Giving Preventive Health Care A Name

Posted on October 15, 2010 by admin

It’s a scene that plays out thousands of times every day in doctors’ offices across the country—the moment the doctor shifts from addressing the concerns that brought the patient into clinic to when he or she attempts to make sure everything else is going okay. Often it happens at the end of a sick visit, after working up an upper respiratory infection or back pain; sometimes it happens after following up a chronic medical problem such as high blood pressure or arthritis, and occasionally it happens under ideal circumstances, during an annual physical or routine wellness visit. It doesn’t necessarily happen at the end of the visit; often it sneaks it’s way into various points in the encounter – as when the doctor places his or her stethoscope over a patient’s chest while evaluating the patient for knee pain.

What I’m referring to is so indistinct that it doesn’t even have an universal name, but rather goes by many titles – preventive health, preventative health, preventive medicine, preventive care, health care maintenance, routine health care, routine check up, annual physical, and health and wellness – to name a few. But whatever you call it nearly everyone agrees how important it is. The health care reform debate was ripe with calls for more “health”-care not just “sick”-care, and one of the most welcome measures in the new health care legislation across both sides of the aisle are provisions to support it. Outside of Capitol Hall, from cereal boxes to magazine racks and celebrity doctors, messages about staying healthy are everywhere, as is the general belief that “an ounce of prevention is worth a pound of cure.”

Preventive health care or preventive care, the terms I prefer to use, can be defined simply as the things a doctor does to keep a patient healthy. If you sprain your ankle and your doctor examines your foot, asks you questions about how you injured it, or refers you to physical therapy, that’s not prevention. But if he or she also examines your heart and lungs, takes your blood pressure, or asks whether you smoke, that’s prevention. From the form you fill out to the waiting room to the vital signs the nurse takes before you go in to see the doctor to the routine questions and physical exam maneuvers the doctor does during the visit, anything not related to what brought you into clinic or medical problems you are already known to have can be considered preventive health care.

Defined in this way, the standard office visit we are all familiar with presents myriad opportunities for prevention. While it may be considered a good thing that preventive care happens seamlessly in everyday medical practice, it is also occurring inconsistently. Study after study has shown us that doctors do not routinely provide the preventive health care that is proven to save lives and prevent disease. From vaccines and cancer screenings to counseling to lose weight and quit smoking, patients on average only get half the preventive care they should be getting. Only half.

Not all preventive health care is made equal. It surprises many people that just as there are medical studies to test out the latest chemotherapy drug or medical device, doctors also study approaches to keep patients healthy. From experiments to figure out which patients benefits most from aspirin and trials of new methods for colon cancer screening to whether doctors should counsel people about wearing seat belts, the medical literature is filled with scientific evidence about which preventive health services work and which don’t, and the evidence base grows every day. Like robotic surgery and biologic therapies, preventive health care has a cutting edge too.

Some preventive care measures have been well-studied and are proven to keep patients healthy; others have been studied but not proven to work; and still others have not been studied or proven. In a time and resource-constrained world, it makes sense to start with those measures that are best studied and best proven. If we have time for more after that, then so be it.

It surprises people to find out where different common preventive care measures fall:

  • Mammograms to screen for breast cancer – studied, proven; yearly breast exams by doctors to detect breast cancer – studied, not proven.
  • Counseling smokers to quit smoking – studied, proven; counseling normal weight people about diet and exercise – studied, not proven.
  • Blood pressure measurement every 1 to 2 years – studied, proven; annual physical exams – not studied, not proven.
  • Cervical cancer screening (Pap smears) in women ages 21 to 65 – studied, proven; prostate cancer screening (PSA) in men at any age – studied, not proven.
  • Routine blood work to check kidney or liver function, calcium levels, or thyroid function – studied, not proven; checking cholesterol levels in people at increased risk of heart disease, including all men over age 35 – studied, proven.

And yet, everyday in medicine we see patients that undergo “yearly blood work” but who aren’t receiving the recommended annual flu vaccine, or men over age 50 who get a digital rectal exam to screen for prostate cancer but who haven’t yet been told about colon cancer screening.

