One more thing: The increasing number of recommendations on prevention

Physicians face an ever-growing list of preventive health screening questions to ask. These questions add to medicine's time pressures, but do they bring value to the exam room?

By Kathleen Phalen Tomaselli amednews correspondent — Posted Jan. 23, 2006

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It's the Wednesday after Hurricane Katrina in New Orleans. The sick and injured continue to flow in and out of a 10-bed critical care tent, and the task of treating them is daunting. Thirty-three patients an hour for 12 hours.

"In a 12-hour shift we saw 400 patients. We treated, stabilized and transferred," says Maurice A. Ramirez, DO, a Kissimmee, Fla., emergency physician who also works for the Dept. of Homeland Security during medical emergencies.

It was a level of efficiency very different from the norm at the rural 22-bed Florida emergency department where Dr. Ramirez regularly works. "My first night back, we barely squeaked through 85 patients," he said. "And everyone thought that was a good night."

The reason why there's such a difference? Medical care during disasters such as Katrina is immune from the pressure of treatment guidelines and prevention screenings that slow traffic through exam rooms around the nation. Whether a rural ED in Florida or a private practice in Ohio, this exploding cache of prevention strategies and lifestyle questions swells already packed schedules and demands on time -- even for physicians who firmly believe in the concept.

"There are so many preventive services possible that physicians often look to the task force recommendations to help prioritize and decide what's important for patients," says Ned Calonge, MD, MPH, chair of the U.S. Preventive Services Task Force and chief medical officer at the Colorado Dept. of Public Health and Environment in Denver.

"On the other hand, some people say, if you really provided all our recommended A [strongly recommend] and B [recommend] list screenings, you would spend an enormous amount of time and they ask, 'How do we put this into daily practice?' "

From the recently added recommendation for abdominal aortic aneurysm screening of men ages 65 to 75 who have ever smoked and the strongly recommended syphilis screening for all at risk, to the long-time recommendation that physicians ask about possible lead exposure in children, about 20 screenings made the task force priority list, and nearly 50 top the American Academy of Family Physicians' recommendations.

"Whether doctors like it or not, screening is here to stay," says Craig Hildreth, MD, a medical oncologist at St. Louis Cancer Care. "In the world of cancer, we have the time, and it works."

With each new recommendation, the list of possible questions to ask patients grows: Are you feeling down? Have you recently traveled to another country? Do you have more than one sexual partner? Does your child live in or regularly visit a house built before 1950? How do you deal with anger? Any trouble sleeping? Do you wear a seat belt? Do you drink alcohol? Does your vision make it difficult for you to recognize your pills or read medication labels? Do you have a gun at home?

"We add a number of recommendations every year, and the technology of health care is to add services. ... Prioritization is essential for the task force to keep on track," Dr. Calonge says. "If we do a little prevention at every visit, if we build it into the basic flow of care delivery, it gives us the ability to wade through this."

The burden is not so much from the good screening recommendations, such as Pap tests, mammograms or colon cancer screening, says Judy Chamberlain, MD, a family physician at Bowdoin Medical Group in Brunswick, Maine. " The frustration comes with the amount of time it takes to explain things, like the fact that there is no effective screening test for ovarian cancer -- no blood tests or ultrasounds," she says. "The same goes for the growing PSA controversy. It takes longer to explain to a man that he may get a result that is meaningless, may lead to more invasive testing and may not lead to a better outcome than it does just to order the test and hope for the best."

In Dr. Chamberlain's group, reminders of important screenings are built into the electronic health record, and doctors are sent reminders of patients with chronic illnesses such as diabetes who may be overdue for regular office and lab follow-up. "This year we will also be creating report cards for each doctor, letting each one know how he or she measures up on recommended care such as Paps and mammograms, immunizations for children and care of people with diabetes and coronary artery disease," she says. "Finally, since each patient's electronic record has a health maintenance flow sheet, we are trying to make [it] part of every visit."

Good intentions not always enough

Still, even with the best intentions, keeping pace is often a challenge. According to a study of 18 Midwestern family medicine offices in the September/October 2005, Annals of Family Medicine, multiple demands and acute-care issues often crowded out prevention efforts, even when clinicians knew about the USPSTF guidelines and were able to recall the recommendations with accuracy. "Many doctors use templates and check [things] off," says Dr. Hildreth, who sees the physicians' notes of patients referred to him. "But some primary care docs aren't screening anybody."

