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VOL. 6 • NO. 4
© December 2011
THE CHOICE OF PRIMARY CARE PROVIDER IS NOT EASY, BUT NECESSARY TO MANAGE OVERALL HEALTH CARE
Primary care covers a wide spectrum of ages. Pediatricians treat children from birth to the teens. Geriatricians treat the elderly with multiple complex conditions.
Of all the health care choices, none is as essential as choosing a primary care provider (PCP). Not only is it difficult to find a PCP that is accepting new patients, what to look for in a doctor can be equally daunting. Personal preferences prevail. Gender and age can be a factor. People might have a higher comfort with a doctor of the same sex. Some might prefer a younger doctor more likely to be up-to-date with newer treatments while others may relish the attention of a more experienced doctor. Hospital affiliation, location and access are also important. Even race or ethnicity often plays a role. People are sometimes more comfortable with someone who looks like them. Unfortunately, a perception exists that doctors trained in another country just don’t measure up in terms of quality. Yet, foreign-trained medical doctors are subjected to the same rigorous standards as American-trained doctors. They undergo residency training in American hospitals and take the same national three-part licensing exams and specialty tests. And they’re helping to fill the void of PCPs created in part by the increased demand. A study published in 2010 in Health Affairs concluded that the medical school attended — international or U.S. — did not affect mortality rates for patients hospitalized for congestive heart failure or heart attack. Rather, board certification and the number of years since graduation had the most impact. Board certification is a measure of quality that certifies a physician’s expertise in a medical specialty. Further complicating a choice in PCP is that there’s more than one type. An internist is a doctor of adult medicine, while a pediatrician tends to the needs of children. Geriatricians confine
their care to the elderly. Family practitioners, on the other hand, provide comprehensive medical and surgical care for the individual and family regardless of age. In some organizations the gynecologist is considered the PCP for females. Non-physician providers, such as nurse practitioners and physician assistants, round out the PCP players. For the most part, medical care and the choice of PCP revolve around age, starting with pediatrics and ending with geriatrics. The good news is that people are living longer. According to a recent report from the Massachusetts Department of Public Health, those born in the Commonwealth in 2008 are expected to live an average of 80 years. But the longevity comes with a price. That’s when a geriatrician, a primary care physician for the elderly, steps in. Geriatricians are trained in internal medicine or family practice, but then specialize in the care of the elderly. The age of patients treated by a geriatrician varies from patient to patient, said Dr. Daniel J. Oates, a geriatrician at Boston Medical Center. The typical age is at least 65, but there is no set age at which a person “graduates” from an internist or family practitioner to a geriatrician. More telling is the health status of the person. “I often treat people with geriatric syndromes,” Oates explained. “These are people with multiple problems that require coordination of care.” The list of problems he sees is long — falls, arthritis, pain, cardiovascular disease, poor vision. Special attention is made to functional independence and activities of daily living — concerns not typical in the younger population. People with memory problems are increasing in number and those with depression require coordinated efforts, not only with other providers but with the family as well. Getting medications right takes a bit of work. Those with complex and multiple medical problems take multiple drugs. It’s easy enough to juggle one or two medications, but, according to the Centers for Disease Control and Prevention, the average 75-year-old takes five prescription drugs. One of the most common reasons an elderly person lands in an emergency room are side effects of medication mishaps. Oates does not view working with the elderly as a challenge. “I see it as an opportunity,” he explained. “It allows me to have a major impact PCP, continued to page 4
HONESTY AT HEART OF GOOD MEDICAL PARTNERSHIP Dr. Julien Dedier, a doctor of internal medicine at Boston Medical Center, readily admits that much has changed in medicine over the years, especially among primary care physicians (PCPs). And that’s a good thing, according to Dedier. While PCPs are still busy diagnosing and treating a litany of illnesses, gone are the days when paternalism ruled the medical approach. Health care is now more of a partnership. “I’m part of a team,” he said. “They have to know that I am working on their behalf. My job is to know my patient and my patient’s overall health well enough to establish trust and confidence.” For Dedier, that means being aware of more than just his patients’ height, weight and blood pressure levels. “I need to know the total picture,” he explained. PCPs like Dedier are in high demand these days. According to the 2008 National Ambulatory Medical Care Survey, more than 60 percent of the 956 million physician office visits that year were for primary care. That’s not unusual. Primary care — considered the portal of entry to the health care system — encompasses the greatest number of patients and provides the widest array of services. People flock to their doctors for colds, aches and pains, immunizations, screening tests and medication. Coughs that don’t abate, rashes that persevere, even broken bones all wind up in a doctor’s office or clinic.