As a recent medical school graduate, I can tell you that at least part of the problem is that prevention is never really taught in medical school. In the first two years of medical school, we learn by the disease-to-symptom approach. We pour over heavy textbooks, turning from one disease to the next, committing to memory its pathophysiology, its pharmacology, and its associated symptoms.  The second two years of medical school we go the other way. We learn how to take the symptoms patients come to clinic or the ER with and then deduce which diseases they have – the symptom-to-disease approach. But prevention isn’t about symptoms. From a prevention point-of-view if the patient has symptoms then it’s already too late. So where in the disease-to-symptom or symptom-to-disease approach does preventive health fit in?

As a medical researcher, another problem I’ve identified is that preventive health care has no home in academic medicine. The hallowed halls of teaching hospitals are divided by medical specialty – surgery, ob-gyn, psychiatry, pediatrics, internal medicine, etc. Internal medicine and pediatrics are further divided into cardiology, pulmonology, gastrointestinal, oncology, and so on. There is no such thing as a specializing in preventive medicine, and thus there is typically no dedicated department or division for prevention. The closest divisions we have are general pediatrics, general internal medicine, and family medicine; the fields which make up “primary care”. While “preventive medicine” residencies exist, they are non-clinical training programs that are more based in public health than everyday practice and are few in number. This leaves prevention without a dedicated space of its own in medicine, without dedicated funding and dedicated practitioners, and still nameless.

As a primary care doctor, another problem is in the delivery of preventive health care. Expert guidelines about preventive health care exist but are often conflicting. Remember the hailstorm last year over the mammography guidelines released by the US Preventive Services Task Force (USPSTF)? When one expert organization tells doctors to start screening for breast cancer by age 50, yet another recommends routine mammography at age 40, doctors and patients are left at a loss for what to do. Even when the guidelines are clear, implementing them can be difficult. Primary care doctors work in hurried practices that use outdated paper charts or meaning-less use health IT and are not reimbursed for the extra time required to coordinate care and counsel patients about preventive health. Patients often refuse preventive health services such as the flu shot citing concerns that the vaccine itself will make them sick. And even if the doctor has time to talk about preventive care, and the patient agrees, it doesn’t mean his or her insurance company will. The Centers for Disease Control and Prevention (CDC) recommends the shingles vaccine for all adults over age 60, yet insurance coverage has lagged behind.

Clearly such a multifold problem will require a multipronged solution. Medical students and residents need more formal training in prevention. Preventive health care needs more funding and support from the government and academic medical centers. Doctors need better tools and more support to deliver prevention. We all agree that prevention is important and the delivery of preventive health care needs fixing. But first thing first – let’s get preventive health care out in the open. Let’s recognize when it is happening as it should and when it isn’t. Let’s be clear about what we mean when we talk about prevention. And by all means let’s give it a name.

- Shantanu Nundy, M.D.

Posted in Thinking Out Loud | Tagged , , , , | 4 Comments

Forgetting to Counsel Patients About Their Chronic Diseases

Posted on October 4, 2010 by admin

The recently instituted 30-hour-shift “work restrictions” placed on medical residents have created a need for “dayfloat” services to safeguard potentially unsafe handoffs in patient care and help residents adhere to duty hour limits. The past two weeks I’ve been the dayfloat resident for the cardiology inpatient service.  My job is to round with the post-call team, help them get out of the hospital on time, and then take care of their patients through the end of the work day. It’s a fairly low stress rotation, as they go, but because I “float” from one team to another without patients of my own, it can be hard to find meaning in the work.

Towards the end of my two week rotation, I was paged because a patient’s husband wanted an update on his wife’s condition. Glancing at my “signout” — a one-page synopsis of the patient’s presenting illness and hospital course — I learned that Mrs. FN was admitted to the hospital for heart failure secondary to “medical noncompliance.” It appeared that she had not had any of her medications for well over a week, which likely precipitated the shortness of breath and fluid overload that led to her admission. On top of this, the patient had a number of “dietary indiscretions” including eating Chinese food, which likely only exacerbated her condition.

