Volume two • Number one Summer 2013
FamilyA JOURNAL OF THE NEW YORKDoctor STATE ACADEMY OF FAMILY PHYSICIANS
www.nysafp.org
FEATURE ARTICLES: CME & POST-TESTs The Manageable Challenge Weight Loss Program
also: • Exercise Prescription • Mold and Healthy Living • HRCOMP-SOAP – A new model for the primary care visit
Focus: HEALTHY LIVING
Family Doctor, A Journal of the New York State Academy of Family Physicians, is Articles published quarterly. It is free to members of the New York State Academy and is Mold and Healthy Living...... 8 distributed by mail and email. Non-member By Eckardt Johanning, MD, MSc, PhD; Pierre Auger, MD, MSc; Chin S. Yang, PhD; subscriptions are available for $40 per year; Philip R. Morey, PhD, CIH; Ed Olmsted, CIH single issues for $20 each.
New York State Academy of Exercise Prescription...... 13 Family Physicians By Michael Kernan, MD and Quoc-Phong Tran, MD 260 Osborne Road Albany, New York 12211 The Manageable Challenge Weight Loss Program...... www.nysafp.org 19 Phone: 518-489-8945 By William Klepack, MD and Ron Rouse 800-822-0700 Fax: 518-489-8961 HRCOMP-SOAP: A new model for the primary care visit...... 25 By William Bayer, MD Letters to the Editor, comments or articles can be submitted by mail, fax or email to [email protected] Maximizing Mental Health Care...... 30 By Kurt R. Bravata, MD; Christopher Leggett, PhD, PsyNP; Amir Levine, PhD, Editor: Janet Lindner, MS LCSW, CASAC; Jose A. Lopez, MD, MPH; Michael McNett, MD; Doug Reich, MD; Jose Tiburcio, MD Editorial Board Robert Bobrow, MD Richard Bonanno, MD, Chair Rachelle Brilliant, DO Robert Ostrander, MD Departments Message from the Executive Vice President: Vito Grasso...... New York State Academy 4 Officers and Board Raymond Ebarb, MD President: Ray Ebarb, MD President’s Post: ...... 6 President-elect: Mark Josefski, MD Vice President: Tochi Iroku-Malize, MD Clinical Notes: Alia Chauhan, MD, FAAP...... 16 Secretary: Robert Ostrander, MD Treasurer: James Mumford, MD Resident/Student Perspective: Grace M. Charles, MD...... 27 Staff In the Spotlight...... 38 Executive Vice President: Vito Grasso, MPA, CAE...... [email protected] Director of Education: Kelly Madden, MS...... [email protected] Index of Advertisers American Dairy Association...... OBC Director of Finance: Donna Denley, CAE...... [email protected] Atlantic Health Partners...... 15 Project Coordinator and Journal Editor: Bassett Medical Center...... 5 Janet Lindner, MS...... [email protected] Colley Asset Management...... IBC Administrator: Barbara Markowitz...... [email protected] Core Content Review...... 24 Energy Plus Holdings ...... 24 For Advertising Information: Fallon Wellness Pharmacy...... 29 Contact Don McCormick at 518-783-9368, Fidelis Care...... 15 fax 518-785-4088 or Mabel M.P. Cheng, MD...... 24 [email protected] MLMIC...... IFC St. Elizabeth Medical Center...... 7
Cover art (plus ça change, plus c'est la même chose): Thanks to Rucker Archive, Mark Rucker and Alison Moore, for images from their collection for our cover. www.TheRuckerArchive.com From the Executive Vice-President By Vito Grasso, MPA, CAE
This issue of Family Doctor Mold and Healthy Living offers a unique illustrates how coordination of the team in addresses several topics that impact insight into a major public health threat a medical home environment can improve significantly upon healthy living. emanating from disasters. The consequences efficiency and enhance comprehensiveness. The effects of obesity on our public health of mold damage and the threat to human He adroitly outlines the elements of the have been detailed in many venues, in health thereby are expertly reviewed in this HRCOMP process of preparing for the medical literature and everywhere in article. The recent spate of natural disasters patient interview and presents the process the public news media. It has become has raised awareness of the danger to first in terms of “lean” practice wherein each omnipresent in discussions of public health responders, health care workers, clean-up member of the clinical team is responsible policy. Dr. Kernan does an excellent job personnel and residents of areas damaged for only those functions that are appropriate of summarizing the impact of obesity on by storms from mold and other toxic for his/her skills. Achieving greater efficiency our public health in his article Exercise substances that invariably appear in the and closer coordination have become the Prescription. His focus on counseling aftermath of water damage. standards for effective practice and Dr. Bayer’s article helps place these objectives patients regarding the health impact Grace Charles’ piece on her personal and the utility of combining the HRCOMP of obesity and the benefits of exercise experience with stress and fatigue from and SOAP processes into perspective. highlights one approach to the issue which the rigorous schedule of a medical student family physicians should certainly include in addresses the importance of maintaining We hope, as always, that you will enjoy and their practice. health for clinicians. Her suggestions for benefit from this issue ofFamily Doctor. The Academy’s Public Health Commission incorporating exercise, meditation and We look forward to hearing from you about has developed the Manageable Challenge breathing exercises into a busy schedule are this issue and any thoughts you may have for program to provide another resource worth serious consideration. future themes. for family physicians to use in treating Dr. Bayer’s article on the use of HRCOMP Vito Grasso, MPA, CAE, is the Executive obese patients. The concept of reducing and SOAP in conjunction as part of a Vice President of the New York State Academy of the patient’s challenge to one meaningful medical team approach to practice Family Physicians. thing; i.e., reducing the volume of calories consumed, is a reflection of the great difficulty inherent in helping obese patients cope with the health and life threatening aspects of obesity. The combination of diet and exercise is simply too much to expect SMTWTFRS for many patients and the Manageable SAVE THE DATE! Challenge model can help by focusing Capital Region Family Medicine Conference – September 7 the patient on one behavior modification: Siena College, Loudonville reducing the volume of calories consumed. Winter Weekend – January 23-26, 2014 High Peaks Resort, Lake Placid
4 • Family Doctor • A Journal of the New York State Academy of Family Physicians achieve success achieve balance
Primary Care positions in Medical Why Choose Bassett? Home Recognized Practices • Group employed model (GEM) of Bassett Healthcare Network, an integrated physicians, providers, ancillary team teaching and research based healthcare system members, hospitals and health centers in Central New York, has Family Medicine, serving patients across eight counties Internal Medicine and Med Ped MD or DO • Bassett Medical Center is a clinical teaching positions available for its Medical Home campus – Opportunity to receive faculty Recognized Practices. appointment • Bassett offers a competitive salary • Expansive and integrated health care and benefits package including, CME, network covering 5,250 square miles and malpractice insurance, generous vacation comprised of: time, pension plan, and relocation - 6 affiliated hospitals assistance - More than 28 regional health centers • Fully integrated EMR, excellent - 19 school-based health centers technological and subspecialty support - Ranked #48 most integrated health • Level 3 Medical Home system in the U.S. - New York Center for Agricultural • Loan repayment opportunities may be Medicine and Health (NYCAMH) available to qualified candidates - Bassett Research Institute
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Summer 2013 • Volume two • Number one • 5 President’s Post By Raymond L. Ebarb, MD
Fellow Family Physicians: So now as private practice physicians we Can you handle one more piece of good also need to be businessmen, informational news? As family physicians you are not The current overhauling of healthcare technologists, statisticians, economists and alone. Your state and national academy are delivery in this country is unprecedented. politicians. Somewhere in the middle of all willing and able to help you through this Not only is the delivery system changing, this we are supposed to stay current with the maze. The academy is our loudest advocate, but so are the treatment regimes we use in medical literature and practice medicine. our closest ally and our most trustworthy the exam room. The standards of medical source of information and services. care, previously thought to be ‘sacred cows’, So much for the bad news, now for the good are being reexamined, re-tooled or just news. The good news is that we are family It is truly an honor to be entrusted with simply thrown out. Medications thought physicians. No other specialty is better the responsibility of leading our academy to be contraindicated for certain medical trained to be able to manage such a wide as president over the upcoming year. I conditions during my medical training are variety of disciplines as family physicians. am optimistically looking forward to the now used as quality-of-care indicators. No other medical specialty is better trained challenges that await us during my term. to handle whatever walks in the front door. My goal is to try to ease the growing pains We have learned over the last few years that There is more good news. Even though we of change that have enveloped us all in public health dilemmas cannot be solved have been doing this for years, society and medicine. simply by throwing money at the problem. the politicians are finally starting to realize The United States spends more healthcare the leading role that primary care needs to Raymond L. Ebarb, M.D., FAAFP is the President of dollars per capita than any other nation in take in order to have an effective healthcare the New York State Academy of Family Physicians for the world by far. However, morbidity and 2013-2014. delivery system. There are many examples mortality statistics show the health of our of this around the world in countries that population doesn’t even make it into the document a healthier population. top ten. So the pressure is on, not only to provide good comprehensive medical treatment, but also to provide economically responsible treatment.
Our competency as physicians is being ...The U.S. spends more healthcare dollars per capita than measured by surrogate statistical markers and misleading outcome data. In order to any other nation in the world by far. However, morbidity and survive in this statistical quagmire, we are mortality statistics show the health of our population doesn’t told we must embrace the computerized even make it into the top ten... management of our charts and business, not as an option, but as a mandate.
6 • Family Doctor • A Journal of the New York State Academy of Family Physicians St. ElizabEth Family mEdicinE RESidEncy PRogRam oPPoRtunitiES Utica, New York
The St. Elizabeth Family Medicine Program has a proud tradition of preparing family physicians for over thirty-five years. More than half of our graduates have stayed in the Upstate New York area, meeting the healthcare needs of this region. We are a dually accredited, unopposed, thirty-resident program, based in our community hospital, which has full specialty representation. Many specialists teach in our program. Our model outpatient teaching unit, the Sister Rose Vincent Family Medicine Center, has more than thirty thousand patient encounters each year, wherein residents and faculty practice in a mentoring and collaborative fashion, helping the underserved and culturally diverse community. Our program serves as a core rotation site for a number of medical schools, physician assistant and nurse practitioner programs. We have the following positions available for consideration:
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For additional Information Contact: Mark E. Warfel, DO FAAFP Interim Program Director, Director of Medical Education (315) 734-4401 • [email protected] MC www.stemc.org
Summer 2013 • Volume two • Number one • 7 Mold and Healthy Living
– in the aftermath of By Eckardt Johanning, MD, MSc, PhD Pierre Auger, MD, MS Superstorm Sandy and Chin S. Yang, PhD Philip R. Morey, PhD, CIH other natural disasters Ed Olmsted, CIH
Superstorm Sandy’s ‘second wave’ has already hit many. from this international group of experts for health care providers: The media are calling it the “Sandy Cough.” There is a growing • What are the health concerns? What have we learned from past concern of adverse health reactions and illnesses encountered in floods and public health investigations? re-occupancy of moldy indoor environments. In particular, the • Exposure assessment: Under what circumstances is testing cleaning and restoration of salvaged homes and businesses, and the needed? challenges posed by mold contaminated personal items and building • Remediation: The basics of cleanup and remediation—the pros materials may expose unprotected workers and homeowners. and cons of biocides; review of professional guidelines. What do you throw away and what can you safely restore? Moldy • Public health response and initiatives: emergency response, wallboards, carpeting and HVAC system and insulation can be education, legal issues. replaced, but if it’s not done right, possible damaged pulmonary, • Special requirements for health care and institutional facilities. immunologic or even neurologic systems may result. In response to this urgent need and growing health concerns, Background: Mold and Fungi the Fungal Research Group Foundation had recently invited an Fungi, often called “mold”, are a heterogeneous group of organisms international group of experts to speak to the health care providers including true fungi, lichens, yeast, slime and water molds. and remediation specialists of the storm-ravaged Tri-State Area Ordinarily beneficial in outdoor nature, most “naturally” occurring (New York, New Jersey and Connecticut), and others (www. fungi found growing indoors may be considered a danger to the dampnessmold.com). We have summarized some of the key points health of animals or humans depending on concentration and route of exposures. There may be 150 species found airborne indoors to over 600 different species from bulk to dust samples collected
8 • Family Doctor • A Journal of the New York State Academy of Family Physicians in water damaged indoor environments. The commonly listed Besides encountering indoor mold conditions in situation like fungi in environmental reports include: Penicillin spp, Aspergillus Superstorms Sandy and Katrina, many patients spend up to 90% spp, Cladosporium spp, Rhizopus, Paecilomyces, Aureobasidium, of their time indoors, where contaminants often are at higher Chaetomium, Stachybotrys chartarum, Trichoderma, etc.) Damp levels than they are in the ambient air due to chronic moisture and building materials, particularly cellulose-containing substrates, are leaks. Many buildings in the U.S. and Western Europe have severe prone to fungal growth and amplification. dampness problems that result in significant fungal contamination in the indoor environments. Typical health complaints of patients living With fungal growth and development, spores are released into the in moldy indoor environments or workers coming in contact with air. Humans maybe exposed to fungi, its fragments or by-products excessive fungal exposure are listed below. (i.e., allergens, glucans, mycotoxins) by inhalation and to a lesser degree by skin contact or ingestion. Fungi have been associated with Typical health complaints after intense allergy and respiratory health such as rhino-sinusitis and asthma, mold exposures but also with irritant or toxic effects such as skin irritation and other • headaches (various types) health disorders. Mycotoxins are well known in veterinary medicine • nausea (vomiting) and food safety and are regulated in many countries regarding • severe fatigue and exhaustion (physical and mental) consumption and food content. These mycotoxins have also been • burning, irritation and watery eyes explored as a possible risk factor in buildings with mold problems • sore throat and hoarseness based on non-allergic clinical presentations of sick-building type • sneezing or irritant-dry (rarely productive) cough, health complaints1 , 2, 3. Patients describing a “mildew smell” are chest tightness, wheezing indicating the presence of microbial volatile organic compounds • unusual epistaxis and hemoptysis (rare) (MVOC’s) that are produced by actively growing fungi. However, the • chest pain and burning, dyspnea concentrations of MVOC typically found in buildings are not believed • skin and mucous membrane irritation (hair loss ?) to be at directly harmful levels. • congestion or rhinorrhoea, epistaxis • dizziness, concentration and memory problems Fungi and health • feverish – flu-like reactions Fungi are known in medicine to be a cause of infections, allergies In most cases adverse health reactions are normally of short duration and irritant-toxic disorders. Symptoms reported by patients are and reversible, provided the exposure has been stopped. However, often non-specific and may relate to reactions of the air-ways, in some cases the adverse health consequences may be more serious skin, mucous membranes or internal organs. Expert reviews of or may be irreversible requiring symptomatic treatment and careful the scientific literature concluded that dampness related fungi are avoidance of microbial triggers. Recognized mold related medical highly associated with allergies, respiratory symptoms or diseases conditions are described below in more detail. such as asthma and changes of the immunological system4; 5,6. There are clinical studies and case reports of adverse health reactions Graph 1: Exposure agents and health outcomes that include non-allergic adverse effects to the lungs: sarcoidosis, infant hemorrhagic lung disease; allergic alveolitis (Hypersensitivity Pneumonitis), neurological system (headaches and cognitive dysfunction), endocrine and reproductive organs (thyroid hormonal Fungal Exposure: changes and menstrual disorders in women), and rheumatological Various agents and disease outcomes disorders (joint pain). An increased risk of cancer from fungal exposures has been explored. Agents Allergy + Non-allergic • Allergens • Dermatitis Some of the fungi produce chemicals that are known genotoxins • Ergosterol • Urticaria and carcinogens, and include (1-3)-ß-D-glucan, mycotoxins, and • (1-3)-ß-D-glucan • Rhinitis, Sinusitis microbial volatile organic compounds (MVOCs). 7, 8; 9; 10; 11,12; 13,14; 15,16 • Mycotoxins • Asthma • Microbial volatile • Extrinsic allergic However, these case studies are difficult to document and validate organic compounds alveolitis "humidifier fever" in epidemiological or experimental studies and have therefore been (MVOCs) • Organic dust toxic syndrome considered debatable by some and further evidence needs to be • ??? • Toxic – irritant effects researched. Also liability and disability claims and special interests of the insurance industry have influenced the debate about causation Fungal Research Group Foundation and attributable risk.