PCPs have their hands full. They diagnose everything from high blood pressure to diabetes to cardiovascular diseases and make referrals to other providers. In a sense, PCPs are CEOs, having the overall responsibility of managing their patients’ total care. But the biggest job, at least according to Dedier, is to listen and pay attention. The PCP needs to know, for instance, why a person shuns flu shots or refuses to take medication for an illness when he or she feels fine. “I have to understand where my patient is coming from and take each concern seriously,” he said. Dedier demands one thing in return from his patients. “Honesty,” he said. “I want patients to feel comfortable telling me what they have or haven’t done. My role is to help them improve their health.” But he has to know the truth. “If I prescribe a medicine and a patient swears up and down that they have taken it when they have not, it causes a problem,” he explained. The patient’s response could cause him to alter the dose or try another medication when either move is not necessary or worse, could be harmful. Though PCPs are essential to the health care system they are in diminishing supply. The 2011 Physician Workforce Study by the Massachusetts Medical Society determined that the shortage of family practitioners and internists in the Commonwealth is severe and critical. The waiting times for an
Dr. Julien J. Dedier, an internist at Boston Medical Center, says that teamwork and trust are essential for a successful doctor/patient relationship. (Photo courtesy of Boston Medical Center)
appointment range from 36 to 48 days. And it’s only expected to get worse. Medical students are not choosing primary care as their area of clinical interest, as noted in a recent study published in the Archives of Dedier, continued to page 4
YOUR PRIMARY CARE PROVIDER — THE CEO OF YOUR HEALTH CARE preventive health measures, such as vaccines that prevent illness, appropriate tests and exams and advice on self-care and healthy habits that you can apply at home. Long-term health problems, such as heart disease, obesity and depression are treated, too. So are acute illnesses and injuries like pneumonia or a sprained ankle. Referrals to specialists and community services are made as necessary. Close teamwork among primary care providers is essential. Team members may use electronic health records to store information on medical visits, tests, procedures and treatments. That way, they can share key health information with one another or with any specialist called upon to consult. This helps prevent duplication of tests and procedures, which saves money for you and the whole health care system. Just as important, it keeps you from being exposed to unnecessary risks.
WAYS TO HELP YOU SAVE MONEY Often, your primary care provider can suggest ways to help you cut costs while getting high-quality health care. Try asking a few simple questions:
Can you prescribe a generic drug?
If you’re making a list and checking it twice this holiday season, why not jot down a few ways to improve your health? Let’s see — there’s quitting tobacco, exercising regularly, eating well, losing extra pounds, getting enough sleep, defusing stress and taking medicine as prescribed. If this looks a tad too ambitious, don’t despair. Your primary care provider can help you select one healthy goal and recommend steps that will set you on a path toward achieving it. WHO ARE YOUR PRIMARY CARE PROVIDERS? Primary care providers (PCPs) are medical professionals trained to handle common injuries and health problems. They act as a hub for all of your medical information, too. That’s true whether you come to their offices, get referred to a specialist, go elsewhere for tests or take an unexpected trip to the hospital. By providing this oversight, a good PCP helps ensure that your health care isn’t fragmented.
Often, PCPs work in a team. Heading it up might be an internal medicine doctor (internist) for adults, a pediatrician for children, a geriatrician for older people or a family practitioner who can help children and adults. Also, you may find a registered nurse or nurse practitioner with training in a particular area, such as pediatrics or internal medicine. Social workers, pharmacists and other clinicians may be team members, too. The best primary care strives to focus on the whole person, rather than responding to health needs illness by illness. Central to this philosophy are wellness care and
When your doctor prescribes medicine, ask about generic options. Generic drugs contain active ingredients that are equivalent to brand name drugs and usually equally effective at far less cost.
How will this test or procedure help me? Has it been done before? If so, is it necessary to repeat it now? It’s true that certain tests and procedures are recommended at regular intervals to see if treatment is needed or check that your current treatment is working well — for example, tests to check blood sugar or cholesterol and triglycerides. Avoiding unnecessary tests or procedures saves you money and exposure to risks, however.
Is there a high-quality, lower-cost site where I can have this test or procedure? If you need imaging tests, such as an X-ray or MRI, a freestanding lab facility may charge less than a hospital. Ditto for a community hospital versus a specialty hospital. Want more suggestions? Check your health insurance policy or call member services to learn where else you might cut costs. For example, Blue Cross Blue Shield of Massachusetts offers a plan with a hospital choice cost-sharing feature. Each hospital listed has met quality benchmarks. Members pay less or more depending on which hospital they choose for certain planned procedures and tests. Interested members can get a list of lower-cost and higher-cost hospitals in their locale by calling 888-636-4808 or checking online at www.bluecrossma. com/plan-education/pdf/hospital-list.pdf.
