Family Physicians Have a Growing Role in Public Health and Health Care Efforts

Family physicians are in an ideal position to lead the nation's public health efforts and play a key role in solving some of the country's most vexing public health issues. This makes family medicine a valuable commodity as policymakers look for ways to control health care costs and improve quality.

That was one of the main messages delivered at the AAFP's State Legislative Conference held here on Nov. 2-3.

Vivek Murthy, M.D., cofounder and president of Doctors for America and an attending physician at Brigham and Woman's Hospital, delivered the keynote address for the conference. He spoke about the need for physician leadership in transforming the nation's health care system from a sick-care model to a wellness- and prevention-based model.

"Who is going to lead this transformation?" Murthy asked. "There has been a tendency in the past to leave it up to public health folks, and there has been a division between public health and medical folks. There is really a need for physician leadership (on this.)"

Murthy said physicians need to have more of a voice in the legislative and political process, and this means physicians have to be comfortable speaking to legislators. He also urged physicians to write opinion pieces (op-eds) for newspapers about the need for greater prevention and wellness efforts. "When a physician writes an op-ed, people in legislative offices actually cut these op-eds out and send them to their member of Congress," said Murthy.

Although having 10 large medical organizations sign onto letters urging a greater investment in prevention and wellness is useful, said Murthy, there is "tremendous value in having 10 doctors in a community or in a district going to meet with their member of Congress."

Murthy also stressed that "there is agreement that prevention needs to be a bigger focus -- that we would be better off if our health care system and communities were based on prevention."

But there are a number of challenges that block this from happening, he said -- challenges ranging from the culture of health care, which is still more focused on treating illness than on preventing it, to a lack of public health education about healthy living.

Murthy also pointed out that the financial incentives for providing care are misaligned and act as a barrier to delivering preventive care. "As a primary care doctor, if you spend the time it takes counseling (patients) about healthy eating, what does that do to your bottom line? It probably hurts it," he said. "We are asking physicians to act against their financial incentives in focusing on prevention, and that is not a way to build a prevention-based health care system."

The conference also addressed a troubling public health problem that could have a major effect on FPs: the physician's role in preventing pharmaceutical drug abuse. The AAFP recently released a position paper on pain management and opioid abuse (16-page PDF; About PDFs) that it subsequently distributed to its chapters and on Capitol Hill.

Family physician Jason Dees, D.O., a member of the AAFP's Commission on Governmental Advocacy, moderated the session on pharmaceutical drug abuse and helped set the tone by saying, "the United States accounts for about 5 percent of the world's population, but we consume 99 percent of the pain medicine in the world. Are we really in that much pain in this country?"

Jeanmarie Perrone, M.D., an emergency physician and director of the division of toxicology at the Perelman School of Medicine at the University of Pennsylvania, provided a brief history of opioid prescribing and use in the United States.

She noted that the number of opioid-related deaths has escalated rapidly during the past 10 years, largely as a result of a paradigm shift in the mid-1990s that eased opioid prescribing and led to an increase in the number of patients who had access to pain medications.

During most of the 20th century, physicians prescribed opioids chiefly for end-of-life care, postoperative pain and cancer. But in the mid-1990s, thinking changed to hold that opioid drugs are not as addictive as had been thought and that severe pain blocks the medications' euphoric effects, making them safe to prescribe for more patients, according to Perrone.

This paved the way for surges in opioid abuse in the 1990s and early 2000s, she said.

Perrone acknowledged that opioids are effective at controlling chronic pain. But for some patients, the medications are like legal heroin, which means these patients will have a desire to get the drugs again.

Perrone divided patients who take opioids into three groups: patients with chronic pain who rarely become addicted to opioids, patients who have comorbid pain and an opioid dependence problem, and patients who simply have an opioid dependence problem.

Primary care physicians can help combat prescription drug abuse in several ways, said Perrone. For example, she urged physicians to participate in prescription drug monitoring programs, which allow physicians in some states to electronically access a patient's prescription history.

"If it is easy to access and you have a program in your state, you should get the log on (address and) save it on your computer," Perrone said. The prescription drug monitoring programs give primary care physicians the ability to confront the patient. "Physicians actually feel less confrontational if they have the evidence in front of them; they are not guessing if the patient is abusing drugs," Perrone said.