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Summer 2013 • Volume two • Number one • 9 Graph 2: Medical conditions associated with indoor also tend to rise with typical allergic symptoms, cough, dyspnea and fungal exposures wheezing. The reported percentages of the population allergic to molds may Health effects of fungi vary from 2% to 18%. A high rate of asthmatics is reported to be allergic to molds. Notably, about a third of newly diagnosed asthma rare irreversible was attributable to workplace mold exposure. Patients can be tested for specific mold allergy using skin or serological tests (IgE-RAST, Mycotoxicosis IgG or IgM-antibodies) to study immunological responses. However, Hypersensitivity pneumonitis/ODTS due to the low sensitivity of some of the commercially available mold Asthma & Bronchitis extract tests, false negative results are not uncommon. Allergic Diseases Dermatitis; air way infections Hypersensitivity pneumonitis (HP) and organic dust toxic Irritative and non-specific symptoms syndrome (ODTS) Hypersensitivity pneumonitis (HP), also called extrinsic allergic frequent reversible alveolitis, is a well-recognized occupational disease and fungi are Fungal Research Group Foundation one of the agents causing such interstitial lung disease21, 22. The clinical features, biochemistry and patho-physiology of allergic or Supposedly, “acceptable threshold levels” or “normal limits” inflammatory-toxic reactions to airborne microbial exposure are to indoor mold have been reported, but variations in sampling difficult to separate. HP can be caused by fungal exposure at work strategies and methodological limitations make these very unreliable and indoors. Organic dust toxic syndrome (ODTS), also called in practical settings. Therefore, the consensus among experts is toxic pneumonitis, is a non-allergic, non-infectious form of an that acceptable and safe threshold limits for fungal indoor exposure acute inflammatory lung reaction to high fungal dust exposure. The cannot be established and it is generally recommended to avoid or differences between HP and ODTS may be difficult to distinguish. minimize unnecessary fungal indoor exposures. Preventive measures have been recommended for occupations Infections primarily in the organic dust industry but also for mold remediation workers by governmental agencies (i.e., the National Institute for Infections caused by fungi are called mycoses and are categorized Occupational Safety and Health (NIOSH)). Although HP/ODTS is as endemic or opportunistic. Opportunistic fungal pathogens have more likely to occur in settings where large amounts of organic public health importance, especially in patients with an altered or dust are present, they may also happen in office and domestic weakened immune system, with human immunodeficiency virus environments during flood and mold remediation . While rare in (HIV) and those receiving organ transplants. Chronic rhino-sinusitis indoor environments, clinicians should have a high suspicion of with eosinophilic inflammation of the airways has been linked to HP if respiratory symptoms persist after exposure cessation, with dampness related fungi from indoor environments and maybe related persistent dyspnea and breathings tests suggestive of restrictive to the development of asthma.17, 18 Endemic mycoses are related to airway disease. Abnormal chest x-ray findings with ground-glass the geographical distribution of certain fungal pathogens. These appearance and hilar node enlargement have a low sensitivity types of infection are caused by the inhalation of airborne spores or early on and typically show well into the disease process and conidia found in certain regions. development of interstitial lung disease. High resolution chest CT and bronchoscopy with lavage are more sensitive and specific for a HP Allergy and respiratory diseases diagnosis. Fungi are a known cause of allergic and respiratory disease, and have been identified as one of the major indoor allergens.19, 20 Mycotoxins Regrettably, extracts that are available for allergy testing in medical So-called “black mold” or “toxic mold” is a great concern for offices often correspond poorly to the fungi found in indoor surveys. many patients. Primary care providers should be aware that there Long duration or intense indoor exposure to fungi can result in acute are currently no good and validated laboratory tests available to hypersensitivity reaction and chronic diseases. Most people usually routinely “test” or measure “toxic mold” in the environment or in a tolerate fungi types and levels comparable to outside background patient’s blood or urine. In spite of this, some laboratories in the US conditions. However, as mold species and concentrations that are now promote such still meaningless and expensive tests to anxious “atypical” in the indoor environment increase because of water leaks patients, but among experts these tests are considered unreliable and and dampness, the incidence of allergy and respiratory problems misleading.
10 • Family Doctor • A Journal of the New York State Academy of Family Physicians What you should know, briefly: Some fungi produce mycotoxins data are still limited and definite dose response models have not that may be harmful to animals and humans when ingested, inhaled, yet been established for these agents (see also http://www.fao.org/ or in contact with the skin. Mycotoxin production is fungi specific. docrep/005/y1390e/y1390e00.htm). Toxigenic fungi found in indoor environments are, for example: certain species of Penicillium and Aspergillus (A. versicolor, A. Remediation ochraseus,) Fusarium, Trichoderma, Cephalosporium, Chaetomium, It is important to address any moisture or water intrusion and Stachybotrys. Then again, the actual toxin production (in- immediately since significant mold growth can occur within 48 vivo) depends on factors such as available nutrients, favorable hours. Drying efforts of water damaged areas should be started environmental conditions, the life cycle and the competitive behavior as soon as possible. It is advisable to follow current professional with other fungi present. These environmental conditions are not guidelines for the identification and remediation of indoor molds. always present when these molds are identified in environmental In general, environmental testing for mold is not necessary if visible reports brought by patients to the doctor’s office. growth is present. The indoor use of any chemicals (i.e., biocides) Note: The finding of toxigenic fungi is not an indicator of “toxicity” is not recommend for the control of fungal growth. Systematic by itself. Toxic effects in humans have been mostly described and source removal of fungal growth, cleaning with soap and water, researched in relationship with food borne diseases affecting animals followed by HEPA vacuuming should suffice in most cases. For any or regional human disease outbreaks. Mycotoxins are important larger scale projects, remediation workers should be medically because they have been found to have genotoxic, mutagenic, cleared and use proper respiratory, skin and eye protection. Several cytotoxic, carcinogenic, nephrotoxic, pseudo-estrogenic, immuno- references are available online (from New York City Dept Health, suppressive, protein synthesis inhibitor or other toxic properties. American Industrial Hygiene Association, American Conference of Governmental Industrial Hygienist (ACGIH), EPA http://www.epa.gov/ There has been a debate regarding the public health importance iedmold1/cleanupguidelines.html, IICRC (http://iicrc.org/standards/ of “toxic mold” in enclosed indoor environments and its impact iicrc-s500/) and NIOSH (DHHS (NIOSH) Publication Number 2013- on the occupants’ health. What is clear is that many of the typical 102). health complaints and clinical findings in patients living or working in wet and moldy buildings cannot be explained by allergy alone. Mycotoxins have ciliostatic effects in the respiratory tract, causing Conclusion diminished mucociliary clearing and local inflammatory effects Indoor fungi (“mold”) are important in public health and worker in the airways and sinuses. In the context of investigating infant health prevention. There is consensus among experts that fungi hemorrhagic lung diseases with indoor toxigenic Stachybotrys associated with dampness leads to preventable health problems, chartarum exposure, experimental research confirmed toxic cell primarily of the respiratory organs and allergy. Anyone involved effects that may have clinical implications.23 Mycotoxins can induce in “mold clean-up” should be educated about mold hazards and abortions and reproductive abnormalities in animals. Human cases proper personal protective equipment. Clean-up workers may need of “mycotoxicosis” appear to be rare. In the medical literature to be evaluated and “cleared” for larger scale mold remediation these are mostly related to ingestion of contaminated food/feed work. In general, the adverse effects of fungal inhalation are related products in some geographical areas. However, occupational or to duration and intensity of exposure and adverse respiratory and environmental inhalation exposures have been described in recent allergy reactions. studies. Environmental sentinel investigations in water damaged buildings have shown detectable levels of airborne mycotoxins from Human susceptibility and intolerance to fungi vary based on Stachybotrys chartarum and others that may be of concern. 24,25,26,3,27 host factors, age and co-morbidity. In most cases diligent The potential risk of nasal airway injury and neurotoxicity caused exposure cessation and control leads to symptoms reversal and by exposure to water-damaged building and mycotoxins has been health improvement. In some cases symptomatic treatments recently demonstrated in experimental research with monkeys.14 with medications are required to control symptoms. Early recognition, preventive building engineering, hygiene and public The health care provider should be aware of characteristic symptoms health interventions can reduce fungal diseases, especially in the and signs such as extreme fatigue, constant sore throat or skin institutional or health care facilities. If needed, health care providers irritation, headaches, neuromuscular or neuro-cognitive dysfunction, should consult with industrial hygienists and remediation experts to bleeding disorders of the lung in infants, irregular menses, diarrhea, improve environmental control and healthy living. dermatitis and irritation of skin, and impaired immune function. The knowledge of the adverse health effects in animal and human health has led internationally to regulatory efforts to protect humans from excess exposure in food and agricultural products based in many cases on a “precautionary principle”, in part because the CONTINUED NEXT PAGE
Summer 2013 • Volume two • Number one • 11 References effects, Assessment, Prevention and Control. 25 Brasel TL, Douglas DR, Wilson SC, Straus DC. 1 Auger PL. Mycotoxins and neurotoxicity. In: Albany, N.Y.: Eastern New York Occupational and Detection of airborne Stachybotrys chartarum Johanning E, Yang CS, editors. Fungi and Bacteria Environmental Health Center; 1999. 84-93. macrocyclic trichothecene mycotoxins on in Indoor Air Environments - Health effects, 13 Johanning E, Landsbergis P, Gareis M, Yang CS, particulates smaller than conidia. Appl Environ detection and remediaton. Albany, NY: Eastern Olmsted E. Clinical experience and results of a Microbiol 2005; 71(1):114-122. New York Occupational Health Program; 1994. Sentinel Health Investigation related to indoor 26 Taubel M, Sulyok M, Vishwanath V, Bloom E, 161-167. fungal exposure. Environ Health Perspect 1999; Turunen M, Jarvi K et al. Co-occurrence of toxic 2 Johanning E, Biagini R, Hull D, Morey P, Jarvis 107 Suppl 3:489-494. bacterial and fungal secondary metabolites in B, Landsbergis P. Health and immunology 14 Carey SA, Plopper CG, Hyde DM, Islam Z, Pestka moisture-damaged indoor environments. Indoor study following exposure to toxigenic fungi JJ, Harkema JR. Satratoxin-G from the black mold Air 2011; 21(5):368-375. (Stachybotrys chartarum) in a water-damaged Stachybotrys chartarum induces rhinitis and 27 Peitzsch M, Sulyok M, Taubel M, Vishwanath V, office environment. Int Arch Occup Environ Health apoptosis of olfactory sensory neurons in the nasal Krop E, Borras-Santos A et al. Microbial secondary 1996; 68(4):207-218. airways of rhesus monkeys. Toxicol Pathol 2012; metabolites in school buildings inspected for 3 Bloom E, Nyman E, Must A, Pehrson C, Larsson L. 40(6):887-898. moisture damage in Finland, The Netherlands and Molds and mycotoxins in indoor environments- 15 Kilburn KH. Inhalation of moulds and mycotoxins. Spain. J Environ Monit 2012; 14(8):2044-2053. -a survey in water-damaged buildings. J Occup Eur J Oncol 2002; 7(3):197-202. Environ Hyg 2009; 6(11):671-678. 16 Kilburn KH. Role of molds and mycotoxins in Eckardt Johanning, MD, MSc, PhD, Fungal 4 King N, Auger P. Indoor air quality, fungi, and being sick in buildings: neurobehavioral and Research Group Foundation (FRG-F), Inc., is Assistant health. How do we stand? Can Fam Physician 2002; pulmonary impairment. Adv Appl Microbiol 2004; Clinical Professor of Medicine in the Center for Family 48:298-302. 55:339-359. and Community Medicine, Columbia University, 5 WHO et al. WHO guidelines for indoor air quality: 17 Ponikau JU, Sherris DA, Kern EB, Homburger College of Physician and Surgeons, New York, New Dampness and Mould. Hesseltine E, Rosen J, HA, Frigas E, Gaffey TA et al. The diagnosis and York. Pierre Auger, MD, MSc, is from Quebec editors. 1-248. 2009. DK-2100 Copenhagen O, incidence of allergic fungal sinusitis. Mayo Clin City, Québec, Canada, Department of Public Health. Denmark, World Health Organization - Regional Proc 1999; 74(9):877-884. Chin S. Yang, PhD, is a mycologist and owner of Office for Europe. 18 Kern EB, Ponikau JU, Sherris DA, Kita H. Fungi the Prestige Microbiology, Inc. Philip R. Morey, 6 Mazur LJ, Kim J. Spectrum of noninfectious and chronic rhinosinusitis (CRS): Cause and PhD, CIH is Principal Consultant in Microbiology, health effects from molds. Pediatrics 2006; effect. In: Johanning E, Morey P, Auger P, editors. ENVIRON International Corporation. Ed Olmsted, 118(6):e1909-e1926. Bioaerosols, Fungi, Bacteria, Mycotoxins in Indoor CIH, is a certified hygienist and owner of Olmsted 7 Koskinen O, Husman T, Meklin T, Nevalainen and Outdoor Environments and Human Health, 1 Environmental Services, Inc. ed. Albany: Fungal Research Group Foundation; A. Adverse health effects in children associated For more information, contact: Fungal with moisture and mold observations in houses. 2012. 89-100. Research Group Foundation FRG-F, 4 International journal of environmental health 19 Horner WE. Assessment of the indoor Executive Park Drive, Albany, New York research 1999; 9:143-156. environment: evaluation of mold growth indoors 8 Olsen JH, Dragsted L, Autrup H. Cancer risk and 31. Immunol Allergy Clin North Am 2003; 12203; 518-459-3336 (phone), occupational exposure to aflatoxins in Denmark. 23(3):519-531. 518-459-4646 (fax) www.bioaerosol.org Br J Cancer 1988; 58(3):392-396. 20 Arshad SH. Indoor allergen exposure in the [email protected] 9 World Health Organization, National Agency for development of allergy and asthma 302. Curr Research on Cancer (IARC). IARC Monographs on Allergy Asthma Rep 2003; 3(2):115-120. the Evaluation of Carconogenic Risks to Humans. 21 Johanning E. Indoor Environmental Quality. In: Lyon, France: World Health Organization (IARC); Lomax JD, Johanning E, editors. Occupational 1993. Medicine. Philadelphia, Pa: Lippincott Williams & 10 Johanning E, Landsbergis P, Gareis M, Yang CS, Wilkins; 2001. 211-226. Olmsted E. Clinical experience and results of a 22 Schachter, N. Hypersensitivity Pneumonitis. Sentinel Health Investigation related to indoor In Johanning E, Morey P, Auger P, editors. fungal exposure 6. Environ Health Perspect 1999; Bioaerosols, Fungi, Bacteria, Mycotoxins in Indoor 107 Suppl 3:489-494. and Outdoor Environments and Human Health, 11 Lorenz W, Sigrist G, Shakibaei M, Mobasheri Albany, New York, USA: Fungal Research Group A, Trautmann S. A hypothesis for the origin Foundation, Inc.; 2012. 37-45 and pathogenesis of rheumatoid diseases. 23 Yike I, Dearborn DG. Pulmonary effects of Rheumatology International 2006; 26:641-654. Stachybotrys chartarum in animal studies. Adv 12 Ammann HM. IAQ and Human Toxicosis: Appl Microbiol 2004; 55:241-273. Empirical Evidence and Theory. In: Johanning E, 24 Johanning E, Landsbergis. Airborne Mycotoxin editor. Bioaerosol, Fungi and Mycotoxins: Health Sampling and Screening Analysis. Santa Cruz: Levin H, editor. Indoor Air; 2002.
