Monday, October 12, 2015

RightCare Action Week is next week!

- Jennifer Middleton, MD, MPH

Overuse of medical services - unnecessary prescribing, testing, and hospital care - may represent as much as 30% of the medical services we provide in the United States. Besides wasting resources, these unnecessary medical services can also cause patient harm and even death. Led by the Lown Institute's RightCare Alliance, several leading patient care advocacy organizations have declared October 18-22 RightCare Action Week:
RightCare Action Week is a grassroots initiative for clinicians and others who want to take action that demonstrates how much better our healthcare system can be.Our healthcare system has strayed from its mission: Healthcare that is effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations. (
RightCare Action Week is an opportunity for all of us to show our patients that they deserve better than to be harmed by unnecessary medical services. You may feel, as a busy family doctor, that participating in such initiatives is unrealistically time consuming, but this week provides plenty of opportunities to get involved on even a very small scale - and when those small actions are added up across the country, they can make a very powerful voice.

The RightCare Action Week Guide to Taking Action describes easy ways to get involved. First, consider participating in an overuse count; simply observe how many unnecessary medical services you see during all or part of the week and share your tally at Second, look for or organize a story slam, a time when healthcare workers can come together and share stories of overuse - and possibly associated harms - they've seen. Third, and perhaps the quickest of all, consider participating in their photo campaign - a pic of you holding a sign describing what "right care" means to you, tweeted or e-mailed to the Lown Institute. You can find more details about each of these initiatives here.

You can also count on AFP to provide you with the point-of-care resources you need to avoid overuse. If you haven't checked out our Choosing Wisely search tool, it's a great way to quickly access those evidence-based guidelines. Under the Department Collections tab on the AFP home page (hyperlink), you can find AFP Journal Club, where AFP editors critically assess recent studies, Medicine by the Numbers, which provides clear-cut summaries of the harms and benefits of various interventions, and a POEMs (Patient Oriented Evidence that Matters) archive which includes the top 20 POEMs by calendar year. Each of these resources has interactive search tools and provide quick answers intended to enhance the care you provide to your patients every day.

If you'd like to read more about overuse, AFP ran a series of editorials on overscreeningoverdiagnosis, and overtreatment by Dr. Mark Ebell, AFP Deputy Editor for Evidence-Based Medicine, earlier this year along with an accompanying editorial by AFP Editor Dr. Jay Siwek. 

RightCare Action Week starts in just 7 days; please consider taking part in at least some small way! Maybe you'll commit to trying one of the AFP resources above that is new to you, or maybe you'll try an overuse count, story slam, or photo campaign. Share your involvement on social media with #rightcare and watch for RightCare Action Week updates from @AFPjournal and myself, @SingingPenDrJen, too.

Wednesday, October 7, 2015

How can tech help Family Medicine for America's Health?

- Kenny Lin, MD, MPH

A randomized trial published last month in JAMA found that sending lifestyle change text messages to patients with coronary artery disease improved smoking cessation rates, increased physical activity, and reduced other cardiovascular risk factors. After only 6 months, the texted group had lower low-density lipoprotein, systolic blood pressure, and body mass index measurements than the usual care group. This was an impressive finding, but an unsettling one, since I had just finished reading an American College of Physicians position paper on the use of telemedicine in primary care settings. Taken together, these publications suggest that virtual care technologies, broadly defined, could make many in-person clinical encounters unnecessary. That's good for patient convenience, but potentially threatens one of the best parts about practicing family medicine: seeing patients in person.

Health information technology (IT), as embodied in electronic medical record systems that have replaced paper charts in most family practices, has thus far been a mixed blessing for our specialty. But what about tech beyond traditional health IT? The technology "tactic team" of Family Medicine for America's Health published a special article in Family Medicine that described strategies for family physicians to utilize an array of evolving technologies to strengthen therapeutic relationships and improve outcomes:

1) Smartphone apps and wearable devices that capture data about patients' health habits and give feedback to influence their behavior

2) Point-of-care musculoskeletal ultrasound

3) Web-based communication for "virtual" hospital rounding and specialist consultations

4) Web-based videos to provide patient and professional education

Although all of these initiatives have great potential to benefit patients, many are being developed in silos without leadership or input from family physicians. Therefore, the paper's authors proposed that Family Medicine for America's Health work to integrate these overlapping efforts into "a united front improving health IT and other technologies for the specialty."

