UAMS Steps Up its Support of Primary Care by Creating a Service Line (and I have a new Job)

UAMS has initiated a Primary Care Service Line and I have accepted their offer to lead it. It is an exciting time for us and for me personally, after over 25 years in my current job as Executive Associate Dean for Clinical Affairs. Here is a copy of the announcement that went out yesterday: Dear Colleagues: We are pleased to announce that Charles W. Smith, M.D., has accepted our offer to be the Director of the Primary Care Service Line. In addition, he will also serve as the Medical Director of the Service Line. Due to the opening of our new distributed clinics, we are accelerating the startup of the Primary Care Service Line in order to adequately support these clinics. Eventually, all primary care services sponsored and supported by UAMS will be a part of the service line. As founder of the UAMS Center for Primary Care, Dr. Smith has been focusing increasingly on this vital component of our clinical enterprise in the past few years. In his new post, he will oversee planning, development, and implementation of the service line, which includes working with the Chairs of the various primary care oriented departments, recruiting and appointing the administrator of the service line as well as the clinic directors, serving as a member of the Council of Service Line Directors, and numerous other service line duties. In his new role, he will report through the Chief Service Line Officer to Dr. Townsend, the Vice Chancellor for Clinical Programs. Dr. Smith is ideally suited for this new role. He has worked in various roles to promote clinical programs and clinical teaching in the College of Medicine and UAMS for the past 25 years. He joined the faculty as a Professor in the Department of Family and Preventive Medicine and Associate Dean for Clinical Affairs in 1989 and was promoted to Executive Dean in 2007. For a number of years, he served in both Associate Dean role and the UAMS Medical Center Medical Director roles. While he will begin service line duties immediately, he will gradually transition out of his current role as Executive Associate Dean by the end of this calendar year. Among many accomplishments, Dr. Smith established the Physician Relations Office to improve processes for referrals and communication with referring physicians. A key component of the office is the UAMS Associates Program, which coordinates annual visits by staff liaisons to 750 referring physicians in Arkansas to provide information and hear and relay their concerns to campus leadership. Dr. Smith also founded the Diagnostic Clinic for referrals. Dr. Smith’s dedication to providing more effective health care for Arkansans kindled his longtime interest in electronic medical record (EMR) implementation and facilitating the use of web technology. He chaired the implementation committee for the campus’ first EMR system and has remained an active leader in EMR adoption, including the comprehensive EPIC system. Dr. Smith has been a leader in the development of a patient portal, online physician consultation and online call schedules. In 1997 he founded an award-winning, web-based medical information company, eDocAmerica, a UAMS BioVentures-supported startup that provides patients with tools, information and input from medical professionals to help individuals make better decisions about their health and health care. Dr. Smith is a founding Co-Editor in Chief of the Journal of Participatory Medicine, an online, peer-reviewed journal of the Society of Participatory Medicine. He has served as President of the American Board of Family Medicine, Deputy Editor of American Family Physician, and Chair of the Association of American Medical Colleges Group on Faculty Practice. He has published many articles in his field and co-authored a book, the Handbook of Family Practice. Prior to his recruitment to UAMS, Dr. Smith was Dean of the School of Primary Medical Care at the University of Alabama School of Medicine in Huntsville. He received his medical degree from the University of North Carolina in Chapel Hill, where he completed his family practice residency. Please join us in welcoming Charlie to his new post. G. Richard Smith, M.D. Roxane A. Townsend, M.D. Dean, College of Medicine Vice Chancellor for Clinical Programs Executive Vice Chancellor, UAMS CEO, UAMS Medical Center

You Can't be Healthy if you don't Exercise

This morning, one of my colleagues admitted: "Charlie, you know I don't work out".  Even though she seems healthy, I immediately replied: "You know, you can't be healthy, if you aren't involved in a regular exercise program!" 

Do you agree with me that this is true?  Most of my patients and friends do, but many of them claim a variety of reasons for not doing it. 