12 • Family Doctor • A Journal of the New York State Academy of Family Physicians Exercise Prescription By Michael Kernan, MD and Quoc-Phong Tran, MD
Exercise prescription has long been an essential component of the physician’s armamentarium to ensure good health. The early Greek physician Hippocrates stated, “eating alone will not keep a man well; he must also take exercise. For food and exercise…work together to produce health.”1 As more evidence accrued in the 20th century showing a correlation between physical inactivity and many chronic conditions, organizations such as the NIH and CDC began to examine more closely the effects of exercise as medicine. With more and more evidence showing the efficacy of exercise in treating a wide range of conditions, ranging from childhood obesity to fractures in the elderly, exercise prescription is becoming more prevalent. Obesity has become increasingly prevalent in the US. As of 2010, more than 17% of children in the US were classified as being obese, up from 5% in 1976.2 In adults, this percentage is even higher, with over one-third of the adult population being obese.3 The economic costs of obesity are staggering, estimated to be roughly 157 billion dollars in 2008.4 Obese children are more likely to suffer from a variety of medical conditions, including metabolic syndrome, cardiovascular disease, joint problems, low self- esteem, and social stigmas, among others.5 Metabolic syndrome, a constellation of risk factors including insulin resistance, dyslipidemia, hyperglycemia, and hypertension, can lead to diabetes mellitus type 2, cardiovascular disease (CVD), and eventual mortality and morbidity from CVD complications.6 Children who suffer from metabolic syndrome walk more slowly and take fewer steps during the day. Furthermore, they require more
CONTINUED NEXT PAGE Summer 2013 • Volume two • Number one • 13 cardiorespiratory effort to move their body activity, and should include vigorous- up is recommended as with any other mass.7 intensity physical activity at least 3 days medical prescription.16 a week. To counteract this, exercise has been With fewer than one out of three patients shown to be helpful in treating obesity.5,6,8 Muscle-strengthening: As part of their 60 even receiving advice to exercise from their Exercise can promote an increase in HDL, or more minutes of daily physical activity, physicians, much less a prescription, the a reduction in glucose and triglyceride children and adolescents should include onus is on primary care physicians to add levels, and can increase cardiorespiratory muscle-strengthening physical activity on exercise prescription more frequently.17,18 endurance. It has also been shown to at least 3 days of the week. To combat the rising tide of obesity in promote the development of self-esteem in adolescents then, a simple prescription is Bone-strengthening: As part of their 60 young children in the short-term.9 Exercise often a good first step in helping children or more minutes of daily physical activity, may be beneficial in the treatment of anxiety avoid the long-term health complications children and adolescents should include and depression as well.10 Schools have long from obesity. bone-strengthening physical activity on at promoted physical exercise in the form of least 3 days of the week. physical education classes, with positive References effects on lifestyle behaviors and physical It is important to encourage young people 1 Berryman JW. Exercise is medicine: a historical health status measures, such as decreases in to participate in physical activities that are perspective. Curr Sports Med Rep. 2010 Jul- television viewing and increases in physical appropriate for their age, that are enjoyable, Aug;9(4):195-201. activity duration.11 Unfortunately, the rise in and that offer variety. 2 Ogden CL, Carroll MD, Curtin LR, Lamb MM, obesity has been accompanied by a decrease Flegal KM. Prevalence of high body mass index in Other organizations have also issued similar in physical education attendance in the U.S. children and adolescents, 2007-2008. JAMA guidelines. In 2011, the American College of US. The rates of high school students who 303(3):242-9. 2010. <- NEED THIS ARTICLE Sports Medicine (ACSM) issued a revision 3 Ogden CL, Carroll MD, Kit BK, Flegal KM. attended physical education (PE) classes of its Position Stand on exercise, which Prevalence of obesity in the United States, 2009- in school decreased from 42% in 1991 to provided updated recommendations for 2010. NCHS Data Brief. 2012 Jan;(82):1-8. 31% in 2011.12 When stratified into grades, adults, recommending that all healthy adults 4 Finkelstein, EA, Trogdon, JG, Cohen, JW, and the percentage of students who attend PE Dietz, W. Annual medical spending attributable th engage in physical exercise that include classes daily dropped from 41% in 9 grade to obesity: Payer- and service-specific estimates. th 12 cardiorespiratory, resistance, flexibility and to only 24% in 12 grade in 2011. In 2009; 28(5): w822-w831. neuromotor components.15 A basic exercise Health Affairs elementary school children, less than 4 out 5 Carrel AL, Bernhardt DT. Exercise prescription prescription can be issued for all children of 10 children met activity and screen-time for the prevention of obesity in adolescents. Curr following these guidelines. Further tailoring recommendations and older children have Sports Med Rep. 2004 Dec;3(6):330-6. can be done to address each child’s need been found to be more sedentary.13 This 6 Gardner AW, Parker DE, Krishnan S, Chalmers and desire for exercise, with age-appropriate correlates with a higher level of obesity. LJ. Metabolic syndrome and daily ambulation in and enjoyable activities. One method for children, adolescents, and young adults. Med Sci With these alarming statistics, increasing codifying exercise prescriptions is to apply Sports Exerc. 2013 Jan;45(1):163-9. recognition has been placed on exercise the FITT-PRO, which is defined as Frequency, 7 Norman AC, Drinkard B, McDuffie JR, Ghorbani as a treatment modality in addition to Intensity, Time, Type, and Progression of S, Yanoff LB, Yanovski JA. Influence of excess medications and other interventions. exercise that patients are to perform (AAFP adiposity on exercise fitness and performance in 2006, ACSM 2011). As there is a wide range overweight children and adolescents. Pediatrics. In 2008, the US Health Department issued of various forms of exercise activity, specific 2005 Jun;115(6):e690-6. for the first time physical exercise guidelines 8 Atlantis E, Barnes EH, Singh MA. Efficacy of 14 prescriptions can be tailored easily. for Americans. One part focuses on exercise for treating overweight in children children and adolescents , with the key The physician must be proactive as patients and adolescents: a systematic review. Int J Obes guidelines as follows: are more likely to engage in exercise if (Lond). 2006 Jul;30(7):1027-40. specifically recommended by physicians 9 Ekeland E, Heian F, Hagen KB, Abbott J, Nordheim Children and adolescents should do 60 (AAFP 2006). Exercise prescriptions L. Exercise to improve self-esteem in children minutes (1 hour) or more of physical are only beneficial if patients choose and young people. Cochrane Database Syst Rev. activity daily. to participate in them and successful 2004;(1):CD003683. 10 Larun L, Nordheim LV, Ekeland E, Hagen KB, Aerobic: Most of the 60 or more minutes exercise prescription often requires a Heian F. Exercise in prevention and treatment of a day should be either moderate- or multi-disciplinary approach, involving anxiety and depression among children and young vigorous-intensity aerobic physical collaborations between physicians, patients, people. Cochrane Database Syst Rev. 2006 Jul 15,16,17 and health fitness professionals. Follow 19;(3):CD004691.
14 • Family Doctor • A Journal of the New York State Academy of Family Physicians 11 Dobbins M, De Corby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007651. 12 CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(SS-4). angel 13 Fakhouri TH, Hughes JP, Brody DJ, Kit BK, Ogden CL. Physical Activity and Screen-Time Viewing face Among Elementary School-Aged Children in the United States From 2009 to 2010. JAMA Pediatr. 2013 Jan 7:1-7. 14 2008 Physical Activity Guidelines for Americans. US Department of Health and Human Services. www.health.gov/paguidelines <- need to clarify how to cite this 15 Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP; American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-59 16 McDermott AY, Mernitz H. Exercise and older To Fidelis Care, every child is an angel. patients: prescribing guidelines. Am Fam Physician. 2006 Aug 1;74(3):437-44. That's why we cover kids with quality, affordable 17 Phillips EM, Kennedy MA. The exercise health insurance through Child Health Plus, prescription: a tool to improve physical activity. a New York State-sponsored health insurance program offered by Fidelis Care. PMR. 2012 Nov;4(11):818-25. • If your child needs health insurance, Fidelis Care can help. 18 Glasgow RE, Eakin EG, Fisher EB, Bacak SJ, • Almost every child up to age 19 in New York State is eligible! Brownson RC. Physician advice and support for • And, we help members keep their health insurance each year. physical activity: Results from a national survey. Am Quality Health Coverage. It’s Our Mission.
J Prev Med 2001;21:189-196. Some children who had employer-based health insurance coverage within the past six months may be subject to a waiting period before they can enroll in Child Health Plus. This will depend on your household income and the reason your children lost employer-based coverage. Michael Kernan, MD, is Associate Professor in the Department of Family Medicine at Upstate Medical University in Syracuse, NY. He is also Assistant Team Physician at Syracuse University, a member of 1-888-FIDELIS (1-888-343-3547) the American Academy of Family Medicine and the (TTY: 1-800-421-1220) • fideliscare.org American College of Sports Medicine. Quoc-Phong Tran, MD, is a resident at St. Joseph’s Hospital Health Center Family Medicine Residency Program in Syracuse, NY. Dr. Tran graduated from Saint Strengthen Your Louis University School of Medicine in St. Louis, Immunization Efforts With MO. after completing undergraduate work at the The Leading Vaccine Resource University of California, Irvine. BENEFITS OF JOINING ATLANTIC HEALTH PARTNERS: • Lowest prices for Sanofi, Merck and MedImmune vaccines • Discounts for medical and office supplies and services • Reimbursement support and advocacy • Medicare Part D Vaccine Program • Patient Recall Program Discount
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Summer 2013 • Volume two • Number one • 15 CLINICAL NOTES
Guidelines on Pediatric Hyperlipidemia By Alia Chauhan, MD, FAAP
Hyperlipidemia is a major Laboratory testing modifiable risk factor for cardiovascular disease. Among young adults, ages 12 to Acceptable, Borderline, and High Plasma Lipid, 19 years, 20.3% have abnormal lipids; Lipoprotein Concentrations (mg/dL) for Children and Adolescents*2 boys are more likely than girls to have Category Acceptable Borderline High High+ at least one lipid abnormality (24.3% vs. 15.9%, respectively)1. In this column I will TC <170 170-199 ≥200 review new guidelines on screening and LDL-C <110 110-129 ≥130 management of pediatric hyperlipidemia Non-HDL-C <120 120-144 ≥145 established by the Expert Panel on Integrated Apo B <90 90-109 >110 Guidelines for Cardiovascular Health and TG Risk Reduction in Children and Adolescents, National Heart Lung and Blood Institute, NIH 0-9 years <75 75-99 ≥100 (October 2012). 10-19 years <90 90-129 ≥130 Hyperlipidemia refers to an elevated HDL-C >45 40-45 <40 concentration of one or more of the ApoA-1 >120 115-120 <115 measured serum lipid components (total cholesterol [TC], low-density lipid [LDL], *Values for plasma lipid and lipoproteins levels are from the National Cholesterol Education Program high-density lipoprotein [HDL], and (NCEP) Expert Panel on Cholesterol Levels in Children. Non-HDL-C values from the Bogalusa Heart triglycerides [TGs]). Lipoproteins are Study are equivalent to the NCEP Pediatric Panel cut points for LDL-C. Values for plasma ApoB and complexes of lipids and proteins essential ApoA-1 are from the National Health and Nutrition Examination Survey III. The cut points for high and 3,4 for transporting cholesterol, TGs and fat- borderline represent approximately the 95th And 75th percentiles, respectively Low cut points for 5 soluble vitamins. HDL-C represents approximately the 10th percentile .
Risk Factors/High Risk Conditions • High level risk factors including Etiology: High risk factors and high risk conditions to hypertension requiring drug therapy, BMI Elevated levels can result from genetically consider for treatment decisions in children ≥97th percentile, and current cigarette based derangement of lipid metabolism. with hyperlipidemia include6: smoker. Primary lipid disorders most commonly • Positive family history of myocardial • Moderate level risk factors including seen in children and adolescents are familial infarction; angina; coronary artery bypass hypertension not requiring drug therapy, combined hyperlipidemia and familial graft/stent/ angioplasty; sudden cardiac BMI ≥95th but <97th percentile, and hypercholesterolemia (heterozygous). death in parent, grandparent, aunt, or HDL-C <40 mg/dL. Secondary causes include obesity, metabolic uncle (if male at age <55 years and syndrome, hypothyroidism, diabetes • High risk conditions including diabetes female at age <65 years). mellitus (type 1 and type 2), polycystic ovary mellitus, chronic kidney disease/end-stage syndrome, juvenile rheumatoid arthritis, renal disease/post renal transplant, post chronic renal disease, Kawasaki disease, and heart transplant, and Kawasaki disease hepatitis. with current aneurysms.
