Guest Post: The Future of Family Medicine - Some Sacrifices Required

- Matthew Loftus, MD

The American Academy of Family Physicians is collecting thoughts now on the future of Family Medicine in America; I shared mine and thought that I would post them here for discussion.

Right now the health care cost curve is being broken across the backs of hospitals & specialists. I think that they'll come for primary care next. If we're not prepared, we'll find our payments decreased and our specialty torn apart as the hospital systems that own us realize that the reimbursable services provided by physicians can often be provided by other types of health professionals. Fighting against nurse practitioner independence wastes time, money, & energy — we need to do more and define all of the roles that work together to create a vigorous primary care system. We're calling on some of our specialist colleagues to sacrifice some of their income and independence for the good of our patients as we try to restrict unnecessary or harmful procedures and tests. However, we have to lead the way by sacrificing a few things of our own — and if we do it now, we’ll get to do it on our terms.

I think that Family Medicine needs to recognize that most primary preventive care doesn't belong in the medical silo at all. While all of us are family physicians because we recognize the value of preventive care, it is important to recognize that our value to our patients and to the population does not come from our ability as physicians to deliver preventive care. Routine preventive care and basic primary care for simple diseases can be done thoughtfully and efficiently by other providers. Rather, our role as physicians is best used doing things that no other provider can do — coordinating care across inpatient and outpatient systems, guiding patients through difficult decisions, managing complex medical problems involving multiple organ systems, and helping to shape policies affecting whole communities. These are challenges uniquely suited for family physicians to address, which give us unique satisfaction even as we give up the often comfortable routine tasks of preventive care. When we are being paid for these services and have the systems in place to support this work, we can expect both our satisfaction with our jobs and our value to our patients to increase.

To this end, we should support the development of community health worker programs made up of residents local to a particular area who are responsible for giving vaccinations, doing basic health education for simple chronic diseases, and following the protocols for screening that clutter our computer screens. While providing preventive care and talking to patients who don't have very many medical problems is an enjoyable part of practice, we must recognize that our medical degrees overqualify us for such tasks and we should be doing them about as often as we are teaching our patients how to give themselves insulin —  it happens and we can do it well because we understand how it works, but it shouldn't be our bread and butter.

Family physicians should then focus on mastering the knowledge and expertise that we have acquired during our medical education and embrace our role as experts at managing multiple complex chronic diseases, especially with psychosocial co-morbidities. We should be supervising and leading teams of community health workers, health coaches, care coordinators, nurses, pharmacists, physician assistants, and nurse practitioners who are managing the simpler medical issues, as is often the case in many other countries around the world. We should also embrace a more active role in coordinating care across the inpatient/outpatient divide; more family doctors should seek inpatient privileges and care for their patients in the hospital. This is one of the ways that we can avoid becoming aloof consultants ourselves. We should learn as much as possible about diseases such as sickle cell anemia & cystic fibrosis so that we can help transition these patients from their pediatric specialists to adult ones.

Another important aspect to our role as family doctors is embracing public health and population health; we should be spending our time not just in seeing very sick patients but also addressing the structural issues pertaining to our local neighborhoods where our patients live. Capitation-based payment may be one way to help tie particular doctors to particular communities, but it is not necessary if we are living in the same places as our patients and getting to know their neighborhoods & leaders. Our residency programs should emphasize leadership training as well as opportunities to engage local communities. I wrote about this in my Family Medicine Educational Consortium "This We Believe" essay titled Proximity, Vulnerability, Faith, & Love.

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care. This is not just about surviving health care reform — it’s about leading it so that our patients get the best care possible.

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Matthew Loftus (@matthew_loftus) is a recent graduate of Medstar Franklin Square Family Medicine Residency. He lives with his wife and daughter in Baltimore, MD, where he will soon begin practicing at Healthcare for the Homeless.

Helmets don't help infant skull deformations

- Jennifer Middleton, MD, MPH

If you're a family physician, chances are you've seen your fair share of infants with skull deformations. Whether it's plagiocephaly (unilateral occipital flattening) or brachycephaly (symmetrical occipital flattening), approximately 1 in 5 infants will have one of these two conditions by age 4 months. Repositioning (especially "tummy time" to help with the flattening due to placing infants on their backs to sleep) often helps, but many infants with persistent plagiocephaly or brachycephaly will end up with a helmet (cranial orthosis) by age 6 months if these deformations persist.

The British Medical Journal published a randomized controlled trial (RCT) from the Netherlands this month investigating the utility of these helmets. The researchers enrolled 84 infants between the ages of 5-6 months with plagiocephaly and brachycephaly who were born after 36 weeks gestation and who didn't have any other dysmorphic features. 42 of them wore a cranial orthosis for 6 months, and 42 of them did not wear a helmet or do any other sort of treatment. Follow-up measurement at ages 8,12, and 24 months showed no difference between groups in the number of infants who had resolution of their skull deformation: 26% of helmet group infants vs 23% of non-helmet group infants for an odds ratio of 1.2 (95% confidence interval 0.4-3.3). Motor developmental outcomes were identical between groups, quality of life scores were the same for both groups, and parents' satisfaction with the shape of their child's head were also the same for both groups. Additionally, every single parent of an infant in the helmet group reported at least one side effect (discomfort, itching, sweating, helmet odor, and/or "feeling hindered from cuddling their child").