In the study, two small rural practices fared best, screening nearly 90% of patients. Physician assistants handled most acute-care visits, leaving time for physicians to attend to chronic conditions and health care maintenance. One large urban practice, inundated with acute-care issues, screened fewer than 50% of patients. And while flow sheets and reminders were in charts, they were rarely used.

But, the demands of today are not new, says Larry Fields, MD, president of the American Academy of Family Physicians, who is in private practice in Ashland, Ky.

"From the beginning, family doctors have been doing prevention," he says. "And as family physicians we see the rise in [screenings and guidelines] as an opportunity, not a challenge. This makes it much easier to do today. Prevention is high on our list of things to do, and screening is not an added burden, it's an added opportunity."

Dr. Fields points to screening PDA programs offered by the AAFP and the Agency for Healthcare Research and Quality. "Actually, as family doctors, we are masters of the science of complexity and juggling many things. These tools give us a way to approach prevention in an organized fashion. It is very helpful rather than relying on the physician's memory. A patient may have four problems in a visit, so an organized reminder is very crucial."

Medical historian Susan Reverby, PhD, professor of Women's Studies at Wellesley (Mass.) College, sees the rise in health screenings as a definite trend that in some ways stems from the current shape of health care. "Really, if you have 15 minutes, what will you learn talking to a patient? There's pressure on the doctor to do something," she says.

And there are certainly upsides, she says. "I'm not a historian who automatically thinks the good old days were better." Pointing to past discrimination and treatment judgments based on patient appearance or socioeconomic status, this approach may be fairer, she says. "If you're a white middle-class girl, you might not get tested for Chlamydia because you wouldn't sleep around."

It's a trade-off. "If you go back to more personalized care, there is the problem of deciding by looks or status," she says. Statistics and screening may be better.

In response, Dr. Calonge hopes that all care is delivered fairly. "I would hope preventive and sick care are both fair, but studies have shown that health disparities exist even in preventive services, and doctors issue different screenings because of ethnicity or background. We work hard in preventive health to stress that we need to provide care to everyone regardless of ethnicity."

It takes a lifetime

Dr. Chamberlain keeps a card in her desk sent by a breast cancer survivor a couple of years ago. It says, "Because you sent me for a mammogram when I only came in for a cold, you saved my life."

"That's what we should strive for at every visit," she says. "We must become the health promotion, disease prevention gurus of medicine. We need to take back the leadership there."


Help patients navigate the system to get age- and sex-appropriate screening tests at recommended intervals, Dr. Chamberlain says. "Our patients, students and residents need to be assured of physicians and teachers who are technologically savvy, promote health, practice evidence-based medicine and who still remember the joy of practicing family medicine."

As Dr. Fields says, it doesn't have to happen in one visit. "That's why I'd like to stress the importance of ... a medical home. We have a lifetime of 15-minute visits."

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No time to manage patients' chronic conditions

Americans receive only about one-half of the applicable services for acute, preventive and chronic disease care partly because of time constraints in primary care, say doctors at Duke University Medical Center's Dept. of Community and Family Medicine in Durham, N.C.

Of particular concern to these researchers is chronic disease care, which, despite national guidelines, appears to fall short. For instance, only about 34% of the 50 million Americans with high blood pressure have readings in the recommended range, and only 37% of patients with diabetes have glycated hemoglobin values below the recommended level.

Still, if doctors were to follow established clinical guidelines for uncontrolled chronic conditions like hyperlipidemia, hypertension, depression, asthma, diabetes, arthritis, anxiety, chronic obstructive pulmonary disease, osteoporosis and coronary artery disease, researchers estimate it would take 10.6 hours per day and exceed the time physicians have annually for patient care by 27%.

Add in acute care -- which, according to a separate study by Case Western Reserve researchers, accounts for 58% of all visits or 4.6 hours per day -- the daily acute and chronic care hours needed would be about 15. And what about preventive care?

"Taken together, the time needed to meet preventive, chronic and acute care requirements vastly exceeds the total time physicians have available for patient care," Duke physicians say. "Our data show that the time requirements of current guidelines are a fundamental obstacle to the delivery of appropriate and recommended chronic disease care."

The Duke study was published in the May/June 2005 issue of the Annals of Family Medicine and is available online (link).

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External links

Case examples of prevention screening for small, medium and large volume practices, Annals of Family Medicine, September/October 2005, in pdf (link)

Guide to Clinical Preventive Services, 2005; recommendations of the U.S. Preventive Services Task Force (link)

American Academy of Family Physicians' recommendations for clinical preventive services, August 2005, in pdf (link)

Agency for Healthcare Research and Quality's Interactive Preventive Services Selector (link)

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