Patients like Mrs. FN are not unusual by any means. Heart failure exacerbation is one of the most common reasons for admission at my hospital, and one of the most preventable. Though acute heart failure can be caused by many things, more often than not a patient goes into heart failure because they don’t take their medications as prescribed or because they consume excess salt. This non-adherence is a constant source of angst for health care providers, who are often frustrated that patients don’t take better care of themselves.

As I walked into the patient’s room, I prepared myself to answer the typical questions families ask: “What did the test show?”, “Did she have a heart attack?”, “When can he go home?” But Mrs. FN’s husband had a different set of concerns. He wanted to talk to me about why his wife’s legs were swollen. The swelling was making it difficult for her to walk, and taking long walks together was their favorite pastime. I explained that the swelling, or edema, was due to her heart failure. Whenever her heart failure acted up, so would the swelling. I was planning on leaving it at that but Mr. FN wanted more. He wanted to know how the swelling got there in the first place.

My gut reaction was to respond that it’s because she isn’t taking her medications or doing what she is supposed to do. But putting my own frustrations aside, and sensing a teachable moment, I decided to answer his question fully. I sat down and explained how in heart failure the heart doesn’t pump blood forward very well. Sensing less blood flow, the kidneys start holding onto salt and fluid. The more fluid the kidney hangs onto, however, the more overloaded the heart gets. The more overloaded the hearts gets, the worse it pumps blood forward. This causes the kidneys to hold onto even more fluid, and so on goes the vicious cycle. Finally, I tied this back into his major concern by pointing out that in the process of building up fluid, patients’ legs get swollen, causing some people to have a hard time getting around.

Far from being glazed over, his eyes looked at me intently. Clearly, he wanted me to go on.

“Lots things can set off this vicious cycle. If you eat too much Chinese food, which has loads of salt, your body will hold onto water. This water can then overload the heart, decreasing blood flow to the kidneys. The kidneys then hold onto more water, which gets the cycle going again. Not taking your medications can also set the whole cycle off. That’s because each medication acts on a particular part of this system. Take for example your wife’s lisinopril medication, which blocks the kidneys from holding onto fluid.”

The conversation went back and forth like this for the next 15 minutes. By the end, we had gone through all of Mrs. FN’s medications, explaining the role each one played in his wife’s leg swelling. We also covered the dangers of salt and explained how it’s not just the salt you add at the table but also the salt that is already in foods that can set off the vicious cycle. To really control salt intake, they needed to stay away from processed foods, frozen dinners, and restaurant meals, which pretty much only left room for home cooked meals.

On my way out, Mrs. FN and her husband told me that no one had ever told them how important it was for her to take her medications and eat a low-salt diet or explain why she was on the treatment regimen she was on. At first, I couldn’t believe that she never received this basic education about heart failure, but the more I thought about it, the more I realized how this could have occurred. Often patients are first diagnosed with heart failure after they present to the hospital short of breath or with chest pain. Having seen a number of “new onset heart failure” admissions during my two weeks on cardiology, I had a sense of how they went. Patients are put through a battery of tests including blood work, a series of EKGs, an echocardiogram, stress testing, and often a cardiac catherization and at the same time are started on 3 to 5  heart failure medications. Patients, and sometimes even the cardiology team, can barely stay on top of all the tests and new medications that counseling about heart failure is often left by the wayside. In clinic, where this patient would be seen next, the cardiologist is often busy piecing together the history from the patient and scattered hospital records. Most of his or her remaining time is spent on changing medications and filling out prescriptions, not on providing basic heart failure education. During the patient’s primary care visit, the doctor may well assume that the cardiology issues are being addressed by the cardiologist and instead focus on the dozens of other issues he or she needs to attend to in their 15-minute office visit. On the patient’s next admission to the hospital for heart failure, he or she would no longer be a “new onset heart failure” patient. The battery of tests would be simpler, but often, as was the case for Mrs. FN, the team doesn’t provide formal heart failure education because they assume the patient has heard it all before.