16 • Family Doctor • A Journal of the New York State Academy of Family Physicians • Moderate risk conditions including CHILD 1: The Cardiovascular Health Children Younger Than Age 10 Years Kawasaki disease with regressed coronary Integrated Lifestyle Diet (CHILD 1) is the Children < age 10 years should not be aneurysms, chronic inflammatory disease first stage in dietary change for children treated with a medication unless they have (e.g., systemic lupus erythematosus, with identified dyslipidemia, children with a severe primary hyperlipidemia or a juvenile rheumatoid arthritis), nephrotic a risk factor/ high-risk medical condition, high-risk condition that is associated with syndrome, and human immunodeficiency and children with a positive family history of serious medical morbidity (homozygous virus infection). early cardiovascular disease. hypercholesterolemia/LDL-C ≥ 400 mg/dL; primary hypertriglyceridemia with TG ≥ 500 Screening Dietary components: Primary mg/dL,positive family history. (Grade C) Screening recommendations are provided by beverage: fat-free unflavored milk; the Expert Panel7. limit/avoid sugar sweetened beverages, Children Ages 10–21 Years encourage water; fat content: Total fat Children with average LDL-C ≥ 250 mg/dL or • Birth to 2 years: No lipid screening. 25-30% of daily kcal/EER; saturated fat average TG ≥ 500 mg/dL should be referred (SOR C) 8-10% of daily kcal/EER; avoid trans fat directly to a lipid specialist. (Grade B). • 2 to 8 years: No routine lipid screening. as much as possible; monounsaturated Children with lipid abnormalities (other (SOR B) Measure fasting lipid profile and polyunsaturated fat up to 20% of than LDL-C ≥ 250 mg/dL or TG > 500 mg/ twice, if the family history is positive for daily kcal/EER; cholesterol <300 mg/d; dL) should be initially managed for 3-6 elevated cardiovascular risk or the child encourage high dietary fiber intake months, with diet changes (CHILD 1,→CHILD has a high level risk factor or condition. from foods. 2-LDL or CHILD 2-TG based on specific • 9 to 11 years: Universal screening with CHILD 2-LDL (for high LDL). Dietary lipid profile findings ,if BMI is≥ 85th non-fasting lipid profile and calculate components: 25-30% of calories from percentile, add increased physical activity, non-HDL-C (TC-HDL-C). (SOR B) If non- fat, ≤7% from saturated fat, 10% from reduced screen time, and calorie restriction. HDL-C is ≥145 mg/dL and HDL <40 mg/ monounsaturated fat, <200 mg/day of Children at high risk should be considered dL, repeat fasting lipid profile twice and cholesterol and avoid trans fat as much as for initiation of medication. (Grade C) obtain average level. possible, plant sterol esters and/or plant Treatment for children with severe stanol esters up to 2 g/day as replacement • 12 to 16 years: No routine screening. elevation of LDL-C: for usual fat sources can be used after age 2 (SOR B) If new knowledge of positive Based on assessment of lipid levels and years in children with FH. family history, new risk factor or new high associated risk factors or risk conditions: risk condition is identified in the patient, CHILD 2-TG (for high triglycerides • Children with average LDL-C ≥ 250 mg/ obtain fasting lipid panel (twice and [average fasting levels of TG ≥ 500mg/dL dL should be referred directly to a lipid average). or any single measurement ≥1,000 mg/dL specialist. (Grade B) related to a primary hypertriglyceridemia]). • 17 years to 21 years: Universal Dietary components: 25-30% of calories • If LDL-C remains ≥ 190 mg/dL after a screening once in this time period, obtain from fat, ≤7% from saturated fat, 10% 6-month trial of lifestyle/diet management non-fasting lipid profile and calculate from monounsaturated fat; <200 mg/d of (CHILD 1→CHILD 2-LDL) for children non-HDL–C; if non-HDL–C ≥145 mg/dL, cholesterol, avoid trans fat, decrease sugar ages 10 years and older, statin therapy HDL–C <40 mg/dL, obtain fasting lipid intake (e.g., no sugar-sweetened beverages), should be considered. (Grade A). panel (twice and average). (SOR B) increase dietary fish to increase omega-3 • If LDL-C remains ≥ 130 mg/dL to < 190 fatty acids. Management: mg/dL in a child age 10 years or older Medication with a negative family history and no Diet Expert Panel recommends decisions high-level or moderate-level risk factor For children with elevated lipids, diet is regarding the need for medication therapy or risk condition, management should recommended as first-line treatment. AAP should be based on the average of results continue to focus on diet changes (CHILD recommends that all children engage in from at least two fasting lipid profiles 2-LDL) plus weight management if BMI ≥ moderate-to-vigorous physical activity obtained at least 2 weeks but no more 85th percentile. Pharmacologic therapy for 1 hour/day and <2 hours/day of than 12 weeks apart. (SOR C). The goal is not generally indicated, but treatment sedentary screen time. The Expert Panel of LDL-lowering therapy in childhood and with bile acid sequestrants might be accepts the 2010 Dietary Guidelines for adolescence is a LDL–C below the 95th considered, in consultation with a lipid Americans (2010 DGA) as appropriate percentile (≤130 mg/dL). specialist. (Grade B) recommendations for diet and nutrition in children 2 years of age and older. CONTINUED NEXT PAGE
Summer 2013 • Volume two • Number one • 17 • If LDL-C remains ≥ 160 to 189 mg/dL fish intake, may be considered for fish oil Apolipoprotein B and AI distributions in the United after a trial of lifestyle/diet management supplementation. (Grade D) States, 1988-1991: results of the National Health (CHILD 1→CHILD 2- LDL) in a child age and Nutrition Examination Survey III (NHANES • Children ≥ 10 years with non-HDL-C 10 years or older with a positive family or III). Clin Chem. 1997;43(12):2364-2378. levels ≥ 145 mg/dL after the LDL-C 4 Srinivasan SR, Myers L, Berenson GS. Distribution at least one high-level risk factor or risk goal is achieved may be considered for and correlates of non-high-density lipoprotein condition or at least two moderate-level further intensification of statin therapy or cholesterol in children: the Bogalusa Heart Study. risk factors or risk conditions then statin additional therapy with a fibrate or niacin, Pediatrics. 2002;110(3):e29. therapy should be considered.(Grade B) in conjunction with referral to a lipid 5 Bachorik PS, Lovejoy KL, Carroll MD, Johnson CL. If LDL-C remains ≥ 130 to 159 mg/dL specialist. (Grade D). Apolipoprotein B and AI distributions in the United after a trial of lifestyle/diet management States, 1988-1991: results of the National Health Statin therapy is recommended as the and Nutrition Examination Survey III (NHANES (CHILD 1→CHILD 2- LDL) in a child initial medication for treating children with III). Clin Chem. 1997;43(12):2364-2378. age 10 years or older with at least two elevated LDL–C or non-HDL–C levels8. 6 Kavey RE, Allada V, Daniels SR, et al; American high-level risk factors or risk conditions Heart Association Expert Panel on Population or at least one high-level risk factor Bile acid sequestrants were the first- and Prevention Science; American Heart or condition together with at least two line medications recommended in the Association Council on Cardiovascular Disease in moderate-level risk factors or risk original NCEP Pediatric Guidelines. The the Young; American Heart Association Council conditions then statin therapy should be primary adverse effects of the bile acid on Epidemiology and Prevention; American considered (Grade C). sequestrants are gastrointestinal including Heart Association Council on Nutrition, Physical bloating, nausea, diarrhea, and constipation; Activity and Metabolism; American Heart • For children ages 8 and 9 years with these significantly affect adherence. NCEP Association Council on High Blood Pressure LDL-C persistently ≥ 190 mg/dL after a recommends reassessing LDL approximately Research; American Heart Association Council trial of lifestyle/ diet management (CHILD every 6 weeks until the LDL goal is met, then on Cardiovascular Nursing; American Heart 1→CHILD 2-LDL), together with positive every 6 to 12 months9. Association Council on the Kidney in Heart family history or the presence of at least Disease; Interdisciplinary Working Group one high-level risk factor or condition or on Quality of Care and Outcomes Research. Resource For Providers: the presence of at least two moderate-level Cardiovascular risk reduction in high-risk risk factors or conditions statin therapy Expert Panel on Integrated Guidelines for pediatric patients: a scientific statement from might be considered. (Grade B). Cardiovascular Health and Risk Reduction in the American Heart Association Expert Panel on Population and Prevention Science; the Children with elevated TG or Children and Adolescents Summary Report. National Heart Lung and Blood Institute. NIH Councils on Cardiovascular Disease in the elevated non-HDL-C: Young, Epidemiology and Prevention, Nutrition, publication No. 12-7486A. October 2012, • Children with average fasting levels of TG Physical Activity and Metabolism, High Blood http://www.nhlbi.nih.gov/guidelines/cvd_ ≥ 500 mg/dL or any single measurement Pressure Research, Cardiovascular Nursing, ped/peds_guidelines_sum.pdf, accessed ≥ 1,000 mg/ dL related to a primary and the Kidney in Heart Disease; and the April 2013. hypertriglyceridemia should be treated Interdisciplinary Working Group on Quality of in conjunction with a lipid specialist; the Care and Outcomes Research: endorsed by the Alia Chauhan, MD, FAAP, is an Assistant Professor American Academy of Pediatrics. Circulation. CHILD 2-TG diet should be started and at Hofstra North Shore-LIJ School of Medicine and use of fish oil, fibrate,or niacin to prevent 2006;114(24):2710-2738. a member of the Faculty of the Family Medicine 7 Expert Panel on Integrated Guidelines for pancreatitis should be considered. Residency Program North Shore/LIJ- Southside Hospital. Cardiovascular Health and Risk Reduction in (Grade D) Children and Adolescents Summary Report. • Children with fasting levels of TG ≥ 200 References National Heart Lung and Blood Institute. NIH to 499 mg/dL after a trial of lifestyle/diet 1 Prevalence of abnormal lipid levels among publication No. 12-7486A. October 2012, http:// youths—United States, 1999-2006. management with CHILD 1→CHILD 2-TG, MMWR Morb www.nhlbi.nih.gov/guidelines/cvd_ped/peds_ should have non-HDL recalculated and Mortal Wkly Rep. 2010;59(02):29-33, http://www. guidelines_sum.pdf, accessed April 2013. cdc.gov/mmwr/preview/mmwrhtml/mm5902a1. 8 Wiegman A, Hutten BA, de Groot E, et al. Efficacy be managed to a goal of < 145 mg/dL. htm, accessed April 2013. and safety of statin therapy in children with familial (Grade D) 2 NCEP Expert Panel of Blood Cholesterol Levels in hypercholesterolemia: a randomized controlled • Children with fasting levels of TG ≥ 200 to Children and Adolescents. National Cholesterol trial. JAMA. 2004;292(3):331-337. 499 mg/dL, non-HDL > 145 mg/dL, after Education Program (NCEP): Highlights of the 9 Third report of the National Cholesterol Education a trial of lifestyle/diet management with report of the Expert Panel on Blood Cholesterol Program (NCEP) Expert Panel on Detection, Levels in Children and Adolescents. Pediatrics. Evaluation, and Treatment of High Blood CHILD 1→CHILD 2-TG and increased 1992;89:495-501. Cholesterol in Adults. (Adult Treatment Panel III), 3 Bachorik PS, Lovejoy KL, Carroll MD, Johnson CL. Executive Summary. (NCEP/NHLBI., 2004-07-13). 18 • Family Doctor • A Journal of the New York State Academy of Family Physicians CME ARTICLE CME & POST-TEST
THE MANAGEABLE CHALLENGE WEIGHT LOSS PROGRAM: TRYING A DIFFERENT APPROACH NO TIME TO BE TIMID ABOUT OBESITY
By William Klepack, MD and Ron Rouse
New York State is losing the war against obesity because our strategy is weak and unimaginative. It is time to attack this costly and disabling public health threat in more creative and aggressive ways. Obesity is a pervasive, expensive problem. Sixty percent of New Yorkers are either obese or overweight, and the condition affects all age and ethnic groups. The health care cost of obesity was estimated at $185 billion nationally in 2012, which means New York State could be expending as much as $15 billion per year, and lost productivity could be another $15 billion. Obesity matches and may surpass tobacco in terms of its negative impact on health and consumption of health care dollars. One of the fundamental requirements for control of health care costs in the near future is to lower obesity rates. Our response to obesity in New York has been neither bold nor effective, nothing like our all-out frontal assault against tobacco. New York State government has expended hundreds of millions of dollars over the past several years on tobacco cessation and prevention programs. It has conducted an aggressive anti-tobacco media campaign. New York has enacted the nation’s highest tax on tobacco. State laws greatly restrict the sites where people can use tobacco. Doctors are reimbursed for helping their Medicaid patients quit. As a result, New York State has one of the lowest tobacco use rates in the nation. But, in contrast, State government has expended much less to fight obesity and enacted few significant legislative actions. The NYS Academy of Family Physicians advocates a statewide campaign to address obesity that matches the budgetary and legislative scope and magnitude of the anti-tobacco campaign. This Many members of the Academy's campaign must create and use multiple strategies to help our patients reach healthier weights. Commission on Public Health It must change our culture and promote awareness that achieving healthy weight is a blend contributed significantly to the of personal responsibility and outside help. We have no choice but to invest money in this development and improvement of the enterprise in order to protect health and reduce costs in the future. Manageable Challenge program, and we thank them for their important What should some of these statewide strategies and investments look like? Consider aggressive contributions. media and social marketing techniques, effective weight loss programs that are financially accessible to all who need them, low-calorie meals at schools and restaurants, calorie posting, smaller portions, a statewide ban or limitation on trans fats, reimbursement for doctors to help patients lose weight, provision of affordable medications where indicated, and creation of local advocacy coalitions. An effective tax policy would also be helpful, even though it would be difficult to accomplish. There are innumerable possibilities for intervention, but more importantly our State needs a coordinated campaign of this magnitude and scope if we are to have a chance at combating obesity. We are facing a scary future of increasing illness and increasing cost. This is no time to be timid. The Academy actively advocates many of the aforementioned strategies. One of the more effective resources for helping people to lose weight is you, the physician. Thus, one of the most powerful actions you can take to help end the obesity epidemic is to help your patients lose weight. The Academy has created a weight-loss program called Manageable Challenge which is described here and we urge you to incorporate it into your practice.
William Klepack, MD, is a family physician in Dryden, NY and was Chair of the NYSAFP Public Health Commission. Ron Rouse is a health care consultant and staff representative on the NYSAFP’s Public Health Commission.
