Tuesday Feb 03, 2015
Over the Long Haul, Family Physicians Are Life Savers
As a resident, I began taking care of a man I’ll call Jim. He was a trucker in his early 50s and loved being on the road. Jim never married and did not have children, so his fellow truckers and other friends became like family. He used to talk about making long journeys across multiple states in a single day, meeting many wonderful people in diners and truck stops across the country. He often had to get out of jams, such as his truck breaking down when he needed to make a timely delivery. I loved seeing him and hearing his stories.
Jim's body suffered from many of the pitfalls that often occur with truckers: He was morbidly obese, had significant hypertension and hyperlipidemia, and he smoked like a chimney.
"I can’t survive without my two packs in a day," he would say. "It helps pass the time."
Jim first started seeing me, he said, because “they’re gonna fire me if I don’t get this blood pressure thing under control.” His blood pressure was in the 160/100s range. In the past, his physician visits had been limited to physical exams for his commercial driver’s license. His Framingham risk score was 30, meaning that he had a 30 percent chance of having a heart attack in the next 10 years.
Clearly, he was tempting fate, but over time, I was able to help Jim make choices that gave him a chance at a longer life.
Family medicine isn't viewed as a "sexy" specialty. Many subspecialists, such as surgeons, cardiologists and intensivists, receive accolades for saving multiple lives in a dramatic fashion. Their work is tremendous, and the praise they receive is certainly warranted. Many medical students choose these specialties so they can feel that rush of taking a failing body and reviving it. What many don't realize, though, is that family physicians often do this, as well, especially those who practice obstetrics or emergency medicine, but you're not likely to see that on Grey's Anatomy.
By and large, family medicine is perceived as bland. Few dramatic, life-saving gestures are associated with our primarily outpatient practices. But when considering the long-term picture, family physicians save just as many lives, if not more, as other specialists. And an added bonus is that we get to experience closer relationships with patients than most other specialists enjoy.
Coronary artery disease (CAD) kills more people in this country than any other illness or injury. According to one widely cited report(jama.jamanetwork.com) published in the Journal of the American Medical Association in 2012, at least half of Americans will have CAD at some point in their lives. Thus, as family physicians, working with patients to prevent diabetes, hypertension, hyperlipidemia, and quit smoking -- the main risk factors for CAD -- and then to treat them once they occur, is a huge part of what we do. If we are able to make a dent in this disease by effectively preventing and treating risk factors, we will save lives.
I made some conservative estimates using numbers needed to treat (NNT) for impact on hyperlipidemia and hypertension, as well as nationally representative primary care practice figures to determine how many lives family physicians save during the course of their careers. I'm no statistician, so my estimates are rough and necessarily make some assumptions. That said, if a family physician practices for about 35 years, with a patient panel of 2,500, he or she will save about 1,000 lives just from addressing hypertension and hyperlipidemia. That equates to about 29 people per year, or a little more than two per month.
This does not even count other services we provide, such as smoking cessation, early cancer detection or injury prevention, among countless others. All added together, family physicians save just as many lives as many other “sexier” specialties.
The main difference is that we get to do this through the relationships and trust we build with our patients over time, which for many is the most rewarding part of our jobs.
Jim and I worked together to decrease his risk factors for CAD. We were able to control his blood pressure, got him on a statin medication, and he made some changes to lose weight. He wasn’t able to kick that smoking habit, however. Still, together, we cut his 10-year risk for a heart attack to 17 percent. This is still much higher than ideal, but it represents a drop of nearly one-half of his baseline risk.
Jim eventually moved elsewhere, and I haven’t seen him in years. Since risk scores and NNTs are based on population models and, thus, make predictions in individuals inexact, I don’t know whether the decrease in Jim’s risk score actually kept him from having a heart attack or prolonged his life. But on a whole, we can all rest assured that we are saving and improving lives, albeit in a less dramatic way than you'll see on reruns of ER.
Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.
Posted at 01:36PM Feb 03, 2015 by Kyle Jones, M.D.