It turns out that basic health education is not so basic afterall. Our health systems are better at getting patients stress tests and cardiac catherizations than educating them about their diseases and how to keep themselves healthy and out of the hospital. Though I only had two more days of cardiology left, I made it a point to see patients who were admitted for heart failure and provide some rudimentary heart failure counseling. But until we find a systematic way to make tailored health education part of a patient’s standard medical care, we’re likely to keep leaving our patients behind.

- Shantanu Nundy, M.D.

Posted in Heart Disease Prevention, Patient Stories, Thinking Out Loud | Tagged , , , , , | Leave a comment

A Food-Based Approach to Eating

Posted on September 12, 2010 by admin

The science of nutrition is changing and not in the way you might expect. After years of “reductionist” thinking — where food has been viewed as the sum of its parts – a call to treat food as food has been sounded. No more poring over nutrition labels to calculate grams of fat or chasing down the latest go-to chemical – be it vitamin E, fish oil or omega-3. Instead we are being asked to call a potato a potato and a piece of steak… well… a piece of steak.

If you haven’t heard about this sea change yet, you are not alone. The food science industry that markets “food products” for our consumption has done a good job giving their laboratory creations a semblance of health with phrases like “low fat” and “high in vitamin C”. For our part, the medical community is also to blame. Despite evidence to the contrary, we have been slow to renounce the “fat is bad” mantra or break away from the nutrient-based approach to eating that first swept the country over 30 years ago.

Until very recently, the dissenting opinion was expressed mainly by food journalists and self-proclaimed naturalists. In the book Good Calories, Bad Calories, Gary Taubes argues persuasively that the science behind vilifying fats is fatally flawed and proposes that carbohydrates, and in particular sugar and high fructose corn syrup, are the real bad guys. Michael Pollan, perhaps the best quoted food journalist-cum-activist, goes further to suggest the whole notion of understanding food by its constituent parts – fat, protein and carbohydrates or even saturated fats, unsaturated fats, and trans fats – is plain wrong. He opens In Defense of Food with three dictums for healthful eating: “Eat food. Not too much. Mostly plants.”

Now the scientific and medical literature is coming around. A review in the Archives of Internal Medicine of over 500 trials found “insufficient evidence” that the intake of dietary fat (except for trans fat) is associated with coronary heart disease.1 More recently, an editorial published in the Journal of the American Medical Association (JAMA) August 2010 entitled “Dietary Guidelines in the 21st Century – a Time for Food” writes “little of the information found on food labels’ ‘nutrition facts’ panels provides useful guidance for selecting healthier foods to prevent chronic disease.”2

Don’t let the plain academic language lull you – what these scientists have published in arguably the world’s most prestigious medical journal is that the entire approach to food based on nutrients is wrong.

It’s not that eating the right nutrients is hard (how are you supposed to know if less than 30% of your calories comes from saturated fats?) and that the science of nutrient-based eating is bad (this is too academic to get worked up about), it’s that our focus on nutrients has actually made our food more unhealthy. In an effort to engineer “better” foods, we created trans fats, which we now know are deleterious to health, and food products that are low in fat but high in dough conditioners (whatever that is). Indeed, as saturated fat consumption has decreased, our collective burden of chronic disease and obesity has only increased.

So if fat is not bad, and we shouldn’t be thinking about food in terms of individual nutrients, what are we left with? Surprisingly, we are pretty much where we were in our grandparents’ generation, a time before we thought we could improve health by manipulating individual nutrients, and when food was just food. As the JAMA article concludes “… although this approach may seem radical, it actually represents a return to more tradition, time-tested ways of eating.”