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Summer 2013 • Volume two • Number one • 19 CME ARTICLE, continued
As physicians, we know that most of our adult patients are obese your patients to set goals that are reasonable. Patients should aim or overweight as are an estimated 60% of New Yorkers. Obesity is to lose 1-2 pounds per week and avoid improbable goals such as one of the deadliest, costliest, and most intractable health problems losing 10 pounds in 20 days. Discourage your patients from basing facing our patients. Many of them want to lose weight, yet most their weight-loss goal on some unrealistic beauty goal or what they either try and fail or simply never try. We want to help them be weighed when they got married or graduated from school. Also, successful but often we find what we are doing is not effective. encourage them to be flexible; if, after dieting, they think they cut Family doctors are looking for some help. back too much on their eating, then encourage them to cut back a little less if they are losing weight. The standard, conventional approach to losing weight often fails because people who for decades have consumed too much, eaten the wrong foods, and not moved are told they now have to eat less, drop A Critical Step: Finding One’s Daily Calorie Cap their favorite foods, and start exercising. This “triple challenge” A critical step in Manageable Challenge is for patients to start with an becomes overwhelming and thus people end up doing nothing or estimate of the maximum amount of calories they can consume and failing within a brief period of time. We have come to realize that an still lose 1-2 pounds per week. A person’s calorie cap is a function entirely different approach is needed if we are to effectively address of age, gender, weight, height, and activity level. For example, with the obesity epidemic among our patients. We must focus weight loss every increase in age by 10 years for males, one’s daily calorie needs initially on one, single challenge – consuming fewer calories. Hence, decrease by about 100; for females it is about 70. Gender plays a the name “Manageable Challenge.” role. Depending on one’s weight and age, females require anywhere from 600 to 1,000 fewer calories than males of the same age and A Single, Manageable Challenge weight. Our approach is based on a “calorie deficit” – burning more A heavier person burns more calories for daily activity than a less calories than the number consumed. The body burns some calories heavy person; for instance, a 230 pound female needs about 400 for basal metabolism and additional calories to accomplish the work fewer calories per day than a 330 pound female. Thus, doctors of simple activities (moving about one’s home or office, shopping should continually remind their dieting patients as they lose weight and doing other easy activities). When people eat fewer calories that eventually their calorie expenditure will decrease to where than what their body needs for these and other purposes, they lose it now equals their reduced calorie intake (what many patients weight. Focusing on helping patients achieve a calorie deficit is less call “getting stuck”). At that new balance point the doctor must intimidating for the patient than facing the “triple challenge.” explain that the patient’s intake should be tweaked further and the patient must now consume fewer calories; otherwise patients, Manageable Challenge does not rely nor insist upon daily exercise or having reached a plateau in their attempts to lose weight, will eating all the “right” foods. For many people who want to lose weight become frustrated and possibly give up. Warning patients about this approach is a welcome and refreshing change. Although eating this phenomenon before they experience it will help preserve your healthy and exercising are laudable lifestyles to adopt, and they do credibility and avoid patient frustration and premature quitting. facilitate weight loss, they are not needed to lose weight. Eating “healthy foods” can reduce one’s health risks but can be a very We recommend that males consume no fewer than 1,500 calories challenging adjustment. Exercise, while beneficial for cardiovascular per day and no fewer than 1,200 for females. The calorie caps health, overall well-being, and maintaining weight loss, is not a very used in Manageable Challenge are based on a widely used formula efficient way to achieve weight loss. However, we believe that once developed by the National Academy of Science’s Institute of Medicine patients start losing weight by consuming less, their success will (see partial Table below; to see full Table, go to http://www.nysafp. motivate them to eat healthier foods and become active, and we will org/weightloss/AFP-MC-Patient-Packet.pdf.) encourage them to do so when the timing is right. The formula is also used by the US Department of Agriculture and the US Department of Health and Human Services. This formula Set A Realistic Weight-Loss Goal takes into account gender, age, weight, and height and therefore Manageable Challenge aims to help patients reach a healthier weight, offers calorie caps that are tailor-made for and recognize individual not necessarily a “perfect” weight, so losing even some weight is characteristics, unlike some programs that simply recommend great success. In fact, a 5%-10% weight loss will still make patients the same or similar caloric intake regardless of patients’ varying feel healthier because they will be healthier. Therefore, direct characteristics. But no method of estimating calorie caps is
20 • Family Doctor • A Journal of the New York State Academy of Family Physicians Daily Calorie Cap Chart (for men)
STEP 3- My age is closest to: STEP 2 - STEP 1- Each Week My Weight is I Want to Closest to: 20 25 30 35 40 45 50 55 60 65 Lose: STEP 4- Then, My Daily Calorie Cap is about: 1 pound 2000 1955 1905 1855 1810 1760 1715 1665 1620 1570 150 2 pounds 1500 ** ** ** ** ** ** ** ** ** 1 pound 2075 2025 1980 1930 1880 1835 1785 1740 1690 1645 160 2 pounds 1575 1505 ** ** ** ** ** ** ** ** 1 pound 2145 2095 2050 2000 1955 1905 1860 1810 1765 1715 170 2 pounds 1645 1595 1550 1500 ** ** ** ** ** ** 1 pound 2215 2170 2120 2075 2025 1980 1930 1886 1835 1790 180 2 pounds 1715 1670 1620 1575 1525 ** ** ** ** ** 1 pound 2290 2240 2195 2145 2100 2050 2005 1955 1910 1860 190 2 pounds 1790 1740 1695 1645 1600 1550 1505 ** ** ** 1 pound 2365 2315 2270 2220 2170 2125 1575 2030 1980 1935 200 2 pounds 1865 1815 1770 1720 1670 1625 1575 1530 ** ** foolproof. The wise physician will take out some verbal “insurance” one of the biggest reasons people do not lose weight is that they with his/her patients and tell them that the estimate is just that and consistently undercount the number of calories they consume. A log will likely need tweaking depending on whether the compliant patient helps to prevent that. Smart phone apps are very helpful for selected is actually losing weight. patients. The sample table is based on a widely-used formula developed by the National Academy of Science’s Institute of Medicine. The formula is Banking Calories used by the US Department of Agriculture and the US Department of One of the more appealing aspects for helping patients cope with Health & Human Services, the emotional ordeal of consuming less is the concept of “banking” calories. This tactic enables patients to exceed their Daily Calorie 500 or 1,000 Cap for a special occasion and still lose weight as long as they go below their Daily Calorie Cap on the other days. For example, if a The Institute of Medicine defines the estimated number of calories a person consumes 150 calories below her/his Calorie Cap for six person needs to simply maintain his/her weight as one’s Estimated days, then that person has “banked” an additional 900 calories Energy Requirement (EER). Other terms that have similar meaning (6 x 150) that s/he then can consume at the upcoming event and include Resting Energy Expenditure or Resting Metabolic Rate. If still meet the goal of losing 1 or 2 pounds per week. Similarly, if a patients want to lose 1 pound per week they have to consume 3,500 patient wants to save up for a special dinner that same night, s/he can fewer calories each week than their EER. Thus, each day they have eat less during the day. Further, if patients go over their Daily Calorie to consume an average of 500 fewer calories; if patients want to Cap, they can cut back the next week. The Calorie Log will help lose 2 pounds per week, then 7,000 fewer calories per week and an patients keep track of their calorie "banking” efforts. While this tactic average of 1,000 fewer calories per day. For example, if a person can be very successful, warn patients about the risky habit of drawing burns 2,700 calories daily to maintain her/his weight – the point on their credit without replenishing their “account”! at which s/he neither gains nor loses weight – then s/he cannot consume more than 2,200 calories per day to lose one pound per week and 1,700 per day to lose 2 pounds per week. A Lapse Now and Then Losing weight is extremely difficult so anticipate that most of your The Next Important Step: patients occasionally will lapse by exceeding their Daily Calorie Caps. Actually Consuming FewerCalories Relapse occurs when several lapses string together. Occasional The next important step, once patients know their Daily Calorie Cap, lapses or a relapse may lead the person to give up and quit the is to remain at their cap. Manageable Challenge’s Patient Packet (see program. Forewarn your patients there is a good chance they will next article) provides several tools to help them do this, such as a lapse but they should not become discouraged, nor should you free Calorie Wheel, Picture Portion Guide, a Daily Log, and Helpful as their physician. Instead, you and your patients should realize Tips, among other items. The Log is particularly important because CONTINUED NEXT PAGE
Summer 2013 • Volume two • Number one • 21 CME ARTICLE, continued
everyone makes mistakes and be prepared to CME POST-TEST respond positively by “picking oneself up” and Instructions: re-starting the weight-loss program. Health care professionals seeking AAFP credits will receive 1 credit for the year in which the quiz is taken upon the completion of this quiz online at www.nysafp.org under the Recommendations on Billing for Education and Events tab. Health care professionals seeking Category 1 AMA credits are Weight-loss Counseling eligible to receive 1 credit in Category 1 of the Physician’s Recognition Award of the AMA. Given that, with rare exception, there are no NYSAFP staff will notify those who take the quiz of their scores. reimbursable codes for obesity counseling and Physicians are responsible for reporting their own CME credits to their respective prevention, it is necessary to use an ICD diagnosis organizations. code for one of the many obesity related 1) What are the three parts of the typical triple challenge to losing morbidities. Then, an appropriate E/M code weight? a) Eating healthy (e.g., 99214, 25-minute counseling) should be b) Banking calories selected which takes into account the time factors c) Maintaining a Daily Calorie Log in counseling and coordinating the patient’s care. d) Exercising Meanwhile, the Academy is actively advocating e) Consuming less food for the creation of unique reimbursement codes 2) The initial focus of Manageable Challenge is to for weight-loss counseling and it appears that the a) Exercise Federal Affordable Care Act requires such codes b) Consume less food beginning in 2014 for many insurance policies. c) Identify the correct billing code for weight-loss counseling d) Eat healthy 3) As a realistic goal, how many pounds should a patient lose per week? Your Comments on Manageable Challenge a) 1-2 pounds per week We are constantly in the process of refining the b) About a pound per day c) About a pound every 2 days program. We welcome your suggestions and d) 1 pound every 2 weeks experiences and ask that you email them to 4) If a patient wants to lose one pound per week, then each day the [email protected]. patient should consume how many fewer calories than their Estimated Energy Requirement? a) 200 b) 300 c) 400 d) 500 5) One of the biggest reasons patients fail to lose weight is they… a) Do not exercise regularly b) Consistently undercount the number of calories they consume c) Do not eat less than 1,200 calories per day d) Use the wrong Daily Calorie Cap 6) True or False. A person’s daily caloric needs ….. a) are not affected by age b) are the same for males and females c) decrease as a person loses weight d) remain the same as they lose weight 7) True or False. Exercise … a) is a must for losing weight b) is not a very efficient method for losing weight c) aids in maintaining weight loss and improves cardiovascular health
To complete the test, go to: nysafp.org>education+events
22 • Family Doctor • A Journal of the New York State Academy of Family Physicians MANAGEABLE CHALLENGE DESCRIPTION OF PROGRAM ELEMENTS 1,000 fewer calories than their EER. The Patient Packet contains a table that enables patients to find their estimated calorie cap or they can go to The two main components of Manageable Challenge are the Patient Schedule the NYSAFP web site to use an automatic calculator http://www.nysafp.org/ for Office Visits & Telephone Calls and the Patient Packet. caloriecap. Again, the table and the automatic calculator provide estimates for their calorie caps. Some people will need more or fewer calories than Patient Schedule the number presented. Both the table and the automatic calculator are based on a widely-used formula developed by the National Academy of We have developed a suggested structure and timeframe for office visits and Science’s Institute of Medicine. phone calls to the patient. This document is meant to serve only as a guide. As the practitioner, you may use it as you see fit. Some practitioners will Help In Meeting One’s Daily Calorie Cap want to conduct several office visits and phone calls while others will want to At this point, patients know what their Daily Calorie Cap is. One of the biggest combine them. Similarly, some practitioners will want to provide individual frustrations in losing weight is that people consume more calories than visits whereas others will prefer group visits. Download the Patient Schedule they think. Manageable Challenge provides some tools on how to avoid this at http://www.nysafp.org/weightloss/AFP-MC-Patient-Schedule.pdf. mistake. The first office visit focuses on introducing Manageable Challenge to your Calorie Counter Wheel. It is distributed by the NYS Department of Health. patient, assessing the nature and extent of her/his weight problem, discussing It gives people the number of calories for many different foods and snacks. prior weight loss attempts, and evaluating the patient’s readiness to lose The wheel offers only an “idea” of how many calories are in food items. The weight. If the patient is prepared to lose weight, the second office visit, which actual number of calories may often vary, especially if a food item has lots of some doctors may choose to combine with the first, focuses on developing a sauces and dressings. You can ask for up to 10 free wheels by sending an personalized weight-loss plan for the patient. The personalized plan includes email to our Academy office at [email protected] or you can directly order setting a weight loss goal, deciding the number of pounds to be lost per week, several dozen free wheels from the NYS Department of Health at http://www. determining the patient’s Daily Calorie Cap, and explaining how to use various health.ny.gov/publications/4208 and ask for Item #1225 (Food & Fitness weight-loss tools to ensure success. Subsequent office visits and telephone Wheel). calls are to determine patient progress, revise the personalized plan if The Visual Portion Guide helps people to more accurately estimate the needed, provide encouragement, and choose a new start date if the patient portion sizes of the food they eat by comparing those portions to common has terminated the plan. items such as a baseball or a deck of cards. “Learning to Read Food Labels” teaches people the importance of Patient Packet determining how many calories are in one serving of the particular item they The Packet explains the program to your patients, but obviously you or are consuming and the number of servings in the container or carton. This your staff will need to answer questions they may have. Some patients will knowledge will help them become sensitive to the fact that eating only one require more time than others to fully understand the program. The Patient serving may equal 250 calories but eating all three servings contained in the Packet also contains tools that will help your patients remain below their carton means consuming 750 calories Daily Calorie Cap. You can download the Packet at: http://www.nysafp. Daily Calorie Log. Patients must not only use the above tools to count calories org/weightloss/AFP-MC-Patient-Packet.pdf or you can ask patients to go to but, just as importantly, they need to add up all those calories so they do not the Academy website so they can access the program directly at http://www. go over their daily and weekly calorie caps. Patients only need to keep a log nysafp.org/loseweight. for a while -- perhaps for four weeks – until they learn to accurately estimate Some of the key elements of the Patient Packet include: their daily caloric consumption. • Steps for explaining the overall concept of Manageable Challenge and Remember: one of the big problems in weight loss is that people eat a lot emphasizing that the program is based on one challenge – consuming more than they think so they become frustrated because they are not losing fewer calories than one’s body burns. The Packet also explains that people weight. The Daily Calorie Log will keep them on track. can still eat some of their favorite foods and that exercise is not a must for “Banking” Calories. As described in the previous article, “banking” is a tactic losing weight. that enables patients to exceed their Daily Calorie Caps for a special occasion • A guide for helping your patients determine their weight-loss goals, and still lose weight as long as they go below their Daily Calorie Caps on the timeframe, and start date. other days. The Calorie Log will help patients keep track of their calorie "banking” efforts. • Finding a patient’s Daily Calorie Cap. As mentioned in the previous article, if patients want to lose one pound per week they must consume 500 Helpful Tips. The Patient Packet contains over 30 tips to help your patients fewer calories per day than their bodies need, also called their Estimated cope with the daily rigors of dieting and to facilitate their efforts is to consume Expenditure Requirement (EER). To lose two pounds, they must consume less food.
