BIOMAB: Research Day Antwerp - 24 Oct 2014: Beste Hierbij wensen wij u uit te nodigen op de jaarlijkse onderzoeksdag van de Faculteit Farmaceutische, Biomedische en Diergene...
Friday, December 5, 2014
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The AFP Community Blog: Right-sizing care of patients with serious illness...: - Kenny Lin, MD, MPH Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Va...
Nurturing the next generation of diverse family physicians
Since joining my current practice two years ago, I've noticed that I
care for a disproportionate number of immigrants of Chinese and other
Asian descent compared to my colleagues. Although both of my parents
were born in Taiwan, I don't speak Mandarin or have special expertise on
medical conditions common in Asian Americans. Nonetheless, Asian
patients seem more comfortable with me anyway. Similarly, U.S. health
workforce analyses show that underrepresented minority physicians
(Black, Latino, and Native American) are more likely to provide primary care to medically underserved populations.
A recent Robert Graham Center Policy One-Pager
examined the racial diversity of family medicine resident physicians
from 1990 through 2012. It compared the proportion of residents of a
particular race with the proportion of the U.S. population of the same
race. The White and Native American resident to population ratio was
close to 1:1, but Blacks and Latinos were present in family medicine
residency programs at only 50 to 75 percent of their proportions in the
population. (Asian residents have always been overrepresented compared
to the population, with a current ratio of 5.1 to 1.) The good news is
that family physicians are diversifying; the bad news is that Black and
Latino physicians still have a long way to go to "catch up" to their
numbers in the population. This means that many Blacks and Latinos will
receive primary care from physicians of different races, which isn't
automatically a bad thing. But it begs the question of why this
situation exists in the first place...
Too many Black and Latino Americans grow up in desperately poor and
crime-ridden neighborhoods with substandard public schools, and for
decades resources have been poured into programs designed to give these
students opportunities for educational success, from Head Start to Fairfax, Virginia's Young Scholars. It's still a rough and treacherous road, as Ron Suskind illustrated in the bestseller A Hope in the Unseen,
about Cedric Jennings, an African American from Washington, DC who
overcame a heartbreaking upbringing (his father was repeatedly
incarcerated for dealing drugs and he and his mother were evicted from
multiple homes for falling behind on rent payments) and dysfunctional
schools to be admitted to Brown University. But if communities can give
these kids enough K-12 support to get them accepted to four-year
colleges, then a good number of them should go on to become doctors,
right?
It's not that simple. In the New York Times Magazine article "Who Gets to Graduate?,"
Paul Tough delved deeply into the problem of college dropouts at the
University of Texas at Austin, a respected public university that offers
automatic admission to any Texas resident who graduates in the top 7
percent of his or her high school class. He followed Vanessa Brewer, an
African American woman raised in a single-parent home who aspired to
become a nurse anesthetist. Vanessa experienced a crisis of confidence
after failing her first statistics test, and wondered: "Am I supposed to
be here? Am I good enough?" Wrote Tough:
There are thousands of students like Vanessa at the University of
Texas, and millions like her throughout the country — high-achieving
students from low-income families who want desperately to earn a
four-year degree but who run into trouble along the way. Many are
derailed before they ever set foot on a campus, tripped up by
complicated financial-aid forms or held back by the powerful tug of
family obligations. ... Many are overwhelmed by expenses or take on too
many loans. And some do what Vanessa was on the verge of doing: They get
to a good college and encounter what should be a minor obstacle, and
they freak out. They don’t want to ask for help, or they don’t know how.
Things spiral, and before they know it, they’re back at home,
resentful, demoralized and in debt.
The bottom line on
national statistics on college graduation rates is that "rich kids
graduate; poor and working-class kids don't." And surprisingly,
graduation rates have little relationship to natural ability and much
more to do with confidence, rooted in one's socioeconomic background.
care for a disproportionate number of immigrants of Chinese and other
Asian descent compared to my colleagues. Although both of my parents
were born in Taiwan, I don't speak Mandarin or have special expertise on
medical conditions common in Asian Americans. Nonetheless, Asian
patients seem more comfortable with me anyway. Similarly, U.S. health
workforce analyses show that underrepresented minority physicians
(Black, Latino, and Native American) are more likely to provide primary care to medically underserved populations.
A recent Robert Graham Center Policy One-Pager
examined the racial diversity of family medicine resident physicians
from 1990 through 2012. It compared the proportion of residents of a
particular race with the proportion of the U.S. population of the same
race. The White and Native American resident to population ratio was
close to 1:1, but Blacks and Latinos were present in family medicine
residency programs at only 50 to 75 percent of their proportions in the
population. (Asian residents have always been overrepresented compared
to the population, with a current ratio of 5.1 to 1.) The good news is
that family physicians are diversifying; the bad news is that Black and
Latino physicians still have a long way to go to "catch up" to their
numbers in the population. This means that many Blacks and Latinos will
receive primary care from physicians of different races, which isn't
automatically a bad thing. But it begs the question of why this
situation exists in the first place...