Key opportunities for family physicians "to capitalize on our collective strengths" in the near future include partnering with developers to create health IT tools that improve clinical outcomes (rather than merely serving administrative or billing functions); supporting primary care-centric data models; participating in the development of primary care quality measures; and collaborating with patient and consumer organizations locally and nationally to identify and promote patient- and family-centered technology solutions that complement the vital functions of family medicine.

Monday, September 28, 2015

Peer review benefits journals, readers, and reviewers #peerrevwk15

- Jennifer L. Middleton, MD, MPH

Today kicks off the first-ever Peer Review Week, a time to both celebrate and debate peer review in scientific publications. A group of 4 publishing organizations came up with this idea as a way to "honor...thcentral role peer review plays – and, we believe, will continue to play – in scholarly communications." You can follow the conversation on twitter with #peerrevwk15.

But what is peer review, exactly? Here's one definition from
Peer review is the system used to assess the quality of scientific research before it is published. Independent researchers in the same field scrutinise [sic] research papers for validity, significance and originality to help editors assess whether research papers should be published in their journal. 
Peer review furthers journals' credibility by ensuring that external reviewers with no stake in the journal (monetary or otherwise) have deemed their content of sufficient quality and interest to disseminate.

Before each crisp new issue of AFP hits your mailbox or your tablet, peer review volunteers have examined every single clinical article it contains. The peer review process at AFP is similar to many other medical journals. Once we receive a manuscript, AFP staff assigns it to 3-4 peer reviewers. Reviewers receive a copy of the manuscript and provide feedback on both the manuscript's content and quality using an online form, which includes an assessment of whether the manuscript is, or could be, publication-worthy. The assigned AFP medical editor collates the feedback and provides it back to the manuscript authors. Most of the time, authors are asked to respond to the feedback with an improved manuscript. The result is a final article that has been made better by peer reviewers' feedback and ideas.

AFP is grateful to its peer reviewers for their contributions. AAFP members may claim CME credit for each manuscript they review, which is easy to do at the AAFP "Your CME Report" website. Additionally, peer reviewing can help writers strengthen their writing and reading skills. Reading a manuscript for peer review requires careful attention to each word, phrase, and sentence, scrutinizing each one for accuracy, clarity, and any possible bias. Being "sensitized" to "common writing mistakes," as AFP Editor Dr. Jay Siwek has said, can improve the quality of writers' own manuscripts, and I would argue that learning how to read carefully benefits peer reviewers every time they read pretty much anything else.

I've been a peer reviewer for a handful of journals since I was a fellow, and I have immensely enjoyed the opportunity to develop my writing and editing skills along the way. Interacting with journal editors and discovering if they concurred with your assessment has been a great learning process and quite a privilege. Anyone can apply to be a peer reviewer, and journals always seem to be looking for them. If you'd like to learn more about the peer review process at AFP, check out our online reviewer's guide, which includes both this handy reference list of peer review resources and the link to apply to be an AFP peer reviewer (click "Fill out the reviewer profile" and you can download a pdf with further instructions). Remember - AAFP members can get CME credit for each manuscript, and you'll help us continue to produce the high-quality work you've come to expect from AFP.

AFP peer reviewers, please chime in - what do you value about being a peer reviewer?

Monday, September 21, 2015

Ready or not, ICD-10 has arrived at last

- Kenny Lin, MD, MPH

After two separate one-year delays, the U.S. implementation of the International Classification of Diseases, Tenth Revision (ICD-10) code sets for medical diagnoses and inpatient procedures is now just 9 days away. If you are an employed family physician like me, you have probably been required by your employer to familiarize yourself with the new codes through face-to-face training or online modules. If you own your own practice, hopefully you have already confirmed with your electronic health record vendor that the switch to the new code sets will happen seamlessly on October 1st.

But if for some reason you have procrastinated, there is still time to get up to speed on the changes. To make this process as painless as possible, the editors of Family Practice Management have assembled a timely collection of links to articles on the ins and outs of ICD-10 coding, including their latest piece about documentation elements to support coding five common conditions in family medicine (asthma, otitis media, diabetes, well-child examinations, and hypertension). If you want to have all of this information in one place, you can purchase an e-book anthology available for iOS, Kindle Fire, Google Play, or Nook.

Although the increased diagnostic specificity that ICD-10 permits compared to ICD-9 can and should benefit the health system, FPM medical editor Ken Adler, MD, MMM warned in a recent editorial that doctors could lose in the short term:

We are told that we need ICD-10 for better quality reporting, public health research, health policy planning, fraud detection, and risk adjustment for quality based payments. That all sounds reasonable. But will the primary beneficiaries of ICD-10 turn out to be payers rather than patients? Will ICD-10 be used as just one more tool to delay or deny payment to physicians? ... There are plenty of reasons to be reasonably specific with our coding, ... but fear of not being paid should not be one of them. As physicians, we need to continue to make that point loud and clear.