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24 • Family Doctor • A Journal of the New York State Academy of Family Physicians HRCOMP-SOAP: A new model for the primary care visit By William Bayer, MD
Many forces are coming together coaches high risk patients. The high risk starts the interview process. The nurse care to change the way we organize primary care patients are selected on the basis of recent manager, or other staff, usually will have visits. The Patient Centered Medical Home hospitalizations, gaps in care targets (such already tracked down hospital and referral (PCMH) model stresses collaborative team as HbA1c), and provider choice. notes, but the MA will need to confirm they care with an emphasis on care coordination are all up to date. I will flesh out below the In addition, we have expanded the role and motivational interviewing through components of the HRCOMP visit. care plans. Studies have analyzed the tasks of the medical assistant (MA) to include of primary care physicians (PCP’s), and collection of data, health coaching, patient H-Hospital record retrieval. In an ideal calculated that 18 hours per day are needed interviewing, medicine reconciliation, and world pertinent hospital information would to complete routine preventive and chronic preventive care assessment. download directly to the medical record, but alas this is often not the case! Our care tasks for an average PCP patient load This work allows the provider to have a rich nurse care manager usually procures this (1,2). Finally, taking the lead from industry, array of information with which to start an information within 60 hours of discharge, so medical programs have incorporated “Lean” effective interview. The preparatory work that the MA only has to confirm the retrieval. practices, as originally implemented by Toyota falls under the pneumonic of HRCOMP, manufacturing. One of the tenets of Lean as described below. After HRCOMP is R-ROS. We perform a basic ROS on each practice is having each worker complete the completed the provider is then able to patient, which screens for depression and tasks which are most appropriate to his or perform an interview using the traditional cardio-respiratory problems. Any red flags her skill level. In the context of medicine, this SOAP format. can be followed up with further testing such would mean freeing the physician of duties as a PHQ-9, pulse oximetry, or EKG, all done The pneumonic HRCOMP lays out the which another team member could handle per protocol before the provider enters the essential elements which need to be more efficiently, thus allowing for “heijunka”, room. or production of care at an even rate. collected for each patient encounter, as follows: C-Care plans. Care plans are an essential In our office we are seeing the team care feature of the PCMH. The nurse care -Hospital record retrieval. concept evolve on various fronts, which H manager reviews the need for care plans include daily team huddles and intensive care R-ROS-a mini ROS to assess depression and before each visit, and the MA updates the coordination. With the PCMH as a framework, cardio-respiratory status. care plans as needed. we employ a part time care coordinator who “preps” the office visits for care discrepancies C-Care plan review, as per PCMH standards. O-Outstanding referrals, labs, and imaging. Outstanding referrals and orders are and gaps in care plans. The care coordinator O-Outstanding referrals, labs, imaging. also prints the hospital census for each of generally managed by a care manager, but our four local hospitals and sends patient M-Medicine reconciliation. the MA may need to track down further summaries to the hospitals. information based on patient responses to P- Preventive care update, including our intake form (Figure 1). Incomplete Our nurse care manager handles transition immunizations. referral, lab, and imaging orders are issues for hospital discharges, does population The MA is in charge of ensuring all this generally reprinted by our care manager management for targeted diseases, and information is up to date before the provider prior to the patient visit. CONTINUED NEXT PAGE Summer 2013 • Volume two • Number one • 25 M-Medicine reconciliation. Patients do most of this work by bringing their medicines to each visit and reviewing a printed medication list (Figure 2) in the reception or exam areas. The MA then reviews the results as needed, marking discrepancies and highlighting meds that need refills. P-Preventive care. Preventive care needs, including immunizations, are highlighted in advance by the care manager. Flu shots are administered by the LPN, per office protocol. In our office the HRCOMP protocol is performed for every scheduled visit, with an attempt to complete most elements for acute visits as well. The “Hub” for this activity is the patient intake form (Figure 1). The care manager generates the intake form which goes through the following iterations; 1. Initially generated by the EHR, with pertinent lab values and overdue preventive care items automatically generated. 2. Reviewed by our care manager, to highlight care gaps and the need for care plans. 3. Continued by the patient on arrival to the office. 4. Completed by the MA when rooming the patient 5. Reviewed and signed by the main provider of care before entering the exam room. The main provider thus has an educated patient as well as a comprehensive data base before starting the patient interview process using traditional SOAP methodology. Figure 1 The HRCOMP-SOAP interview process involves a much more comprehensive medical visit with a great deal more resource utilization than the traditional visit format of 10 or 20 years ago. The process is congruent, however, with team concepts and patient involvement outlined by the PCMH model. It also allows the main provider to conduct the medical interview with greater efficiency, per Lean guidelines. Regarding resource utilization, the process for one main provider requires about 2 hours per day of care management time and one MA is needed for each provider. On the other hand, having the vital information supplied by the HRCOMP format streamlines the main provider visit. Many of these visits will be billed at a higher level of care than traditional visits. Finally, most certified medical homes receive compensation in various ways for providing more comprehensive care. In summary, this paper outlines a new approach to medical office visits, using the HRCOMP-SOAP format. This new model ensures a comprehensive, thorough approach to care, using a team model with patient interaction. The team, consisting of a care manager, MA, and provider interact through the use of a patient intake sheet which ensures completeness of care for each medical visit, and allows each team member to participate as is appropriate to his or her training.
References 1 Yarnell et al. Am J Public Health 2003; 93:635 Figure 2 2 Ostbye et al., Annals of Fam Med 2005; 3:209.
William Bayer, MD, has been a private family practitioner for over 20 years in downtown Rochester, NY. He attended Harvard Medical School and interned at Highland Family Medicine in Rochester. Currently, he is a Clinical Associate Professor of Family Medicine at URMC which has had NCQA Level III Patient Centered Medical Home status since 2010.
26 • Family Doctor • A Journal of the New York State Academy of Family Physicians RESIDENT PERSPECTIVE
My Personal Exploration into Mind-Body Medicine By Grace M. Charles, MD
As a recent medical school graduate with a physician no doing, only being, whatever that may mean to for a mother, I had the opportunity to appreciate the individual practitioner. Tan suggests beginners many of the advances my generation experienced institute a practice of two minutes of mindfulness in medical education: recorded lectures, patient each day, so that is what I did. Regular mindfulness simulators, online testing, electronic medical records, practice, as Tan explains, “deepens the inherent and a deeper knowledge of molecular medicine calmness and clarity in the mind. It opens up the amongst them. One thing that continues to lag, possibility of fully appreciating each moment in unfortunately, is the support and training of medical life, every one of which is precious. It is for many students in caring for themselves. It was my own people, including myself, a life-changing practice. struggle with this, and my mother’s confirmation of Imagine—something as simple as learning to just the same difficulty during her training, that prompted be can change your life 2.” my exploration of ways to prevent stress and I was searching for a practice that would keep maintain overall health during my years of limited me grounded in the moment so I could better sleep, difficult work, and living in that nebulous state appreciate and take advantage of the valuable of being a student doctor. time I spent with my patients, peers, and teachers. Below I report on some practices I discovered that And so my practice of mindfulness began. Every benefited me during medical school in particular. morning, I sat down, set a timer for two minutes, These practices tend to be included under the closed my eyes, and would simply “be” until the umbrella of mind-body medicine, defined by the timer chimed. Starting my day in this way had National Center for Complementary and Alternative several personal benefits. For one, it put the day Medicine as practices that focus on the interactions before me into perspective, enabling me to see the among the brain, mind, body, and behavior, with the many items on my to-do list in the larger context intent to use the mind to affect physical functioning of what I actually was accomplishing with my and promote health 1. I’ve found them to be useful, life. Second of all, it gave me a mental anchoring and I hope you will, too. point. When I found my mind growing tired and restless as the day wore on, I reminded myself of Be Mindful how only hours before I sat and was present in the moment for those two minutes. This enabled In the book Search Inside Yourself, based on author me to more easily return to that familiar state of Resident/Student Perspective Chade-Meng Tan’s mindfulness course he teaches at mind no matter what I was doing in the present We hope that students and Google, Tan explains that mindfulness is simply the moment, be it a patient interaction or written exam. resident physicians will contribute practice of paying attention moment-to-moment without Thirdly, since undertaking a regular mindfulness to this column in future issues, judging. Thus, he says, it is inherent within us and easy practice, I have observed an increasing emotional particularly to inform Academy to learn; the difficulty lies in developing it to the point maturity that I believe to be largely related to members about projects or that one can encounter difficult moments with calm and making the effort to be purposefully present in research in which they are involved thoughtfulness as well. He recommends two ways of the moment. In particular, during some difficult or interesting clinical situations practicing mindfulness: the Easy Way and the Easier Way. patient interactions, I have noted the presence of they have encountered. (Email In the Easy Way, the practitioner focuses his attention on the emotion while maintaining the mental calm to [email protected] for more the breath; if his mind wanders, he gently brings it back figure out how to best handle the situation at hand. information.) ◗ Editor to the breath. The Easier Way lacks any agenda; there is CONTINUED NEXT PAGE
Summer 2013 • Volume two • Number one • 27 Exercise and refocus after returning home from a long day. After that short respite, I felt an improved outlook and was able to get back to work We all know exercise is good for our bodies. It took a disruption in with vigor and positivity. Especially after spending the day working my normal exercise routine to teach me the extent of what it does hard in a bright and noisy hospital, I have found it particularly for my mind-body wellness. Having practiced yoga and been a gym effective to meditate sitting or lying down in the dark and quiet. regular for years, I didn’t have much experience living life without In addition to the Chopra Center challenges, other sites, including exercise. I learned my lesson the hard way: as my hours of sleep YouTube, offer access to free guided meditations. There are many dwindled and exams loomed, I stopped making time for exercise. forms of meditation, including imagery, mantras, walking meditation, To give my education my all, I decided to spend all of my time on body scans, and so on. Experiment and choose what works it. It was to the hospital, home to study, rinse and repeat. This was, best for you. in fact, incorrect; devoting all of my time to my medical education ultimately detracted from it. Without exercise, I found my thoughts more scattered, my mood more labile, and my body less strong Breathe and in shape, resulting in my feeling more mentally vulnerable as Deep breathing has played an important role in all well. In addition, my mind was restless when it came time to study, three of my practices mentioned above. In yoga, resulting in less efficient study sessions. I realized that physical the breath is synchronized with movement so as to activity is a necessary part of my day. At some point continuing support both the mind and physical body through to work your mind without giving your body the opportunity to the flow of poses. A deep inhalation can summon exercise too reaches a point of diminishing returns. strength for both the mind and body to inspire Yoga in particular is a form of exercise I enjoy and oneself to hold a difficult pose; a deep exhalation recommend. The word yoga is Sanskrit for yoke or union, encourages relaxation of the thoughts as well as specifically referring to the integration of the mind and body. of tight muscles. In meditation and mindfulness The standard practice requires strength, flexibility, and practices, prolonged deep breaths may be balance, while encouraging students to be present in the the primary focus of the mind or may be used moment, to keep the mind clear of unrelated thoughts, and to support the slowing of the whirl of one’s to have an open heart full of wishes for peace, happiness, thoughts. In recognition of these benefits, I and liberty for all beings. Yoga also offers practitioners the expanded deep breathing to other areas of my opportunity to set an intention for their practice or to dedicate life. Particularly as we know that the breath tends it to a specific individual or group of individuals. I often find to become more rapid and shallow when times get myself thinking of my clinical duties and how, by learning hectic, slow deep breathing is a great way to counter to have a more open heart through my intentions, I can the body’s excitement and to encourage a return to become better at empathizing with and caring for a state of calm. Therefore, I like to check in with my patients. Ultimately, my yogic intentions myself every now and then while at work, observing infuse into my approach to everyday my thoughts and emotions, where I feel tension body, life, reminding me to be positive in and the quality of my breathing. Then I take a deep my dealings with others and to breath in and out of my nose: with the inhalation I appreciate and be grateful for feel the sequential expansion of my abdomen and opportunities to share with, learn then my thorax and with the exhalation their slow from, and care for them. If you are release in the opposite direction. This purposeful interested in trying yoga or increasing your practice, breathing helps to quiet my mind and release physical consider taking a class designed for your skill level at a local tension throughout my body. Check in with yourself studio or getting a DVD so you can practice at your convenience. periodically throughout the day. If you need a reminder, consider aiming to observe your breathing every hour on the hour and to practice one deep breath at that Meditate time, noting how the state of your mind and body I used to lose a lot of valuable time in the transition period between changes after the breath. arriving home from the hospital and getting anything of significance I encourage you to try each technique and modify them done at home. I wanted to rest and play but needed to get work as you like to find what resonates with you. Then you done. I found my solution in the form of meditation. The Chopra can incorporate into your life the practices that best Center occasionally releases free 21-day meditation challenges. A serve you and share them with your friends, family, friend of mine forwarded me an invitation to one such challenge, patients, and students. and I found the 15 minute guided meditations—an inspiring lesson held within each—to give me the opportunity for rest, relaxation,
28 • Family Doctor • A Journal of the New York State Academy of Family Physicians References Grace M. Charles, MD, is a first-year Family Medicine resident at Overlook Hospital 1 Meditation: An Introduction. National Center for Complementary and Alternative in Summit, New Jersey. She is a yoga teacher and studies yoga therapy and holistic Medicine (NCCAM), created Feb 2006, updated Jun 2012. Web. Accessed May and integrative medicine. She has conducted research on hyperkalemic periodic 2013. http://nccam.nih.gov/health/meditation/overview.htm paralysis and is a board member of the Periodic Paralysis Association. She graduated 2 Tan, Chade-Meng. Search Inside Yourself. New York: HarperOne, 2012. Print. from the Icahn School of Medicine at Mount Sinai.
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Summer 2013 • Volume two • Number one • 29 Maximizing Mental Health Care by Pairing Primary Care Physicians with Mental Health Providers
By Kurt R. Bravata, MD; Christopher Leggett PhD PsyNP; Amir Levine, PhD, LCSW, CASAC; Jose A. Lopez, MD, MPH; Michael McNett, MD; Doug Reich, MD; Jose Tiburcio, MD
Abstract: General practitioners (GPs) are often the first health care professionals consulted when mentally ill patients seek help. This important role uniquely positions GPs as gatekeepers or points-of-access to the mental health services their patients receive. Because of this, close collaboration between mental health providers and primary care physicians is absolutely essential in order to maximize the scope of mental health care available to patients. This is not to say that primary care physicians should ever abdicate their role in providing mental health care. However, a close marriage between a patient’s primary doctor and mental health provider often results in better outcomes. Still, studies have shown that family practitioners frequently under-use community mental Android Digital Artwork by Kurt Bravata, MD Bravata, Artwork by Kurt Digital Android health resources. This may be simply due to a stylistic approach to medical practice or a result of barriers to integrated care. In urban communities it is particularly true that obstacles such as differing cultural values, skewed perceptions, and frustrating language barriers can complicate the ability of a single provider to provide quality mental health care on a comprehensive level. Because of this, it is important for general practitioners and mental health providers to collaborate in order to create a broad safety net of mental health resources for these vulnerable patients.
Editorial
“In my opinion, primary care providers in I am a family medicine resident currently in my senior year of residency at Bronx-Lebanon general, and Family Medicine providers Hospital Center in Bronx, New York. I treat patients with mental health disorders every day. A in specific should be encouraged to large percentage of my patients carry diagnoses of bipolar disorder or some other psychiatric treat the basic mental health issues they malady. However, I would be hard pressed to think of a scenario where I did not rely to some encounter within the comfort level of their extent on the support of a psychiatrist or other mental health worker to assist in the care of training. With the proper screening tools, my patients with emotional and psychiatric disorders. The complicated medical management depression, anxiety, bipolar disorder, and of my patient's myriad comorbidities is a formidable task by itself without adding to it the obsessive-compulsive disorder can be responsibility of carrying out the full duties of a psychiatrist. On the other hand, I am sure managed by primary care providers who are that my experience is not that much different from many other general practitioners in that I knowledgeable about these disorders and often find myself falling into the role of adjunct behavioral health specialist or counselor. their recommended treatments. I would I believe that one has to be psycho-socially astute to be a good primary care physician. advocate that all Family Medicine providers Patients come in a package that includes a body, mind, and yes, spirit, which is a discussion should seek out extra training or skills if we can save for another day. I take the point of view that true primary care must encompass they feel uncomfortable with providing or at the very least attempt to recognize the integral importance of all three components that this care. I believe we will be serving our make up a human being. However, as a primary care provider, I also understand the need patients needs better, as well as preserving to know the boundaries of my area of expertise. It is one thing to be capable of providing the psychiatrists for cases that are more a service, but being proficient in its delivery is another thing altogether. That is why, when complex or more resistant to standard it comes to administering psychiatric medication, I often defer to my colleagues who are therapies.” formally trained in the field of psychiatry. Michael McNett, M.D.