In fact, the most convincing studies of dietary patterns that prevent or retard chronic disease are food-based. Fruits, vegetables, whole grains, and nuts have been consistently associated with lower risk of disease while fish consumption has lowered the risk of death from heart disease. And these effects are above and beyond what you see from diets with equal levels of protein, fat, and carbohydrates.*

A food-based approach to eating is not only healthier but also easier. Instead of worrying about things you can’t see, smell or taste; it asks you to pay attention to what you are putting in your mouth. It supports an eating plan of fruits and vegetables, whole grains, and unfettered meats over processed foods, packaged meats, and sugar-laden beverages; and favors home-cooked food over store-brought or restaurant meals.

So the next time the hunger pangs strike, check your energy bar at the door and drive on by the local diner. Instead go to your local grocery store, buy yourself some fresh food, and prepare yourself a hearty, wholesome and healthy meal.

- Shantanu Nundy, M.D.

*It’s not hard to imagine why. Fish has way more in it than protein, different types of fat, and carbohydrates; and even if we could categorize every vitamin and micronutrient in fish we wouldn’t yet understand how these nutrients work synergistically to impact health.

1 Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med. 2009 Apr 13;169(7):659-69.

2 Mozaffarian D, Ludwig DS. Dietary guidelines in the 21st century–a time for food. JAMA. 2010 Aug 11;304(6):681-2.

Posted in Healthy Living | Tagged , , , , , | 2 Comments

A Great Save?

Posted on August 27, 2010 by admin

In the real world of medicine, “great saves” are rare. Most patients that you expect to die will die, and those who experience a cardiac arrest or code rarely survive. Mr. GR is the closest I’ve seen to an exception to both of these rules, and his story illustrates the best but also the worst of what our health care system achieves.

I first met Mr. GR in the emergency room (E.R.). As the cardiac ICU resident on call, I was urgently paged down to the E.R. for a “cath lab activation.” The “cath lab” (cardiac catherization laboratory) is where cardiologists balloon and stent open arteries using flexible instruments called catheters. A “cath lab activation” is an emergency call placed when a patient is suspected of having an acute heart attack. From the moment I saw him I knew Mr. GR’s chances of recovery were slim. He was “found down” by emergency medical services (EMS) without a pulse, shocked back to life, and then intubated on arrival to the E.R. Once stabilized a stat EKG was obtained. The diagnosis instantly became clear. From across the room “tombstones” could be seen marching across his EKG — concave-down electrical waves that are telltale signs of a major heart attack.

My team was called down, and he was taken emergently to the cath lab. (Picture a gurney whizzing down crowded corridors, me getting slammed against the wall at every sharp corner.) After wiring a series of catheters through his groin, cardiologists found a “tight” blockage of his LAD artery, which feeds most of the blood supply to the heart, and popped it open with a metallic stent. Still on the ventilator, he was then transferred to the cardiac ICU, where we infused ice cold water down his nose into his stomach to cool his core body temperature down to 32 degrees C (89.6 degrees F). His heart and his lungs had been stabilized, but after nearly 10 minutes without adequate blood flow to the brain, there was no telling if he would make any meaningful recovery.

Twenty-four hours later he was gradually rewarmed. The following day we weaned the heavy sedatives that allowed us to cool him, and held our breaths. Gradually, hour by hour, he showed signs of life. He began to take breaths on his own and make purposeful movements. The next day he followed simple commands, wiggling his toes and squeezing our hands, and was taken off the ventilator. He began talk, giving simple “yes” and “no” answers. By the time my rotation in the cardiac ICU was over, we were beginning to talk about transferring him to a rehabilitation facility. The extent of his neurologic recovery remained to be seen — while he was talking, he seemed to have limited short-term memory (every day we had to reorient him to place and time) and his mother lamented he didn’t seem to recognize her. But he was very much alive and getting better day by day.

–

It’s hard to convey how remarkable his story is. Even though I’m in medicine, I can’t help but marvel not only in our technical capacity to literally bring this man back from death but also in our successful and timely execution of an incredibly complicated set of tasks. Here is a brief reconstruction of the early hours of the case:

10.06 AM: Patient found down by strangers. 9-1-1 called for concern of “seizure.”

10:11 AM: EMS at the scene. Heart monitor placed, ventricular fibrillation detected. Patient shocked. Normal rhythm restored.