Hear, hear.

Monday, September 14, 2015

When "drink plenty of fluids" isn't enough

- Jennifer Middleton, MD, MPH

Treating the dehydration that can accompany foodborne illness may seem straightforward, and many physicians advise little more than "drink plenty of fluids" to patients who are only mildly ill. In the current issue of AFP, though, the authors of "Diagnosis and Management of Foodborne Illness" recommend making specific recommendations about oral rehydration therapy, especially for younger patients.

Without specific guidance, many parents will use soft drinks and juices to prevent and treat their children's dehydration. These sugar-rich and electrolyte-poor beverages can exacerbate diarrhea and cause hyponatremia. Sports beverages that tout electrolyte replacement are also not appropriate as they typically contain excessive sugar. Physicians should instead recommend oral rehydration solutions with an appropriate balance of carbohydrate and electrolytes; in the US, Pedialyte and Enfalyte are options. These commercially available solutions eliminate the risk of preparation error (and possible electrolyte imbalances and/or worsening diarrhea) of homemade oral rehydration solutions.

Physicians may wish to counsel families of infants and young children to keep these solutions on hand at well visits, so that they are immediately available should their child become ill. For outpatient treatment of mild dehydration, parents may give 1 mL per kg every 5 minutes over a 4-hour period. For maintenance after that time, parents should aim for 1 oz of oral rehydration per hour for infants, 2 oz per hour for toddlers, and 3 oz per hour for older children for as long as illness symptoms persist. As they recover, patients will experience decreased thirst, which inherently protects against over-hydration. If you'd like more information, check out the AFP By Topic on Gastroenteritis and Diarrhea in Children, which includes this 2012 article with more detail about using oral rehydration solutions.

Physicians may find it helpful to have patient information handouts (either on paper and/or integrated into electronic health records) for patients to refer to at home like this one from or this Information from Your Family Doctor on treating dehydration. Either way, providing specific recommendations about oral hydration can help our younger patients better recover from foodborne illness.

Monday, September 7, 2015

Guest Post: Quality medical care makes patients feel at home

- William Gilkison, MD

For decades, health care analysts, policy makers, administrators, and pundits have talked and written about “good quality health care.” But has anyone ever defined just what good care means? Does it mean the patient got well? That the physician met all the quality measures criteria? What defines quality medical care for patients? What is it that gives them reassurance and the knowledge that they are being well-cared for? After all, it’s the patient's definition that really matters.

Now that I’m retired from family medicine, I frequently hear from friends and former patients stories about how their doctor doesn’t seem to listen to them, how they can’t get through on the phone, how he doesn’t return their calls, how she doesn’t get back to them with lab or x-ray results, and how their staff doesn’t seem to care. These perceptions all play a role in how the patient (an anxious human being) defines quality care.

They say first impressions define the situation, so it is imperative that the first contact patients have with the doctor’s office does not result in frustration. The individual who answers the phone sets the tone for the whole encounter. If this person is surly or curt, could the doctor be like that, too? How comforting it is to a patient when the person on the other end of the line recognizes their concern, anxiety, or voice and treats him or her as one would a friend.

Many other seemingly minor issues determine the patient’s perception of good medical care. Was the patient allowed time to relate the history and symptoms? Did the doctor listen, not interrupt, and seem interested? Were appropriate follow-up questions asked? Were all the patient’s concerns addressed and questions answered before he left the exam room?

Anxiety is made worse by fear of the unknown. It drives people nuts to have to wait a week or longer for important, sometimes life-changing results when they’re in pain or worried they may have cancer. Results of blood work, the abdominal CT for that belly pain, the MRI for that headache, or the biopsy of the breast or prostate mass - all of these normal and abnormal test results should be reviewed by the physician as soon as they are available, and a disposition made immediately. Patients appreciate this more than one can imagine.

In my view, then, the definition of good care includes communication, patience, concern, and perseverance. A high quality, "patient-centered" medical home is based on these human characteristics and not on outcome criteria, EHR meaningful use, or other measures. To the patient, good care means this: the doctor saw me when I needed him, diagnosed my problem correctly, treated it appropriately and effectively, gave me my test results without my having to ask, communicated permitted pertinent information to my loved ones, and asked how I was doing the next time we met. And better yet, his office staff knew my name when I came in. Isn’t that just like being at home?