This RCT's primary outcome, skull measurement, is admittedly a disease-oriented outcome. Several of the secondary outcomes, though, were patient-oriented evidence that matters: motor development, quality of life, parental satisfaction, and side effect frequency. An accompanying editorial states that this RCT is the first to compare helmets to observation.

AFP published an article on "Diagnosis and Management of Positional Head Deformity" in 2003. While the BMJ RCT provides an updated perspective on the use of helmets, the AFP article still provides some excellent pictures and references to aid family physicians in counseling parents. Another AFP article (this one from 2004), "Craniosynotosis," provides a useful review of how to differentiate plagiocephaly and brachycephaly from craniosynotosis (premature fusion of the cranial sutures) which necessitates surgical referral.

Will this RCT change how you counsel parents about treatment for infant skull deformations?

For sepsis, protocol-driven care is not superior to clinical judgment

- Kenny Lin, MD, MPH

Unwarranted variations in medical care contribute to poor health outcomes in the United States. In many cases, following a standard management protocol is likely to produce as good or better results than clinical judgment alone. For example, American Family Physician's Point-of-Care Guides provide high-quality clinical decision rules and tools designed to improve quality of care for problems encountered by family physicians in outpatient and inpatient settings.

Similar principles have guided the management of patients presenting to emergency departments with severe sepsis and septic shock since a 2001 randomized trial found that early goal-directed therapy, or EGDT (including central venous catheterization, intravenous fluids, vasopressors, inotropes, and blood transfusions) improved mortality compared to usual care. A 2013 AFP review, "Early Recognition and Management of Sepsis in Adults: The First Six Hours," recommended using the EGDT protocol and concluded that "timely initiation of evidence-based protocols should improve sepsis outcomes."

This conclusion was recently put to the test in a multicenter trial published in The New England Journal of Medicine. 1,341 patients presenting to 31 emergency departments in the U.S. were randomly assigned to protocol-based EGDT, procotol-based standard therapy, or usual care. Surprisingly, the trial found no statistically significant differences between the three groups in 60-day mortality, longer-term mortality, or the need for organ support. An accompanying perspective cautioned policymakers against rushing to implement regulatory mandates to adhere to sepsis protocols in light of the increasing incidence of this diagnosis and potential harms of protocol-based care:

Protocols that force physician behavior risk promoting inappropriate prescribing of broad-spectrum antibiotics for noninfectious conditions, unnecessary testing, overuse of invasive catheters, diversion of scarce ICU capacity, and delayed identification of nonsepsis diagnoses.

Two lessons from this study for the management of sepsis and other areas of family medicine are that decision rules and protocols should be derived from replicable studies conducted in multiple settings; and that these tools can sometimes enhance, but should not supplant, best clinical judgment.

What is the best topical antifungal for treating tinea pedis?

- Jennifer Middleton, MD, MPH

A section in this month's Prescriber's Letter regarding a new topical antifungal medication stated that a 2012 systematic review found no clinical difference among topical antifungals for treating dermatophyte infections. This statement contradicts what a clinical pharmacist once taught me: that topical terbinafine is superior to topical clotrimazole for treating tinea pedis. Given how frequently I treat tinea pedis, I have relied on this lesson countless times during my career to date. Thanks to the AFP By Topic on Skin Conditions I found an AFP article, "Dermatophyte Infections," citing the relevant randomized controlled trial (RCT) from 1993. Knowing from my Evidence-Based Medicine education that a well-done systematic review can trump a single RCT, I decided to check out both.

The 1993 study (that I assume my clinical pharmacist teacher referenced) was published in BMJ and divided 256 patients "with mycologically confirmed tinea pedis" into two groups; one group received 1% topical terbinafine twice daily for 1 week followed by 3 weeks of placebo, and the other group received 1% topical clotrimazole twice daily for 4 weeks.* The authors measured both microscopic and clinical cure rates, and terbinafine beat clotrimazole handily, with success rates of both measures combined of 89.7% vs 58.7% at week 4 and 89.7% vs 73.1% at week 6 (both p < 0.01).

The authors of the 2012 systematic review, published in the British Journal of Dermatology, looked at several comparisons among antifungal medications for multiple conditions. In one comparison, they reviewed 17 studies comparing allynes (medication class that includes terbinafine) and azoles (medication class that includes clotrimazole) for all topical dermatophyte infections and found no statistically significant difference.
The systematic review authors did not specifically single out studies comparing terbinafine and clotrimazole for tinea pedis, however.

