger role in fixing America's health care problems. Instead of subdividing patients by age or body system, family medicine is the specialty trained to handle "diagnostic complexity," which requires a broad and varied skill set:
Every day we treat children, mend bones, manage chronic diseases, deal with hypertension, diagnose intestinal conditions, carry out eye exams, deliver babies, help control diabetes, take skin biopsies, inject aching joints, evaluate stroke victims, monitor depression and in some cases perform minor surgeries. And yes, this range of skills, while broad, does constitute a genuine and focused medical specialty -- the specialty of knowing your patient inside out and over years. We are meant to be experts as much in the person who comes to see as we are in the medical procedures we employ, to build a shared trust with our patients, to be partners with them toward the lifelong goal of staying healthy -- enough, by the way, to avoid too often the need for one those other specialists, whose practices often depend on people being very sick in the first place.
There is an odd logic that diminishes the status of family doctors. It is also faulty logic. People think that the more a physician knows about a specific medical problem or body part and the higher that physician's salary, the better care they will receive. Leaving aside whether that's actually true, it sets up a phony reverse corollary -- the belief that a doctor whose knowledge is more generalized, and whose pay scale is lower, is therefore providing inferior care. This is just wrong. As generalists, we believe the ability to see the patient's big picture; knowing "enough" about most problems; and understanding the preferences, past medical history and the resources of the person seeking care is far more important in most situations than narrow expertise.
Mishori and Bauer go on to ask whether family medicine (which not that long ago was called "family practice") should be renamed "total medicine" to better represent everything that family physicians do. But I think that family medicine needs more than a simple re-branding. When 1/3rd of the U.S. physician work force consists of generalists and 2/3rds consists of subspecialists, patients not only receive less value for their money (since subspecialists have higher salaries), but poorer health outcomes to show for it. A 50/50 ratio, which is the norm in much of the world, would not only save health care dollars, but likely result in fewer illnesses and deaths from preventable conditions. So let me say this as clearly as possible to those who are predicting a vast physician shortage in the upcoming years: America does not need more physicians, it needs more family physicians.
Every day we treat children, mend bones, manage chronic diseases, deal with hypertension, diagnose intestinal conditions, carry out eye exams, deliver babies, help control diabetes, take skin biopsies, inject aching joints, evaluate stroke victims, monitor depression and in some cases perform minor surgeries. And yes, this range of skills, while broad, does constitute a genuine and focused medical specialty -- the specialty of knowing your patient inside out and over years. We are meant to be experts as much in the person who comes to see as we are in the medical procedures we employ, to build a shared trust with our patients, to be partners with them toward the lifelong goal of staying healthy -- enough, by the way, to avoid too often the need for one those other specialists, whose practices often depend on people being very sick in the first place.
There is an odd logic that diminishes the status of family doctors. It is also faulty logic. People think that the more a physician knows about a specific medical problem or body part and the higher that physician's salary, the better care they will receive. Leaving aside whether that's actually true, it sets up a phony reverse corollary -- the belief that a doctor whose knowledge is more generalized, and whose pay scale is lower, is therefore providing inferior care. This is just wrong. As generalists, we believe the ability to see the patient's big picture; knowing "enough" about most problems; and understanding the preferences, past medical history and the resources of the person seeking care is far more important in most situations than narrow expertise.
Mishori and Bauer go on to ask whether family medicine (which not that long ago was called "family practice") should be renamed "total medicine" to better represent everything that family physicians do. But I think that family medicine needs more than a simple re-branding. When 1/3rd of the U.S. physician work force consists of generalists and 2/3rds consists of subspecialists, patients not only receive less value for their money (since subspecialists have higher salaries), but poorer health outcomes to show for it. A 50/50 ratio, which is the norm in much of the world, would not only save health care dollars, but likely result in fewer illnesses and deaths from preventable conditions. So let me say this as clearly as possible to those who are predicting a vast physician shortage in the upcoming years: America does not need more physicians, it needs more family physicians.
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