WHAT IS A MEDICAL HOME?
Primary care, first. When it comes to your health, your primary care provider is an important ally. He or she gives you annual checkups, refers you to specialists, and is your go-to health expert if you’re sick or injured. We encourage all our members to designate a primary care provider. If you’re a Blue Cross Blue Shield of Massachusetts member, you can find a primary care provider and learn more about the care you need at www.bluecrossma.com/membercentral.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
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A fresh concept in health care is the patientcentered medical home (PCMH or “medical home”). It builds on the existing strengths of primary care practice. Contrary to what you might picture, a medical home is not the office you visit to see a doctor. Much as described above, it’s a comprehensive team approach that can be shaped to address most of your health issues. Care differs depending on your health needs, values, culture and preferences — even your family situation may come into play. Electronic medical records and extended hours of availability are the norm, speeding access to care and advice. Although this sounds like costly concierge medicine, it’s not. Nor does it use gatekeepers to restrict access to specialists as managed care often does. Demonstration projects of medical homes are being studied in multiple sites around the country. Some early results — fewer hospitalizations and modest improvements in care, according to recent research — are promising. While you await further developments, you can do much to improve your own health. That’s right: work toward quitting tobacco, exercising regularly, eating well, losing extra pounds, getting enough sleep, defusing stress and taking medicine as prescribed. Your PCP will be happy to help.
Questions & Answers 1. Since a person’s medical information is in the medical record, is it necessary to keep a health journal to keep track of one’s health history? It is a wonderful idea for people to have a health journal. It is important for people to be empowered and in charge of their own health. While Alysia L. Green, M.D. the electronic medical Family Medicine record is great for both Boston Medical Center patients and physicians, it is often not accessible to patients if, for example, they see a physician out of their hospital system or they are seen out of state for an emergency. Having a health journal that is a log of their medical history, surgical history and medications can be very helpful for both patient and doctor. 2. Should a person discuss personal matters with the doctor, such as divorce and stress? Yes. Personal matters can often affect both mental and physical health. Divorce, problems with their children and difficulty at work can all cause stress, which can negatively influence a person’s health. Primary care physicians are in a unique position to care for the whole patient and anything that impacts them. Therefore, patients should discuss everything that has a bearing on their daily life because of the affect it can have on their general health. 3. If a person has pain in the knee, for example, is it best to go directly to an orthopedic surgeon rather than the primary care physician (PCP)? No. They should not go directly to an orthopedic surgeon. In most instances, the cause and treatment of knee pain will not require surgical intervention. If the history and physical examination create concerns, then referral to an orthopedic surgeon would be appropriate, but the PCP should be the first person to evaluate any condition prior to referral to a specialist. Furthermore, patients are often not aware of the type of specialist best skilled to treat their particular complaint.
A CLOSER LOOK To check a particular doctor’s background, contact the Massachusetts Board of Registration in Medicine at (800) 377-0550 or visit http://profiles. massmedboard.org/MA-Physician-Profile-Find-Doctor.asp.
