Author Archives: STFM News

Another Uncommon Ethical Dilemma We Must Now Consider

Alison Huffstetler, MD

Claudia Allen, PhD, JD

The myriad challenges posed by the COVID-19 pandemic are immense. We face shortages in personal protective equipment, brisk reallocation of clinicians, management of novel telehealth visits, and a looming increase in physician burnout. The family medicine community has engaged in remarkable efforts to ensure patients continue to receive necessary care. But as the pandemic begins to impact places like Washington, DC,  two imminent ethical questions arise: How will we balance care for the urban underserved of DC and the political figures, both of whom are sure to be affected by COVID-19? And how will we maintain professionalism while caring for our own medical colleagues?

Boris Johnson, Prime Minster of the UK, was admitted to the intensive care unit at St Thomas’s Hospital in London on April 5th.1 On the day of Johnsons’ ICU admission, there were 799 ICU beds available in the UK but 9,646 were needed.2 According to his physicians, Johnson clearly needed ICU-level care, but what about the other 8,850 patients who also needed ICU-level care? What ethical considerations exist when caring for high-powered officials? And even closer to home, how will we responsibly care for our colleagues, our nurses, and our families?

We will not presume to have a definitive answer, nor will we be able to solve the ventilator crisis in this post. But we will offer an evidence-based approach to the ethics of caring for very important patients (VIPs). 

  1. First, do no harm. Avoid the trap of protecting the VIP from an invasive or uncomfortable treatment if it is the standard of care. In the past, VIPs have suffered from lapses in quality care due to poor adherence to standards.3 Conversely, resist the urge to bend the rules toward overuse and avoid unnecessary tests, inappropriate medications, or delayed discharge.4 
  2. Acknowledge the situation. Opt for an up-front conversation with VIPs. Let the patient and family know that you will treat them as you treat all of your patients. Recognize that your feelings and decision making may be affected by the VIPs status. As a human reminder, it is ok (and warranted!) to show empathy for your friends, colleagues, and public figures. However, remind yourself that decisions should be rooted in the clinical picture and evidence base.
  3. Keep the right team in place. VIPs, families, or hospital staff might place pressure for a more senior, administrator-clinician to care for the VIP. This is often known as “chairman syndrome,” which refers to a demand to have care from the department chair, an individual who may be removed from frequent clinical care. Instead, the patient should be cared for by the team at the appropriate level of care and with the most expertise. Residents should not be removed from these teams as they consistently care for hospitalized patients and are equipped with tools to remain up to date on management. Do not escalate care without the appropriate clinical indications.5 
  4. Thoughtfully manage communication. There are two concepts here. First, ensure that you are speaking with the VIP and family routinely and honestly; aim to maintain an open line of communication with necessary boundaries. Second, patient case discussions and management decisions should only take place with direct team members. Consider a hospital pseudonym that can be used during verbal discussions and in the chart/nursing boards to reduce the likelihood of a confidentiality breech.
  5. Enlist the team to maintain these standards. It is not possible to avoid an effect on our mentality as we care for a patient who is prominent or personally close to us. What we can do is acknowledge the potential for confusing feelings, clarify them in our own minds by putting them into words, and enlisting the whole team to hold one another accountable. Give the whole team the task of keeping an eye on whether professional standards are being adhered to, and permission to hold one another accountable when anyone notices standards slipping.

We face unprecedented numbers of critically ill patients in the hospital. Family physicians are taking this opportunity to expand our presence and provide excellent care to patients. These patients will begin to include other physicians, administrators, hospital staff, friends, and well-known figures. We argue all of these are VIPs and all deserve our attention. Take time now to plan for and discuss what your team will do when caring for one another. Anticipate that these plans will change and acknowledge flexibility in the plan. Our patients will more equitably benefit from the strategies we put into place today. 

References

  1. Booth W, Adam K. Boris Johnson heads into second night in intensive care unit. The Washington Post. https://www.washingtonpost.com/world/boris-johnson-receives-oxygen-support-as-he-battles-covid-19/2020/04/07/0f21fa86-7885-11ea-a311-adb1344719a9_story.html. Published April 7, 2020. Accessed April 8, 2020.
  2. Institute for Health Metrics and Evaluation.| COVID-19 Projections. https://covid19.healthdata.org/projections. Accessed April 8, 2020.
  3. Lerner BH. Revisiting the death of Eleanor Roosevelt: was the diagnosis of tuberculosis missed? Int J Tuberc Lung Dis Off J Int Union Tuberc Lung Dis. 2001;5(12):1080-1085.
  4. Allen-Dicker J, Auerbach A, Herzig SJ. Perceived safety and value of inpatient “very important person” services. J Hosp Med. 2017;12(3):177-179. https://doi.org/10.12788/jhm.2701
  5. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. 2011;78(2):90-94. https://doi.org/10.3949/ccjm.78a.10113

 

Four Things Medical Educators Are Doing to Adapt to COVID-19

By Vince Munoz, STFM

While most COVID-19 news coverage has centered around clinical and systemic challenges in the American health care system, medical education has also been disrupted. To help disseminate actionable information as quickly as possible, we’ve asked educators on our member forum how they’re adapting their teaching practices to clinical considerations regarding the novel coronavirus. Here’s what some of them had to say: 

1.) We have sent our M4 students to work (for elective credit) at the local health department. They perform surveillance of COVID-19 cases, educate the public via online communications, and help the health department trace pockets where COVID is located. They work from the health department headquarters under the supervision of an MD infectious disease epidemiologist. The objectives are not yet written due to the nature of this abrupt change. This is a way to expand our base for managing this disease.