10:18 AM: Ambulance arrives in the E.R. Patient intubated, central line placed. EKG obtained. Cath lab activated.

10:41 AM: Patient in the cath lab. Coronary artery blockage identified and ballooned open.

11:15 AM: Patient in the cardiac ICU. Cooling initiated.

Stringing together this series of events required multiple systems of care. Onlookers who witnessed the patient collapse had to recognize his critical illness and know to call 9-1-1. EMS had to be immediately available and the phone call appropriately triaged as a medical emergency. The ambulance team had to have the right equipment and right training to immediately place a defibrillator, recognize a life-threatening heart rhythm, and deliver an electrical shock. The E.R. had to quickly stabilize the patient and amidst a chaotic situation recognize an acute heart attack. The cath lab had to have the equipment and staff on hand to immediately receive the patient and proceed to angiography. The hospital had to have a cooling protocol and the right equipment and staff to initiate it (at our hospital by paging “C-O-O-L”).

A breakdown in any of the steps above would have dramatically changed this patient’s course. The data is clear: every minute the patient is down without adequate oxygen delivery increases the risk of permanent brain damage and death. “Time is brain.” But for every success story like Mr. GR’s there are many more not don’t end well. As someone who practices medicine, these breakdowns are not hard to imagine. Onlookers think patient has only “passed out” and delay calling 9-1-1. There’s heavy traffic on the way to the hospital. The ER is busy with a trauma patient and an EKG is not ordered in time. It’s the middle of the night and the cath lab team takes over an hour to assemble. Cooling is not initiated because the right equipment is not available. That all these moving and imperfect parts came together to help Mr. GR is almost miraculous.

–

Through the week I spent taking care of Mr. GR, I had the opportunity to learn more about him from his family. Though he had a job and health insurance, Mr. GR did not have a regular doctor. He was a lifelong smoker and drank 5-6 beers on the weekends. He had high blood pressure but was never started on medications for it. Moreover, for the past 4 months, he had been complaining of episodes of abdominal pain that were brought on by exertion. He had sought care at a local hospital E.R. on more than one occasion but was told he had heartburn and prescribed an antacid. In hindsight, this abdominal pain was likely the earliest salvo of the heart attack that almost claimed his life.

I don’t blame the outside hospital E.R. for misdiagnosing his abdominal pain. Abdominal pain is common and it is difficult to know how Mr. GR presented at that time. Each time he went to the local E.R. he likely saw a different doctor. E.R.s are best designed to handle emergencies; chronic and refractory medical problems often slip through the cracks. In a primary care office, he may have initially been diagnosed with heartburn as well. But if his symptoms worsened despite appropriate medications, the primary care doctor would have been more likely to re-visit the initial diagnosis. He or she would have also addressed his controllable risk factors for coronary heart disease, including tobacco use and hypertension.

Mr. GR in many ways typifies the larger problems with our health care system. Our health care system is designed and is really best at acute care. This underlies our ability to coordinate and execute the incredibly complex series of steps needed to resuscitate Mr. GR. However, for all of our specialized and acute care, we have yet to figure out how to deliver primary and preventive health. We can shock, intubate and cath people who present with a cardiac arrest in under 90 minutes, but can’t get patients to see a regular doctor, to take their medications, to follow up when they aren’t doing well.

–

I don’t want to dismiss what we did for Mr. GR this past week. Rather, our success in his case emboldens me to believe that with the right science and the right resources we can improve the delivery of primary and preventive health. It dares me to dream not just of a health care system that handles medical emergencies perfectly each and every time but of one that doesn’t have to. After all, the greatest save is not having to make a save at all.

- Shantanu Nundy, M.D.

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What Primary Care Can Learn from Oncology

Posted on August 3, 2010 by admin

Why do my patients with cancer get better care than my patients in primary care?