30 • Family Doctor • A Journal of the New York State Academy of Family Physicians Primary care is an art as well as a science. It naturally follows that the art of practicing medicine is one that is perfected over time. Because of this, it is perfectly reasonable to “The cornerstone of family medicine is assume that a physician who once deferred the bulk of his mental health cases to psychiatrists the ability to treat the whole person. Our might with time gradually take on more of that responsibility as his comfort level grew. values and knowledge base are fueled by However, it is my opinion that regardless of the mental health expertise of the general the biopsychosocial perspective which takes practitioner, it is important to maximize the breath of the safety net of mental health resources into account the interaction of biological, available in order to optimize outcomes. social, psychological and emotional factors Kurt R. Bravata, M.D. as they interact to form a very unique picture Resident Physician, Bronx-Lebanon Hospital of illness in every patient. Currently, primary AAFP-AMA Resident Fellow Section Delegate care providers are the gate-keepers of AMA-RFS Sectional Alternate Delegate patient care and are already the first line of treatment for most patients struggling with mental health conditions. Throughout my years of clinical experience as a behavioral medicine educator and provider I have witnessed time again the way in which Literature Review family physicians provide compassionate and effective mental health care to the most General practitioners (GPs) are often the for a mental health problem do so in the 3 vulnerable patients struggling with multiple first health care professionals consulted first instance from a GP, FPs are often the medical and psychological co- morbidities. when mentally ill patients seek help. This first professionals consulted when mentally important role uniquely positions family ill people seek help. Overall, FPs see the It is my clinical opinion that family physicians physicians (FPs) and other primary care most patients with mental disorders, and are perfectly positioned and equipped to providers as gatekeepers or points-of-access they play an important role in delivery of diagnose and treat mental health conditions. to the mental health services their patients mental health care. Collaborative care Furthermore, family physicians cannot afford receive. Because of this, collaboration between mental health providers and to "outsource" mental health care as many between mental health providers and PCPs lies on a continuum that ranges patients prefer and feel comfortable being primary care physicians (PCPs) is absolutely from occasional courtesy communication treated by their primary care provider. I am essential. However, studies have shown that to on-site collaboration and teamwork. hoping that in the future we will ask how to GPs frequently under-use community mental Health care professionals working in close create behavioral health training programs health resources. A number of obstacles collabora¬tion need to share common so that family physicians feel empowered to to integrated care have been suggested, values, perceptions, lan¬guage, and continue to manage mental health care in such as lack of awareness and education, thinking about their joint work to provide the most effective ways possible , rather than differing cultural values, misconceptions, and effective patient care.4 However, studies have ask whether primary care physicians should communication barriers between the medical suggested that FPs under-use community treat mental health conditions. This is the community and patient population. This resources in managing patients with way of the future and we should embrace it.” is particularly true in urban communities psychiatric and psychosocial problems, Amir Levine, Ph.D., LCSW, CASAC plagued by limited resources, poverty, and that they tend to use a narrow range of a high disease burden. In such setting, it resources, and that they tend to favor becomes even more imperative to bring medically oriented services.5 providers together in primary care settings in Although a substantial number of patients order to ensure adequate patient care. with mental illness are treated by their Community mental health teams are the primary care providers, often the FP established model for supporting patients serves as a point of access for specialty with serious mental illness in the community. mental health services; nevertheless, However, up to 25% of those with psychotic significant barriers to referrals exist at disorders are managed solely by primary the patient as well as provider levels. care teams.1 Among patients visiting FPs, Patient demographics, social stigma, lack the prevalence of psychosocial problems of knowledge, and patient and physician is as high as 40%.2 With data indicating that about 75% of patients who seek help CONTINUED NEXT PAGE
Summer 2013 • Volume two • Number one • 31 attitudes influence a person’s chance of General on mental health proclaimed stigma The quality of primary mental health care accessing adequate mental health care. as the “most formidable obstacle to future seems to vary considerably from one region progress in the arena of mental illness and to another.32 This may be related to some Studies have demonstrated that ethnic health.”24 In one study, black women, of the above-mentioned factors, such as minorities traditionally receive less care particularly immigrants, were found to have social stigma, lack of adequate insurance for depression than do white populations.6 much higher stigma concerns than their coverage, and under-diagnosis by PCPs. For example, a survey of patients found U.S.-born counterparts.22 However, little is known about challenges that immigrants were 60% more likely to PCPs face arranging mental health referrals have undiagnosed anxiety disorders than Large-scale epidemiological studies have and hospitalizations.33 Although a variety of natives.7 Specifically, African-Americans and shown that women are more likely than men community, educational, recreational and Hispanics have been found to utilize mental to use mental health treatment services.25 voluntary sector resources may be available health resources significantly less than non- Studies of women seeking treatment for for patients with psychosocial problems, GPs Hispanic whites, even when accounting for substance abuse have documented increased often under-refer to these programs because insurance coverage, income, geographic economic barriers compared to men, of lack of knowledge and time.34 location, employment status and level of resulting in a lower likelihood of seeking education.8-11 A number of theories have treatment. Perceived need for care may also influence been suggested to explain this disparity, a patient’s readiness for treatment and An analysis of data from the 2005 National among them mistrust and suspicion of utilization of mental health services. Multiple Health Interview Survey found that among medical authorities along with perceptions investigations cite patient beliefs that their respondents experiencing significant of discrimination.12 “problem can be handled without medical mental distress, those older than 65 years intervention”, “treatment is a waste of Recent immigrants may be particularly of age had less contact with a mental health time”, and a “lack of need” as reasons for susceptible to emotional imbalances as provider and were more likely to report they are subject to additional psychological not affording mental health care.26 Yet, strains as a result of their relocation.13 roughly 22% of older adults meet criteria These new members of society tend to rely for psychiatric disorders, a prevalence “I think FPs can and should treat mental primarily on community health centers rate similar to that in people younger than health issues of patients in their primary care and public hospitals. Hence primary 65.27 The data suggests that despite poor practices. And in fact they already do. Most care facilities end up serving as a health health outcomes and increased health care psychotropic medication in this country is care safety net and, as a result, inner-city costs associated with psychiatric disorders already prescribed by primary care providers. populations are much more likely to receive in older adults, mental health services are And it has been estimated that more than mental health care through primary care underutilized, and access to assessment half of all primary care patients in public providers.14,15 Conversely, immigrants are and treatment by specialty mental health clinics have some diagnosable mental much less likely than natives to use any providers is poor. Fewer than 3% of older condition worthy of attention - many times type of mental health service, including adults report seeing a mental health mild to moderate anxiety and/or depression. alternative sources such as community professional for treatment, a rate lower than The FP is well-situated to identify & treat leaders, religious groups or alternative that of any other adult age group. Instead, them since many of these cases respond well medicine practitioners.16,17 older adults tend to seek mental health to relatively simple and brief intervention - treatment in primary care.28 Studies have indicated that racial and ethnic empathic listening/reassurance and perhaps minorities tend to have a considerably strong An investigation by Borowksy, et al., found medication such as an antidepressant. The attitude of mistrust towards the medical that mental health disorders were less key issue is knowing when to refer, which establishment.18-20 Various reasons for this frequently diagnosed in younger male entails recognizing the limits of one's own disposition exist, including significantly patients.29 This may be partly due to knowledge and training. This in turn is guided lower insurance coverage, cultural beliefs parental resistance related to stigmatic by the FP’s individual interest and comfort surrounding mental health and coping, fear misconceptions about mental health level with psychological and psychiatric of undocumented status, and unfamiliarity care.30 The unfortunate reality is that issues. Whether you are treating diabetes, with existing mental health resources.14,21-23 studies using structured clinical interviews hypertension or depression, you don't always and parent-completed behavioral rating need to call the specialist, but you must know A long history of stigmatization and rejection scales have shown that 11% to 20% of enough to judge when the specialist must of individuals with mental illness plays school-age children attending primary care indeed be called.” significantly into how patients view their own pediatric clinics evidence one or more DSM mental health. A 2001 report by the Surgeon Christopher Leggett, Ph.D., PsyNP diagnosable mental health problem.31
32 • Family Doctor • A Journal of the New York State Academy of Family Physicians not seeking mental health services or not Physicians who feel burdened by mental The role of the PCP in addressing mental showing up to appointments.21, 35-37 The health patients, who view their patients as health is important in urban communities result is that patient resistance to referral non-compliant, or not ready for psychiatric plagued by limited resources and a high presents a major barrier to treatment and treatment, are less likely to provide adequate disease burden. In such communities, has been correlated with high rates of mental health care.47,54 The same is true of poverty and unemployment negatively impact missed referral appointments, according to physicians who lack interest in participating mental health.67 Poor communication several surveys of PCPs.36-41 in psychiatric care, believe that treatment between the referring physician and the of the mentally ill is not part of their job, specialist is one of the most prominent Another barrier to successful treatment of have low comfort levels with psychiatric barriers to mental health care in primary mental health disorders is the ability and illness, or have the perception that medical practice, according to several surveys of desire of patients to adhere to the prescribed problems are competing with psychiatric PCPs.68,69 Several surveys point to low regimen. Studies have shown that in certain issues.56-59 Financial considerations satisfaction with mental health providers as a cases the phenomenon of noncompliance may sway PCPs as well, with inadequate barrier to psychiatric specialty services.45,47,70 may be related to marital status. In general, reimbursement of mental health services The results of an Ontario study showed that married patients are less likely to adhere to discouraging physicians from initiating FPs believed their role in delivering mental treatment as well as to receive referrals to treatment.39,40 Studies have also evidenced health services would improve if support specialty care from a PCP.14, 42 higher rates of referrals for patients who were more accessible to them. Bringing The high prevalence of psychiatric are viewed as suitable for specialty care and providers together in primary care settings morbidity in primary care, the growing for patients who evoke negative emotional is one way to assist FPs in caring for their perception of the need for specialized responses in their general provider.60 patients’ mental health.2 help by the least severe patients, and the Physical environment may have a profound lack of accuracy in referrals, contribute to Conclusion effect on whether mental illness is properly the increasing overload in mental health identified. For example, studies have shown GPs, as the term implies, treat a broad range services.43 Patients are much more likely to that women living in public housing face a of comorbidities. In fact, the majority of prefer counseling to medication, yet PCP’s lower likelihood of appropriate diagnosis.61 GPs manage patients with mental health schedules may predispose them towards the This may be primarily related to a number disorders on a daily basis. This dynamic latter treatment.44 Multiple surveys of PCPs of factors stemming from socio-economic adds complication to the already formidable have suggested that the reason for this is the status. Similarly, patient income has been task of managing medical issues often lack of time needed for consultation and shown to significantly the outcome of coinciding within the same patient. Despite referral.39,45-49 The extra workload induced patient treatment, as indicated by a national this fact, many GPs find themselves taking by patients with mental health problems survey in which 34% of respondents on the role of adjunct behavioral health may sometimes cause GPs to be reluctant to reported they were unable to afford specialist or counselor. Others feel perfectly become involved in a patient’s mental health psychiatric medications.62 The availability comfortable prescribing psychotropic care.50 of transportation and the ability to physically medications and therefore are less likely to According to some surveys, PCPs have reach clinics or providers have also been refer their patients to psychiatrists. cited perceived inadequacy of training as cited as significant barriers to care.21,51,63,64 At the center of this debate over practice a barrier to providing appropriate mental Hence, co-location of both primary care styles is the patient who has taken a leap health care.39,45 It has been proposed that and mental health services has been cited of faith to put his or her welfare into the cross-cultural training may be as important as means to improve primary care-mental hands of the GP. Because of this, there is as medical expertise in the diagnosis and health collaboration and patient care.4,65,66 an ethical imperative to assure that each treatment of psychiatric problems.21,23,51,52 Physician demographics and practice patient receive comprehensive broad-based This lack of capacity to treat mental health characteristics have also been proposed as care that involves a multidisciplinary team disorders, physicians’ attitudes towards factors related to quality of mental health to optimize outcomes. Therefore, GPs mental health, failure of communication, care. For example, studies have documented should develop healthy streamlined working and lack of resources impede a patient’s more frequent referrals by physicians that relationships with their local mental health ability to receive adequate treatment. are males, Caucasians, and more recent professionals and should be comfortable The result is a flawed system in which medical school graduates.5,59 Whereas, calling consults or making referrals to them physicians fail to detect mental disorders pediatricians, solo/small group practices, on a routine basis. in approximately half of those patients who and private practices are more likely to present with one.53-55 encounter difficulties in mental health referrals.33 CONTINUED NEXT PAGE Summer 2013 • Volume two • Number one • 33 As gatekeepers to the world of medical References Supplement to Mental Health: A Report of the specialists and mental health services, GPs 1 Hull, S.A., et. al. Relationship style between GPs and Surgeon General. 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Psychiatry Med. 2000;30(2):127-43. Med. 2006 Jun;21(6):584-9. May 2008 43 Moré, M.A., et. al. Preliminary study aimed at the 60 Morgan D. Psychiatric cases: an ethnography construction of a questionnaire for referral from of the referral process. Psychol Med. 1989 Kurt Bravata, MD, is a Senior Resident at Bronx- primary care to mental health services. Actas Esp Aug;19(3):743-53. Lebanon Hospital Department of Family Medicine. Psiquiatr. 2008 Jul-Aug;36(4):210-7 61 Fertig A, Reingold D. Public Housing, Health and He received hisMD at Ross University. Dr. Bravata 44 Galambos C, Rocha C, McCarter A, Chansuthus D. Health Behaviors: Is There a Connection? 2007. J represented Bronx-Lebanon Hospital Department of Managed care and mental health: personal realities. Policy Anal Manage. 2007 Autumn;26(4):831-59. Family Medicine as NYSAFP alternate delegate 2010- J Health Soc Policy. 2004;20(1):1-22. 62 Mojtabai R. Trends in contacts with mental health 2011, served on the NYSAFP Leadership Commission 45 Grenier J, Chomienne M, Gaboury I, Ritchie P, professionals and cost barriers to mental health 2011-201 and as AAFP AMA-RFS alternate delegate Hogg W. Collaboration between family physicians care among aduts with significant psychological 2011-2012. Currently he is Primary AAFP AMA-RFS and psychologists: what do family physicians know distress in the United States: 1997-2002. Am J Public delegate and alternate AMA-RFS Sectional delegate. about psychologists' work? Can Fam Phys. 2008 Health. 2005; 95:2009 Christopher Leggett, PhD, PsyNP, is Assistant Feb;54(2):232-3. 63 Davis R, Ressler K, Schwartz A, Stephens K, Bradley Professor of Psychiatry & Behavioral Science at Albert 46 Telford R, Hutchinson A, Jones R, Rix S, Howe R. Treatment Barriers for Low-Income, Urban Einstein College of Medicine and Associate Chief A. Obstacles to effective treatment of depression: African Americans with Undiagnosed Posttraumatic Psychologist & Psychiatric Nurse Practitioner in the a general practice perspective. Fam Pract. 2002 Stress Disroder. J Trauma Stress. 2008 April ; 21(2): Department of Psychiatry at Bronx-Lebanon Hospital Feb;19(1):45-52. 218–222. Center. Amir Levine, PhD, LCSW, CASAC, is a 47 Younes N, Gasquet I, Gaudebout P, Chaillet M, et al. 64 Ahmed, SM, Lemkau, JP, Nealeigh, N and Mann Psychotherapist and Assistant Clinical Professor of General Practitioners' opinions on their practice in B. Barriers to healthcare access in a non-elderl Family and Social Medicine at Albert Einstein College mental health and their collaboration with mental urban poor American population. Health Soc Care of Medicine, Behavioral Scientist Instructor at Bronx- health professionals. BMC Fam Pract. 2005 May Community. 2001 Nov;9(6):445-53. Lebanon Hospital Department of Family Medicine, 2;6(1):18. 65 McNeil, G. The collaboration between psychiatry and Co-founder of NYC Therapy Center. Jose Lopez, 48 Wise, T. Commentary: psychiatry and primary care. and primary care in managed care. Psychiatr Clin MD, MPH, was the Principle Investigator on this Gen Hosp Psychiatry. 1985 Jul;7(3):202-4. North Am. 2000 Jun;23(2):427-35. article and is Director of Medical Informatics at Bronx 49 Brown A, Kent G. Factors associated with the 66 Valenstein M, Klinkman M, Becker S, Blow F, et al. Lebanon Hospital. He has been an Attending in the decision to refer patients with anxiety disorder or Concurrent treatment of patients with depression in Department of Family Medicine since 2006 and teaches sexual dysfunction. Fam Pract. 1992 Mar;9(1):32-5. the community. J Fam Pract. 1999; 18(3): 180-187. and supervises residents at an inner-city program. 50 Zantinge, E.M., et. al. Does the attention General 67 Galea S, Bresnahan M, Susser E. Mental Health in Michael McNett, MD, is a Primary Care Provider Practitioners pay to their patient’s mental health the City. In: Freudenberg N, Galea S and Vlahov D, at Bronx-Lebanon Hospital. He is board certified in problems add to their workload? BMC Fam Pract. Eds., Cities and the Health of the Public. Nashville: Family Medicine and has special expertise HIV/AIDS and 2006 Dec 5;7:71 Vanderbilt University Press, 2006 integrative/Chinese medicin. He also sub-specializes in 51 Sadavoy J, Meier R, Ong A. Barriers to access 68 Kates N. Psychiatric consultation in family transgender medicine and pain management. Doug to mental health services for ethnic seniors: physician's office. Advantages and hidden benefits. Reich, MD, is the Chairman of the Bronx-Lebanon the Toronto Study. Can J Psychiatry 2004 Gen Hosp Psychiatry. 1988 Nov;10(6):431-7. Hospital Department of Family Medicine. Jose Mar;49(3):192-9. 69 Fickel J, Parker L, Yano E, Kirchner J. Primary Tiburcio, MD, is the Residency Director at Bronx- 52 Johnson J, Cameron M. Barriers to providing care - Mental health collaboration: an example of Lebanon Hospital Department of Family Medicine.