For now, given that 1 week of therapy is probably preferable to most patients instead of 4, and given that the price difference between the two medications is negligible (around $10-16 for 30 grams of either), I will still favor terbinafine for treating tinea pedis. One option I will definitely not take is using the new brand new Luzu (luliconazole) referenced in this month's Prescriber's Letter for a reported $180 per 30 grams.

How do you choose which topical antifungal to prescribe for tinea pedis?

* According to Lexicomp, 1 week is a sufficient starting place for treating tinea pedis with terbinafine, but it recommends at least 4 weeks of clotrimazole.

Family physicians are natural health system leaders

- Kenny Lin, MD, MPH

Last week, the subtitle of a JAMA editorial on accountable care caught my attention: "the paradox of primary care physician leadership." The authors observed that although a typical family physician's or general internist's patient panel accounts for about $10 million in annual health care spending (of which only $500,000 is primary care revenue), primary care physicians have been "underused" as role players in health system reform. They further suggested that claiming leadership positions in accountable care organizations could be "a powerful opportunity [for family physicians] to retain their autonomy and make a positive difference for their patients - as well as their practices' bottom lines."

The American Academy of Family Physicians recently launched Family Medicine for America's Health, also known as Future of Family Medicine 2.0. One of the key questions considered by this ambitious initiative is "What are the core attributes of family medicine today?" Dr. Robert L. Phillips, Jr. and colleagues from seven U.S. family medicine organizations answer in a special article on the future role of the family physician in the current issue of Annals of Family Medicine:

Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.

This forward-looking definition of family physicians as natural health system leaders contrasts with the "foil definition" that the group envisioned family physicians becoming if they accept passive roles and allow themselves to be acted on by various forces that are changing American health care:

The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill-defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient panel management, community health, or collaboration with public health.

Are tomorrow's family physicians prepared to be leaders instead of followers? A research study published in Family Medicine explored relationships between specialty plans and clinical decision making in a national survey of 4,656 senior medical students. Students were asked to choose between management options in patient vignettes that exemplified principles of health reform: evidence-based care, cost-conscious care, and patient-centered care. Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle change counseling to starting medication for a mild chronic condition. Future family physicians were also more likely to prefer U.S. Preventive Services Task Force recommendations on preventive care to those from disease-oriented or patient advocacy groups, although this finding was not statistically significant.

Neglected parasitic infections - what every family doc should know

- Jennifer Middleton, MD, MPH

The phrase "parasitic infections" probably brings to mind tropical locales and medical mission work, but the May 15th AFP article, "Neglected Parasitic Infections: What Every Family Physician Needs to Know," describes the Centers for Disease Control and Prevention's (CDC) effort to raise awareness of these infections in the United States. The authors review the 5 neglected parasitic infections (NPIs) that the CDC is focusing on:

Chagas disease (Trypanosoma cruzi)

Trypansoma cruzi is transmitted by triatomine bugs, which live in mud walls and thatched roofs in Central and South America. Infections in the US occur in persons who acquired the disease in those areas prior to entering the US. T. cruzi infection is asymptomatic for years but can later cause heart failure and gastrointestinal problems. Triatomine bugs have been found in the southern 1/2 of the US, and CDC researchers are working to determine if transmission is happening in the US as well.

Neurocysticercosis (Taenia solium)

Taenia solium, or pork tapeworms, are transmitted via the fecal-oral route. T. solium eggs travel to the brain and form cysts which can cause seizures. Approximately 1,000 persons are hospitalized with neurocysticercosis in the US every year, with most cases to date in New York state, Illinois, California, Oregon, and Texas.

Toxocariasis (Toxocara canis and Toxocara cati)

Humans accidentally ingest Toxocara eggs from dog or cat feces. The two most severe forms of the disease, which typically affect children, can cause blindness and liver disease. According to the CDC, NHANES III data showed that 13.9% of the US population has antibodies to Toxocara. Deworming infected cats and dogs along with good hand hygiene can limit the spread of toxocariasis.

Toxoplasmosis (Toxoplasma gondii)

T. gondii is transmitted in cat feces and undercooked meat. Pregnant women who contract it are at risk of miscarrying. The CDC is working to improve diagnostic tests and also to develop a vaccine for cats against T. gondii.

Trichomoniasis (Trichomonas vaginalis)

The most common STD in the US, trichomoniasis is asymptomatic in 70% of cases. Infection with T. vaginalis increases the risk of infection by subsequent STDs (including HIV) and can also contribute to pre-term births. 

The CDC's webpage, "Neglected Parasitic Infections (NPIs) in the United States," describes the CDC's efforts to educate physicians and the public, provide testing and treatment recommendations, and bolster research to better understand these diseases. There is a wealth of information there, as well as at this hyperlink to the American Journal of Tropical Medicine and Hygiene's special section on NPIs in their May 2014 issue.

Has your practice seen any of these parasitic infections?