THE PROFILE WILL GIVE: • Date of licensure in Massachusetts • Education and training (residency) • Medical specialties • Board certification(s) • Professional information Address and telephone number Insurance plans accepted Hospital affiliations Availability of translation services • Awards, research and publications • Malpractice claims paid, hospital discipline and criminal convictions in the past 10 years • Disciplinary actions of the Massachusetts Board of Registration in Medicine in the past 10 years
TYPES OF PRIMARY CARE PROVIDERS • INTERNIST — treats adults of all ages • PEDIATRICIAN — treats children from birth to age 18 • FAMILY PRACTITIONER — treats the entire family regardless of age • GERIATRICIAN — treats elderly people with complex and multiple diseases • GYNECOLOGIST — treats females usually of child-bearing age • NURSE PRACTITIONER AND PHYSICIAN ASSISTANT — provide primary care under the supervision of a doctor
4. Should people with a chronic illness, such as diabetes, receive follow-up care from an endocrinologist, a specialist in the treatment of diabetes, rather than a PCP? There are several patients with a chronic illness that can be managed by their PCP. More severe or complicated conditions may require evaluation and management from a specialist. However, in these cases, the PCP remains informed of their treatment plan and encourages follow-up with the patients to ensure continuity of care. 5. Why should patients report to their doctors all the medicine they take, even over-the-counter and herbal drugs? There is a misperception that herbal and other over-the-counter medications do not produce harmful side effects. However, nonprescription drugs can cause interactions with other non-prescription drugs as well as with medications people are currently taking or could be prescribed. 6. How should a person prepare for a visit to the doctor? Whether going for a physical or a general office visit patients should prepare to make the best use of their time. Sometimes patients visit their doctor and have things they want to discuss or ask but forget once in the office. It’s best to write down questions and concerns beforehand and review the list with the doctor. 7. Should a patient request a particular screening test if a PCP does not offer it? If a patient is interested in a screening test that the PCP does not offer, it’s best to discuss it with the doctor. Sometimes the test that the patient wants is not necessary because of the patient’s medical history or age. However, you should know — based on your age, gender, race and family history — the best screening schedule for you and discuss it with your doctor. 8. Is the emergency room a good source of primary care? No. The emergency room should be used only for emergencies. Continuity of care is crucial in health care and a patient’s PCP — not a hospital emergency room — is best able to coordinate that care. Even when seen in the emergency room for a serious illness, follow-up with the PCP is always advised. 9. If a person feels well and is in generally good health, is it necessary to visit the PCP? Yes. Prevention is key, and even for those patients who are generally healthy, it is advisable to check in with your doctor once a year for routine health care maintenance. Many illnesses are silent and can be detected only through screening.
The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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PCP, continued from page 1
on a person’s quality of life. The focus is more on quality instead of quantity.” One challenge he and other geriatricians deal with regularly is the lack of research on the elderly. Clinical trials typically do not include elderly subjects. “It makes it difficult to know how older people will respond [to treatment],” he said. “We have to look more at personal experience.” But Oates is not complaining. And he has his work cut out for him. The American Geriatric Society (AGS) has determined that the current
model of health care practice. Questions are posed regarding child abuse, bullying, depression and trauma. Is there evidence of an eating problem? Is the child anxious or stressed? What is his or her academic achievement? “All these factors are intricately interwoven,” she said. Her reach extends beyond the doctor’s office. A thorough analysis of a child’s environment can involve the school system and interaction with principles, guidance counselors and teachers. Boynston-Jarrett explained that in order to optimize a child’s health and well being, it is essential to consider and coordinate all the environmental risk and protective factors that may come into play and have an impact. “It’s important to never disregard a parent’s concern,” she said. “I have a snapshot view of the child. The parents live with the child. They speak with authority.” The types of concerns change as the child
PERSONAL HEALTH JOURNAL A personal health journal — a handy tool for both you and your doctor — is simply a collection of information about your health that you gather and manage. The journal should include not only the names and numbers of your doctors, but lifestyle goals as well. Your health information should be accurate, detailed and current. A HEALTH JOURNAL SHOULD INCLUDE: • Illnesses and injuries • Hospitalizations • Surgeries • Diagnostic tests, such as X-rays and scans • Screening tests • Treatments and procedures • Allergies • Immunizations • Medicines, including exact name and dosage • Over-the-counter vitamins and supplements • Family history of diseases Be sure to include dates. For instance, if you are hospitalized, make note of the date admitted and the date of discharge. Be specific. If you have had abdominal surgery, specify the type. You do not need to include minor illnesses, such as coughs and colds. Take your journal to your doctor’s appointments.
Daniel J. Oates, M.D, M.Sc. Geriatrics Medicine Boston Medical Center
For tips on creating a family health history, visit https://familyhistory.hhs.gov/fhh-web/home.action.
number of 7,100 geriatricians is not enough to go around. That’s only one geriatrician to every 2,620 Americans 75 or older. Due to the expected increase in the number of older Americans, the AGS estimates one geriatrician for every 3,798 elderly in 2030. On the other end of the age spectrum are pediatricians with a different set of problems. Their care begins shortly after birth and lasts for at least 18 years. They take care of sniffles and colds, provide immunizations, keep track of developmental milestones, monitor nutrition and escort teens into puberty. Pediatricians are unique in that when they treat a child, the entire family comes in the deal. “It’s about creating a therapeutic alliance,” explained Dr. Renee Boynton-Jarrett, a pediatrician at Boston Medical Center. “There’s a bond with the family.” Pediatrics spreads a much broader swath than just runny noses and shots. Times have changed, requiring a more trauma-informed
Dedier, continued from page 1
Renee D. Boynton-Jarrett, M.D. Pediatrician Boston Medical Center grows. While breastfeeding may be an issue with infants, exercise and healthy eating take its place for older kids, and drug addiction and smoking become issues for adolescents. Obesity is a growing concern among children of all ages. “Obesity before the age of 10 can result in obesity in adults,” she said, “and lead to high blood pressure and diabetes even in the young.” Boynton-Jarrett is clear on her role as a PCP. “I intervene early,” she explained. “Adversities early in life may have an enduring impact on health and development.”