Perhaps the most common reason I hear for a lack of regular exercise is not having sufficient time.  But my answer to you is that no one has time, they just have to make it.  How can you do this?  By just scheduling your exercise session and dropping everything else to do it.  After all, what is more important than improving and safeguarding your health?  I believe those that do not have enough time to exercise simply aren't putting this high enough on their priority list.  As for me, I found that if I don't get up early and get my workout in before I leave for work, I have a lot of trouble juggling personal and family needs when I get home in the afternoon.  If becoming and staying healthy is truly important to you, it is worth adjusting your daily schedule to ensure 30 min or more of aerobic exercise on at least 5 days of the week.

One of the other very common reasons I hear for not exercising is people telling me that they are too tired.  However, exercise is actually a good treatment for fatigue!  Researchers at the University of Georgia found that persons who exercised for at least 20 minutes at least three times a week for 6 weeks were much less likely to report fatigue than those who didn't exercise.

It's never too late to get started with this program.  If you are currently sedentary, you should start slow and work up to 150 or more minutes per week of aerobic exercise.  Increase your duration and intensity by about 10% per week until you reach your goals.

So, get on board and get healthy!

 

What is a Vacation Anyway?

What is your idea of a vacation? 

Most consider it to be a week or two (or more) of kicking back in the pool or on the beach.  My wife, Connie, and I returned today from a week in our house in Fayetteville, AR.  Our idea of a relaxing week away from the grind of everyday life may strike you a bit differently than the traditional vacation.  We enjoy our own version of a week of fitness "boot camp".  Well, it may not be THAT intense, but it certainly is active.  We wake up early, eat breakfast and walk for 2 1/2 hours, with our Golden Doodle "Dolly" in tow.  This usually includes a cinnamon roll break at the Little Bread Company, one of the coolest little places you have ever seen and, currently, rated the # 1 eating establishment in Fayetteville.  It is essentially a hippie joint where the employees all seem happy and the ambience of the place puts you in a great mood.  On our way back to our house, Dolly terrorizes 3 or 4 squirrels in the center of the U of A campus. 

Before lunch, we load a yoga video for 20 to 30 minutes before replenishing for the afternoon.  These are devoted to biking on our tandem.  Fayetteville, courtesy of the Waltons, is almost finished with a dedicated walking/biking path from Fayetteville to Bella Vista, AR, a distance of about 35 miles. It is called the Razorback Greenway. Since it not yet quite finished, we spent most days doing about a 25 mile loop from Lake Fayetteville to south of town but, one of the days, we drove to Spingdale to take in the northernmost aspect of the Greenway through Bentonville and the Crystal Bridges grounds to Bella Vista, AR and back.

As a side note, we were there during the annual Wal Mart associate/shareholder meetings and the scene is interesting, to say the least.  There are Wal Mart workers from all over the world there, hosted in student dorms and transported around campus by golf carts and buses.  While I was in Sam's buying a TV, one came up and asked me if I needed help (I did).  I asked him a question he couldn't answer and then I realized he was a Wal Mart associate visiting from South Africa.  The event was hosted by Hugh Jackman and featured concerts by Elton John and Jennifer Hudson.  Interesting company, Wal Mart!

About mid week, we decided it was time to take in Crystal Bridges in Bentonville, founded by Sam Walton's daughter, Alice, and regarded as one of the premier art collections in the world.  To say it is impressive would be a gross understatement.  We are not aficianados but it was very nice and well worth the afternoon we spent seeing it.

Evenings were time to dine out and Fayetteville has diverse, excellent cuisine from Taste of Thai (our favorite) to Celi's Mexican and, the last night Theo's with great salads, wine and Filet Mignon.  We had early dinners, so we would have time for wine and music (courtesy of Pandora) on our deck at home.  A little TV, then to bed and do it again tomorrow.

We came back a little tired and sore, but very relaxed, refreshed and ready to resume "normal life" tommorow. 

Does that sound like a vacation to you?  It certainly does to us!

The Scope of Participatory Medicine--Does it really include Everyone?

Several of my colleagues recently joined me in writing a new chapter to add the White Paper: "E-Patients.  Can they help us heal Health Care?.  This chapter was recently published in the on line Journal of Participatory Medicine, titled "A Model for the Future of Health Care".  The paper describes a health care system where patients and providers participate as partners, with patients largely in control of their own health.  The authors encourage you to open the link, read the paper and add your comments  at the end of the paper.  We would benefit from your feedback!