 – Stuart Goldman MD, Chair of Family Medicine, Rosalind Franklin University 

2.) I’m a Faculty at a family medicine residency and M3M4 clerkship director.  My work is shifting my attention to telehealth, as we are looking hard at ways to protect our residents and students.  AAMC has dropped the news to move all medical education including M3 and M4 out of the clinical arena. I’m looking for ways to continue some aspects of their curriculum via telehealth. On the clinic side, we’re trying to throw together a structure for residents to move to telemedicine.

Joy Shen-Wagner MD FAAFP, Clerkship Director and FM POCUS Director, University of South Carolina SOM Greenville/Prisma Health 

3.) I created a learning/discussion module that residents or medical students can work on virtually or individually.  It has readings about how the Coronavirus pandemic is worsened by inequality and health disparities (endangering everyone).  The activity promotes conversation around what kind of policies could be put into action to improve public health and reduce risk for all Americans.  I think this is a moment when COVID is making us realize how inequality doesn’t only hurt the poor. In addressing the current pandemic there are opportunities for long lasting change (like the recent bill for paid sick leave).

Jen Flament, Swedish Cherry Hill Family Medicine Residency Faculty, Swedish Medical Center/Cherry Hill 

4.) Students are doing telemedicine visits – they get history, pend orders, present to attending while the patient watches, and the student then writes notes. Some attendings observe the entire visit, write their note as the visit progresses and have a great feedback/teaching opportunity.

We also have students help patients transition to telemedicine visits. We have done very little telemedicine here, so we have a steep learning curve for our patients. Some of our students have called patients to educate them about telemedicine, discuss doing their upcoming visit that way, help them load zoom onto their devices, and problem solving microphone function. The loading/problem solving step is taking a lot of time and students are better at walking patients through that than any one in our offices!​

Robert Hatch, Director of Medical Student Education, University of Florida

Lessons From an Unlikely Land – Reflection From the Recent Trip to Cuba by STFM

The 1966 AMA Report of the Ad Hoc Committee on Education For Family Practice (aka “The Willard Report”) affirmed an AMA House of Delegates assertion “…that family practice is important for optimal health care…” while also expressing concerns over the adequacy of the future supply and preparation of the family practitioner. The report argued “that there is a need for a new kind of specialist in family medicine, educated to provide comprehensive personal health care…”  soon thereafter, in 1969, the 20th major specialty, “Family Practice,” was born to great promise and hope.

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Richard Streiffer MD    University of Alabama

 

Today, despite compelling and robust international evidence of the importance of a well-trained, accessible, and ample family physician workforce to the health of a population, we remain well short of that goal in the United States. I believe that many family physicians feel a sense of collective disappointment in this failing, and clearly many are dissatisfied with the narrowing scope and role of the family physician. Many are frustrated by the perception of the collective failure of family medicine to have a greater influence on the nation’s health  as envisioned at our discipline’s launch.  

Still, family physicians aspire to the role which Ian McWhinney clearly laid out his classic Textbook of Family Medicine, where he said that the comprehensive family physician:

  • sees every encounter as an opportunity for prevention
  • sees himself or herself as part of the community-wide network of supportive health care agencies
  • views his or her practice as a “population at risk”
  • visits patients in their homes and “should share the same habitat as their patients” 
  • is a manager of resources.

Elsewhere around the world, this model of the comprehensive, familiar, accessible, prevention- and community-oriented family physician is not only alive and well, but is fundamental to health systems, most of which have better outcomes than here. 

In January 2020, 25 STFM members spent a week in Havana, Cuba, where we visited one such system—the resource-frugal health care system that the Cubans have built is admired around the world for its achievements. A major motivation in visiting Cuba was to see a model where the family doctor is central and deeply inculcated into the very design of the system. 

During our week, we visited and had talks and conversations at numerous representative facilities in the greater Havana area, including a family doctor/nurse consultorio, a polyclinic, a maternity care specialty hospital, a maternity home, a diabetes specialty care center, Centro de Investigación y Desarrollo de Medicamentos (CIDEM – Cuba’s Center for Drug Research and Development), Escuela Nacional de Salud Pública  (ENSAP – the national school of public health), the Facultad Manuel Fajarod campus of the Universidad de Ciencias Médicas de la Habana (The University of Medical Sciences of Havana), and Escuela Latinoamericana de Medicina (ELAM- the Latin American School of Medicine). We also experienced the culture and values of this fascinating Caribbean land, one that at times seems stuck in the 1950s, yet whose people are happy, positive, appreciative of our presence, and have achieved so much not just in medicine, but in science, music, arts and the humanities. 