As the senior resident on my hospital’s inpatient leukemia service this past month, this question troubled and intrigued me daily. Despite the sheer complexity of treating leukemia (administration of chemotherapy, bone marrow biopsies, stem cell transplantation), the resources required (transplantation routinely costs $1 million), and the severity of the illness (patients with little to no functional immune system), I couldn’t help but marvel at how coordinated, integrated, and patient-centric the care was.

From the first day I saw that things in leukemia worked differently. Most inpatient ward teams consist of an attending, a senior medical resident, one or two interns, and medical students. Each member of the team is “on service” for 2-4 weeks after which they rotate to different parts of the hospital or to the outpatient or research setting. As a result a patient admitted to general medicine today is taken care of by a completely different team than took care of her 3 months earlier when she came in for the same problem. On leukemia, our medical team included an advanced practice nurse (APN) who did not rotate off and on service. Being on the inpatient leukemia team was her primary responsibility 365 days a year. When I wondered if a patient admitted for chemotherapy needed an interval CT scan, she would remind me that the patient had just received one a month earlier. When the patient later developed a rash that I considered getting a biopsy of, she reassured me that the rash looked no different than the one the patient had developed the last time she received chemotherapy. And when I was trying to determine which prophylactic antibiotics to discharge the patient on, she contacted the primary oncologist to get his opinion and, if necessary, arranged prior authorization for medications that her insurance company might otherwise deny coverage for. Perhaps most importantly, our APN was a constant presence for patients fighting a disease that wrecked havoc on their bodies and their lives. Often when the medical team finished examining a patient, the patient would ask to speak to our APN privately, no doubt to receive additional emotional and psychosocial support, something that is terribly lacking in many patients with chronic disease yet serves to reduce treatment breaks and improve adherence and identify co morbid conditions such as depression that are common but often go unnoticed.

Then there was the weekly leukemia conference I was reminded to attend. Thinking I was walking into another research lecture, I was surprised to learn that this meeting was really a “tumor board” in which new and active patients were discussed. Sitting around the expansive conference table were leukemia attendings and fellows, advanced practice nurses, social workers, case managers, and the inpatient leukemia team. We began by discussing the admitted patients with my team providing the updates and the outpatient oncologist providing context and overall direction. I left with a better understanding of my patients while my intern jotted down to-dos and made notes for herself. We then discussed the new patients — while multiple leukemia specialists went back and forth formulating the diagnostic plan and initial chemotherapy, the case managers and social workers figured out how to best coordinate the dozens of steps required to place a central line, draw routine blood tests at home, and schedule chemotherapy and follow up visits. Finally, everyone was encouraged to bring up concerns about any patient on the roster. In general medicine, doctors are often left to deal with complex medical and social issues with little input from others. Though I’m in a large group practice of over 100 primary care physicians we have no clear and formal mechanisms for asking and receiving advice from each other on individual patients. In addition, despite the fact that many of the day-to-day challenges of primary care center around not the medical but rather the socioeconomic determinants of health, I do not have access to dedicated social work and case management services.

At the conference we each received a roster of all the patients the group was actively managing. Each line of the roster included the patient’s name, date of birth, type of leukemia, and treatment plan – nothing surprising. But in addition, it included the name of any clinical trial or research protocol the patient was on. Flipping through the roster, I was stunned to see that virtually every patient was enrolled in a research study of one sort or another. Those who were not in a study of a new experimental chemotherapy or drug (Phase I or Phase II trial) were instead on a study to collect and track patient responses to an established leukemia treatment. General medicine is no less cutting edge than leukemia; many of our treatments have no good data supporting their use and new drugs come out each year. And yet, to my knowledge, I don’t have a single patient in my practice on a research protocol. Worse still, we don’t even analyze our own data. If you asked me what the average HbA1c is for my patients with diabetes, I couldn’t tell you. In comparison, the oncologists at my hospital can report their institutional survival rates for specific types of leukemia by age of diagnosis, gender, and ethnicity.