Too many Black and Latino Americans grow up in desperately poor and
crime-ridden neighborhoods with substandard public schools, and for
decades resources have been poured into programs designed to give these
students opportunities for educational success, from Head Start to Fairfax, Virginia's Young Scholars. It's still a rough and treacherous road, as Ron Suskind illustrated in the bestseller A Hope in the Unseen,
about Cedric Jennings, an African American from Washington, DC who
overcame a heartbreaking upbringing (his father was repeatedly
incarcerated for dealing drugs and he and his mother were evicted from
multiple homes for falling behind on rent payments) and dysfunctional
schools to be admitted to Brown University. But if communities can give
these kids enough K-12 support to get them accepted to four-year
colleges, then a good number of them should go on to become doctors,
right?
It's not that simple. In the New York Times Magazine article "Who Gets to Graduate?,"
Paul Tough delved deeply into the problem of college dropouts at the
University of Texas at Austin, a respected public university that offers
automatic admission to any Texas resident who graduates in the top 7
percent of his or her high school class. He followed Vanessa Brewer, an
African American woman raised in a single-parent home who aspired to
become a nurse anesthetist. Vanessa experienced a crisis of confidence
after failing her first statistics test, and wondered: "Am I supposed to
be here? Am I good enough?" Wrote Tough:
There are thousands of students like Vanessa at the University of
Texas, and millions like her throughout the country — high-achieving
students from low-income families who want desperately to earn a
four-year degree but who run into trouble along the way. Many are
derailed before they ever set foot on a campus, tripped up by
complicated financial-aid forms or held back by the powerful tug of
family obligations. ... Many are overwhelmed by expenses or take on too
many loans. And some do what Vanessa was on the verge of doing: They get
to a good college and encounter what should be a minor obstacle, and
they freak out. They don’t want to ask for help, or they don’t know how.
Things spiral, and before they know it, they’re back at home,
resentful, demoralized and in debt.
The bottom line on
national statistics on college graduation rates is that "rich kids
graduate; poor and working-class kids don't." And surprisingly,
graduation rates have little relationship to natural ability and much
more to do with confidence, rooted in one's socioeconomic background.
A case in point: I failed my first anatomy exam in medical school. It
felt terrible to see my score near the bottom of the class, but as the
son of a pharmacist and a computer scientist with two Master's degrees,
and the grandson of a neurologist and related to a long line of doctors,
I pulled myself together and eventually earned a passing grade. Had
this sort of setback happened to a student who was the first in his
family to finish college, it could easily have led to that student
leaving medical school entirely.
felt terrible to see my score near the bottom of the class, but as the
son of a pharmacist and a computer scientist with two Master's degrees,
and the grandson of a neurologist and related to a long line of doctors,
I pulled myself together and eventually earned a passing grade. Had
this sort of setback happened to a student who was the first in his
family to finish college, it could easily have led to that student
leaving medical school entirely.
A U.T. program called the University Leadership Network (ULN) not only
confirmed that a lack of confidence related to humble upbringing puts
students at the highest risk of dropping out, but successfully tested an
brief online intervention that measurably improved their odds of
completing at least 12 credits during their first semester and staying
on track to graduate in four years. Tough summarized ULN's
straightforward strategy: "Select the students who are least likely to
do well, but in all your communications with them, convey the idea that
you have selected them for this special program not because you fear
they will fail, but because you are confident they can succeed." The
payoff for replicating this program at universities across the nation,
Tough suggested, could be immense:
Beyond the economic
opportunities for the students themselves, there is the broader cost of
letting so many promising students drop out, of losing so much valuable
human capital. ... Most well-off students now do very well in college,
and most middle- and low-income students struggle to complete a degree.
... These two trends are clearly intertwined. And it is hard to imagine
that the nation can regain its global competitiveness, or improve its
level of economic mobility, without reversing them. ... A big part of
the solution lies at colleges like the University of Texas at Austin,
selective but not superelite, that are able to take large numbers
of highly motivated working-class teenagers and give them the tools
they need to become successful professionals. The U.T. experiment
reminds us that that process isn’t easy; it never has been. But it also
reminds us that it is possible.
confirmed that a lack of confidence related to humble upbringing puts
students at the highest risk of dropping out, but successfully tested an
brief online intervention that measurably improved their odds of
completing at least 12 credits during their first semester and staying
on track to graduate in four years. Tough summarized ULN's
straightforward strategy: "Select the students who are least likely to
do well, but in all your communications with them, convey the idea that
you have selected them for this special program not because you fear
they will fail, but because you are confident they can succeed." The
payoff for replicating this program at universities across the nation,
Tough suggested, could be immense:
Beyond the economic
opportunities for the students themselves, there is the broader cost of
letting so many promising students drop out, of losing so much valuable
human capital. ... Most well-off students now do very well in college,
and most middle- and low-income students struggle to complete a degree.