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To understand the health achievements in Cuba, it’s critical to appreciate that the “developing country” conditions—illnesses and disparities of access to care that characterized the country at the time of the Cuban Revolution in the middle of the 20th century—have been eliminated. Today, despite economic and political challenges, the overall health measures of the Cuban population are near to, and in some areas above that of the United States, and all achieved at a fraction of the per capita costs.  

How have they done this? First, health care is accessible and guaranteed for all, and prevention is first and foremost to their method. Public health and medicine, as well as attention to social determinants of health, are largely integrated compared to the United States, where the fields have largely pursued separate tracks in training and practice. In addition to these principles that guide them, the Cubans are able to articulate clear priorities that drive their resources, attention, and approach. For example, virtually every health professional we met talked about the importance of prevention and of the role of the family doctor, and how pregnant women and their babies followed, closely by the growing elderly population, are at the top of their priority list.  

Perhaps most fundamental to their success has been the foundation provided by the network of the neighborhood-based family doctor-nurse consultorio dyads. Each family doctor/nurse pair lives in a neighborhood where they care for a defined population that they can describe in some detail at the drop of a hat. They use population health methods to conduct risk stratification for their patients, and track their patients with simple, low-tech techniques like daily logs, family (paper) charts, manual screening registries, and home visits. The family doctors are in turn supported through a team of health professionals that includes an epidemiologist based out of the larger hub called the polyclinic. These polyclinics are served by general and specialty hospitals, and a series of subspecialized clinical and research institutes. Throughout the system, the role and importance of the family doctor for implementation and follow-up of any plan is reinforced. 

One of the other more remarkable institutions we visited is ELAM—the Latin American Medical School in Havana—where some 100 US citizens are studying medicine along with thousands of other young people mostly from developing countries from around the world. The Americans do so at no cost to themselves, with only the expectation that they return to their home and serve as physicians in communities with a need. We were privileged to meet with a group of these US students over dinner and learn how unique and special they are. Mostly underrepresented in medicine students, largely from economically disadvantaged backgrounds, 100% fluent in Spanish, predominantly women, disproportionately interested in family medicine careers, and well trained in public health, community involvement in health care, and low-tech, patient-centered care, they are admirably committed to the principles of population health and returning to practice in an underserved community of the United States.  

Most fascinating, this diverse group of Americans is studying in Cuba by choice. Few of them even considered or applied to US medical schools, opting purposefully for the Cuban model out of conviction of its superiority for their future service in communities of need. By training side by side with Cuban medical students and living and working in this system, these Americans are experiencing firsthand the value of the family physician-nurse team’s knowledge of their patients and the neighborhood influences; of the role of the community assessment and home visits; of the potential of prevention and lifestyle change; of how to judiciously use precious resources and a low-tech approach; and of systematic data collection to inform population-oriented priorities.

The burning question for me throughout the trip was “Are there lessons here that we might apply back home?”  Mind you, there’s no delusion here, though at times we were admiring, and perhaps a bit euphoric and somewhat envious. We all knew that this was Cuba—that quirky little embargoed island just off the coast of Florida. Our size, political, and cultural differences from Cuba are significant, so that adoption of a system like theirs is neither realistic nor advisable for the United States. Yet, there are lessons to learn from the principles upon which their successes are based, the most important one being the value of the family doctor to a health system and its ability to improve population health. 

Suggested Reading 

Bhardwaj N, Skinner D. Primary Care in Cuba: considerations for the US. J Health Care Poor Underserved. 2019;30(2):456-467.   https://doi.org/10.1353/hpu.2019.0041

Campion EW, Morrissey S. A Different Model—medical care in Cuba.” N Engl J Med. 2013;368(4):297-299.() https://doi.org/10.1056/NEJMp1215226

Gorry C. Your primary care doctor may have an MD from Cuba: Experiences from the Latin American Medical School.” MEDICC rev. 2018;20(2):11-16.

Gorry C. Cuba’s family doctor-and-nurse teams: a day in the life.” MEDICC Rev 2017;19(1):6-9.

Keck C, Reed GA. The curious case of Cuba.” Am JPubHealth. 2012;102.8:e13-e22.

Ladden M, Mende S. Field Notes: c. Robert Wood Johnson Culture of Health Blog. https://www.rwjf.org/en/blog/2015/01/field_notes_whatcu.html. Posted January 29.  Accessed February 27, 2020.

Dwamena A. Why African-American Doctors Are Choosing To Study Medicine In Cuba.  The New Yorker. https://www.newyorker.com/science/elements/why-african-american-doctors-are-choosing-to-study-medicine-in-cuba. Published June 6, 2018. Accessed February 27, 2020.

Frist B. A Look Inside Cuba’s Family Clinics. Forbes.https://www.forbes.com/sites/billfrist/2015/10/07/a-look-inside-cubas-family-clinics/. Published October 7, 2015. Accessed February 27, 2020.

Hamblin J. How Cubans Live as Long as Americans at a Tenth of the Cost. The Atlantic. https://www.theatlantic.com/health/archive/2016/11/cuba-health/508859/. Published November 29, 2016. Accessed February 27, 2020.