This dedication to building evidence was matched by a commitment to use the available evidence. At times it almost seemed as if they were speaking another language. Sentences often were punctuated by phrases such as “per the CALBG 10580 protocol” and frequently, recommendations were accompanied by specific citations from the oncology literature. In primary care, most of our recommendations are based on experience or habit; seldomly we may refer to a consensus guideline. It’s no wonder then that studies shows it takes 7-10 years after a new guideline or seminal study is released for practice patterns to change. It’s not that such data doesn’t exist — it’s just that often we just aren’t using it.

Perhaps the best evidence in support of the care we provided our leukemia patients came from my most startling observation: nearing the end of my 4-week rotation I have yet to admit a single patient from the emergency room. In general medicine, by contrast, well over 90% of admissions come from the ER. ER admissions are undesirable for a number of reasons. For one, everything in the ER costs more. Though I have never verified this myself, it is rumored that ERs routinely charge $200 for a single dose of aspirin. Furthermore, because ER doctors are trained to address the worst-case scenario and often know little about the patients besides what is written in the medical record, patients often get unnecessary and expensive tests and procedures in the emergency room. Finally, because leukemia is so super-specialized, leukemic patients are also at risk for substandard care from ER physicians who are generalists by nature. How are inconvenient, costly, and potentially suboptimal ER stays avoided in leukemia? At diagnosis and frequently thereafter patients with leukemia are educated about the signs and symptoms of serious complications such as infection. When fever or another acute issue arises, they have a clear care plan. They know who to call and can often reach their primary oncologist directly. Physicians that receive the call triage patients over the phone. If the patient needs to be admitted, she will be told to come into the hospital directly where an inpatient bed will have already been arranged and where the resident on call (e.g., me) will have already been made aware of the oncologist’s concerns and given an initial plan and workup. Patients that need to be seen urgently but necessarily admitted will be scheduled for a same day or next day appointment. Because every doctor in the group knows each patient (thanks to the weekly leukemia conference), even if the patient’s provider does not have a clinic spot available the patient can be seen by another provider.

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So why do my primary care patients not get as good a care as my patients on leukemia? It’s not that primary care doctors are bad and leukemia doctors are good. Clearly it’s not that simple. Reimbursement in oncology is higher than in primary care, and in general oncology has a higher proportion of commercially insured rather than publicly insured patients. This gives oncologists resources primary care physicians can only dream of – outpatient laboratory services, IV infusion suites, advanced practice nurses, and dedicated case managers. Oncology also receives greater NIH funding, which supports research of new and existing treatments, and funding from philanthropic institutions and charity (think “Live Strong” and breast cancer awareness). It is also a more narrowly scoped field that requires fellowship training, compared to primary care which spans three different specialities (internal medicine, pediatrics, and family medicine) and includes general and subspecialty trainees. But some of it is cultural as well. When I asked one of my leukemia attendings to explain why there were so few ER admissions, his answer was that leukemia specialists viewed inpatient and outpatient care as part of the same continuum of care and took responsibility for patients over the full cycle of care. Comparatively, in general medicine, outpatient and inpatient care are treated quite separately, a reality that has been formalized by the growing hospitalist movement, in which patients admitted to the hospital are taken care of by a group of physicians wholly separate from their outpatient providers.

As primary care doctors, we often argue that we need more resources, better compensation, and greater reimbursement. I agree on all fronts, and in fact many of my observations above only support this notion. But I think even with the resources at hand there is much we can improve upon. We must become more scientific in our methods, more integrated in our care, and more patient-centric in our approach. We need not wait for change in Washington to get started. We can begin by taking a closer look at our peers and learning from their successes, starting (at least at my institution) with leukemia. This will provide useful answers to the important question of why the care of oncology patients seems to be better than that of general medicine patients. As I leave the world of oncology and return to general medicine, I can’t help but ask myself another question: what would happen if my primary care patients benefited from the same systems of care as my patients in oncology? How much better off would they be? I’m not sure of the answer, but given what I observed this past month, I would love to find out.

- Shantanu Nundy, M.D.

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