... These two trends are clearly intertwined. And it is hard to imagine
that the nation can regain its global competitiveness, or improve its
level of economic mobility, without reversing them. ... A big part of
the solution lies at colleges like the University of Texas at Austin,
selective but not superelite, that are able to take large numbers
of highly motivated working-class teenagers and give them the tools
they need to become successful professionals. The U.T. experiment
reminds us that that process isn’t easy; it never has been. But it also
reminds us that it is possible.
Becoming a family physician isn't easy. But America's need for the next
generation of diverse family physicians has never been greater, and
Tough's article has convinced me that nurturing them is possible.
generation of diverse family physicians has never been greater, and
Tough's article has convinced me that nurturing them is possible.
Know the problem of pain
My patients lie to me every day. Some tell me that they have been taking
their medications regularly when they haven't. Some say that they have
been eating a healthy diet and exercising for at least 30 minutes every
day and don't know where the extra pounds are coming from. Some lie that
they are using condoms every time they have sex, that they have quit
smoking, and if they drink alcohol at all, it's only a single glass of
wine with dinner. They bend the truth for many reasons: because they
want to please their doctor, because they don't like to admit lapses of
willpower, or because they are embarrassed to tell me that they can't
afford to pay for their medications. I forgive them; it's part of my job
to understand that patients (and health professionals) are only human.
The only lies that I find hard to forgive are the lies about pain.
Like many doctors, I have complicated feelings about prescribing for
chronic pain. On one hand, I recognize that relieving headaches,
backaches, arthritis and nerve pain has been a core responsibility of
the medical profession for ages. On the other hand, deaths and emergency
room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years,
and I have inherited many patients with narcotic addictions that
resulted from a prior physician's well-intentioned generosity with his
prescription pad.
Even worse, I've had patients I trusted turn out to be junkies in need
of a fix. An earnest, well-dressed young man once came to my office
complaining of a common chronic condition that, he said, had not been
relieved by high doses of over-the-counter painkillers. He convinced me
to to prescribe him narcotic pills, and didn't bat an eye when I asked
him to sign a pain contract
that required him to return every month for refills and only receive
prescriptions from me in person. For the better part of a year, he never
missed an appointment, and seemed genuinely receptive to unrelated
preventive care that I recommended based on his age and risk factors.
His deceit was exposed only after he stumbled, intoxicated, into an
acute care facility staffed by a doctor who knew me and requested an
early refill of a prescription for a different brand of painkillers
prescribed by a third doctor for another imaginary condition. My
colleague told him the gig was up, and I've never seen him again.
I believe that drug addiction is a disease.
So why do I find this patient's lies (and those from others like him)
so hard to forgive? Because they have consequences for people who are
truly in pain. For patients' convenience, I transmit virtually all
prescriptions electronically to the pharmacy, but I'm not allowed to do
this with "controlled substances" such as painkillers. Wary of
encouraging drug abuse, some insurers impose arbitrary limits on the
number of pills a patient may be prescribed in one month, which I can
only override by spending hours on the phone or not at all. One chain
pharmacy recently started demanding signed copies of chart notes that
included the pain-causing diagnosis before they would dispense
painkillers (a practice that I believe to be an illegal invasion of
privacy, but they didn't budge an inch when I told them so). And worst
of all, doctors like me who have been burned before are that much more
likely to view our patients with suspicion.
In the July issue of Health Affairs, Janice Schuster described a health odyssey
that began with a seemingly minor surgical procedure and ended with her
becoming "one of the estimated 100 million American adults who live
with chronic pain" - in this case neuropathic pain, or pain from nerve
damage that in my experience can be the most difficult type to treat.
She wrote about how health system restrictions designed to discourage
abuse created obstacles to her obtaining adequate pain relief, and about
a lack of compassion from her primary care physician (who "dismissed my
symptoms") and her surgeon (who "said again and again that he had not
heard of a patient experiencing such pain"). As the author of a popular
self-help book for persons facing serious illness, Schuster understood
better than most the public health crisis posed by prescription
painkillers, but that understanding offered little consolation as she
navigated "the maze of pain management" that has evolved to deal with
it:
Pain patients like me often feel trapped between the clinical
need to treat and manage pain and the social imperative to restrict
access to such drugs and promote public safety. ... When I am not
overwhelmed by pain, or depressed by it, I am furious at the attitudes I
encounter, especially among physicians and pharmacists. It has been
stigmatizing and humiliating. ... Surely, we can find better ways to
ease the suffering and devise treatments and strategies that do more
good than harm and that do not shame and stigmatize those who suffer.