I asked several friends and colleagues to read and comment on the paper and the responses I got were interesting and a little unexpected.  To summarize, they said:  "This is all well and good, but some patients, even educated ones, just aren't interested in the "participatory" model".  Their point was that many patients trust their providers and don't have the energy or motivation to do on line research, prepare questions for the office visit, or even track their own lab results.  They just want to visit their doctor periodically and hear their recommendations and follow them!

The other feedback theme was that there are still many patients who don't have the health literacy or the technological wherewithal to function as participatory partners in their health.  These are the disabled, poor and disenfranchised.  They don't have smart phones, data plans, lap top computers, ipads or wireless internet access.  Many of them hardly know how to read, much less understand the often complex health discussions found online.

So, in spite of an engaged, activated, increasingly empowered cadre of e-patients out there, those of us in the Participatory Medicine movement have a big problem we need to address:  What do we do about the able but unmotivated, uninterested group and how do we addressthe poor and disenfranchised?

Your thoughts, comments, and expressed opinions are greatly appreciated!

Sometimes, the Best Care is to do Nothing

The dynamics, interactions, and expectations that are played out in the office between doctor and patient can lead to some uncomfortable moments.  Most of the time, as a provider, I feel the need to obtain some test or order new medication to address the patient's issues.   Often, the provider feels obliged to prescribe something, or to obtain a study, even when there is no a clear indication for doing so.  This may be an attempt to provide a satisfactory encounter or to avoid professional liability risk.  Often, appropriately, the provider may be simply giving the patient the benefit of the doubt.  However, it may be a disservice to the patient to prescribe a test or medication if the doctor believes it isn't necessary.  We should, as providers who are committed to high quality care, renew our commitment to carry out the most appropriate course of action, regardless of whether that may lead to an awkward moment with the patient.  Here are a few simple illustrative examples:

• Patient has respiratory illness, probably viral, but requests antibiotic treatment.
• Patient has headache, probably tension, but feels a CT scan should be ordered "for good measure".
• Patient has chest pain and chest wall tenderness, but gets admitted to "rule out" a myocardial infarction.
• Patient has fatigue and mild depression, with "low normal" testosterone level, and asks you to prescribe testosterone supplement.
• Patient has had trouble losing weight with dieting and requests amphetamines for weight loss to "jump start" the process.

These are representative examples, but there are many other scenarios in which the cost or risk of side effects from the treatment likely outweigh the potential beneficial effects.  It is often tempting, rather than taking the time and effort to explain the reason why "a" or "b" is not needed, to go ahead and provide the prescription or order the test, then move on to see the next patient.  When we do this, we not only do the patient a disservice, but we contribute to the unsustainable cost of health care.

I consult a variety of financial, legal, and other professionals expecting them to render their honest appraisal and recommendations.  If this is a recommenation not to do something, I would certainly accept, and appreciate their candor; as a doctor I should do no less!

Your comments and dissenting opinions are always welcome!

What to Do If You Have the Flu

Flu season is in full swing this year, with thousands of Americans suffering from its symptoms. The Centers for Disease Control (CDC) has estimated that an average of 36,000 people in the U.S. die from influenza or from its complications each year. Influenza is particularly hard on the elderly, people with a weakened immune system, children, and those with chronic illnesses, such as emphysema and diabetes.

Several weeks ago, a Health Tip went out encouraging everyone 6 months or older to receive the flu immunization. As expected, most of this year's flu cases have occurred in those who were not vaccinated. Unfortunately, getting a flu shot does not guarantee that you will not get the flu. While immunization remains the most effective way of preventing the flu, recent statistics from the CDC indicates that the effectiveness of the vaccine this year is 62%. This means that if you received the vaccine you are about 60 percent less likely to get the flu, but not completely immune.

How do you know if you have the flu? Mild cases of the flu can be similar to a common cold, but typically, the flu is much more severe. Muscle aches, severe fatigue, cough and headache predominate over common cold symptoms of runny nose and sore throat. Characteristic of the flu also is fever (100-102 degrees F) that can last for three to four days. Of particular concern in those who contract the flu are its complications, including bronchitis and pneumonia, which are responsible for the majority of flu-related hospitalizations and deaths.

