Friday, December 31, 2010

Complementary/Alternative Medicine in the Family

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

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

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

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

Is it lack of knowledge leading to this attitude whether hostile or dismissive?
Is it because there lacks evidence in many cases regarding the efficacy of CAM?
Or is part of it from racist and superior attitudes (whether consciously recognized or not) that Western, white medicine must necessarily be better than anything that could come from other cultures, whether Chinese, Ayurvedic or others?

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

There are a few problems with complementary-alternative medicine before it can be an effective partner with family medicine:
1) Evidence-based practices: much of CAM remains word-of-mouth and "expert opinion-based." If CAM is to become a credible partner and treatment, it must produce credible clinical studies for physicians to embrace it.
2) Regulation: CAM for the large part is unregulated and practitioners can vary in terms of the amount of training they receive. To receive more credibility and standardization of practices, CAM practitioners must become regulated.

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

Tuesday, December 21, 2010

'Family Medicine is a Waste of Your Talent'

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

Here are some things I have heard recently
"Family Medicine is a Back-Up Plan"
"Sub-specialize until you can't specialize anymore"
"The IOM sold out on primary care & now want ARNPs to pick up the slack"
"Aww family medicine? That's so nice of you."
"You're Too Smart For Family Medicine"
"The ship may have already sailed on primary care"
First, I will start out by saying that every time I hear this or read it, I get an acidic taste in my mouth, probably signifying vomit encroaching on my pharynx (5-yard penalty on the vomit).

When I look back on reasons for going into family medicine, I would consider myself a student who was "on the fence" about the specialty. In its current state, going into primary care is a decision that my financial planner would probably strangle me over.
The primary care loan forgiveness programs provide financial relief over several years that could be made up over 1/2 to 1 year in most specialties. Nursing leaders are advocating that they can provide the same care just as good as I will while lobbying for equivalence in pay but deny they are trying to replace primary care physicians. Then there is the SGR, the RUC, hospital network/ACO-wannabes taking over private practice....
I initially wanted to go into orthopaedics - not because I wanted to hit the "ROAD" (though it must be nice), but because of my love for sports and desire to have a niche in something. It was not until my first time rotating with a family medicine physician with a CAQ in sports medicine that I realized it was possible to help athletes and non-athletes with musculoskeletal issues, not go through an ortho residency that could potentially ruin my marriage, and continue to see patients without sports medicine issues as a primary care physician.

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

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

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

Monday, December 13, 2010

What Is Family Medicine?

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

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

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

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

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

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

My conclusion is that you cannot really define family medicine.

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

Furthermore, we are defined by the number of specialists required to refer to in order to practice proper defensive medicine when involved in a malpractice case when asked
"'x' specialist was located in close proximity as an 'expert' for 'y' condition. Why did you choose to follow evidence-based medicine instead of referring your patient to 'x' specialist to follow the same evidence-based medicine?"
When it comes down to it, a family physician can do whatever they want to do, as long as they are flexible in their location for practice and are providing services that others are not willing to practice within that given area. The most important thing to remember is knowing when to refer to that academic center - inconveniently located in an area that already has at least 2 other of its kind within walking distance.

Friday, December 3, 2010

Access to care following health care reform: Lessons from Massachusetts

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

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

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

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

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

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

So, what can we do?

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

Thursday, December 2, 2010

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

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

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

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

Enter EVMS. They also received a grant, though their vision seems a bit different. The grant of $2.1 million over 5 years is intended to develop a project called Predoctoral Education for Advancing Community Health (PEACH). They plan to "create a simulated community-health center where medical students will learn how to manage complicated cases effectively within a busy practice."
The goal is to teach not just primary-care medicine, but to teach primary-care practice systems that are necessary to achieve success for the patients. Every week they're going to be going to their simulated medical office and taking care of patients as if they were interns in a family-medicine residency.

It's getting them ready for 21st-century primary care. If they go into primary care, they'll be better prepared. If they go into a specialty, they'll be better prepared to interact with the primary-care physicians that are in their community
A curriculum that allows for longitudinal training while incorporating the use of the PCMH seems like a no-brainer. Having a panel of patients of all ages, male and female, with a wide variety of biopsychosocial issues to "take care of" and coordinate care for during non-clinical years would really bring the basic science foundations learned concurrently to life. Providing clinical relevance is something that most medical students enjoy during the non-clinical years.

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

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

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

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