A few of my colleagues have become so disillusioned with the dilemmas of
pain management that they have sworn off prescribing narcotic
painkillers entirely. As often as I've been tempted to take that path, I
won't abandon patients in pain, for whom the services of caring and
competent family physicians are needed now more than ever.
their medications regularly when they haven't. Some say that they have
been eating a healthy diet and exercising for at least 30 minutes every
day and don't know where the extra pounds are coming from. Some lie that
they are using condoms every time they have sex, that they have quit
smoking, and if they drink alcohol at all, it's only a single glass of
wine with dinner. They bend the truth for many reasons: because they
want to please their doctor, because they don't like to admit lapses of
willpower, or because they are embarrassed to tell me that they can't
afford to pay for their medications. I forgive them; it's part of my job
to understand that patients (and health professionals) are only human.
The only lies that I find hard to forgive are the lies about pain.
Like many doctors, I have complicated feelings about prescribing for
chronic pain. On one hand, I recognize that relieving headaches,
backaches, arthritis and nerve pain has been a core responsibility of
the medical profession for ages. On the other hand, deaths and emergency
room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years,
and I have inherited many patients with narcotic addictions that
resulted from a prior physician's well-intentioned generosity with his
prescription pad.
Even worse, I've had patients I trusted turn out to be junkies in need
of a fix. An earnest, well-dressed young man once came to my office
complaining of a common chronic condition that, he said, had not been
relieved by high doses of over-the-counter painkillers. He convinced me
to to prescribe him narcotic pills, and didn't bat an eye when I asked
him to sign a pain contract
that required him to return every month for refills and only receive
prescriptions from me in person. For the better part of a year, he never
missed an appointment, and seemed genuinely receptive to unrelated
preventive care that I recommended based on his age and risk factors.
His deceit was exposed only after he stumbled, intoxicated, into an
acute care facility staffed by a doctor who knew me and requested an
early refill of a prescription for a different brand of painkillers
prescribed by a third doctor for another imaginary condition. My
colleague told him the gig was up, and I've never seen him again.
I believe that drug addiction is a disease.
So why do I find this patient's lies (and those from others like him)
so hard to forgive? Because they have consequences for people who are
truly in pain. For patients' convenience, I transmit virtually all
prescriptions electronically to the pharmacy, but I'm not allowed to do
this with "controlled substances" such as painkillers. Wary of
encouraging drug abuse, some insurers impose arbitrary limits on the
number of pills a patient may be prescribed in one month, which I can
only override by spending hours on the phone or not at all. One chain
pharmacy recently started demanding signed copies of chart notes that
included the pain-causing diagnosis before they would dispense
painkillers (a practice that I believe to be an illegal invasion of
privacy, but they didn't budge an inch when I told them so). And worst
of all, doctors like me who have been burned before are that much more
likely to view our patients with suspicion.
In the July issue of Health Affairs, Janice Schuster described a health odyssey
that began with a seemingly minor surgical procedure and ended with her
becoming "one of the estimated 100 million American adults who live
with chronic pain" - in this case neuropathic pain, or pain from nerve
damage that in my experience can be the most difficult type to treat.
She wrote about how health system restrictions designed to discourage
abuse created obstacles to her obtaining adequate pain relief, and about
a lack of compassion from her primary care physician (who "dismissed my
symptoms") and her surgeon (who "said again and again that he had not
heard of a patient experiencing such pain"). As the author of a popular
self-help book for persons facing serious illness, Schuster understood
better than most the public health crisis posed by prescription
painkillers, but that understanding offered little consolation as she
navigated "the maze of pain management" that has evolved to deal with
it:
Pain patients like me often feel trapped between the clinical
need to treat and manage pain and the social imperative to restrict
access to such drugs and promote public safety. ... When I am not
overwhelmed by pain, or depressed by it, I am furious at the attitudes I
encounter, especially among physicians and pharmacists. It has been
stigmatizing and humiliating. ... Surely, we can find better ways to
ease the suffering and devise treatments and strategies that do more
good than harm and that do not shame and stigmatize those who suffer.
A few of my colleagues have become so disillusioned with the dilemmas of
pain management that they have sworn off prescribing narcotic
painkillers entirely. As often as I've been tempted to take that path, I
won't abandon patients in pain, for whom the services of caring and
competent family physicians are needed now more than ever.
Posts