Summer 2013 • Volume two • Number one • 35 New NYSAFP Officers for 2013-2014
President – Raymond L. Ebarb, MD Vice President – Tochi Iroku-Malize, MD Raymond L. Ebarb, MD, is a Board Certified Family Tochi Iroku-Malize MD, MPH, is the Chair of the Physician in private practice for 25 years. He is on newly created Family Medicine Department at the the faculty of both SUNY Stony Brook and Hofstra Hofstra-North Shore LIJ School of Medicine and Medical School. He is the Medical Director of the NSLIJ Health System. She is also the Program the Association of Help for Retarded Children for Director for their Family Medicine Residency last 25 years in Bohemia, NY and has served as Program at Southside Hospital. Dr. Iroku-Malize received her medical the Chair of the Family Medicine Department of education at the University of Nigeria. After completing her residency Southside Hospital in Bay Shore, NY. Dr. Ebarb has been an active at Southside Hospital, she obtained an MPH from Columbia University member of the NYS Academy for over 20 years. His priorities in the and is board certified in Family Medicine as well as Hospice and upcoming years will be focusing on the participation of new physicians Palliative Medicine. with the Academy and recruiting medical students to the specialty of As a hospitalist at Southside Hospital, Dr. Iroku-Malize helped Family Medicine. develop the “Hospitalist 101” course for the NSLIJ Health System Dr. Ebarb has special interest in Disaster and Wilderness Medicine. and she remained an active faculty member in the Family Medicine He made two trips to New Orleans for hurricane relief and to Haiti Residency Program, eventually becoming Associate Director of for earthquake relief, attended numerous Western U.S. conferences the program. She obtained a White Belt in Six-Sigma and Core of the WMS, and enjoys adventure vacations with his wife, Therese Management Certification in 2008. and sons Theo and Ray. Dr. Iroku-Malize was instrumental in revising the AAFP Recommended Curriculum Guidelines for FM Residents. She has presented on President-Elect – Mark Josefski, MD numerous topics locally, nationally and internationally. Mark Josefski, M.D., is a Board Certified She has been an active member of the NYSAFP, serving on several Family Physician at the Institute for Family commissions including Public Health, Leadership and Education, and Health, practicing at the Family Health Center as 2008-2009 Chair of the Board of the NYSAFP. Dr. Iroku-Malize of Kingston, in Kingston, NY. He is the former has been a representative to the AAFP National Conference of Special director of the Mid-Hudson Family Residency Constituencies and is currently a member of the AAFP Commission Program, where he remains as a senior faculty on Continuing Professional Development. member. He is on the Board of Directors of the Health Alliance of the Hudson Valley in Kingston, where he is Vice President of the Medical Staff. Dr. Josefski has been active with the AAFP, NYSAFP and STFM since 1989; he currently serves on the Operations Commission and Executive Committee. Dr. Josefski is Clinical Assistant Professor at Albert Einstein College of Medicine and the New York College of Osteopathic Medicine, and serves on the Board of Directors of NYCOMEC. He enjoys playing competitive baseball in the Capital District Men’s Senior Baseball League, and performs with Ars Choralis, a community singing group in Woodstock, N. Y.
36 • Family Doctor • A Journal of the New York State Academy of Family Physicians Treasurer – James Mumford, MD Secretary – Robert J. Ostrander, MD James M. Mumford, MD, FAAFP, is a board certified Robert J. Ostrander, M.D., FAAFP is a family Family Physician serving as Vice-Chair and Inpatient physician in private practice in rural Yates County Director of the Beth Israel Department of Family in the Finger Lakes since 1986. In addition to Medicine in New York City. Dr. Mumford has been his primary work caring for patients, he is an active with the NYSAFP since 2005 and currently Assistant Professor in the Department of Family serves as NYSAFP Secretary and Chair of the Medicine at SUNY Upstate Medical University Leadership Commission. Annually Dr. Mumford focuses on developing in Syracuse, where he is part of the University’s Rural Scholars leadership curriculum for our NY resident members as well as our Program and whose students he teaches in a longitudinal program seasoned members. In addition, he works with his commission to in his practice. He serves on the Medical Home Workgroup and the identify the talented NYSAFP up-and-comers to represent NY on the Follow Up and Treatment Subcommittee for the Secretary of Health national stage at the National Conference of Special Constituencies. Dr. and Human Services Advisory Committee on Heritable Diseases Mumford is Assistant Professor of the Department of Family and Social of Newborns and Children, and is a member of the ACTion Sheet Medicine, Albert Einstein College of Medicine. Dr. Mumford sees Workgroup for the American College of Medical Genetics. He also the integrated use of technology in both the inpatient and outpatient serves on the Governor’s Rural Health Council for the New York State settings as a key factor in health care transformation. He believes Department of Health. He graduated in 1983 from SUNY Upstate Family Physicians are uniquely positioned to navigate these new Medical College in Syracuse and completed his Residency in Family developments to lead our patients and communities successfully to Practice at St. Joseph’s Hospital and Health Center in 1986. He enjoys better health and care delivery primitive canoe camping and making maple syrup.
Speaker COD: Vice Speaker: AAFP Delegate: Alt. AAFP Delegate: Sarah C. Nosal, MD Barbara Keber, MD Andrew Merritt, MD Marc Price, DO
Delegate to MSSNY: Alt. Delegate to MSSNY: Director: Director: Paul Salzberg, MD Jose “Jun” David, MD Healther Paladine, MD Andrew Symons, MD
Director: New Physician Delegate: Jose Tiburcio, MD KrisEmily McCrory, MD
Summer 2013 • Volume two • Number one • 37 IN THE SPOTLIGHT
25 & 50 Year Certificates 25 YEAR MEMBERS Sharon A. Alger-Mayer, MD Latham, NY Mark Montera, MD Woodstock, NY Carmen Adriana Alvarez, MD Buffalo, NY John O’Bryan, MD Troy, NY Joseph P. Augustine, MD East Syracuse, NY Kevin C. Oeffinger, MD New York, NY Richard J. Bebirian, DO Massapequa, NY Frank C. Pedevillano, DO Poughkeepsie, NY Allan A. Berger, MD Great Neck, NY Anthony Petracca, MD Queensbury, NY Holly Bienenstock, DO Port Washington, NY David Frank Pfalzer, MD Kenmore, NY Meera S. Boppana, MD Ozone Park, NY Diane W. Piela, DO Sun City, CA Randall L. Burchell, MD Stillwater, NY Gurmukh Singh Raince, MD Greenlawn, NY Yuk-Wah Ng Chan, MD Poughkeepsie, NY Nancy Colon Sapio, MD Clifton Park, NY Peter J. Christiano, MD Baldwinsville, NY Vishnudat Seodat, MD Aquebogue, NY Debra Clark, MD Keesville, NY Virginia T. Shephard, MD Hornell, NY Mark Costanza, MD Amherst, NY James Ritchie Simcoe, MD Norwich, NY Laurel Ann Dallmeyer, MD Canandaigua, NY Bruce Soloway, MD New Rochelle, NY George F. Davis, MD Copake, NY Elizabeth N. Sousa, MD Pleasantville, NY Anthony DiGiovanna, MD Cortland, NY Ann Carey Tobin, MD Delmar, NY Arthur DiNapoli, MD Woodstock, NY Miriam Therese Vincent, MD, PhD, JD Valley Stream, NY Joseph George DiSalvo, MD Lagrangeville, NY Anna Marie Ward, MD Norwich, NY Joseph Dic, DO Deer Park, NY George G. Weis, DO Amsterdam, NY Joan L. Donoghue, MD Hollis, NY Ruth Willner, MD New York, NY Mary D. Driesch, MD Penn Yan, NY Brooke D. Durland, MD Rochester, NY 50 YEAR MEMBERS Bruce Robert Elwell, DO Marcy, NY Gerard J. Diesfeld, MD Arcade, NY Richard L. Farrell, MD Saratoga Springs, NY Elio Joseph Ippolito, MD Tarrytown, NY Shawn Fazio, MD Syracuse, NY J. Keith Festa, MD Marlboro, NY Robert Basil Hayes, MD Avon, NY H. S. Scholarship Awards Avraham Henoch, MD New York, NY Arielle J. Flowers Gasport, NY Thomas Hughes, MD Lockport, NY Rachael Utech Williamsville, NY Marc Immerman, MD Elmira, NY Brian James Izzo, MD Saratoga Springs, NY The Student Externship Matching Grant Awards from the Raja A. Jaber, MD Stony Brook, NY AAFP/Foundation and the NYSAFP/Foundation are: Shelley E. Justa, MD Clifton Park, NY Michael Alan Ladinsky, DO West Islip, NY Lindsey Anne Fuller, a student at Albert Einstein College of Medicine– Tat Sum Lee, MD Cherry Creek, NY Mentoring Family Physician is William B. Jordan, Bronx, NY Peter M. Liljeberg, MD Palatine Bridge, NY Danielle Schenone, a student at SUNY Upstate Medical University– Federica A. Manetti, MD Syracuse, NY Mentoring Family Physician is Megan Westervelt, DO, Big Flats, NY Richard F. Mittereder, MD Rochester, NY Thomas Gyorgy Molnar, MD Manhasset, NY
38 • Family Doctor • A Journal of the New York State Academy of Family Physicians The “ups” and “downs” of a staircase recovery often highlight the irregularity of its momentum. In short, three dynamics are playing out:
Three Primary Reasons: 1. Stock markets have been choppy and displaying more volatility than earlier in the year with the result being some short-term fade in prices of both value and growth names, including blue chip stocks. The Dow, S&P 500, and NASDAQ as the broader barometers have retreated about 7-10% from recent highs and even the go-to stocks like Johnson & Johnson, IBM, Disney, Proctor & Gamble, and National Grid have pared back. Short-term adjustments are a necessary and normal part of the ebb and flow we have historically experienced in bull runs. Because “straight up” runs can be dangerous, we have found this kind of “back and fill” consolidation to be constructive and healthy … though a little concerning when going through it. 2. With the QE-3 taper talk being a bit abstract and inconclusive, we have seen bond prices pull back too. Some of this is in anticipation of higher interest rates to come and some of this reflects the greater flow of money into stocks. Investor trends have been pro- stocks both for yield and growth and that money has come from money market cash and fixed income sources. Risk is “on” and fewer investors want to stay in cash or bond funds, despite the good yields in the latter. The price retreat in fixed assets corresponds to the emotional pullback we experienced around year end 2012 when the fiscal drama (an unknown) was playing out. Eventual changes to the country’s monetary policy are behind some of the anxiety. Until the next global shock hits, these assets are looking to level off and stabilize … but the flight to safety will eventually cause prices to come back some as investors who want steady income yield choose to buy them. Some will slightly change allocation and stay put with minor adjustments. Others may make a bigger switch in asset allocation and tolerate more stock risk, but wait on dips to do new buys. All in all, the bull run is still in place but a little more pullback is possible. The bond fund fade is a little disconcerting too but this phenomenon has occurred before and will iron itself out. Nevertheless, even more recently a revised GDP growth figure of 1.8% (down from 2.4%) has called into question the actual strength of the recovery. Although the signals are mixed, we will be here to keep you on a straight path. 3. Global Factors still playing a key role in investor sentiment. A lot to elaborate on here, so I’ll suffice it to say that the dynamics from the Eurozone and Asia are still with us and influencing the outlooks of investors. This anxiety has tended to be fleeting and the intensity seems tied to the severity of the headline news itself. I certainly don’t want to oversimplify the situation either so feel free to call me at any time. I recognize that generalizations can be helpful summaries but I also like to personalize plans/approaches to your situation. As many of you know this is one of my hallmark beliefs … let’s review the risks and objectives to your satisfaction and react or be prepared to adjust as necessary. This is a “touch base” write-up designed to explain the recent market gyrations and I welcome your questions and feedback.
*co-written with Brendan Callanan This is one of our typical e-mails to clients (distributed 2-3 times per week). If you would like to talk or consider our investment advisor services please call me at 518-581-0500. We have been in downtown Saratoga Springs for the past 18 years. Colley Asset Management, Inc.
It is vital to check the economy’s pulse…
Summer 2013 • Volume two • Number one • 39 260 Osborne Road PRSRT STD US POSTAGE Albany, NY 12211 PAID PERMIT #203 ALBANY, NY
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