What you can do for the flu? Most people with the flu end up being miserable for a few days, but recover on their own. A number of non-prescription medications, while not treatments for the virus itself, can help with flu symptoms. Over-the-counter medications and self-care measures include:

1. Limiting activity and getting plenty of rest.
   
2. Staying hydrated by drinking water, sports drinks or electrolyte replacement fluids.
   
3. Gargling salt water (1 : 1 ratio) or using throat lozenges for sore throat.
   
4. Taking acetaminophen (e.g. Tylenol®) or ibuprofen (e.g. Advil®, Motrin®, others) for fever or muscle aches.
   
5. Taking decongestants (Claritin-D, Sudafed, others) can ease discomfort from stuffy nose, sinuses, ears, and chest.
   
6. Using cough medicine or cough drops for temporary relief from coughing.

It is important that aspirin be avoided in anyone under the age of 18 with the flu because of its association with Reye syndrome, a condition affecting the nervous system and liver. In most people, medical attention or antiviral drugs are generally not required.

When should someone seek medical attention? People at increased risk of serious flu-related complications, including young children, elderly persons, pregnant women and people with chronic illnesses, such as diabetes, should contact their medical provider with the first signs of an influenza infection. Emergency warning signs in children include difficulty breathing, bluish skin color, extreme irritability, inability to keep food or liquids down, and high fever. Adults with shortness of breath, confusion, chest or abdominal pain, and persistent vomiting should receive urgent medical care. Someone in whom flu symptoms improve initially but later develop worsening cough and fever may have a bacterial infection and should receive medical attention.

What is the doctor able to do? Antiviral medications are modestly effective in shortening the duration of the flu and may help to avoid complications. For these to work effectively, however, it is important to start treatment within 48 hours of the development of symptoms. Below are antiviral medications approved for treating adults and children one year and older:

1. oseltamivir (Tamiflu)
   
2. zanamivir (Relenza)
   
3. amantadine (Symmetrel)
   
4. rimantadine (Flumadine)

In December 2012, the U.S. Food and Drug Administration expanded the approved use of oseltamivir for treating children between the ages of 2 weeks to one year. Antibiotics used for bacterial infections, such as Ampicillin, Keflex, Cipro, etc., are not used to treat uncomplicated cases of the flu. These may be required, however, with certain flu-related complications, such as pneumonia or ear infections.

When can I return to work or school? The Centers for Disease Control recommends that people recovering from the flu stay at home for at least 24 hours after their fever is gone. While at home, flu victims should avoid contact with others in the household to keep them from getting sick. Also, frequent hand washing will help to keep from infecting others.

Is it Possible to Really Receive "Whole Person" Care?

This week, along with a psychologist colleague, Chris Rule, I began a Balint Group with senior Family Medicine residents at the University of Arkansas.  This approach was inspired by Michael Balint, a general practitioner in London who led groups of GP's along with his partner and wife Enid at the Tavistock Clinic in the late '40's and early '50's.

Balint explored concepts such as the "collusion of anonymity", in which he decried the tendency of specialists to pass patients around to each other with no one caring for the whole patient.  So, through the use of these groups, and the use of case presentations with discussion, he set out to deeply explore the nature of the doctor-patient relationship and to encourage his colleagues to "go deeper", to "listen to patients in a new way" and to recognize that much of the value of being a primary care doctor had nothing to do with ordering tests, writing prescriptions or assigning a physical diagnosis to every symptom.

He noted that, time after time, the groups' patients "offered" up a symptom and the doctor "accepted" it, in a sense allowing that process to thwart the opportunity to explore what was truly going on with the patient.  This process in no way means that the physician seeks to find a psychological cause to all symptoms but it does suggest that no one in the health care system is as well positioned to integrate psychosocial issues with biological issues to truly provide whole person care.  To do this, the physician must learn to truly listen to patients, without jumping to a diagnosis or treatment approach too soon to get to the real issues.

This is why I went into Family Medicine and why, after 39 years of training and practice, I am still inspired to go to work every day.   I'm still learning how to get better at talking to, and understanding, patients.  And, I thank mentors like Michael Balint for providing the model for integrating medicine and psychology for us.