THE RIGHT CHOICE Finding the right primary care physician for you is not always easy and it shouldn’t be taken lightly. It is one of the most important relationships you will ever have. This is the person who will monitor and direct all your care. You need to be sure. There are many factors to consider.
Do you prefer male or female?
Are the office hours convenient?
How easy is it to reach the doctor?
Is the doctor board certified?
Is the office staff helpful and professional?
Where is the office located? What is the doctor’s hospital affiliation?
How are emergencies handled?
Will you be involved in your care?
Does the doctor listen and show concern?
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men with a family history is a disservice,” he said. “Some men want to know and the Internal Medicine. Furthermore, the health care reform bill enacted by President Barack decision for PSA testing should be a decision made by the patient after discussion with his Obama expands coverage to millions of undoctor.” The AUA further affirms that “when insured Americans, making the PCP central interpreted appropriately, the PSA test proto meeting the increased demand and the vides important information in the diagnosis, law’s success. pre-treatment staging or risk assessment and An important function of the PCP is monitoring of prostate cancer patients.” As screening. And that is not always as straight forward as it would seem. Screening guidelines for Wang, he will continue to discuss the test can fluctuate and PCPs — and patients — have with his patients. The task force is recommending to keep pace. The U.S. Preventive Services changes in the guidelines for Pap smears as Task Force (USPSTF) is a group of PCPs well, which screen for cervical cancer. It is charged with examining research and making recommendations of the types and frequency of advocating testing every three years between the ages of 21 and 65 in women who have screening tests to be followed by PCPs. had sex and have a cervix. Prior recomThe group’s decisions are not taken mendations called lightly and can for screening within determine those three years of vaginal tests for which intercourse and insurance plans repeat tests every one will pay. Some of to two years. their decisions are For Dedier, controversial and keeping an open cause uproar and mind should always confusion. be the rule rather than The USPthe exception. Take STF recently alternative medicine, released a new example. The draft recom— Dr. Julien Dedier for 2007 National Center mending against for Health Statistics prostate-specific found that almost 40 percent of adults and antigen (PSA), the blood test used to screen for prostate cancer, stating that there is “mod- 12 percent of children used some form of complementary or alternative medicine, such erate or high certainty that the service has no as acupuncture or herbs. net benefit or that the harms outweigh the Dedier said that he is not opposed to benefits.” The task force thus discourages the different forms of medicine. “I just need use of PSA screening even for men of high to make sure that the patient is not being risk, which include African Americans and harmed,” he explained. If a patient prefers those with a family history of the disease. garlic over medication to bring down choThe group’s position is that many proslesterol, it might be worth a try, according to tate cancers are slow growing and ultimately Dedier, but he is quick to point out that if the not fatal, and that the aggressiveness of the cancer cannot always be accurately predicted. cholesterol is not down in three months’ time it’s best to have another discussion. Consequently, the medical treatment preSensitive topics that a patient prefers not scribed is often excessive. Also, false-positive discussing are not overlooked. Like obesity. results can lead to unnecessary — and often He starts with the BMI, a measure of harmful — medical care. healthy weight based on height. “I present it Dr. David Wang, a urologist at Boston in medical terms,” he said. “Your BMI is one Medical Center, said that he adheres to the standards of the American Urological Associa- that doctors would consider obese and it’s a tion (AUA) and respectfully disagrees with the cause of mortality and morbidity.” That starts the conversation on the USPSTF recommendation. “The PSA is not health impact of weight and measures to take a perfect test,” he acknowledged. “But it’s the to reduce it. best we have. We don’t want to turn the clock More than most, Dedier says he is keenly back 25 years when the majority of men were aware that while he is examining a patient, he diagnosed after the cancer had spread.” too is being carefully examined as well. Wang said that he recognizes that overHe welcomes the scrutiny. “They have treatment of prostate cancer exists. “But to to figure out if I’m the right one,” he said. deny the test to African American men or
“I’m part of a team. My job is to know my patient and my patient’s overall health well enough to establish trust and confidence.”
Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.